Sandia LabNews

Columbia study review: Sandia shares many practices with NASA

Columbia study review: Sandia shares many practices with NASA

A Labs review team that studied in detail a NASA report on the Feb. 1, 2003, explosion of the Space Shuttle Columbia has concluded that Sandia shares many of the organizational factors that led to the accident.

"The Columbia Accident Investigation Board deduced that the management practices at NASA overseeing the space shuttle program were as much a cause of the accident as the foam that struck the left wing," says David Carlson, Director of Surety Assessment Center 12300, who led the Sandia review team. "Although there are important organizational differences, we follow many of these same management practices. In reviewing and discussing this accident, we all recognized ourselves in many respects."

The shuttle launched on Jan. 16, 2003, in what seemed to be a normal takeoff. Unknown was that insulating foam separated from the external tank, breaching the leading edge of the left wing. Upon re-entry the breach allowed superheated air to penetrate the leading edge insulation and progressively melt the aluminum structure of the left wing. This resulted in a weakening of the structure until increasing aerodynamic forces caused loss of control, failure of the wing, and breakup of the orbiter. The accident killed seven crew members.

Executive VP Joan Woodard and VP 2000 John Stichman tasked David to lead the review of the NASA investigation. Starting work on Sept. 1, team members — all senior scientists and senior management — spent some 60 hours each reviewing information.

Their review centered on four themes: risk assessment, adequacy of technical understanding, decision making, and organizational and safety culture.

The end of the Cold war eroded the urgency and sense of NASA’s mission, much as it did Sandia’s. There were significant budget pressures associated with the space shuttle program. Increasing costs and operational needs caused safety upgrades, in some cases, to be deferred. Also, a firm, Feb. 19, 2003, completion date was established to finish the US portion of the International Space Station, which was probably pushing the envelope, David says.

"We, too, face schedule and budgetary pressures that challenge us to meet our many requirements," David says. "Among those requirements is safety in our designs. Safety is part of performance and not easy to judge. It’s one of those things that seem easy to trade off. You can’t weigh it, can’t see it on the calendar, but it is very real."

He adds that the NASA people, just like Sandia’s, have a "can-do attitude."

"This attitude is vital to our success, but it must be judiciously managed. It is essential to understand and manage our risks," Dave says.

Another issue with management was that some did not have a full understanding of technical difficulties associated with Columbia. This is not unusual in complex systems such as the space shuttle or in systems like those designed by Sandia.

"However, we must always provide proof that the design is safe rather than, as in the case of the shuttle engineers, expecting safety professionals to prove to the program management that its system is unsafe," David says.

The NASA engineers found themselves in the unusual position of having to prove that the situation was unsafe.

Sandia is subject to many of the same pitfalls in decision making and communications that contributed to the Columbia accident. These include reliance on past experience and technical expertise; communication barriers including a culture of "over-politeness" which may make it difficult for management to appreciate the depth of engineers’ concerns; and potential erosion in our expectations of first-level management for technical leadership, direction, and judgment.

"The lessons from the Columbia accident speak to us as managers at Sandia," David says. "However, these are important issues to all of us — not just managers — in conducting our everyday work. Our review heightened our recognition of these issues. They are difficult to resolve but essential to recognize and address if we are to strengthen our safety culture."