columbia case analysis_group 3
TRANSCRIPT
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Columbias Final Mission
By Group 3
Abhishek Singhvi12P182
Aditya Gautam 12P184
Aneesha Chandra12P186
Arpit Jain 12P189
Arunabh Thakur
12P190Kartik K 12P204
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NASA
High Interactive complexity or tightcoupling Multiple Interdependencies
Lot of focus on Research with largeamount of uncertainties
Excessive focus onefficiency(deadlines) rather thancollaboration and communication
Subtle change in working environmentfrom organic to mechanistic
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Technical
Cognition
Group Level
Organizational
What caused the disaster?
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Foam Issue
Crater software not up to date
Cameras not sufficient
Technical
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Confirmatory bias
Overconfidence on initial assessments
Assumption that only TPS tiles
affected, no effect on RCC tiles
Cognitive
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Poor team designAd-hoc group with poorly defined lines of
authority
Limited access to resources
No tiger team implying that Foam issue is notvery serious
Other teams not co-located
Team climate Interpersonal climate was not conducive to
dissent or questioning especially when powerdistance was high
Group Level
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Organization Structure
Strict reporting relationships
Information flow is not rapid/Rigid
Communication protocols Organization Culture
Lots of hard data needed as culture
was of proving something does notwork rather than vice versa
Organizational
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xes e oam pro em,would this be effective in
preventing future accidents?
Why not? NO
Complex and Unstable Environment
requires
Hierarchy
Formalization
Specialization:
Centralization:
OrganicStructure
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Reasons that led to downplay of
foam strikes
Environment attributes leading todownplay
Budget cuts
Aggressive competition with otherspace agencies
Deadlines
Schedules
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Reasons that led to downplay of
foam strikes
Debris Assessment Team (DAT) was formed with
people from diversified background to work together
and give an answer in 3 days
No definite structure defined in DAT forreporting/working
DATs requests were all shutdown by managers of
SSP (Space shuttle program)
No support given to DATs request for imagery fromthe management
Led to DATs flawed and uncertain analysis submitted
within deadline
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Reasons that led to downplay of
foam strikesManagement Level Issues
Preoccupied with success and Arrogance of Optimism Management tended to wait for dissent rather than seek it, which is likely to shut off
reports of failure and other tendencies to speak up
Reluctance to Change The Columbia disaster is an unfortunate illustration of how NASAs strong cultural
bias and optimistic organizational thinking undermined effective decision-making.Over the course of 22 years, foam insulation strikes were normalized to the pointthat they were simply a maintenance issue - a concern that did not threaten amissions success
Resilience To bounce back from the ambiguity of blurred images, NASA could, for example,
have expanded data collection to include asking astronauts to download all of theirfilm of the launch and to see if they could improvise some means to get an in-flightview of the damaged area. Although both actions were suggested, neither was
done.
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Recommendations to avoid
future mistakes
High Technical Complexity
High Flexibility
Low Efficiency
Need High Responsiveness Organic Structure
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Recommendations to avoid
future mistakes Focus on schedules and deadlines is
incorrect approach in a research
environment
Structure: Direct teams in problem-solving efforts with clear reporting
lines, responsibilities and authority
DAT Structure with SSP & Mgt. shouldhave been Pooled Interdependence
R d ti h
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Recommendations on how
NASA can avoid such mistakes
in future Culture: Challenging and testingexisting assumptions andexperimenting with new behaviors and
possibilities. Exaggerate threats
Acting rather than waiting
A mindset of openness
Promoting Experimentation
Encouraging constructive conflict anddissent
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Thank youGroup 3