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Volume 42, No. 3 • May-June 2006
Outside the Lines

Whose Risk Is It Anyway?

Evolution of Risk Acceptance Practices

In contrast, after the Air France accident, British Airways developed Kevlar blankets for installation in its Concordes' fuel tanks to mitigate their vulnerability to tireburst shrapnel. The Kevlar blanket modification would have added about 400 kg (882 lbs.) - 0.2 percent - of the planes' maximum gross take-off weight of 185,066 kg (~408,000 lbs.).11

British Airways never got the chance to test its safer fuel tanks on the line. After the Air France accident, the Concorde would never return to commercial service.

Example #3 of an Uncoupled Accountability Gap that was Recoupled: NASA Space Shuttles Discovery and Atlantis

The decision by NASA administrators to accept the risks of launching the STS121 space shuttle Discovery with known potential insulating foam hazards is an example of how accountability can be uncoupled from decision-makers, despite concurrence by the sole risk-takers: the crew. The decision to launch was explained in terms of qualitative risk trade-offs by top managers over objections by NASA's risk-assessment staff. Risks of vehicle loss or personal harm to individuals operating or exposed to the system's operations were incorporated into the risk-acceptance calculus, but personal risk to the decision-maker — the risk creator — apparently was not.

In contrast, NASA's risk accepters recently made another decision that could have been critical to the success of the impending space shuttle Atlantis mission. As described in the Aero-News Network:

Engineers at NASA have discovered a potentially serious problem with the shuttle Atlantis…. At issue are a series of bolts holding the support box for… the KU-band antenna to the inside of the orbiter's payload bay. …Should the box break free during liftoff, it could cause catastrophic damage as it falls the length of the 60-foot-long cargo bay.

…Incidentally, NASA has known of potential problems with the bolts for some time ... in fact, the bolts were replaced onboard sister shuttles Discovery and Endeavour after it was found the bolts may have been manufactured too short to safely accomplish their task. CBS News reports the bolts were not replaced in Atlantis…
.12

NASA's risk decision-makers seem to have re-evaluated possible outcomes should another shuttle be lost, including the likelihood of termination of the program. As a result, they appear to have chosen to recouple the agency's accountability gap in favor of discretion:

It's something that's never been done before: repairing a component mounted inside the main payload bay of the space shuttle… on the launch pad…. NASA shuttle manager Wayne Hale gave Florida Today an extremely descriptive account of the potentially dangerous repair job …: "So imagine operating on a surfboard that's tied down at one end, sticking out over a six-story balcony.… I mean, this has got all kinds of implications."13

Apparently, the "implications" of the risks to the technician who surfed out to change the bolts (which, in fact, did turn out to be too short, despite being engaged) could be interpreted as having been trumped by implications of the risks to NASA's space shuttle program had the antenna broken loose and damaged Atlantis irreparably.

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11 http://www.ainonline.com/issues/07_01/july_01_concordetheorypg12.html.
12 From “Shuttle Comm Bolts Become A Worry - May Require Replacement.” www.aero-news.net, August 15, 2006.
13 From “NASA Decides to Play it Safe.” www.aero-news.net, August 21, 2006.