The Columbia mishap: an interview with RDML Steve Turcotte: RDML Turcotte commanded the Naval Safety Center until August 2003. He was a member of the NASA Columbia Accident Investigation Board, and currently is Commander, Naval Region Mid-Atlantic

Approach, March-April, 2004 by George Platz, Rick Boyer, Derek Nelson

How did you become a member of the Columbia Accident Investigation Board?

After the Challenger accident [on January 28, 1986], a standing investigation board was created, replicating the Navy's squadron mishap-investigation-board process. Representatives were selected from the Navy, Air Force, FAA, DOT's National Transportation Safety Board, and NASA's Ames Research Center. The board meets once a year for a training exercise. Right after the Columbia accident, the board was convened and Adm. Gehman was selected to chair the board. The investigation team ended up including approximately 120 people. The expertise of the people involved was incredible.

What were your responsibilities on the board?

We stated our preferences to Adm. Gehman. I asked to head up the maintenance portion of the investigation. I have had an extensive maintenance background through my operational experiences in naval aviation, and I felt this aspect of the mishap was going to represent a significant part of the final report. I spent my time commuting between Houston and Cape Canaveral, walking the floors and communicating with the engineers responsible for the different shuttle maintenance programs.

Secretary of Defense Rumsfeld has recently set a DOD-wide goal to reduce the aircraft-accident rate by 50 percent in the next two years. One of the primary causal factors revealed in the Columbia Accident Investigation Report was that of a culture at NASA that helped to spawn the events leading to the mishap. Did your work on the board give you any insight into how Secretary Rumsfeld's goal could help to be achieved by changing the culture of nasal aviation?

I think we do a lot of things right in naval aviation and we really need to give ourselves a pat on the back. It took only a short time to realize that there were some serious communication issues going on at NASA between the engineers and the senior management. In naval aviation, when an aircraft is designed and built, the engineering process does not end there. Every time something goes wrong with a naval aircraft, it is well-documented and new procedures are put in place to deal with those engineering problems on a continuous cycle based on operational data. The same is not always true at NASA. The engineering analysis did not always keep pace with the operational deficiencies of the shuttle program. NASA lived in a world of extrapolated physics versus realistic physics. A problem at NASA would surface, the problem would be fixed, but then no system was put into place to ensure that problem was reevaluated periodically. From the professional engineers at NavAir all the way down to the Sailor carrying their individual MRC [maintenance requirement cards], naval aviation is well ahead of NASA in that respect. We don't rest on design criteria to ensure that systems are operating correctly. Another important observation I took away from the investigation is there needs to be a more inclusive Safety Center relationship with naval aviation to make sure the lessons we learn from maintenance and operational anomalies are communicated to the fleet.

Earlier this year, VAdm. Malone sent out a "Personal For" message to squadron commanding officers, asking for ideas on how to improve the Navy's accident rate. One of the requirements resulting from this message was the mandatory participation of Navy squadrons in the Naval Safety Center's culture-workshop program. Did your work on the Columbia Accident Investigation Board influence your opinion on the potential effectiveness of this program for Navy and Marine Corps squadrons?

My second big takeaway from the investigation process was the necessity for more hands-on intervention at the leadership level, and I believe that the culture workshop is the ideal tool to support this requirement. NASA lived in a "we've been doing it like this for years" safety culture. The knowledge of system deficiencies was right in front of them, but they could or would not see it. Squadrons can sometimes be caught up in this same type of thought process. There are warning signals all around, but nobody acknowledges them until it is too late. The culture-workshop program takes an experienced set of trained eyes from the outside and provides an intervention process for the CO to make sure that those hazards are identified and acted upon before they become mishaps.

The culture workshop's foundation statement reads: "Operational excellence is built on a foundation of trust, integrity rend leadership, created and sustained by effective communication." Did any of these pillars of safety break down and allow the Columbia accident to occur?

I can give you an excellent example of integrity. At NASA, senior engineers were making go/no-go decisions on systems they were not technically qualified to make. These individuals were swayed by senior NASA management's desire to keep the program on schedule. It was like making a junior officer the CO. Risk decisions were not only made at the wrong level, but unqualified individuals were making them. This resulted in a terrible breach of integrity in the engineering decisions made at NASA. As for trust, a leader has to always know whom they can and cannot rely on for good advice. I sometimes use the old ploy of asking a question I already know the answer to. If I get an honest reply, then I know I can trust that person in the future. If the reply is less than sincere, then I know that individual needs further guidance. Leadership is the overall key to how a squadron operates. Commanding officers must realize they are always being looked at and emulated. A commanding officer's attitude and actions will ultimately decide the direction that a squadron takes.