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Richland, Wash., Nuclear Reservation Could Learn Lessons From Shuttle Disaster

Posted on: Tuesday, 27 July 2004, 06:00 CDT

Jul. 27--Hanford officials are hoping to learn how to prevent problems at the nuclear reservation from the lessons learned in the investigation of the Columbia space shuttle disaster last year.

"Complex systems fail in complex ways," said retired Major Gen. John L. Barry, who served as executive director of the Columbia Accident Investigation. He spoke Monday to Hanford managers and supervisors in Richland.

The investigation concluded that a piece of foam broke off the shuttle's external fuel tank, hitting and damaging the leading edge of the left wing. The damage in the initial seconds of flight caused the shuttle to break up on re-entry, and the seven crew members aboard died.

But the investigation looked beyond the technical problem and those directly responsible for it to find what Barry called a more insidious reason for the accident -- how NASA management and culture contributed to the failure to prevent the disaster.

"Communication, communication, communication," he preached.

The February 2003 shuttle flight was the seventh time that foam insulating a shuttle's external fuel tank came off during flight. Only once before, in October 2002, had the foam hit a shuttle, but it glanced off without causing damage.

In Columbia's last flight, 2.6 pounds of foam broke off in three pieces. The largest of those hit the 1Ú4-inch-wide leading edge of the wing at 500 mph. On re-entry, superheated air rushed into the wing's breach.

NASA officials knew Columbia had been hit but assumed no damage was done.

Barry called NASA's reaction to the history of foam problems "normalizing deviance." The foam problem occurred again and again, but because it caused no damage in the initial incidents, NASA officials assumed it would not in future incidents.

It was a bit like playing Russian roulette, Barry said.

NASA employees at all levels failed to address the problem, he said.

Engineers and other nonmanagement employees discussed concerns in e-mails and informal conversations that the foam could have damaged the Columbia shuttle after launch. But they did not present their concerns formally to those in charge, Barry said.

The balance of power in NASA led them to believe it was not their place to raise the issue. In addition, adherence to bureaucracy, timidity and NASA officials' predetermination that the foam was not a problem kept them from reporting their concerns, Barry said.

Those in charge of safety had little rank or authority, Barry said.

"It had become a silent safety program," he said.

NASA also lacked checks and balances at its top levels. The program manager who held the power to make decisions was not required to consult independent parties when making important rulings on unusual matters, he said.

NASA also had fewer employees with the experience, knowledge and time to watch for problems and address them as it turned increasingly to contractors.

"There wasn't the ear to hear the small things that go wrong," Barry said.

Although NASA had developed a list of 1,600 items that could fail and lead to a loss of the shuttle or crew, more than half were waived and never re-examined even as Columbia aged.

Some of the cultural and management problems might have been addressed if NASA had its employees study the lessons learned from the earlier Challenger disaster. Although the Navy had 5,000 managers study the 1986 disaster to learn from it, NASA instead chose to put the Challenger disaster behind it.

"NASA had not become a learning organization," Barry said.

An active safety organization, trend analysis, redundancy, checks and balances and communication are essential to any organization with a high-risk mission, he told Hanford managers Monday.

Managers at other DOE sites also are looking to learn from the Columbia investigation. The Defense Nuclear Facilities Safety Board, which provides independent oversight of DOE nuclear sites, has focused on what the report can teach DOE about developing a culture to prevent accidents.

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