columbia case study - jaif · columbia case study •discuss prior events leading to the foam...
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© 2012 Institute of Nuclear Power Operations
Columbia
Case
Study
© 2012 Institute of Nuclear Power Operations
Columbia Case Study
• Discuss prior events leading to the foam strike of
STS-107
• Understand the culture of NASA at the time of the
launch and foam strike
• Review and discuss lessons learned in maintaining
the delicate balance of safety and production.
• Learn from each others personal experiences to
recognize challenges to the balance of safety and
production.
© 2012 Institute of Nuclear Power Operations
A Balancing Act:
PRODUCTION
P R O T E C T I O N
Bankruptcy
Catastrophe
Source: James Reason. Managing the Risks
of Organizational Accidents, 1997 (in press).
© 2012 Institute of Nuclear Power Operations
Foam
Strike
Mission
Management
Safety
Apollo 1
&
Challenger
Nuclear
Industry
© 2012 Institute of Nuclear Power Operations
Foam Strike
113th Shuttle Mission (STS-107)
Launched 10:39 am January 16, 2003
At T+ 81.7 sec, a piece of the left
bipod ramp foam broke loose.
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
Foam Strike
113th Shuttle Mission (STS-107)
Launched 10:39 am January 16, 2003
At T+ 81.7 sec, a piece of the left
bipod ramp foam broke loose.
At T+ 81.9 sec, Columbia ran into the
foam at a relative velocity of 545 mph
although the shuttle was traveling at 1568
mph. (2500 kph)
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
ENGINEERING
© 2012 Institute of Nuclear Power Operations
Flight Day 4 Jan 19, 2003
Engineering Analysis
From video imaging, impact angle on the RCC wing leading
edge was closer to 20 deg. (Pg 81 of report)
© 2012 Institute of Nuclear Power Operations
Engineering Presentation January 23, 2003
Outside Experience
Base?
© 2012 Institute of Nuclear Power Operations
???
Engineering Presentation January 23, 2003
© 2012 Institute of Nuclear Power Operations
Flight Day 7 Jan 22, 2003
Second Debris Assessment Team Meeting
© 2012 Institute of Nuclear Power Operations
Rodney Rocha – Engineer and Co-chair
Debris Assessment Team
© 2012 Institute of Nuclear Power Operations
Flight Day 8 Jan 23, 2003
Mission Operations Directorate = Mission Control
© 2012 Institute of Nuclear Power Operations
MISSION
MANAGEMENT TEAM
© 2012 Institute of Nuclear Power Operations
Flight Day 7 Jan 22, 2003
Lambert Austin, Mgr of Space Shuttle Systems Integration, JSC
© 2012 Institute of Nuclear Power Operations
Flight Day 7 Jan 22, 2003
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
Note: The ET separation photo could have been downlinked from orbit but wasn’t
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
SAFETY
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
NASA Senior
Management
(Organization and
Culture)
© 2012 Institute of Nuclear Power Operations
ORGANIZATION
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
Trying to Do Too Much
with Too Little
• Staffing reduced from 30,091 → 17,462
– NASA headquarters staff working on the shuttle went from 120 in 1993 to 12 in 2003
– NASA employees 3,781 → 1,718 (45% reduction)
– NASA contractors 26,310 →15,744 (60% reduction)
© 2012 Institute of Nuclear Power Operations
Trying to Do Too Much
with Too Little
• Overall budget steadily reduced from 1993-2002
– 17.1 billion → 14.9 billion
– 40% reduction in purchasing power when inflation is accounted for
• Upgrades, including safety were delayed or deferred based on the assumption the shuttle would be replaced in the near future
© 2012 Institute of Nuclear Power Operations
LACK OF VISION?
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
Time To Come
Home
© 2012 Institute of Nuclear Power Operations
At 8:50 am on Feb 1, Columbia entered the
period of peak heating during re-entry.
Traveling Mach 24.1 at 243,000 feet.
At 8:53 am, the first sighting of debris
being shed from the left wing was
observed.
During the next 5 minutes witnesses
observed 23 separate debris shedding
events.
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
DIRECT CAUSE The impact was on the leading edge of the left wing
on or near RCC panel #8 creating a hole in the left
wing of approximately up to ~ 16 x 17 inches.
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
© 2012 Institute of Nuclear Power Operations
Apollo Fire vs Challenger vs Columbia
In each case NASA was outside it’s
experience base
In each case production pressure
overshadowed safety
In each case, the safety culture had
broken down
© 2012 Institute of Nuclear Power Operations
A Balancing Act:
PRODUCTION
P R O T E C T I O N
Bankruptcy
Catastrophe
Source: James Reason. Managing the Risks
of Organizational Accidents, 1997 (in press).
© 2012 Institute of Nuclear Power Operations
PRODUCTION
P R O T E C T I O N
Bankruptcy
Catastrophe
Mercury
& Gemini
Apollo 1 1967
Challenger 1986
Columbia 2003
Moon &
1st Shuttle
87
Missions
Source: James Reason. Managing the Risks
of Organizational Accidents, 1997 (in press).
A Balancing Act:
© 2012 Institute of Nuclear Power Operations
A Balancing Act:
PRODUCTION
P R O T E C T I O N
Bankruptcy
Catastrophe
1740
Rx-Yrs
TMI
1979
Chernobyl
1986
Davis-Besse,
PAKS, JCO
2002
4020
Rx-Yrs
10500
Rx-Yrs
16860
Rx-Yrs
Source: James Reason. Managing the Risks
of Organizational Accidents, 1997 (in press).
Fukushima
2011 ?
© 2012 Institute of Nuclear Power Operations
NUCLEAR INDUSTRY
What can we learn?
© 2012 Institute of Nuclear Power Operations
NUCLEAR INDUSTRY
What can we learn?
• Break into your 9 groups.
• Each group assigned 1 Safety Culture Principle.
• 60 minutes to identify a real life example that
illustrates your assigned principle.
• Back in the large group, each will present their
case study, including lessons learned (20 minutes).
• The 9th group will identify and present their
personal warning signs.