Among the “tragedy of errors” that doomed the space shuttle Columbia, perhaps the most damning were NASA’s organizational blunders. Sheila Widnall served on the board investigating Columbia’s destruction in February, 2003, and she can describe the technical failures that led, moment by moment, to the ghastly trail of debris across the western United States. But the investigation board traced the roots of this disaster to NASA’s “culture of invincibility,” years in the making. Well-intentioned people, Widnall states, became desensitized to deviations from the norm. NASA managers treated repeated anomalies -- such as foam smashing into shuttle tiles on take off -- as “maintenance turnaround events.”

Foam striking protective tiles on the leading edge of Columbia’s wing led to the horrors of re-entry: gases in excess of 5000 degrees F entered through a possibly 10-inch-wide breech in the wing, melting sensors and internal structure, sending the shuttle out of control. The failures that led to this moment, are both engineering system failures, and human communication failures.

Widnall and the investigation board recommend independent safety oversight for shuttle flights; NASA leadership that heeds minority points of view and doesn’t let scheduling or budget pressures define space missions; and routine inclusion of engineers who have the right to address both technological and operational issues of a flight.