rca in the space shuttle columbia investigation 2003

8/19/2019 RCA in the Space Shuttle Columbia Investigation 2003

1/24

The Role of RCA in the Space

Shuttle Columbia Investigation

Presented by:

Robert J. Latino

Sr. VP – Strategic Development

Reliability Center, Inc.

.reliability.com


2/24

Presentation Basis!"e presentation as developed to demonstrate t"e

ded#ctive logic t"o#g"t process involved in t"e

application o$ Root Ca#se %nalysis as applied by

Reliability Center, Inc. &RCI'.

%ll veri$ications presented are based on literat#reavailable t"ro#g" t"e p#blic domain so#rces s#c"

(%S%, t"e Col#mbia %ccident Investigation )oard

&C%I)' Report, rep#table nespaper articles and

associated ebsites.

RCI does not claim to "ave any in$ormation t"at

$#rt"er validates or disproves t"ese so#rce*s claims.

!"e sole p#rpose o$ t"is presentation is $or ed#cational

p#rposes on t"e topic o$ Root Ca#se %nalysis.


3/24

The Day of

LaunchJanuary !" #$$%$&%' a(m(


4/24

!"e La#nc" o$ Col#mbia + Debris Impact At Some )

Secon*s Into Launch


5/24

!"e La#nc" o$ Col#mbia + -


6/24

!"e La#nc" o$ Col#mbia +


7/24

+riginally ,stimate* Area of -oam Impact


8/24

Columbia.s Thermal Insulation


9/24

+rbiter /ing 0 Carbon Panels

1ore Li2ely Area of

Impact


10/24

+rbiter /ing 0 -ront 3ie4


11/24

+rbiter /ing 0 Bottom 3ie4


12/24

Re5,ntry 6eating an* Attitu*e


13/24

Left /ing Sensor Triggering Se7uence


14/24

The Debris -iel* Path


15/24

/at"ering 0vidence + Recovery


16/24



17/24



18/24

(otable 1#otes

2 34t"e %tlantis incident s"o#ld "ave p#t (%S% on "ig" alert abo#t

ing damage.5 – Paul C( C8ys8" Par2s College of,ngineering an* Aviation

2 3I*m "earing a little bit o$ an ec"o "ere 6re$erring to t"e C"allengeraccident7.5 – Dr( Sally Si*e" formerastronaut on CAIB

2 34(%S% "ad decided t"e occasional damage $rom dislodged

$oam and ot"er li$to$$ debris as a ris8 (%S% "ad groncom$ortable it".5 – Ron Dittemore" ColumbiaProgram 1anager

2 34(%S%*s incremental descent into poor 9#dgment.5 – Prof( Diane3aughn" Boston College

2 34t"e agency 6(%S%7 does not "ave eno#g" money to do its 9ob

over t"e long r#n it"o#t c#tting corners.5 + Prof( Diane 3aughn" Boston College


19/24

(otable 1#otes

2 34it is clear t"at t"e space agency*s decision ma8ing c#lt#re "as become as important to t"e )oard &C%I)' as any $alling $oam or data

recorder.5 – La4rence 1ulloy" Roc2et BoosterProgram Lea*er for Challenger 1ission

2 3!"e no+$a#lt approac" bot"ers some at (%S%, "o say t"at t"ey believe t"at determining responsibility $or mista8es is important.5 –

A*miral 6arol* 9ehman" CAIB Chairman

23nless yo# can point yo#r $inger at t"e man responsible "ensomet"ing goes rong, t"en yo# "ave never "ad anyone reallyresponsible5 – A*miral 6yman Ric2over" The -atherof the :uclear :avy

2 3;o# "ave to loo8 beyond t"e individ#als and loo8 into t"e sit#ationin "ic" t"ey or8.


20/24

(otable 1#otes2 3!"e mista8e in 9#dgment e all made as accepting deviance in t"e

per$ormance $rom t"e "ardare $rom "at it as designed to do –La4rence 1ulloy" Roc2et Booster Program Lea*er for

Challenger 1ission

2 3I$ t"e ca#se o$ t"e Col#mbia accident is t"e acceptance o$ debris $allingo$$ t"e tan8 in ascent, and impacting on t"e orbiter, and ca#sing damageto t"e tiles – i$ t"at t#rns o#t to be t"e ca#se o$ t"e accident, t"en t"elesson e learned in C"allenger is $orgotten, i$ it as ever learned.5 –

La4rence 1ulloy" Roc2et Booster Program Lea*er for Challenger 1ission

2 34(%S% and its contractors contin#ed to "ave a =corporate c#lt#re o$denial* t"at led t"em to so$t+pedal sa$ety problems instead o$ reportingt"em o$$icially5 – Lyn*a Bottos" ;nite* Space Alliance

2 3;o# can c"ange t"e cast o$ c"aracters, and yo# don*t c"ange t"e

organi>ational conte?t5 + Prof( Diane 3aughn" Boston College


21/24

The Similarities to Challenger 5

Columbia Challenger@oam Debris Impact –P"ysical Ca#se

Secondary


22/24

The Similarities to Challenger 5 #

Columbia Challenger

@oam Debris Impact 0vents%naly>ed Individ#ally and

(ot as a !rend

Secondary ed Individ#allyand (ot as a !rend

(%S% being !rans$ormed$rom an RBD ation toore o$ a )#siness

(%S% being !rans$ormed$rom an RBD ation toore o$ a )#siness

Comm#nication @lo o$In$ormation @rom


23/24

The Similarities to Challenger 5 %

Columbia Challenger

(%S% Sa$ety Systems did not%ttempt to Reverse t"eCo#rse o$ 0vents it" t"e@oam Debris.

(%S% Sa$ety Systems did not%ttempt to Reverse t"eCo#rse o$ 0vents it" t"e ation o$ Deviance5Paradigm Re+0merged

3(ormali>ation o$ Deviance5Paradigm Revealed


24/24

The Real Trage*y of Columbia

rca in the space shuttle columbia investigation 2003

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