PART TWO: WHY THE ACCIDENT OCCURRED

PART TWO: WHY THE ACCIDENT OCCURRED

¶Part Two, "Why the Accident Occurred," examines NASAʼs organizational, historical, and cultural factors, as well as how these factors contributed to the accident.

¶As in Part One, Part Two begins with history. Chapter 5 examines the post-Challenger history of NASA and its Human Space Flight Program. A summary of the relevant portions of the Challenger investigation recommendations is presented, followed by a review of NASA budgets to indicate how committed the nation is to supporting human space flight, and within the NASA budget we look at how the Space Shuttle Program has fared. Next, organizational and management history, such as shifting management systems and locations, are reviewed.

¶Chapter 6 documents management performance related to Columbia to establish events analyzed in later chapters. The chapter begins with a review of the history of foam strikes on the Orbiter to determine how Space Shuttle Program managers rationalized the danger from repeated strikes on the Orbiterʼs Thermal Protection System. Next is an explanation of the intense pressure the program was under to stay on schedule, driven largely by the self-imposed requirement to complete the International Space Station. Chapter 6 then relates in detail the effort by some NASA engineers to obtain additional imagery of Columbia to determine if the foam strike had damaged the Orbiter, and how management dealt with that effort.

¶In Chapter 7, the Board presents its view that NASAʼs organizational culture had as much to do with this accident as foam did. By examining safety history, organizational theory, best business practices, and current safety failures, the report notes that only significant structural changes to NASAʼs organizational curlture will enable it to succeed.

¶This chapter measures the Shuttle Programʼs practices against this organizational context and finds them wanting. The Board concludes that NASAʼs current organization does not provide effective checks and balances, does not have an independant safety program, and has not demonstrated the characteristics of a learning organization. Chapter 7 provides recommendations for adjustments in organizational culture.

¶Chapter 8, the final chapter in Part Two, draws from the previous chapters on history, budgets, culture, organization, and safety practices, and analyzes how all these factors contributed to this accident. The chapter opens with "echoes of Challenger" that compares the two accidents. This chapter captures the Boardʼs views of the need to adjust management to enhance safety margins in Shuttle operations, and reaffirms the Boardʼs position that without these changes, we have no confidence that other "corrective actions" will improve the safety of Shuttle operations. The changes we recommend will be difficult to accomplish – and will be internally resisted.