The Space Shuttle Columbia: A Case Study

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In the conclusion to Chapter 4, Manuele states: "To avoid hazard-related incidents resulting in serious injuries, human error potentials must be addressed at the cultural, organizational, management system, design, and engineering levels, and with respect to the work methods prescribed." Briefly discuss how each of these levels contributes to human error. Which one of these levels, if addressed, is likely to result in the greatest benefit for reducing human error reduction? The best answer one can give to this is by giving the example of the Space Shuttle Columbia that was destroyed and the lives of all seven of its crew were lost precisely due to all of these conditions as was later discovered by the Columbia Accident Investigation Board (CAIB), conducted in order to investigate the causes of the Columbia disaster. 1. Cultural, - This can mean both the culture of the individual worker and the culture of the organization itself. Communication must be on a par with the individual culture so that each understands precisely his particular task and does not fall into ambiguity. Communication, too, must be transparent between workers and between management and employees so that all details of the task are thoroughly understood and agreed upon by both. As regards the organization's culture, the environment must be suitable for safe results. The NASA organizational culture was stuck in a mood of complacency and averse to risk-taking and change. There was lack of
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