U.S. Space Shuttle Disaster Analysis Case Study

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The report identifies NASA as "working with an unrealistic set of flights" (Cases Study. N.D.); timelines "which were retained and increased pressure to meet schedules by senior NASA managers" (Case Study. N.D.). The Challenger disaster was marked by the reality that

"NASA had found evidence that O-rings had allowed hot exhaust to burn through a primary seal. Since 1982 the O-rings had been designated a "Criticality 1" issue. Indeed, a January shuttle launch in cold weather just a year earlier had shown significant burn through of the O-rings. The day before the Challenger launch, engineers at Morton Thiokol, a NASA contractor, raised concerns that the frigid temperatures at Cape Canaveral would cause the shuttle's rocket booster "O-rings" to fail -- which would mean catastrophe for the shuttle. Just hours before liftoff, Thiokol engineers were recommending that the launch be delayed. After hours of discussion, NASA pressed forward with the launch anyway" (O'Leary, J. June 2, 2010).

Much like the Challenger incident the CAIB report finds "NASA management practices to be as much a cause of the accident as the foam that struck the left wing 81 sec into flight. These practices included: allowing the shuttle to fly with known flaws, blocking the flow of critical information up the hierarchy, and inadequate safety monitoring" (O'Leary, J. June 2, 2010).

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As with the O-ring on Challenger, a seemingly minor technical issue was the problem. "Foam had been falling off the tank since the very first shuttle flight, and NASA had long been trying to fix it. But in each case, NASA decided it was okay to keep flying. Over time, this led to a significant understating or a collective ignoring of an actual risk" (O'Leary, J. June 2, 2010).

Clearly, there were systemic organizational issues which confronted NASA over the course of several decades which led to the two disasters however, what specifically went wrong and more importantly how could these areas have been addressed?

At the core of both of these incidents was an organizational inertia "reflecting missed opportunities, blocked or ineffective communication channels, flawed analysis, and ineffective leadership" (Case Study. N.D.). After the Challenger flight the Rogers report's "recommendations included that NASA restructure its management to tighten control, and set a group dedicated to finding and tracking hazards in regard to shuttle safety" (Case Study. N.D.). Yet, after the Columbia disaster, the CAIB report found that "though NASA underwent many management reforms in the wake of the Challenger accident…the agency's powerful human space flight culture remained intact, as did many practices…such as inadequate concern over.....

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