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---ENDED FOR ALL TIME THE "COMMON BELIEF" THAT FOAM STRIKES ARE ← JUST A TURN AROUND ISSUE ---SERVES AS A DRAMATIC STIMULUS TO CHANGE SOME PEOPLES ← ATTITUDES ABOUT WHAT WE REALLY "KNOW" SHEILA: -FIVE PARALLEL LINES OF WORK: --AERO [[light circling]] --THERMO [[light circling]] (THESE TWO REALLY CLOSELY RELATED) --TIMELINES FROM SENSORS ← --VIDEO/PHOTO ANALYSIS ← --DEBRIS RECONSTRUCTION AND FORENSICS ← -ENTRY DATA DEMONSTRATES THE FLAW WAS PRE-EXISTING -FLIGHT EVENTS FAIRLY WELL DOCUMENTED, PROGRESSIVE DESTRUCTION CAN BE FAIRLY WELL ESTABLISHED -HEAT FIRST, AERO FORCES SECOND -NO POSSIBILITY OF RECOVERY GROUP II -FOAM AUDIT, DOCUMENTATION OF SCHEDULE PRESSURE AND THE EMAIL STORY OF IMAGERY REQUESTS CAN BE CONSIDERED "DATA" -ANALYSIS OF HOW HIGH RELIABILITY ORGANIZATIONS HANDLE RISKY ENTERPRISES CREATES A "TEMPLATE" OR A "MENU" FOR US TO USE TO EXAMINE MANAGEMENT AND CULTURE AT THE SSP -WE USE THE ANALYSIS OF THE "DATA" TO CONCLUDE SSP DOES NOT HAVE THE CHARACTERISTICS OF A HIGH RELIABILITY ORGANIZATION -FURTHERMORE, WE REVIEWED HISTORY AND PREVIOUS STUDIES AND DETERMINED NASA DOES NOT LEARN WELL. [[right margin]] ) ||||| /// [[/right margin]] GROUP I: JB: -FOUND EVIDENCE IN REAL LIFE THAT SUPPORTS THE ORGANIZATIONAL CAUSE STATEMENT: --BROKEN SAFETY CULTURE ← ---QUESTIONS REGARDING INDEPENDENCE ← ---ORGANIZATIONAL SHORTFALLS ON CHECKS AND ← BALANCES - QAUDRUPLE [[QUADRUPLE]] HATTING ACROSS PROGRAM, CENTER AND HQ ---LACK OF INTEGRATED SAFETY FUNCTIONS ← ---BARRIERS TO COMMUNICATION: LACK OF SHUTTLE INTEGRATION; INEFFECTIVE SAFETY INFORMATION SYSTEMS AND DATABASES ---"SILENT SAFETY" SHORTFALLS WITH STS-107: FRR, DAT, MMT AND TURKEY: -STUDIED SCORES OF FINDINGS OF OTHER SIGNIFICANCE - HOW TO PREVENT THE NEXT ACCIDENT: --EXAMPLES: BETTER ENGINEERING DRAWINGS, BETTER SAFETY AND QA, IMPROVED DOCUMENTATION