Widnall Says Columbia Accident Raises Issues in Educating, Utilizing Engineers

By Lois Slavin

Click here to see Professor Widnall's presentation on MIT World.

The February 1, 2003 Columbia shuttle accident that killed seven astronauts resulted from failures in both technical and organizational systems. According to Institute Professor Sheila Widnall, a member of the Columbia Accident Investigation Board (CAIB), the lessons learned from this investigation can be applied not only to NASA, but also to other types of organizations – and engineers must play a key role in implementing them.

“The response of engineers and program mangers during the 16 days that Columbia was in orbit raises important issues for educating and utilizating engineers, as well as questions about the their responsibility to treat system-level issues with the same disciplinary respect and expertise with which they treat components,” said Widnall.

Widnall delivered her presentation, entitled “The Columbia Tragedy: System-Level Issues for Engineering” on November 4, 2003, to a standing room only audience at the third annual Brunel Lecture Series on Complex Systems. The event was sponsored by MIT’s Engineering Systems Division.

Widnall began with background on the CAIB’s formation, noting that initially it was comprised solely of government employees and chartered to report to NASA. “Congress and the press let us know very quickly that this was not a good idea, so the CAIB was re-chartered and civilian members were added,” said Widnall, who joined the Board as one of its new members on February 18, 2002. “We decided that NASA would be a colleague in the investigation and that we would report to the American people.”

Widnall described the technical problems that caused the accident. She then commented on how they resulted from problems within the organizational systems that allowed insulating foam from the external tank to impact the shuttle, creating a breech in the wing’s leading edge, enabling 5000 degree F gases to enter the wing, and devastating the internal structure. Although foam problems had been noted in prior shuttle launches, schedule pressure created a motivation to treat these in-flight anomalies as maintenance turn-around events, or even the results of planned/unplanned tests, rather than as an immediate danger to the shuttle and its occupants.

Commenting on this problem, Widnall observed that “Well-intentioned people and high risk organizations can become victims of the normalization of deviance. Although there had been several close calls before both the Columbia and the Challenger disasters, Widnall said “the unexpected became the expected, which became the accepted.”

The lesson: poor organizational structure can be just as dangerous to a system as technical, logistical, or operational factors. “They can create blind spots, group-think, and unwritten rules that make it change-resistant.”

Widnall concluded by emphasizing that mishap prevention often lies at the interface between technology and the organizational frameworks in which it is embedded. “Engineers must think about the organization as well as the technology and learn how to put their concerns in actionable form.”