The Shuttle Columbia Disaster - Lessons That Were Not Learned

Explore the critical lessons from the Space Shuttle Columbia disaster in this 56-minute conference talk from GrrCON 2017. Delve into the causes of the Apollo 1 and Challenger accidents, examining the landscape of poor communication and the normalization of deviance within NASA. Understand the constant problem of foam shedding, management's preference for brevity, and how past events predict future outcomes. Analyze the impact of budget constraints on safety decisions. Learn about the importance of bravery and honesty in risk assessment and communication. Gain valuable insights into organizational failures and the crucial lessons that should have been learned to prevent future tragedies in space exploration and beyond.

Intro
APOLLO 1 ACCIDENT CAUSES
CHALLENGER ACCIDENT CAUSES
WHAT HAPPENED
THE LANDSCAPE OF POOR COMMUNICATION
RISK REGISTER
BE BRAVE! BE HONEST!
FOAM SHEDDING WAS A CONSTANT PROBLEM
MANAGEMENT WANTS US TO BE BRIEF
THE PAST PREDICTS THE FUTURE
NORMALIZATION OF DEVIANCE
BUDGET ISSUES ABOUND
LEARN THE LESSONS