Sharing information is part of the human experience and is how we learn. The need to share information can be dated back to approximately 10,000 B.C. to 5,000 B.C. when the dominant method of documenting information was in the form of pre-writing symbols known as petroglyphs, seen on cave walls throughout the world. It is interpreted that these images had both cultural and religious importance to their creators. From a safety professional's standpoint, one would hope that these petroglyphs provided information, lessons learned, that addressed such things as not standing in front of a charging elephant or that the antlers of an elk must be given adequate clearance in the event the elk moves its head from side to side. Unfortunately, many of these images and concepts shared on the cave walls have yet to be interpreted. The process of sharing lessons learned in the age of computers is both easy to implement and, if well written, easy to understand.
Few safety-related incidents over the past twenty years have been noticed by as many people worldwide as the loss of the Space Shuttle Challenger on January 28, 1986, the crash of Air France's Concorde on July 25, 2000, and the loss of the Space Shuttle Columbia on February 1, 2003. Images of the loss of these highly technical and complex vehicles were shown on television and resulting investigations documented in various forms of media, including the outcome of the root cause analysis phase. Each of these incidents was the result of what sociologist Diane Vaughn refers to as the "normalization of deviance" (Vaughn 62) The Space Shuttle program, prior to the Challenger incident, saw regular erosion of the solid rocket booster's field joint O-rings; the Concorde had as many as seven incidents of tire failure, resulting in damage to the underside of its wing (Covault 32); and again, the Space Shuttle program saw an estimated 1.67 pound piece of low-density foam insulation fall of the External Tank during assent and strike the leading edge of the shuttle's left wing.
In August 2003, the Columbia Accident Investigation Board (CAIB) published its report documenting the events leading up to the loss of the Space Shuttle Columbia. The Board Chairman of the CAIB, Adm (ret.) Harold W. Gehman, Jr. indicated that the lost of Columbia on reentry could not be attributed to a random event, but was the predictable outcome of a multiyear saga that evolved as the National Aeronautical and Space Administration's (NASA) safety program grew ineffective and embroiled with management issues (Covault 27). When reviewing the issues related to the foam on the External Tank, Aviation Week and Space Technology (AWST) published an editorial making reference to the Marshall Space Flight Center and the Johnson Space Center; the Marshall Space Flight Center manages the External Tank while the Johnson Space Center manages the Space Shuttle.
