Columbia Case Study Institute of Nuclear Power Operations

Transcription

1 Columbia Case Study

2 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.

3 Source: James Reason. Managing the Risks of Organizational Accidents, 1997 (in press). A Balancing Act: Bankruptcy P R O T E C T I O N Catastrophe PRODUCTION

4 Safety Mission Nuclear Industry Foam Strike Management Apollo 1 & Challenger

5 Foam Strike 113 th Shuttle Mission (STS-107) Launched 10:39 am January 16, 2003 At T sec, a piece of the left bipod ramp foam broke loose.

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8 Foam Strike 113 th Shuttle Mission (STS-107) Launched 10:39 am January 16, 2003 At T sec, a piece of the left bipod ramp foam broke loose. At T sec, Columbia ran into the foam at a relative velocity of 545 mph although the shuttle was traveling at 1568 mph. (2500 kph)

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10 ENGINEERING

11 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)

12 Engineering Presentation January 23, 2003 Outside Experience Base?

13 Engineering Presentation January 23, 2003???

14 Flight Day 7 Jan 22, 2003 Second Debris Assessment Team Meeting

15 Rodney Rocha Engineer and Co-chair Debris Assessment Team

16 Flight Day 8 Jan 23, 2003 Mission Operations Directorate = Mission Control

17 MISSION MANAGEMENT TEAM

18 Flight Day 7 Jan 22, 2003 Lambert Austin, Mgr of Space Shuttle Systems Integration, JSC

19 Flight Day 7 Jan 22, 2003

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21 Note: The ET separation photo could have been downlinked from orbit but wasn t

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24 SAFETY

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31 NASA Senior Management (Organization and Culture)

32 ORGANIZATION

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35 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)

36 Trying to Do Too Much with Too Little Overall budget steadily reduced from 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

37 LACK OF VISION?

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44 Time To Come Home

45 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.

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49 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.

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52 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

53 Source: James Reason. Managing the Risks of Organizational Accidents, 1997 (in press). A Balancing Act: Bankruptcy P R O T E C T I O N Catastrophe PRODUCTION

54 Source: James Reason. Managing the Risks of Organizational Accidents, 1997 (in press). A Balancing Act: Bankruptcy P R O T E C T I O N Moon & 1 st Shuttle Mercury & Gemini 87 Missions Apollo Challenger 1986 Columbia 2003 Catastrophe PRODUCTION

55 Source: James Reason. Managing the Risks of Organizational Accidents, 1997 (in press). A Balancing Act: Bankruptcy Rx-Yrs P R O T E C T I O N 1740 Rx-Yrs 4020 Rx-Yrs Rx-Yrs Chernobyl 1986 TMI 1979 PRODUCTION Fukushima 2011? Davis-Besse, PAKS, JCO 2002 Catastrophe

56 NUCLEAR INDUSTRY What can we learn?

57 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 9 th group will identify and present their personal warning signs.