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.”
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