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Report Blames Flawed NASA Culture for Tragedy
In Broad Indictment of Practices, Shuttle Panel Says Safety Suffered

Kathy Sawyer and Eric Pianin
Washington Post Staff Writers
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.

Concern about the schedule "may have begun to influence" managers' decisions regarding the foam shedding during Columbia's launch and one of Atlantis last October, the report said. The rigorous shuttle schedule "had no margin to accommodate unforeseen problems," and with flights coming in rapid succession, there was no assurance that anomalies on one flight would be identified and resolved before the next.

Yesterday O'Keefe reiterated his intention to "comply with the full range of recommendations released today" and said the agency has set up a special team to help "change the culture." NASA has already removed several top shuttle managers from their jobs and mobilized its workforce to begin implementing a number of the board's previously released recommendations. O'Keefe has set a target date of next March for resuming shuttle flights, but a launch next summer is considered more realistic.

Bush issued a statement yesterday that implied continued support for his appointee, saying, "The next steps for NASA under Sean O'Keefe's leadership must be determined after a thorough review of the entire report, including its recommendations." He added, "Our journey into space will go on. The work of the crew of the Columbia and the heroic explorers who traveled before them will continue."

Addressing the painful subject of the crew's fate, the board, working with a NASA team, found that the seven astronauts died in the final seconds of their vehicle's breakup over Texas as the result of "blunt trauma and hypoxia. The exact time of death -- sometime after 9:00:19 a.m. Eastern Standard Time -- cannot be determined because of a lack of evidence. The failure of the crew module, the report noted, was "a rapid catastrophic sequential structural breakdown rather than an instantaneous 'explosive' failure."

During its seven months of exhaustive investigation, working seven days a week, the 13 board members always kept the crew members' names and faces in mind, they said. "If this board has any impact whatsoever, we felt that the loss of their lives had better make a difference, or both them and us have wasted our time," Gehman said at the briefing.

Board members personally delivered copies of the report to the astronauts' families.

In Houston, Jonathan Clark, the widower of Columbia astronaut Laurel Clark, called the report "extremely comprehensive and blunt, bold and directive in its scope. Like the board members said, this is not about what is right about NASA. This is about what is wrong. So it is inherently critical -- not in a bad way or destructive but in a way to take into consideration everything that happened and make sure this never ever happens again.

"I think the comfort comes in knowing that this is a road map to the future. It's a blueprint for the continuation of high-risk space exploration. It's either do this or don't do it at all. This is what needs to be done if you're going to fly humans in space."

As the board had previously documented during its public hearings and tests, the report said the insulating foam that came off Columbia's external propellant tank during the ascent smashed the heat shielding along the underside of the leading edge of the left wing. When the shuttle reentered the atmosphere on Feb. 1, superheated air at temperatures as high as 8,000 degrees penetrated the wing structure, melting it from the inside and leading to the vehicle's disintegration.

NASA is redesigning the external tank to eliminate the most serious source of foam shedding -- a problem the board said engineers had wrongly come to accept as routine, much as engineers did almost two decades ago when they accepted problems with the O-ring seals of the shuttle rocket boosters before the Challenger disaster.

But because it is unlikely that all debris impacts on the shuttle can ever be eliminated, the board also has called on NASA to harden the shuttle's protective heat shielding to better withstand minor impacts, and to develop in-flight inspection and emergency repair capabilities before the next flight.

The panel detailed a list of both immediate and long-term recommendations. Among the 15 items it said should be done before the next flight are:

* Adjusting the ambitious shuttle schedule to fit available resources and make sure any risk incurred to meet a deadline is "recognized, understood and acceptable."

* Expanding the training program that puts managers through various simulated emergencies, such as potential loss of vehicle or crew, and forces them to "assemble and interact with support organizations across NASA/contractor lines and in various locations."

The report's 29 recommendations included some that would apply only if the shuttle is to keep flying beyond 2010. These include improving the onboard sensors that monitor the orbiter's performance and a way to inspect all wiring as the fleet ages.

The board criticized "the nation's poor record of developing either a complement to or a replacement for the space shuttle," but said the blame for this extends well beyond NASA.

In a sharp blow to an agency that has always prided itself on its engineering prowess, the board focused heavily on what it called substandard engineering practices. They were the result, it said, of officials prematurely declaring the shuttle an "operational" vehicle rather than treating it as the highly risky, experimental space plane it really is. This meant that funding for further shuttle research dried up.

In the category of fundamental organizational change, the board called on NASA to set up a powerful, independent Technical Engineering Authority that would be responsible for all shuttle technical requirements and any waivers that relax them. This team should "build a disciplined, systematic approach to identifying, analyzing and controlling hazards," including deciding what is or is not an anomaly and independently verifying that a shuttle is ready to launch.

To ensure its independence, this new group should be funded by and report to NASA headquarters, not the shuttle program managers, and presumably would not be influenced by scheduling pressures.

Similarly, the board said, the NASA headquarters safety office should be given direct line authority over the shuttle program's safety organization, with its own independent funding.

These and other recommended organizational changes do not have to be achieved before the shuttles fly again, the board said, but NASA must develop a detailed plan for the changes by then and must report its progress annually to Congress, as part of the NASA budget review process.

In its assessment of what went wrong during Columbia's flight, the report was especially tough on Linda Ham, who headed the mission management team.

"Most of Linda Ham's inquiries about the foam strike were not to determine what action to take during Columbia's mission, but to understand the implications" for the next flight, the report said.

During a managers' meeting on Jan. 21, five days after Columbia's launch, she reviewed the rationale put forward the preceding October, the last time a significant foam chunk had come off the tank. She e-mailed shuttle program manager Ronald D. Dittemore that day, saying, "Rationale was lousy then and it still is. . . ." The board found that shuttle engineers' initial estimates of the foam debris size, speed and origin were "remarkably accurate." That is, they had the information they needed to appreciate the danger -- but did not. In their analysis, the engineering team used "judgment" rather than hard data or rigorous analysis, as they underestimated the probable damage to the shuttle's heat shielding, the report said.

In the managers' meetings run by Ham, "no Mission manager appeared to 'own' the Team's actions," the report said. This meant the managers provided no direction for the engineers, nor did they consult formally with the team's leaders. Ham also vetoed requests for spy satellite imagery of the wing.

Among the more damning lines in the report was the board's conclusion that NASA had managed to re-create an atmosphere that officials had sworn would be banished forever after the Challenger exploded -- one in which "engineers had to produce evidence that the system was unsafe rather than prove that it was safe."

Staff writer Rob Stein and researchers Margot Williams and Lucy Shackelford contributed to this report.

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