Two of the major accidents on the History of space science and technology are the ones of the NASA shuttles Challenger and Columbia. After some research, there is plenty of evidence tracing the cause to an ill-functioning information flow among key actors in the development of the shuttles.

Challenger launched on its 10th mission on Jan. 28, 1986. A mere 73 seconds after lift-off, live television coverage showed the shuttle break apart and disappear from view, killing seven astronauts in less than two minutes.

Analysis later showed that a seal, called an O-ring, on the shuttle's right solid rocket booster had failed at lift-off, allowing pressurized hot gas to escape from inside the booster. This vaporized material impinged on the strut connecting the solid rocket booster to the shuttle's huge orange external tank, causing both pieces of hardware to break down.

A commission was created to investigate the causes of the accident, which uncovered the malfunctioning of the mentioned O-ring. However, a more striking conclusion was drawn from the way of working at NASA:

“The commission […] brought to light cultural problems at NASA, such as failing to voice all problems to the launch decision team.”

More specifically,

“…The commission found issues in NASA's decision-making processes and construction flaws in O-rings and the shuttle solid rocket boosters.”

In fact, the “Presidential Commission on the Space Shuttle Challenger Accident Report” is quite straight forward, pointing clearly to the fact that information was not reaching the ones who were making critical decisions. Had it been mitigated somehow, the course of the events would have been very different.

On the official report, the problem of knowledge not reaching the necessary staff is addressed:

“Chapter 5 -THE CONTRIBUTING CAUSE OF THE ACCIDENT

The decision to launch the Challenger was flawed. Those who made that decision were unaware of the recent history of problems concerning the O-rings and the joint and were unaware of the initial written recommendation of the contractor […]. If the decision makers had known all of the facts, it is highly unlikely that they would have decided to launch 51-L on January 28, 1986.[…]
1. The Commission concluded that there was a serious flaw in the decision making process […]. A well-structured and managed system emphasizing safety would have flagged the rising doubts about the Solid Rocket Booster joint seal […]”

Seventeen years later, a similar tragedy occurred. The Columbia space shuttle disintegrated as it reentered Earth's atmosphere, due to a piece of foam insulation that broke off from the external tank and struck the left wing. Consequently, a commission was appointed to investigate the causes of the disaster. The conclusions were striking:

“The Columbia Accident Investigation Board (CAIB) concluded that NASA had failed to learn many of the lessons of Challenger. […] The same "flawed decision making process" that had resulted in the Challenger accident was responsible for Columbia's destruction.”

The Columbia Accident Investigation Board was very clear. The information flows were not working effectively and critical facts did reach its way through the hierarchy.

“Again, past policy decisions produced system effects with implications for both Challenger and Columbia. Prior to Challenger, Shuttle Program structure had hindered information flows, leading the Rogers Commission to conclude that critical information about technical problems was not conveyed effectively through the hierarchy”

These two are probably the most visible and documented cases of an ineffective knowledge management, which lead to enormous losses both human and material. Of course, not all the risks by not implementing a proper KM are this high, but we can conclude that by the execution of a comprehensive KM, we would contribute to minimize many hidden and pernicious inefficiencies that threat our organizations at many levels. NASA’s Knowledge Management enterprise has been the answer to the caveats presented by the barriers within the information flow, as could be experienced in the disasters of the shuttles. Noteworthy APPEL, the Academy of Program/Project & Engineering Leadership as well as the Lessons Learned system, which hosts about 4000 public entries at the issuing of this document.

References

Image

https://en.wikipedia.org/wiki/List_of_Space_Shuttle_missions#/media/File:Space_Shuttle_Columbia_launching.jpg 

http://www.space.com/18084-space-shuttle-challenger.html

http://www.space.com/10677-challenger-tragedy-overview.html

The Presidential Commission on the Space Shuttle Challenger Accident Report, June 6, 1986 p.82, p.104, p.117-118, http://science.ksc.nasa.gov/shuttle/missions/51-l/docs/rogers-commission/Chapter-5.txt

http://en.wikipedia.org/wiki/Rogers_Commission_Report#Result

Columbia Accident Investigation Board, p. 198, http://anon.nasa-global.speedera.net/anon.nasa-global/CAIB/CAIB_lowres_chapter8.pdf