What System Safety Engineering Can Learn from the Columbia Accident

摘要

An accident investigation allows a view into an organization that is normally not possible. The strong system safetyprogram established at NASA after the Apollo fire has evolved into a program in which the name remains but mostof the important safety management and engineering functions have disappeared or are performed by contractors.The title remains, but the essence is gone.Many of the dysfunctionalities in the system safety program at NASA contributing to the Columbia accident can beseen in other groups and industries. This paper summarizes some of the lessons we can all learn from this tragedy.While there were many factors involved in the loss of the Columbia Space Shuttle, this paper concentrates on therole of system safety engineering and what can be learned about effective (and ineffective) safety efforts. Theinformation contained in this paper comes from the Columbia Accident Investigation Board (CAIB) report (ref. 2),the SIAT report (chartered in 1999 to evaluate the Shuttle program after a number of close calls) (ref. 9), theauthors’ personal experiences with NASA, and communications with current and former NASA system safetyengineers.