Beyond the Widget: Columbia Accident Lessons Affirmed

Article excerpt

Editorial Abstract:

Circumstances surrounding the loss of the space shuttle Columbia affirm multiple lessons that emerged from analyses of similar tragedies of the past 40 years. General Deal takes a hard look at the findings of the Columbia Accident Investigation Board so that senior leaders of other high-risk operations can prevent similar mishaps and promote healthy organizational environments.

THE DATE 1 February 2003 presented the world with images that will be forever seared in memories of all viewing them-images of the space shuttle Columbia's final moments as it broke apart in the skies over Texas. As tragic as the Columbia accident was, multiple lessons to prevent future accidents can be "affirmed" from the circumstances surrounding this accident. The emphasis is on "affirmed," because all of those lessons had been previously learned during the past 40 years through the analysis of other tragedies:

* April 1963, loss of the USS Thresher, while operating at the edge of several envelopes

* January 1967, Apollo I capsule fire on launchpad

* December 1984, Union Carbide pesticide factory tragedy in Bophal, India, resulting from insufficient attention to maintenance and training, and its leadership ignoring internal audits

* January 1986, loss of the space shuttle Challenger

* April 1986, Chernobyl disaster, where safety procedures were ignored during reactor testing

* July 2000, crash of a Concorde supersonic passenger plane in Paris after multiple prior incidents

* September 2001, al-Qaeda attacks on the United States despite more than a decade of uncorrelated signals and warnings

* October 2001, Enron collapse, despite multiple warnings and indications

The lessons gleaned from these and other prominent accidents and disasters, management and leadership primers, and raw experience are the same lessons that should have prevented the Columbia accident. The saddest part is that some in the National Aeronautics and Space Administration (NASA) had simply not absorbed, or had forgotten, these lessons; the result was the deaths of seven astronauts and two helicopter search team members, as well as the intense scrutiny of a formerly exalted agency.

This article highlights many of the major lessons affirmed by the Columbia Accident Investigation Board (CAIB)-lessons that senior leaders in other high-risk operations should consider to prevent similar mishaps and to promote healthy organizational environments. Admittedly NASA-specific and greatly condensed, the specific Columbia-related vignettes and perspectives presented here are intended to provide the reader an opportunity to step back and contemplate how his or her organization has the potential to fall into the same type of traps that ensnared NASA. Due to NASA's size, complexity, mission uniqueness, and geographically separated structure, some specific lessons may not be applicable to all organizations; however, the fundamental principles apply universally, as many of these same conditions may be present in any organization.

Effective leaders recognize that every organization must periodically review its operations to avoid falling into complacency as NASA had done. They also recognize that it is far better to prevent, rather than investigate, accidents. To assist with that prevention, readers should carefully examine the situations in which NASA found itself, perhaps drawing relevance by substituting their own organization's name for "NASA," and affirm those lessons once again. These situations are organized and examined in the three categories of basics, safety, and organizational self-examination.

We are what we repeatedly do. Excellence, then, is not an act, but a habit.


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