ENDNOTES FOR CHAPTER 7

¶The citations that contain a reference to "CAIB document" with CAB or CTF followed by seven to eleven digits, such as CAB001-0010, refer to a document in the Columbia Accident Investigation Board database maintained by the Department of Justice and archived at the National Archives.

Sylvia Kramer, "History of NASA Safety Office from 1958-1980ʼs," NASA History Division Record Collection, 1986, p. 1. CAIB document

¶CAB065-0358.²² Guidelines per NASA Policy Guideline 8621.

Ralph M. Miles Jr. "Introduction." In Ralph M. Miles Jr., editor, System Concepts: Lectures on Contemporary Approaches to Systems, p. 1-12 (New York: John F. Wiley & Sons, 1973).

¶"The Aerospace Safety Advisory Panel, " NASA History Office, July 1,

¶1987, p. 1.⁴⁴ JSC Form 564 (March 24, 2003).

¶On Rodneyʼs appointment, see NASA Management Instruction 1103.39,

¶July 3, 1986, and NASA News July 8, 1986.⁵⁵ Harold W. Gehman to Sean OʼKeefe, February 25, 2003. 238 Report Volume I August 2003

NASA Facts, "Brief Overview, Office of Safety, Reliability, Maintainability and Quality Assurance," circa 1987.

¶"Space Program Safety: Funding for NASAʼs Safety Organizations

Should Be Centralized," General Accounting Office Report, NSIAD-90- 187, 1990.

¶"Aerospace Safety Advisory Panel Annual Report," 1996.⁸⁸ The only actual flight tests conducted of the Orbiter were a series of Printing Office, 1998) for an account of the aftermath of the accident. Approach and Landing Tests where Enterprise (OV-101) was dropped Much of the account in this section is drawn from this source. from its Boeing 747 Shuttle Carrier Aircraft while flying at 25,000 feet. 19 Logsdon, "Return to Flight," p. 348. These tests – with crews aboard – demonstrated the low-speed handling 20 Presidential Commission on the Space Shuttle Challenger Accident capabilities of the Orbiter and allowed an evaluation of the vehicleʼs (Washington: Government Printing Office, June 6, 1986). landing characteristics. See Jenkins, Space Shuttle, pp. 205-212 for more information. 26 Report Volume I August 2003Show full note

¶The quotes are from the Executive Summary of National Aeronautics

and Space Administration Space Shuttle Independent Assessment Team, "Report to Associate Administrator, Office of Space Flight," October- December 1999. CAIB document CTF017-0169.

Harry McDonald, "SIAT Space Shuttle Independent Assessment Team Report."

¶NASA Chief Engineer and NASA Integrated Action Team, "Enhancing

¶Mission Success – A Framework for the Future," December 21, 2000.¹¹¹¹ Thompson, "The Risk of Groundling Fatalities;" Code of Federal Regulations (CFR) 14 CFR Part 415, 415, and 417, "Licensing and Safety Requirements for Launch: Proposed Rule," Federal Register Vol. 67, No. 146, July 30, 2002, p. 49495. 224 Report Volume I August 2003

¶The information in this section is derived from a briefing titled, "Draft

Final Report of the Space Shuttle Competitive Source Task Force," July 12, 2002. Mr. Liam Sarsfield briefed this report to NASA Headquarters.

Dr. Karl Weick, University of Michigan; Dr. Karlene Roberts, University of California-Berkley; Dr. Howard McCurdy, American University; and Dr. Diane Vaughan, Boston College.

Dr. David Woods, Ohio State University; Dr. Nancy G. Leveson, Massachusetts Institute of Technology; Mr. James Wick, Intel Corporation; Ms. Deborah L. Grubbe, DuPont Corporation; Dr. M. Sam

Mannan, Texas A&M University; Douglas A. Wiegmann, University of Illinois at Urbana-Champaign; and Mr. Alan C. McMillan, President and Chief Executive Officer, National Safety Council.

Todd R. La Porte and Paula M. Consolini, "Working in Practice but Not in Theory," Journal of Public Administration Research and Theory,¹¹ NASA Agency Contingency Action Plan for Space Flight Operations, January 2003, p. D-2. (1991)

¶pp. 19-47.

¶Scott Sagan, The Limits of Safety (Princeton: Princeton University Press,

¶1995). 16

¶Dr. Diane Vaughan, Boston College; Dr. David Woods, Ohio State

University; Dr. Howard E. McCurdy, American University; Dr. Karl E. Weick, University of Michigan; Dr. Karlene H. Roberts; Dr. M.

¶Elisabeth Paté-Cornell; Dr. Douglas A. Wiegmann, University of Illinois at Urbana-Champaign; Dr. Nancy G. Leveson, Massachusetts Institute of

¶Technology; Mr. James Wick, Intel Corporation; Ms. Deborah L. Grubbe,

¶Dupont Corporation; Dr. M. Sam Mannan, Texas A&M University; and

¶Mr. Alan C. McMillan, President and Chief Executive Officer, National

¶Safety Council. 17

¶Dr. David Woods of Ohio State University speaking to the Board on Hind-

¶Sight Bias. April 28, 2003. 18

¶Sagan, The Limits of Safety, p.258. 19

¶LaPorte and Consolini, "Working In Practice." 20

¶Notes from "NASA/Navy Benchmarking Exchange (NNBE), Interim

¶Report, Observations & Opportunities Concerning Navy Submarine

¶Program Safety Assurance," Joint NASA and Naval Sea Systems

¶Command NNBE Interim Report, December 20, 2002.

¶Theodore Rockwell, The Rickover Effect, How One Man Made a

¶Difference. (Annapolis, Maryland: Naval Institute Press, 1992), p. 318.

¶Rockwell, Rickover, p. 320. 23

¶For more information, see Dr. Diane Vaughn, The Challenger Launch

¶Decision, Risky Technology, Culture, and Deviance at NASA (Chicago:

¶University of Chicago Press, 1996).

¶Presentation to the Board by Admiral Walter Cantrell, Aerospace

¶Advisory Panel member, April 7, 2003. 25

¶Presentation to the Board by Admiral Walter Cantrell, Aerospace

¶Advisory Panel member, April 7, 2003.

¶Aerospaceʼs Launch Verification Process and its Contribution to Titan Risk

¶Management, Briefing given to Board, May 21, 2003, Mr. Ken Holden,

¶General Manager, Launch Verification Division. 27

¶Joe Tomei, "ELV Launch Risk Assessment Briefing," 3rd Government/

¶Industry Mission Assurance Forum, Aerospace Corporation, September

¶24, 2002.

¶NASA Policy Directive 8700.1A, "NASA Policy for Safety and Mission

¶Success", Para 1.b, 5.b(1), 5.e(1), and 5.f(1).

¶Charles B. Perrow. Normal Accidents (New York: Basic Books, 1984). 30

¶A. Shenhar, "Project management style and the space shuttle program

¶(part 2): A retrospective look," Project Management Journal, 23 (1), pp. 32-37. 31

¶Harry McDonald, "SIAT Space Shuttle Independent Assessment Team

¶Report." 32

¶Ibid. 33

¶"Post Challenger Evaluation of Space Shuttle Risk Assessment and

¶Management Report, National Academy Press 1988," section 5.1, pg.

¶Harry McDonald, "SIAT Space Shuttle Independent Assessment Team

¶Report." 35

¶NSTS-22254 Rev B. Ibid.

¶GAO Report, "Survey of NASA Lessons Learned," GAO-01-1015R,

¶September 5, 2001.

¶E. Tufte, Beautiful Evidence (Cheshire, CT: Graphics Press). [in press.] 39

¶Ibid., Edward R. Tufte, "The Cognitive Style of PowerPoint," (Cheshire,

¶CT: Graphics Press, May 2003).

¶Ibid.

195

Chapter 8: History As Cause: Columbia and Challenger

¶The Board began its investigation with two central questions about NASA decisions. Why did NASA continue to fly with known foam debris problems in the years preceding the Columbia launch, and why did NASA managers conclude that the foam debris strike 81.9 seconds into Columbiaʼs flight was not a threat to the safety of the mission, despite the concerns of their engineers?