NASA under siege

Risk & Insurance, May, 2004 by Ann Deering, William E. Haynes

Had the National Aeronautics and Space Administration applied proper risk management guidelines, the destruction of shuttle Columbia last year might have been averted. In an investigation, it was revealed that the risk of flying with damaged insulation tiles had been identified by engineers. Yet they were stonewalled, they claimed, as a result of the agency's myopic, fractured and ineffective approach to risk management.

Space exploration is an inherently dangerous and costly business. With a new mission from the Bush administration, the National Aeronautics and Space Administration will soon embark on the greatest risk management challenge ever to face mankind. On Jan. 14, President Bush announced that "human beings are headed into the cosmos." By doing this, he set bold new initiatives for the U.S. manned space program: to colonize the moon and send astronauts to Mars.

It has been a little more than a year since the charred pieces of shuttle Columbia streaked across thousands of square miles killing seven astronauts and leaving the orbiter in millions of pieces.

The Columbia Accident Investigation Board blamed the failure on NASA's mismanagement, culture and attitude. It all boiled down to an organization that failed to embrace risk management and a culture that ignored risk by refusing to face unwelcome consequences.

If future catastrophes are to be avoided, NASA has to change its culture and address risk regardless of potentially discomfiting public perceptions.

Current NASA administrator Scan O'Keefe, responding to the CAIB report and the issue of culture change, said "there needs to be a fundamental shift from the current ethic of 'prove that it is unsafe' to one wherein all the processes seek to 'prove that it is safe.'"

O'Keefe's most recent public risk-related decision wax to cancel a shuttle mission to the Hubble telescope. That decision, scientists agree, insures that the Hubble will run out of power in the next three years. For O'Keefe, the decision was made because he didn't believe the mission would be "compatible with the recommendations" made by the CAIB.

O'Keefe noted that if the shuttle was crippled in an attempt to fix the Hubble, there would be no way to reach the International Space Station in time to deal with any potential problems, and it would leave the astronauts on the station just 14 days to survive.

"I will not under any circumstances authorize the conduct of a mission like that," O'Keefe said

If any organization should be obsessed with risk management, it should be NASA. In response to the CAIB report, NASA established an Independent Engineering and Safety Center at its Langley Research Center. But, despite this new operation, critics question whether the center will be truly independent of NASA administrators concerned about scheduling and budgets. The issue is whether safety will be an overriding concern if it comes into conflict with a tight space exploration schedule.

Peter Rutledge, director of enterprise safety and mission assurance, insists that risk management is at the heart of NASA's current culture. "I think that risk management is certainly important to all that NASA does," he says. "It's an essential part of improving NASA culture. It will be an important part of saving lives in the future."

The present NASA risk management process involves five steps: identify risks; analyze and prioritize those risks; plan mitigation actions; track progress; and control the outcomes.

TURNING A BLIND EYE

Had NASA applied these risk management guidelines, the Columbia accident might have been averted. In the Columbia investigation, for example, there is testimony that the risks of the shuttle flying with damaged insulation tiles had been identified by NASA engineers. Yet they were stonewalled when they attempted to analyze the implications of a breach to the shuttle's thermal shield.

According to the testimony, the mitigation, progress tracking and outcomes analysis steps were ignored. The result was catastrophic.

Post-accident analysis of the 1986 Challenger and the 2003 Columbia accidents show that NASA managers knew the technical causes of the failures before either catastrophe occurred. The specific problems were documented and provided to NASA leadership.

Even if the engineering and technical issues had been resolved, a more serious issue sits at the heart of NASA's failures: NASA's culture prevented it from allowing its line managers to take risk management very. seriously, even after the lessons of the 1986 Challenger accident.

In a 1994 NASA-funded study, Space Program Reliability--Failure Models, Risk Management for the Tiles of the Space Shuttle, NASA is accused of failing to conduct risk analysis going back to the 1960s, when it eventually landed a man on the moon.

The report, written by M. Elizabeth Pate-Cornell of Stanford University and Paul S. Fischbeck of Carnegie Mellon University, states that NASA "forbid the use of risk analysis" because it would "scare the public and discourage congressional funding."