Although the design flaws that contributed to the Challenger and Columbia accidents were different, the accidents themselves were similar. The CAIB during the investigation of the root causes of the accidents, identified contributing organizational problems that played a factored in both cases. NASA had received early warnings of safety issues, however, they failed to take them seriously and resolve them. “What we find out from [a] comparison between Columbia and Challenger is that NASA as an organization did not learn from its previous mistakes and it did not properly address all of the factors that the presidential commission identified.” - Dr. Diane Vaughan.
Creativity is the first form of learning; if individuals of an organization,
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“Environments that generate radical, discontinuous change require organizations that are effective in enacting double loop learning.” (PENN STATE LESSON) Organizations, such as NASA, are good at single loop learning, whereas, double loop learning is a difficult practice for any organization to move towards. Organizations shy towards practices and create norms that hinder double loop learning. An organization typically will not incorporate double loop learning into their process unless faced with a transformation from within or a disaster. An organization needs to create information and knowledge, not simply use and process …show more content…
Edward W. Rogers. This office is responsible “for assuring that the Center operates as a learning organization. It is responsible for policy and guidance on Lessons Learned, Knowledge Management and Learning Practices. The OCKO provides the Center with knowledge management services and support facilitating the application of knowledge and enhancing Goddard’s development as a learning organization.” (NASA)
“The role of the OCKO is to design, develop and deploy meaningful learning activities that augment individual learning, sharing and collaboration. The focus of OCKO initiatives is local learning practices that benefit NASA personnel in tangible ways through enlarging the understanding of how NASA works, presenting case studies that make for effective learning across multiple projects, facilitating reflective learning from current experiences and sharing acquired knowledge with Goddard, NASA and the public.” (NASA) The OCKO has a unique method, when it comes to documenting and communicating lessons learned and other forms of knowledge. They utilize a storytelling approach utilizing case studies which for the most part are available to the public. “Finally, the OCKO developed the Pause & Learn (PaL) process as a facilitated team meeting for reflective learning. PaLs are often used to informally transfer individual lessons about a specific
Two tragic incidents, the Challenger Space Shuttle crash of 1986, and the Three Mile Island near meltdown of 1979, have greatly devastated our nation. Both these disasters involved failures of communication among ordinary professional people, working in largely bureaucratic companies. Two memos called the “Smoking Gun Memos,” authored by R. M. Boisjoly, of Morton Thiokol, and D. F. Hallman, of Babcook and Wilcox, will always be associated these two incidents. Unfortunately, neither of these memos were successful in preventing the accidents of the Challenger and the Three Mile Island near meltdown.
This tragic accident was preventable by not only the flight crew, but maintenance and air traffic control personnel as well. On December 29, 1972, ninety-nine of the one hundred and seventy-six people onboard lost their lives needlessly. As is the case with most accidents, this one was certainly preventable. This accident is unique because of the different people that could have prevented it from happening. The NTSB determined that “the probable cause of this accident was the failure of the flightcrew.” This is true; the flight crew did fail, however, others share the responsibility for this accident. Equally responsible where maintenance personnel, an Air Traffic Controllers, the system, and a twenty cent light bulb. What continues is a discussion on, what happened, why it happened, what to do about it and what was done about it.
NASA has faced many tragedies during their time; but one can question if two of the tragedies were preventable by changing some critical decisions made by the organization. The investigation board looking at the decisions made for the space shuttle tragedies of the Columbia and Challenger noted that the “loss resulted as much from organizational as from technical failures” (Bolman & Deal, 2008, p. 191). The two space shuttle tragedies were about twenty years apart, they both had technical failures but politics also played a factor in to these two tragedies.
The next level is Precondition for Unsafe Acts. Precondition begins at level two and it is dividing into environmental factors, condition of operator, and personnel factors. In regards to Flight 3407, the environmental factors would be the weather condition. Icing was a factor when occurred on the wings. Both pilots were experiencing fatigue during their flight. They have pushed their body to limits where as their reaction times were not fully functional. Furthermore, due to fatigues and not adequate situational awareness, the crew did not perform to their best optimal on the job.
The disaster that took place on the Ocean Ranger had a very large effect on the way Newfoundlander's feel about the gas and oil industry. The government examined the safety issues that led to this disaster and has implemented numerous changes to enhance the safety of the offshore workforce. The Newfoundland and Canadian government set up a combined royal commission to investigate the disaster of the Ocean Ranger and to provide recommendations to improve safety. Two years after the disaster, the royal commission on the Ocean Ranger disaster concluded that the deaths resulted not only from the storm and flaws in the rig's design, but also from a lack of human knowledge.
Even though there were many factors contributing to the Challenger disaster, the most important issue was the lack of an effective risk management plan. The factors leading to the Challenger disaster are:
Collins and Pinch draw a distinctive line between what actually happened and the public’s perspective on what happened. The public had a compulsive desire to create a moral lesson and provide heroes and villains. Many people misconstrued this as a conflict between the knowledgeable engineers and the greedy management. The public believed that NASA and Thiokol’s managers were ignorant to the engineering, but this is not true, since they were all engineers before their promotion to management. The authors stress the phrase “after the event” to show that hindsight bias is contributing to the public’s view on what actually happened. The physicist, Richard Feynman, awed the public with a demonstration of putting rubber, the material of the O-ring, in icy water. Th...
In today’s ever changing world people must adapt to change. If an organization wants to be successful or remain successful they must embrace change. This book helps us identify why people succeed and or fail at large scale change. A lot of companies have a problem with integrating change, The Heart of Change, outlines ways a company can integrate change. The text book Ivanceich’s Organizational Behavior and Kotter and Cohen’s The Heart of Change outlines how change can be a good thing within an organization. The Heart of Change introduces its readers to eight steps the authors feel are important in introducing a large scale organizational change. Today’s organizations have to deal with leadership change, change in the economy,
It’s very hard to say what steps, if any, could have been taken to prevent the Space Shuttle Columbia disaster from occurring. When mankind continues to “push the envelope” in the interest of bettering humanity, there will always be risks. In the manned spaceflight business, we have always had to live with trade-offs. All programs do not carry equal risk nor do they offer the same benefits. The acceptable risk for a given program or operation should be worth the potential benefits to be gained. The goal should be a management system that puts safety first, but not safety at any price. As of Sept 7th, 2003, NASA has ordered extensive factory inspections of wing panels between flights that could add as much as three months to the time it takes to prepare a space shuttle orbiter for launch. NASA does all it can to safely bring its astronauts back to earth, but as stated earlier, risks are expected.
Rodney Rocha is a NASA engineer and co-chair of Debris Assessment Team (DTS). When possibility of wing damage appeared he requested an additional imagery to obtain more information in order to evaluate the damage. This demonstrates that he actually tried to resolve the issue. However, due to absence of clear organizational responsibilities in NASA those images were never received. Since foam issue was there for years and risk for the flights was estimated as low management decided not to proceed with this request. After learning of management decision Rocha wrote an e-mail there he stated that foam damage could carry grave hazard and have to be addressed. At the same time this e-mail was not send to the management team. Organizational culture at NASA could be described as highly bureaucratic with operations under standard procedures only. Low-end employees like Rocha are afraid to bring any safety-related issues to the management due to delay of the mission. They can be punished for bringing “bad news”. This type of relationship makes it impossible for two-way communication between engineers and managers, which are crucial for decision-making in complex env...
For this assignment we will discuss some theories on organizational change learned during this class and how they relate to the case study of NASA (The Challenger and Columbia Shuttle Disaster). First we will look the images of managing change used by NASA in the case study. Then we will discuss the types of change(s) NASA under took. Next we will look at some of the challenges of change that NASA faced. Next we will discuss some of the resistance to change that NASA dealt with. Then we look at how NASA implemented change. Next we will discuss vision and change and the impact in the case study. Finally we will discuss sustaining change as it relates to the changes implemented by NASA in the case study.
What started out with futures planning at RDS has now become something much more. A major force behind the creation of a school of thought coined the learning organization; Royal Dutch Shell and U.S. Shell were successful in transforming themselves into competitive and effective enterprises. Their work is not done however, because the work of a learning organization is never done. It must continually improve and develop, and every employee in the company must commit to this, from the janitor to the CEO.
Bob Ebeling and Mark Boisjoly were both engineers and are best known as the main people who tried to cancel the launch. The O-ring problem at lower temperatures wasn’t something we later learned. Ebeling knew that given low enough temperatures it would fail and cause the main tank to explode. However, “Problem reporting requirements are not concise and fail to get critical information to the proper levels of management. Little or no trend analysis was performed on O-ring erosion and blow-by problems.”
I chose to write about the Space Shuttle Columbia engineering failure. NASA sent out a shuttle to orbit the earth for 16 days mission to research how can a life survive being out in space. The mission was completed in success and it was time to return back to earth but with no knowledge of the risk due to a damage to the left wing that they didn’t even know. The reason why the error happened because the team at NASA were not careful enough and wasn’t thinking of finding other options to save those lives. First of all, Columbia was the oldest and it was on its 25th mission.
The learning organization is the opposite of the traditional organization. It believes that there is always a better way to do things, it listens to those who work within the company, utilizes a systems approach, is orientated towards people and ideas, prevents problems, quality and customer-service is essential, and accountability to the team is essential (Anderson, 2003). The lear...