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NASA Repeatedly Ignored Safety Warnings, Accident Investigation Board Finds

Posted on: Friday, 29 August 2003, 06:00 CDT

Aug. 29--During the 17 years between space-shuttle accidents, a succession of advisory groups sounded the alarm that NASA's safety systems and communications were slowly eroding.

Despite those repeated warnings, NASA often did little to heed them.

That point was driven home this week when the Columbia Accident Investigation Board blamed many of those same continuing problems for creating "blind spots" that helped doom the shuttle Columbia and its seven-member crew.

In 1990, a General Accounting Office report warned that the safety offices at NASA field centers were not independent enough from the programs they were supposed to monitor.

Ten years later, the Shuttle Independent Assessment Team report, headed by then-Ames Research Center Director Henry McDonald, repeated that criticism. That group also warned that workers were afraid to speak up and that NASA managers had been lulled into a false sense of security because of years of successful shuttle flights.

All the while, the Aerospace Safety Advisory Panel -- which issues an annual report on the agency's human-spaceflight programs -- worried about budget cuts and their affect on shuttle safety.

Yet in its 248-page report on the Feb. 1 accident, the Columbia board said all of those problems, and many more cited in reports, still exist.

"They lost their ability to accept criticism, leading them to reject the recommendations of many boards and blue-ribbon panels," the board's report says.

A supplement to the report, written by board member Duane Deal, an Air Force brigadier general, is even more blunt: "History reveals NASA has repeatedly demonstrated a lack of regard for outside studies and their findings."

For example, numerous reviews found that NASA didn't effectively recognize risk or spot dangerous trends. In its report, McDonald's team called it "success engendered safety optimism."

In other words, if a surprise cropped up but didn't cause a problem, it became part of the accepted landscape instead of a red flag. It happened with the O-rings on Challenger, and again with the insulating foam on the shuttle's external tank, the physical trigger that brought down Columbia.

On the advice of the McDonald task force, NASA worked on better methods to track trends, gather data and analyze risk. But the Columbia accident investigators found the system -- and NASA's risk-taking attitude -- still very troubling, calling the databases used to analyze problems "dysfunctional" and "marginally effective decision tools."

The Columbia report called the Aerospace Safety Advisory Panel, chartered after the 1967 Apollo 1 launchpad fire that killed three astronauts, "independent, but often not very influential."

McDonald, who is now a professor at the University of Tennessee-Chattanooga, said the findings of the Columbia investigators brought back dispiriting memories of his own experience with NASA.

"It's the same finding we found -- and when we tried to shake them up, we found the same reluctance to change that is now being evidenced," he said. "I'm not at all surprised at what they're finding. Disappointed, unhappy, but not surprised."

In their report, the Columbia investigators reached back to the recommendations of the so-called Rogers Commission, which played a similar role after the 1986 Challenger accident. The Columbia panel found that many of the same communications and safety issues discovered by the Rogers Commission are just as problematic now.

"There have been safety panels out the gazoo. But NASA just tells them to go talk in their hat," said Robert Hotz, a member of the Rogers Commission. "It's a deep part of the NASA culture. They won't listen to anyone else."

NASA was cooperative just after the Challenger accident, just as agency chief Sean O'Keefe is now promising to convert all of the Columbia board's recommendations into major changes.

"But they wore off," Hotz said. "That's what's frightening to me. NASA is back where it was 17 years ago."

Tom Young, a former head of Martin Marietta and a longtime member of the NASA Advisory Council, attributes the problems to the mind-set within the human spaceflight program itself.

"They're the experts on human spaceflight and as a result, my observation is they're very difficult to help -- and what I mean by that is when you're insular, even if you're very good, things pass you by," he said. "They're not a lot interested in what other people have to say, and have a lot of confidence in their own abilities."

This time, O'Keefe has vowed to follow the Columbia board's recommendations to the letter.

"That is our commitment," O'Keefe said Wednesday. "We intend to do that without reservation."

Already, the agency has moved to create an independent safety and engineering office, to be based at Langley Research Center in Virginia. That new group, which will report to the Office of Safety and Mission Assurance at NASA headquarters, is aimed at making the workers responsible for safety and technical issues completely independent of the shuttle program, to ensure that any concerns are fully aired.

NASA also has named a 27-member task force to advise the agency on how to turn those recommendations into major changes. Led by Apollo-era astronaut Thomas Stafford and Richard Covey, who flew on the first mission after the Challenger accident, the group is supposed to issue a report to O'Keefe about a month before the next launch.

But McDonald and others wonder whether that will be enough because the Stafford-Covey panel is only chartered for two years.

"Without the follow-up of an independent review team of high technical caliber, you're not going to see real changes," McDonald said. "I'm concerned that will be the result [with the CAIB report], because that has been the result in the past."

Young said he truly believes that NASA will try very hard, and that NASA employees are genuine when they say safety is the ultimate priority. But major changes can only happen if agency workers really believe what the Columbia board is saying, he said.

"They'll do an excellent job of implementing all the technical recommendations. The real issue is, will they be sensitive to the next technical issue that's not included in the report?" he asked. "I would say the jury's out. I would say we should hope that the answer is yes, but I think you've got to be skeptical."

The Columbia board, in fact, suggested additional independent oversight, not just for its recommendations but for the agency as a whole. And U.S. Sen. Barbara Mikulski, a Maryland Democrat who sits on the appropriations subcommittee that writes NASA's budget, plans to push for a congressionally appointed panel to check up on the agency.

But Richard Blomberg, former chairman of the aerospace advisory panel, said any chance of changing the organization is going to require funding. Budget cutbacks were a big worry for his panel, he said, because some other recommendations likely were never implemented for lack of money.

"We'd issue our recommendations and NASA would come back and agree and initiate a plan," he said. "Plans don't get things done. If no one gives them a budget, they can't do anything but plan."

By Debbie Salamone and Gwyneth K. Shaw.

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