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By Group 3
NASA
Lot of focus on Research with large amount of uncertainties Excessive focus on efficiency(deadlines) rather than collaboration and communication Subtle change in working environment from organic to mechanistic
Cognition
Group Level
Organizational
Technical
Foam Issue Crater software not up to date Cameras not sufficient
Cognitive
Confirmatory bias Overconfidence on initial assessments Assumption that only TPS tiles affected, no effect on RCC tiles
Group Level
Team climate
Interpersonal climate was not conducive to dissent or questioning especially when power distance was high
Organizational
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 not work rather than vice versa
If NASA fixes the foam problem, would this be effective in preventing future accidents? Why not? NO
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 for reporting/working DATs requests were all shutdown by managers of SSP (Space shuttle program) No support given to DATs request for imagery from the management Led to DATs flawed and uncertain analysis submitted within deadline
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 point that they were simply a maintenance issue - a concern that did not threaten a missions 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 their film of the launch and to see if they could improvise some means to get an in-flight view of the damaged area. Although both actions were suggested, neither was done.
Efficiency Low
Recommendations on how NASA can avoid such mistakes in future Culture: Challenging and testing
existing assumptions and experimenting with new behaviors and possibilities. Exaggerate threats Acting rather than waiting A mindset of openness Promoting Experimentation Encouraging constructive conflict and dissent
Thank you
Group 3