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Final Report by Columbia Board Shows NASA Knew Risks, But Let Safety Slide

Posted on: Wednesday, 27 August 2003, 06:00 CDT

Aug. 27--WASHINGTON--A foam strike during launch doomed shuttle Columbia, but NASA's broken safety culture was equally responsible for America's second in-flight space disaster, according to a tough final report released Tuesday by the Columbia Accident Investigation Board.

A nearly seven-month probe into Columbia's Feb. 1 breakup over Texas concluded that the National Aeronautics and Space Administration was too comfortable with risk and too obsessed with meeting its schedule for building the international space station. As a result, safety concerns -- such as the requirement that foam debris from the shuttle's external tank not be allowed to break off and hit the orbiter -- often went unheeded.

The 248-page report determined that the physical cause of the Columbia accident was a chunk of insulating foam that broke off the ship's external fuel tank and struck the leading edge of the left wing during launch on Jan. 16. The impact damaged the shuttle's protective heat armor and allowed 5,000-degree gases to penetrate the wing during re-entry, causing Columbia to disintegrate and killing its crew of seven.

However, NASA's flawed management culture had as much to do with the disaster as foam did, the board found, and attitudes must fundamentally change if the shuttle is to return to flight safely.

"Without these changes," the report said, "we have no confidence that other corrective actions will improve the safety of shuttle operations.

The changes we recommend will be difficult to accomplish -- and will be internally resisted. . . . The board strongly believes that if these persistent, systemic flaws are not resolved, the scene is set for another accident."

The report describes a shuttle program that failed to learn the lessons of the first shuttle disaster, the 1986 Challenger accident. In both cases, safety requirements were ignored by schedule-driven managers and concerns of lower-level engineers fell on deaf ears. Included among the board's 29 recommendations are creation of an independent engineering organization and new oversight authority for NASA's Office of Safety and Mission Assurance that would move control of safety decisions away from shuttle-program managers.

At a news conference following the report's release, board members predicted that revamping NASA's culture would be a slow, painstaking process. Many long-term changes won't be fully implemented until well after the shuttle returns to flight, which NASA hopes will happen next spring.

The report noted that previous investigation boards -- including the Rogers Commission that investigated Challenger -- had come and gone without permanently fixing NASA's organizational problems. Harold Gehman, the retired admiral who chaired the board, said the government must remain vigilant to make sure NASA follows through this time.

"We are putting a little bit of a burden here on both the Congress, the oversight committees, and on the White House to make sure that these changes are implemented," Gehman said. "You can establish review panels and blue-ribbon panels and annual reports and all that kind of stuff, all of which we think should be done. But I don't believe we should just trust NASA to do this."

The report held few surprises but lots of new details on causes that contributed to the accident. Most issues covered in the report were outlined by the 13-member board during 10 public hearings between March 6 and June 12.

Fifteen of the board's 29 recommendations on how to fix the space agency's technical and cultural problems ask for changes before the shuttle fleet's three remaining orbiters start flying again.

Among the board's key short- and long-term recommendations: Better training for the teams that oversee shuttle missions. More independent safety oversight. A redesign of parts of the orbiter to "harden" it against debris impacts. A requirement that future shuttle crews have the ability to inspect and repair their ships' thermal-protection systems in orbit. And a new flight schedule more consistent with the program's budget.

NASA managers publicly pledged Tuesday to do everything possible to implement the board's recommendations. Some items -- such as the new independent safety office and thermal-protection system repair -- already are being worked on.

During a televised question-and-answer session with employees, Administrator Sean O'Keefe called the report a road map for the space agency's future.

"Do we intend to comply with the recommendations? You bet -- without reservation," O'Keefe said. "The issue is how we go about picking the options to comply."

Exactly what options NASA will pick already is being debated inside the space agency. Within minutes of the report's release, NASA managers in Washington and at field centers around the country convened in "action centers" to compare the report's recommendations to an internal agency plan for returning the shuttle to flight.

The early reaction was relief that the board's recommendations didn't go further. Most agency officials were anticipating the worst.

"We were expecting a few more surprises than we got," one veteran NASA manager said. "We also were expecting it to be even rougher than it was."

The board found close parallels between the Columbia's final flight and America's first shuttle disaster, the 1986 Challenger accident.

Challenger exploded during liftoff after an O-ring seal on one of the shuttle's solid rocket boosters failed; managers had ignored the concerns of engineers and launched despite the low temperatures that caused the seal to fail. The board concluded that in both accidents "schedule concerns, production pressure, cost-cutting and a drive for greater efficiency . . . had eroded NASA's ability to assure mission safety."

While Columbia's final flight was one of the few recent shuttle missions not bound for the international space station, investigators found that pressure to build and service the outpost was a factor nonetheless. When Atlantis' external tank lost a large chunk of foam during launch two missions before Columbia's liftoff, shuttle managers quickly rationalized that the debris hadn't hurt the orbiter in order to stay on schedule for the next launch to the space station.

"The high-pressure environments created by NASA headquarters unquestionably affected Columbia, even though it was not flying to the international space station," the report noted.

The report adds new details to the now-familiar stories of how lower-level engineers with concerns about possible damage to Columbia never were heard by managers. A damage-assessment team and other engineers asked three times for photos of the shuttle in orbit from classified satellites or telescopes. But officials on the Mission Management Team turned down the requests for not going through proper channels. Meanwhile, those same officials -- who were supposed to meet daily -- convened only five times during the 16-day mission.

"The same NASA whose engineers showed initiative and a solid working knowledge of how to get things done fast had a managerial culture with an allegiance to bureaucracy and cost-efficiency that squelched the engineers' efforts," the report said. "When it came to managers' own actions, however, a different set of rules prevailed. The board found that Mission Management Team decision-making operated outside the rules even as it held its engineers to a stifling protocol."

Meeting some of the panel's technical recommendations -- especially finding a means of inspecting and repairing the thermal panels on the leading edges of the shuttle's wings in orbit -- is expected to be a tough task for NASA. Ultimately, however, experts think changing NASA's cultural behavior will prove a far more formidable challenge.

Karlene Roberts, a business professor at the University of California at Berkeley, has studied such high-risk organizations as aircraft carriers for the Navy. She says changing NASA's mind-set won't be easy.

"It can be extremely difficult to do, and to tell you the truth, I have to wonder how they're going to do it," Roberts said. "There are lots of dedicated people at NASA, but the organization is just apparently rife with communication problems, no trust and a lot of competition" for resources.

Amid questions on whether the accident will lead to more money for NASA, the White House's response to the report was muted. President Bush issued a brief statement shortly after the report's release that thanked the board for its work but offered no specifics on the path ahead.

"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," the statement said. "Our journey into space will go on."

Many members of Congress also were taking a wait-and-see attitude before promising additional funding. All said the space agency had its work cut out for it to recover from the disaster.

"If they're expecting us to write a blank check, we're unwilling to do so," said U.S. Rep. Sherwood Boehlert, R-N.Y., chairman of the House Science Committee. "If they're expecting us to go forward at any risk, we're unwilling to do that also."

U.S. Rep. Dana Rohrabacher, a California Republican who chairs the space and aeronautics subcommittee of the House Science Committee, said the underlying cause of the accident is what makes the future so unclear.

"It would have been much easier if the Gehman commission would have found that there was a widget that needed to be fixed and it just slipped by through somebody's incompetence and that person could be removed and then the widget could be fixed," he said. "But obviously, that's not the case."

Gwyneth K. Shaw and Robyn Suriano of the Sentinel staff contributed to this report.

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