Elisabeth Paté-Cornell and Paul S. Fischbeck, "Risk Management

for the Tiles of the Space Shuttle," pp. 64-86, Interfaces 24, January- February 1994. CAIB document CAB005-0141.

Letter to M. Elisabeth Paté-Cornell, Stanford University, from Benjamin Buchbinder, Risk Management Program Manager, NASA,¹⁰¹⁰ The civil aviation study indicates that the risk to groundlings is significantly 25 Julie Kramer, et al., "Minutes from CAIB / Engineering Meeting to higher in the vicinity of an airport. The average annual risk of fatality Discuss CAIB Action / Request for Information B1-000193," April 24, within 0.2 miles of a busy (top 100) airport is about 1 in a million. 2003. CAIB document CTF042-00930095. May 1993. CAIB document CAB038-36973698.

¶M. Elisabeth Paté-Cornell, "Follow-up on the Standard 1990 Study of the

Risk of Loss of Vehicle and Crew of the NASA Space Shuttle Due to Tile Failure," Report to the Columbia Accident Investigation Board, 18 June 2003. CAIB document CAB006-00970104.

M. Litwinsk and G. Wilson, et al., "End-to-End TPS Upgrades Plan for Space Shuttle Orbiter," February 1997; K. Hinkle and G. Wilson, "Advancements in TPS," M&P Engineering, 22 October 1998.

Daniel B. Leiser, et al., "Toughened Uni-piece Fibrous Insulation (TUFI)" Patent #5,079,082, 7 January 1992.

Karrie Hinkle, "High Density Tile for Enhanced Dimensional Stability," Briefing to Space Shuttle Program, October 19, 1998. CAIB document CAB033-32663280.

Daniel B. Leiser, "Present/Future Tile Thermal Protection Systems," A presentation to the CAIB (Group 1), 16 May 2003.

John Kowal, "Orbiter Thermal Protection System (TPS) Upgrades." Space Shuttle Upgrades Safety Panel Review,¹⁰¹⁰ The civil aviation study indicates that the risk to groundlings is significantly 25 Julie Kramer, et al., "Minutes from CAIB / Engineering Meeting to higher in the vicinity of an airport. The average annual risk of fatality Discuss CAIB Action / Request for Information B1-000193," April 24, within 0.2 miles of a busy (top 100) airport is about 1 in a million. 2003. CAIB document CTF042-00930095. February 2003.

"Problem Reporting and Corrective Action System Requirements," NSTS-08126, Revision H, November 22, 2000. CAIB document CTF044-

Diane Vaughan, The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA (Chicago: University of Chicago Press, 1996).

Richard Feynman, Minority Report on Challenger, The Pleasure of Finding Things Out, (New York: Perseus Publishing, 2002).

¶See Appendix D.17 Tiger Team Checklists. 44

Allen J. Richardson and A. H. McHugh, "Hypervelocity Impact Penetration Equation for Metal By Multiple Regression Analysis,"

¶STR153, North American Aviation, Inc., March 1966. 45

¶Allen J. Richardson and J. C. Chou, "Correlation of TPS Tile Penetration

¶Equation & Impact Test Data,"³³ See John M. Logsdon, "The Space Shuttle Program: A Policy Failure?" Report, 1985. Science, May 30, 1986 (Vol. 232), pp. 1099-1105 for an account of this 14 The quote is from page 2 of the We Deliver brochure, reproduced in decision process. Most of the information and quotes in this section are Exploring the Unknown Volume IV, p. 423. taken from this article. 15 NASA Johnson Space Center, "Technology Influences on the Space President George H. W. Bush, "Remarks on the 20th Anniversary of the Apollo 11 Moon Landing," Washington, D.C., July 20, 1989.Show full note March 1985. 46

¶"Review of Crater Program for Evaluating Impact Damage to Orbiter

TPS Tiles," presented at Boeing-Huntington Beach, 29 Apr 2003. CAIB document CTF070-29492999.

L. Rand, "Impact Testing of Orbiter HRSI Tiles," Texas Engineering

Experiment Station Report (Texas A&M), 1979; Tests conducted by NASA (D. Arabian) ca. 1979.

Drew L. Goodlin, "Orbiter Tile Impact Testing, Final Report", SwRI Project # 18-7503-005, March 5, 1999.

Allen J. Richardson, "Evaluation of Flight Experience & Test Results for Ice Impaction on Orbiter RCC & ACC Surfaces," Rockwell International, November 26, 1984.

Though this entry indicates that NASA contacted USSPACECOM, the correct entity is USSTRATCOM. USSPACECOM ceased to exist in October 2002.

concern. Briefed at post-STS-42 PRCB and STS-45 Flight Readiness Review.

177

The Accidentʼs Organizational Causes

¶Many accident investigations make the same mistake in defining causes. They identify the widget that broke or mal- functioned, then locate the person most closely connected with the technical failure: the engineer who miscalculated an analysis, the operator who missed signals or pulled the wrong switches, the supervisor who failed to listen, or the manager who made bad decisions. When causal chains are limited to technical flaws and individual failures, the ensuing responses aimed at preventing a similar event in the future are equally limited: they aim to fix the technical problem and replace or retrain the individual responsible. Such corrections lead to a misguided and potentially disastrous belief that the underlying problem has been solved. The Board did not want to make these errors. A central piece of our expanded cause model involves NASA as an organizational whole.

ORGANIZATIONAL CAUSE STATEMENT

¶The organizational causes of this accident are rooted in the Space Shuttle Programʼs history and culture, including the original compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fluctuating priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed national vision. Cultural traits and organizational practices detrimental to safety and reliability were allowed to develop, including: reliance on past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing in accordance with requirements/specifications); organizational barriers which prevented effective communication of critical safety information and stifled professional differences of opinion; lack of integrated management across program elements; and the evolution of an informal chain of command and decision-making processes that operated outside the organizationʼs rules.