Report Blames Flawed NASA Culture for Tragedy
Wednesday, August 27, 2003
The shuttle Columbia and a crew of seven were lost on Feb. 1 because NASA, for the second time in its recent history, allowed its engineering to grow careless, its safety system to wither, its communications to become muddled and prudent professional curiosity to become stunted.
Those conclusions were part of a far-reaching indictment issued yesterday by the Columbia Accident Investigation Board, in a comprehensive and unsparing assessment of the human spaceflight program. Laying at least part of the blame for NASA's failings on persistent budget and other pressures flowing from Congress and the White House over several administrations, the plainspoken 248-page report is designed to provide the foundation for an unprecedented national debate on the future of human spaceflight, which the board said is long overdue.
A 1.7-pound chunk of foam insulation that struck Columbia's left wing at more than 500 mph during the Jan. 16 ascent was "the direct, physical action that initiated the chain of events leading to the loss of Columbia and her crew," the board wrote.
But, in chilling echoes of the environment that produced the 1986 Challenger tragedy, the board found that NASA's management and cultural mind-set were as culpable because they paved the way for the foam strike to do its deadly work. Before the mission, managers did not heed foreshadowings of the potential threat; and during the mission, they allowed deadline pressures to squelch the aggressive pursuit of information about the possible damage and its implications.
"Management decisions made during Columbia's final flight reflect missed opportunities, blocked or ineffective communications channels, flawed analysis, and ineffective leadership," the report said. "Perhaps most striking is the fact that management . . . displayed no interest in understanding a problem and its implications."
Unless the agency makes fundamental changes this time, the board warned, "the scene is set for another accident." At the same time, the investigators repeatedly said that, based on NASA's past performance, they expect the NASA bureaucracy to resist such a transformation. "The changes we recommend will be difficult to accomplish -- and will be internally resisted."
There were bits of good news for NASA scattered throughout the board's grim verdict, however. Among them, the board did not find the shuttle to be "inherently unsafe."
Retired Adm. Harold W. Gehman Jr., the board chairman, said at a briefing for reporters, "If this board had set out to spend seven months listing all the good things that NASA does, the report would be thicker than this one. Unfortunately, that's not what our task was."
To make certain that NASA implements not only the 15 actions it recommended before the next shuttle flight, but also the more basic and difficult long-term changes, the board called for a system of long-term external policing.
While the panel had signaled many of its findings in advance, there were some surprises. For example, the report offered the first direct criticism in the investigation so far of NASA Administrator Sean O'Keefe. Citing unsolicited comments from NASA personnel, the report said employees blamed O'Keefe for a seemingly "arbitrary" buildup of pressure to meet a deadline of February 2004 for the launch of a key space station component -- at the same time top management was denying there was schedule pressure.
The board found that the four flights scheduled in the months from October 2003 to February 2004 would have required a shuttle processing push comparable to the much-criticized pattern that led up to the Challenger accident 17 years ago.
President Bush appointed O'Keefe, then deputy director of the White House Office of Management and Budget, in early 2002 to implement a plan he had developed to improve management of the struggling, over-budget International Space Station. The space station program and NASA were "on probation," the board wrote, and the strategy for regaining credibility focused on the early 2004 date for completing the U.S. portion, or core, of the orbiting laboratory.