The Role of RCA in the Space
Shuttle Columbia Investigation
Presented by:
Robert J. Latino
Sr. VP Strategic Development
Reliability Center, Inc.
www.reliability.com
Presentation Basis
The presentation was developed to demonstrate the
deductive logic thought process involved in the
application of Root Cause Analysis as applied by
Reliability Center, Inc. (RCI).
All verifications presented are based on literature
available through the public domain sources such
NASA, the Columbia Accident Investigation Board
(CAIB) Report, reputable newspaper articles and
associated websites.
RCI does not claim to have any information that
further validates or disproves these sources claims.
The sole purpose of this presentation is for educational
purposes on the topic of Root Cause Analysis.
The Day of
Launch
January 16, 2003
10:39 a.m.
The Launch of Columbia - 1
Debris Impact At Some 81
Seconds Into Launch
The Launch of Columbia - 2
The Launch of Columbia - 3
Originally Estimated Area of Foam Impact
Columbias Thermal Insulation
Orbiter Wing Carbon Panels
More Likely Area of
Impact
Orbiter Wing Front View
Orbiter Wing Bottom View
Re-Entry Heating and Attitude
Left Wing Sensor Triggering Sequence
The Debris Field Path
Gathering Evidence - Recovery
Gathering Evidence - Recovery
Gathering Evidence - Recovery
Notable Quotes
the Atlantis incident should have put NASA on high alert about
wing damage.
Paul C. Czysz, Parks College of
Engineering and Aviation
Im hearing a little bit of an echo here [referring to the Challenger
accident].
Dr. Sally Side, former
astronaut on CAIB
NASA had decided the occasional damage from dislodged
foam and other liftoff debris was a risk NASA had grown
comfortable with.
Ron Dittemore, Columbia
Program Manager
NASAs incremental descent into poor judgment. Prof. Diane
Vaughn, Boston College
the agency [NASA] does not have enough money to do its job
over the long run without cutting corners. Prof. Diane Vaughn, Boston College
Notable Quotes
it is clear that the space agencys decision making culture has
become as important to the Board (CAIB) as any falling foam or data
recorder.
Lawrence Mulloy, Rocket Booster
Program Leader for Challenger Mission
The no-fault approach bothers some at NASA, who say that they
believe that determining responsibility for mistakes is important.
Admiral Harold Gehman, CAIB Chairman
Unless you can point your finger at the man responsible when
something goes wrong, then you have never had anyone really
responsible
Admiral Hyman Rickover, The Father
of the Nuclear Navy
You have to look beyond the individuals and look into the situation
in which they work. Otherwise youre just going to reproduce the
problem, and that is what happened again. Prof. Diane Vaughn, Boston College
Notable Quotes
The mistake in judgment we all made was accepting deviance in the
performance from the hardware from what it was designed to do
Lawrence Mulloy, Rocket Booster Program Leader for
Challenger Mission
If the cause of the Columbia accident is the acceptance of debris falling
off the tank in ascent, and impacting on the orbiter, and causing damage
to the tiles if that turns out to be the cause of the accident, then the
lesson we learned in Challenger is forgotten, if it was ever learned.
Lawrence Mulloy, Rocket Booster Program Leader for Challenger Mission
NASA and its contractors continued to have a corporate culture of
denial that led them to soft-pedal safety problems instead of reporting
them officially
Lynda Bottos, United Space Alliance
You can change the cast of characters, and you dont change the
organizational context Prof. Diane Vaughn, Boston College
The Similarities to Challenger - 1
Columbia
Challenger
Foam Debris Impact
Physical Cause
Secondary O-Ring Erosion
Physical Cause
Foam Debris Impact Known
About for Years
Secondary O-Ring Erosion
Known About for Years
Foam Debris Impact Deemed Secondary O-Ring Erosion
an Acceptable Flight Risk in Deemed an Acceptable Flight
Flight Readiness Reviews
Risk in Flight Readiness
Reviews
Evidence that the Design was
not Performing as Expected
was Reinterpreted as
Acceptable
Evidence that the Design was
not Performing as Expected
was Reinterpreted as
Acceptable
The Similarities to Challenger - 2
Columbia
Foam Debris Impact Events
Analyzed Individually and
Not as a Trend
Challenger
Secondary O-Ring Erosion
Events Analyzed Individually
and Not as a Trend
NASA being Transformed
NASA being Transformed
from an R&D Organization to from an R&D Organization to
More of a Business
More of a Business
Communication Flow of
Information From Opposing
Views was Discouraged and
Stifled
Communication Flow of
Information From Opposing
Views was Discouraged and
Stifled
The Similarities to Challenger - 3
Columbia
Challenger
NASA Safety Systems did not
Attempt to Reverse the
Course of Events with the
Foam Debris.
NASA Safety Systems did not
Attempt to Reverse the
Course of Events with the ORing.
NASA Appeared to be
Immersed in a Culture of
Invincibility
NASA Appeared to be
Immersed in a Culture of
Invincibility
Normalization of Deviance Normalization of Deviance
Paradigm Re-Emerged
Paradigm Revealed
The Real Tragedy of Columbia
