Spaceflight Now

CAIB issues bleak shuttle report
Posted: August 26, 2003

  NASA receives report NASA Administrator Sean O'Keefe (left) receives copies of the report of the Columbia Accident Investigation Board from board chairman Hal Gehman. Photo: NASA/Bill Ingalls.
The Columbia Accident Investigation Board released its long-awaited report today, blaming the Feb. 1 disaster on bureaucratic inertia, slipshod internal communications and ineffective management at the top levels of NASA. The scathing, pessimistic tone of the report left little doubt the Board believes the so-called "NASA culture" is deeply flawed and in need of major modifications to prevent a repeat of the Columbia disaster in the years ahead.

"Based on NASA's history of ignoring external recommendations, or making improvements that atrophy with time, the Board has no confidence that the space shuttle can be safely operated for more than a few years based solely on renewed post-accident vigilance," the report states.

Unless NASA takes strong action to change its management culture to enhance safety margins in shuttle operations, "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 they will be internally resisted."

For an agency with such a proud tradition - sending 12 men to the surface of the moon, establishing a permanent presence in low Earth orbit, exploring the solar system with unmanned robots and launching scientific sentinels to probe the depths of space and time - the criticism levied by the accident board likely will seem extreme in its harshness.

But the accident investigation board members and their investigators clearly believe the sharp tone is appropriate, in their view essential to ensuring that wide-ranging corrective actions are actually implemented. The board's investigation found that "management decisions made during Columbia's final flight reflect missed opportunities, blocked or ineffective communications channels, flawed analysis and ineffective leadership."

In the end, the report concludes, NASA managers never really understood the lessons of the 1986 Challenger disaster and "echoes of Challenger" abound in the miscues that led to Columbia's destruction.

"Connecting the parts of NASA's organizational system and drawing the parallels with Challenger demonstrate three things," the board found. "First, despite all the post-Challenger changes at NASA and the agency's notable achievements since, the causes of the institutional failure responsible for Challenger have not been fixed.

"Second, the Board strongly believes that if these persistent, systemic flaws are not resolved, the scene is set for another accident. Therefore, the recommendations for change are not only for fixing the shuttle's technical system, but also for fixing each part of the organizational system that produced Columbia's failure.

"Third, the Board's focus on the context in which decision making occurred does not mean that individuals are not responsible and accountable. To the contrary, individuals always must assume responsibility for their actions. What it does mean is that NASA's problems cannot be solved simply by retirements, resignations, or transferring personnel."

NASA managers had no immediate response to the CAIB report.

The 13-member Columbia Accident Investigation Board, under the leadership of retired Adm. Harold Gehman, spent seven months investigating the Feb. 1 Columbia disaster, reviewing more than 30,000 documents, conducting more than 200 formal interviews and collecting testimony from expert witnesses. The board also oversaw debris recovery efforts in Texas and Louisiana that involved more than 25,000 searchers. The investigation is expected to cost $19.8 million when all is said and done.

The board's 248-page report was released at 10 a.m. at the National Transportation and Safety Board in Washington. Reporters were allowed to review the report ahead of time, surrendering cell phones and wireless laptop network cards before entering a closed off "reading room" at 6 a.m. Gehman and other members of the panel plan to discuss the report during an 11 a.m. news conference. This status report will be updated as soon as possible thereafter.

In the meantime, key lawmakers vowed to take the board's recommendations to heart.

"The people of NASA have accomplished great things," Dana Rohrabacher, D-Calif., chairman of a key House space committee, told CBS News Monday. "They've put a man on the moon within a very short period of time, the people of NASA have been a source of great pride ... for the people of the United States.

"But for far too long, they've been resting on their laurels and bathing in past glories, nostalgic about the glory days," he continued. "It's time to look to the future and it's time to recapture a tough, hard-working body of people who have new challenges and are not just looking at the past but looking to the future. And that means Congress and the president have got to act on the Gehman report."

It should be noted, however, that NASA cannot develop new manned spacecraft or significantly change the general thrust of the nation's space program without approval and funding from Congress and the White House. The Bush administration has been virtually silent when it comes to the nation's manned space program and Congress has not endorsed any major changes beyond controlling the budget of the international space station.

President Bush has not yet weighed in on the report or its implications for NASA and the international space station project. He said last week he wanted a chance to review the report before commenting.

The report focuses on two broad themes: The direct cause of the disaster - falling external fuel tank foam insulation that blasted a deadly hole in the leading edge of Columbia's left wing 82 seconds after liftoff - and the management system that failed to recognize frequent foam shedding as a potentially lethal defect before Columbia even took off.

The report also focuses on how NASA's mission management team, a panel of senior agency managers responsible for the day-to-day conduct of Columbia's mission, failed to recognize the severity of the foam strike that actually occurred, virtually eliminating any chance to save the shuttle's crew, either by attempting repairs in orbit or launching a rescue mission.

The report makes 29 recommendations, 15 of which must be implemented before shuttle flights resume. Five of those were released earlier, requiring NASA to eliminate foam shedding to the maximum extent possible; to obtain better imagery from the ground and in orbit to identify any problems with the shuttle's thermal protection system; and development of tools and procedures to repair any such damage in space.

The more difficult recommendations address management changes and the establishment of an independent Technical Engineering Authority to verify launch readiness, oversee and coordinate requests for waivers and to "decide what is and is not an anomalous event." The TEA "should have no connection to or responsibility for schedule and program cost." In addition, NASA's Office of Safety and Mission Assurance should have direct authority over all shuttle safety programs and be independently funded.

"It is the Board's opinion that good leadership can direct a culture to adapt to new realities," the panel wrote. "NASA's culture must change, and the Board intends (its) recommendations to be steps toward effecting this change."

Columbia, carrying a crew of seven and scores of scientific experiments, blasted off from the Kennedy Space Center in Florida on Jan. 16. Strapped in on Columbia's upper flight deck were commander Rick Husband, making his second flight; rookie pilot William "Willie" McCool; flight engineer Kalpana Chawla, making her second flight; and rookie astronaut-flight surgeon Laurel Clark. Seated below on the shuttle's middeck were payload commander Michael Anderson, making his second flight; and two more rookies, physician-astronaut David Brown and Ilan Ramon, the first Israeli space flier.

At 81.7 seconds after liftoff from pad 39A, a suitcase-size chunk of foam broke away from the ship's external fuel tank and slammed into the left wing. The shuttle was racing skyward at more than twice the speed of sound at the time - 1,650 mph - and engineers later calculated the foam hit the left wing at some 530 mph.

The foam strike was not seen until the day after launch when engineers began reviewing tracking camera footage as they do after every launching. A film camera in Cocoa Beach that could have photographed the impact on the underside of the left wing was out of focus. A video camera at the same site was properly focused, but it lacked the resolution, or clarity, to show exactly where the foam hit or whether it caused any damage. A third camera at a different site showed the foam disappearing under the left wing and emerging as a cloud of debris after striking the underside. Again, the exact impact point could not be seen.

Stunned engineers immediately began analyzing the available film and video and ultimately determined the foam had struck heat shield tiles on the underside of the wing, perhaps near the left main landing gear door. No one ever seriously considered a direct heat on the reinforced carbon carbon panels making up the wing leading edge because no trace of foam debris was ever seen crossing the top of the wing. As the board ultimately concluded, however, the foam did, in fact, strike the leading edge on the lower side of RCC panel No. 8.

In hindsight, it's difficult to understand why the possibility of a leading edge impact didn't receive more attention. The board concluded that was due at least in part to the influential role of Calvin Schomburg, a senior engineer at the Johnson Space Center with expertise in the shuttle's heat-shield tiles.

"Shuttle program managers regarded Schomburg as an expert on the thermal protection system," the board wrote. "However, the board notes that Schomburg as not an expert on reinforced carbon carbon (RCC), which initial debris analysis indicated the foam may have struck. Because neither Schomburg nor shuttle management rigorously differentiated between tiles and RCC panels, the bounds of Schomburg's expertise were never properly qualified or questioned."

In any case, a team of Boeing engineers at the Johnson Space Center, under direction of NASA's mission management team, ultimately concluded the foam strike did not pose a safety of flight issue. Their analysis, using a computer program called CRATER, predicted areas of localized, possibly severe damage to the underside of the left wing, but no catastrophic breach. The concern, rather, was that any damage likely would require extensive repairs before Columbia could fly again.

While the damage assessment was getting under way, at least three different attempts were made to obtain spy satellite photography of the impact site to resolve the matter one way or the other. But in a series of communications miscues, the efforts ultimately were quashed by the MMT, under the direction of former flight director Linda Ham.

Ham says she was never able to find out who wanted such photographs and, without a formal requirement, had no reason to proceed. As for the debris assessment, Ham and other members of the MMT never challenged the hurried analysis or questioned the conclusion Columbia could safely return to Earth as is.

Many mid-level engineers said later they had serious misgivings about the debris assessment and heavy email traffic indicated fairly widespread concern about potentially serious problems if the foam strike had compromised Columbia's left main landing gear. Yet those concerns never percolated up the Ham, Dittemore or other members of the mission management team.

Ham and Dittemore both have said they were always open for questions or comments from lower-level engineers and that everyone on the team was encouraged, even duty bound, to bring any serious concerns to the attention of senior management.

But the CAIB disagreed.

"Communication did not flow effectively up to or down from program managers," the board wrote. "After the accident, program managers stated privately and publicly that if engineers had a safety concern, they were obligated to communicate their concerns to management. Managers did not seem to understand that as leaders they had a corresponding and perhaps greater obligation to create viable routes for the engineering community to express their views and receive information. This barrier to communications not only blocked the flow of information to managers but it also prevented the downstream flow of information from managers to engineers, leaving Debris Assessment Team members no basis for understanding the reasoning behind Mission Management Team decisions."

As for not hearing any dissent, the board wrote, "managers' claims that they didn't hear the engineers' concerns were due in part to their not asking or listening."

"Management decisions made during Columbia's final flight reflect missed opportunities, blocked or ineffective communications channels, flawed analysis and ineffective leadership," the board wrote. "Perhaps most striking is the fact that management - including Shuttle Program, Mission Management Team, Mission Evaluation Room (personnel) and flight director and mission control - displayed no interest in understanding a problem and its implications.

"Because managers failed to avail themselves of the wide range of expertise and opinion necessary to achieve the best answer to the debris strike question - 'Was this a safety-of-flight concern?' - some space shuttle program managers failed to fulfill the implicit contract to do whatever is possible to ensure the safety of the crew. In fact, their management techniques unknowingly imposed barriers that kept at bay both engineering concerns and dissenting views and ultimately helped create 'blind spots' that prevented them from seeing the danger the foam strike posed."

Shuttle program manager Dittemore and members of the mission management team "had, over the course of the space shuttle program, gradually become inured to external tank foam losses and on a fundamental level did not believe foam striking the vehicle posed a critical threat to the orbiter," the board wrote.

In the end, many NASA managers say privately, it was a moot point. Once the foam breached the leading edge of Columbia's left wing, the crew was doomed. The astronauts had no way to repair the breach - no robot arm and no tile repair equipment - and there was no realistic chance another shuttle could be readied in time for a rescue mission.

Maybe so. But NASA's flawed management system never gave the agency a chance to prove it still had the "right stuff."

It is that institutional system, or "culture," at NASA that must be changed, the board believes, to prevent another accident.

"An organization system failure calls for corrective measures that address all relevant levels of the organization, but the Board's investigation shows that for all its cutting-edge technologies, 'diving-catch' rescues and imaginative plans for the technology and the future of space exploration, NASA has shown very little understanding of the inner workings of its own organization," the report states.

"NASA's bureaucratic structure kept important information from reaching engineers and managers alike. 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.

"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. Management was not able to recognize that in unprecedented conditions, when lives are on the line, flexibility and democratic process should take priority over bureaucratic response."

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