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Board Investigating Columbia Space Shuttle Accident Faults NASA's Culture

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

Aug. 27--WASHINGTON--America's "can-do" space agency should be able to fix the shuttle and get it flying again, but it may not be up to an even bigger and more important challenge: Fixing itself.

Harold Gehman, chairman of the Columbia Accident Investigation Board, said Tuesday that he had no doubt NASA would address safety issues with "vigilance,""zeal" and "attention to detail."

But in the next breath, Gehman warned that deeper problems embedded in the culture of the space agency might creep back and undo any short-term improvements after just a few flights.

"The board is concerned that over a period of a year or two, the natural tendency of all bureaucracies, not just NASA, to morph and migrate away from" the renewed attention to safety that comes after an accident, Gehman said. "The history of NASA is that they've done it before."

The Gehman panel devoted much of its report Tuesday to the cultural underpinnings of the shuttle's destruction and the deaths of its seven astronauts, citing overconfidence, blind spots and emphasis on bureaucracy as hindrances. Many were problems when the National Aeronautics and Space Administration lost shuttle Challenger 17 years ago.

If the lingering issues are to be corrected for good, NASA's leadership has to create a new culture that embraces safety above all else; and the agency must be reorganized to encourage those attitudes.

Experts say the changes will take time and a willingness to relinquish long-established ways of doing business. None of it will be easy.

"I can see how they [organizational changes] can be made, but whether or not NASA will make them is another issue," said Diane Vaughan, a Boston College professor who studied cultural factors behind the Challenger and Columbia tragedies and was a consultant who wrote part of the Columbia board's report. "I'm certain that they want to make them, but I also know they're in a hurry to get back to launching and I don't know if they will take the time to really study the organization."

The report goes deep into NASA's psyche, finding that many cultural contributors to Columbia's destruction have been around for decades.

"Despite all the post-Challenger changes at NASA and the agency's notable achievements since, the causes of institutional failure responsible for Challenger have not been fixed," the report states.

Part of the problem is that NASA steels itself against change because of a long-held belief that the agency is a "perfect place" uniquely qualified to safely launch humans into space. Gehman's group noted that this notion is tied to the astonishing successes of the Apollo era, when NASA beat the former Soviet Union in a race to the moon.

"NASA personnel maintained a vision of their agency that was rooted in the glories of an earlier time even as the world around them changed," the report states.

It said the "can do" attitude that put men on the moon also fosters an acceptance of risk and a belief in the inevitability of technical problems.

Gehman's group identified a litany of cultural influences that must be addressed:

The space agency has become overconfident and overly bureaucratic. Past successes have numbed the agency to new potential problems. The agency defers to cumbersome regulations rather than the fundamentals of safety.

NASA is in denial about the nature of its own safety program. NASA officials maintain that anyone can stop an operation at the "glimmer" of a problem, but that view does not reflect reality. The report found that often workers are too intimidated to speak out.

The attitude that the shuttle is an operational -- rather than an experimental -- vehicle. The shuttle should still be viewed as a test vehicle that needs constant monitoring and analysis for potential problems.

This perception of the shuttle as a routine means of space travel has tempered the way NASA assesses potential dangers. For example, recurring problems become accepted as part of the shuttle's normal operations rather than warning bells that something might be brewing, the report found.

What's more, the agency has gotten away from the vigilant technical oversight that existed in earlier times. The report notes that even NASA's way of presenting technical information -- in condensed PowerPoint presentations -- results in offering a slimmed-down view of the issue.

Gehman's panel called for a return to highly detailed technical analyses to ensure that higher-level managers get enough information to truly assess the nature of a problem.

To make the improvements, the report suggested NASA take some pointers from other agencies that manage high-risk situations. The U.S. Navy's nuclear-powered fleet has traveled a total of 127 million miles without a reactor accident because of a robust safety culture, the report said. The Navy requires timely communication of problems, gives credence to the concerns of even a few people and seeks input from outside experts.

"Operations that successfully operate high-risk technologies have a major characteristic in common," the report found. "They place a premium on safety and reliability by structuring their programs so that technical and safety engineering organizations own the process of determining, maintaining and waiving technical requirements."

To create the changes, the report calls on organizational changes that create separate and independent safety and technical groups. But one board member, Air Force Maj. Gen. John Barry, said that re-organization won't be enough.

"The second part of that recipe is leadership, and that's where NASA has to do its role," Barry said. "Leadership is clearly key to that."

While the agency's own leaders have to be on board, experts said NASA is also going to need outside pressure to keep focused on the overhaul of agency attitudes.

"It's going to be tough, but I think with some good outside pressure, they might be able to fix themselves," said Karlene Roberts, a professor of business at the University of California at Berkeley and a consultant for minimizing dangers in high-risk fields. "It's a matter of life and death for them."

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