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Topic(s):
Human Dimensions of Fire Management
High Reliability Organizing
Decisionmaking & Sensemaking

NRFSN number: 16259
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The Columbia Accident Review Board’s (CAIB) investigation of the February 1, 2003 loss of the space shuttle Columbia lasted nearly 7 months. The loss of seven crew members and later, two debris searchers, lead to a thorough attempt to discover the truth behind the accident. The board recognized early that the accident was not likely to be a random event, and that it was more likely rooted in NASA’s history and the space flight program’s culture. Therefore, the investigation broadened to examine historical and organizational issues that may have been involved in the accident. This report, and its findings, conclusions, and recommendations, places as much weight on the historical and organizational causal factors as it does on the more easily understood physical causes. This report also discusses attributes of an organization that could more safely and reliably operate a risky space shuttle, but it does not attempt to provide organizational prescriptions. These attributes include: a robust and independent program, technical authority that has control over specifications and requirements, an independent safety assurance organization with control over safety oversight, and an organizational culture that represents a learning organization. Part I of the report deals with the accident itself, including the program, launch, accident analysis, and other factors involved. Part II discusses why the accident occurred, including a comparison to the Challenger accident, issues of decision making, organizational causes, and historical causes. Part III explores the look ahead, including implications, observations, and recommendations for the future. Part II is of particular interest to those concerned with high reliability organizations, especially Chapters 6 and 7, which deal with decision making and the accident’s organizational causes.

Citation

Columbia Accident Review Board. 2003. Columbia accident review board report. Vols. I-VI. Washington, DC: Government Printing Office. 341 p. Available: https://www.nasa.gov/columbia/caib/html/start.html

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