Twenty years after the Columbia disaster, what can we learn from the mistake of ignoring problems?

Twenty years ago this week, I, like many, watched in horror as breaking news showed footage of the Space Shuttle Columbia disintegrating as it streaked through the Earth’s atmosphere, killing all seven astronauts on board. Every year on the last Thursday of January, the National Aeronautics and Space Administration (NASA) holds a Day of Remembrance to honor the lives lost in the tragedy, as well as those of the Apollo 1 fire and the Space Shuttle Challenger explosion. Though decades apart, the three disasters eerily all took place within the same calendar week.

Honoring the men and women lost throughout America’s history of space exploration is reason enough to set aside time for an annual memorial. But I believe the Day of Remembrance also serves another purpose, one which touches on many aspects of life, including health: it reminds us of the potential consequences of ignoring a problem.

What happened to the Columbia?

For those who aren’t familiar with the details, the Columbia disaster was caused by a piece of insulative foam that broke from the external fuel tank during launch and struck the orbiter’s left wing. The debris strike compromised the heat shield designed to prevent thermal damage to the wing’s interior during re-entry, 16 days later, during which shuttle surface temperatures typically exceed 2000°F. Thus, as the orbiter traveled back into Earth’s atmosphere, superheated air was able to penetrate the wing and melt its internal components, destabilizing the orbiter and causing it to break apart.

The danger of dismissing the problem

After the launch, NASA ground analysts noticed the foam strike during a routine review of video footage. A Debris Assessment Team was assembled to determine possible harm to the orbiter as a result of the collision, but from then on, a dismissive attitude seemingly dominated every key decision point. Models indicating that the impact likely affected the heat shield were disregarded as inaccurate. Debris Assessment Team engineers were denied their request to conduct imaging of the shuttle in orbit. In notifying the shuttle crew of the debris strike, Mission Control stated that there was “absolutely no concern for entry” because foam strikes had occurred on many previous launches without serious consequences. The result of this chain of dismissal? The catastrophic failure that ended the lives of seven astronauts.

Following the disaster, a Columbia Accident Investigation Board was formed and conducted a seven-month examination into the underlying causes. In addition to describing the direct physical causes of the orbiter breakup, the Board’s report cited numerous concerns with NASA organization and culture – such as the tendency to rely on “past success as a substitute for sound engineering practices” – that had evolved in an environment of changing priorities and budget cuts. It criticized the repeated denial of safety concerns after the debris strike, as well as the ongoing tolerance of foam strikes – a known problem – as an acceptable risk in the Space Shuttle program. The report also described feasible rescue and repair strategies which, had they been implemented, might have saved the lives of the shuttle crew.

The Board indicated that these findings were all the more concerning because they were so familiar – the Rogers Commission charged with investigating the Challenger disaster had reported many of the same shortcomings in safety culture and organizational structure 17 years earlier. As with the Columbia, the 1986 tragedy was caused by a known design flaw which key officials chose to ignore, despite grave warnings by engineers prior to launch. (For those interested, a fascinating – and sobering – mini-series documentary on the Challenger disaster is available on Netflix titled “Challenger: The Final Flight.”) Both space shuttle disasters have become common case-studies in ethics and decision-making.

Learning from Tragedy

The purpose of this newsletter isn’t to criticize NASA twenty years after the fact, but rather to use the Day of Remembrance as an opportunity to evaluate how we approach problems in our own lives and as a society. When it comes to space exploration, the margin for error is extraordinarily small, and the results of failure are catastrophic and highly publicized. But virtually all of us are guilty of brushing problems under the rug from time to time.

While choosing to leave dirty dishes in the sink until the following morning might not matter, choosing to postpone action for one’s own physical, social, or financial health may have irreversible consequences. We know colonoscopies can save lives and are recommended starting at age 45, but it’s remarkable how few people in their sixties and seventies have even had one. We know atherosclerosis develops slowly over our entire lives, and yet many ignore high cholesterol levels until middle age or later. When seemingly little problems go unaddressed, they have a tendency to turn into big problems. And the longer they’re left, the greater the risk. 

So perhaps the most meaningful tribute NASA can offer to the lost astronauts is simply to learn from the mistakes of the past – to uphold a culture of preparedness, honest consideration of possible contingencies, and proactive risk mitigation. And in turn, perhaps we can apply some of those same lessons to our own lives and health.