Columbia and Tenerife Case study
Decision Making Analysis Report
Mengjie Chen
Instructor, Peter G. Dominick
Columbia and Tenerife Case study
The Tenerife crash, recently referred as the biggest air disaster in history, seems to have little connection with the tragedy of Space Shuttle Columbia. However, there are similarities, especially some decisions made by two people from the two cases respectively. When they made certain decisions, they did fall into similar cognitive traps which, if identified in time, would prevent the two tragedies from happening.
The two people are Rodney Rocha, a NASA engineer, and Klass Muers, the First Officer of KLM plane. Rodney Rocha chaired the Debris Assessment Team to analyze the foam strike happened during Columbia’s launching. Klass Muers, was on his first co-pilot flight with Captain Van Zanten, who was also the head of KLM’s Training Department.
1. Individual-level Decisions
a. Columbia Case
During the first five eight flight days, Rodney Rocha had made the following decisions.
Day 1
Rocha concerned about the foam strike due to the unusual size of debris.
Day 2-4
Rocha asked a JSC manager for conducting space walk to check the wing with no reply.
Day 5
Rocha begged Paul Shack for images about the wing.
Day 6
Rocha angrily wrote an email in belief that management team was wrong in withdrawing the imagery requiring. However, Rocha did not send the email.
Day 7
Rocha discussed his concern but was ended by “there’s not a damn thing we can do about it!”
Day 8
Rocha believed that MMT did not realize the limitation and uncertainty in the DAT analysis.
Clearly, Rocha made good decisions when dealing with complex technical problems. First of all, he realized the unusual size of debris could have serious and complicated effects, despite the previous harmless strikes. He conducted successful self-awareness in identifying the difference between Columbia and previous strikes; He