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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.”
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