Scathing report points finger at NASA's 'blind spot'

0 Comments | Oakland Tribune, Aug 27, 2003 | by Marcia Dunn, Associated Press

WASHINGTON -- NASA's overconfident management and inattention to safety doomed Columbia every bit as much as the chunk of foam that struck the shuttle with deadly force, investigators concluded Tuesday. Without drastic changes, they said, another disaster is likely.

In a scathing 248-page report coming almost seven months to the day after the spacecraft disintegrated over Texas, the Columbia Accident Investigation Board said the shuttle was not "inherently unsafe," but issued a series of recommendations for a safe return to flight.

"The board strongly believes that if these persistent, systemic flaws are not resolved, the scene is set for another accident," the investigators wrote.

They added: "NASA's blind spot is it believes it has a strong safety culture."

The board said the space agency lacks "effective checks and balances, does not have an independent safety program and has not demonstrated the characteristics of a learning organization."

Board member John Barry put it this way: "NASA had conflicting goals of cost, schedule and safety. Unfortunately, safety lost out."

NASA Administrator Sean O'Keefe, prepared in advance for the sharp criticism, pledged to make the necessary changes. "We are, all of us at NASA, a part of the solution," he told space agency employees. And President Bush declared, "Our journey in space will go on."

The board concluded that safety engineers used "sleight of hand" tactics even before the Feb. 1 Columbia tragedy to play down the frequency of strikes by fuel-tank foam insulation and managers pressed ahead because of intense pressure from high up to stay on schedule. Even shuttle managers said the rationale for continuing to launch in the face of foam strikes was "lousy."

In all, the Columbia investigators issued 29 recommendations to NASA, six focusing on organizational change.

Dr. Jonathan Clark, a NASA flight surgeon whose wife was Columbia astronaut Dr. Laurel Clark, said the report "hit right on the money" and noted that changing the space agency's culture will be the real challenge.

The board agreed. "The changes we recommend will be difficult to accomplish and will be internally resisted," the report said.

"We know how hard it is for big organizations to change," said retired Navy Adm. Harold Gehman, the board's chairman.

NASA's vigilance after the 1986 Challenger explosion lessened as the years went by, and the recommendations by those investigators were forgotten or overlooked. So the Columbia investigators sought a deeper, broader analysis.

Observed board member Sheila Widnall, a former Air Force secretary: "I wanted to make sure that we were not just the second report on a shelf to be joined by a third report."

Some of the changes urged by the Columbia board -- eliminate as much fuel-tank foam shedding as possible, toughen the vulnerable thermal shielding on the wings, give astronauts inspection capabilities and repair kits -- are needed before shuttle flights resume, Gehman said. The culture issues will take longer, he said.

Key members of Congress are promising close scrutiny; the first round of hearings begins next week.

The board has done its job, "now it's time for us to do ours," said Rep. Bart Gordon, D-Tenn., a member of the Space and Aeronautics Subcommittee. "But the committee will not have done its work if we just listen to NASA mea culpas and do nothing to bring about changes."

"There should not be a rush to judgment," urged Rep. Sherwood Boehlert, R-N.Y., chairman of the Science Committee.

He said it will take time to put together "a full picture" of shuttle risks and costs, and determine whether and how the program should be run.

The board was unanimous in finding that that the 11/2-pound chunk of foam insulation that broke off the external fuel tank just over a minute into Columbia's mid-January launch created the breach in the left wing that led to the ship's destruction and the deaths of all seven astronauts.

"In four simple words, the foam did it," said NASA's Scott Hubbard, a board member who coordinated an incriminating series of foam-impact tests.

Columbia's mission managers missed at least eight opportunities to check the shuttle's left wing for damage, the report noted. The investigators determined that the astronauts died of blunt trauma and lack of oxygen, rather than the effects of rapid acceleration of the crew cabin. The exact time of death could not be determined; the destruction of the crew module took 24 seconds.

"Given the current design of the orbiter, there was no possibility for the crew to survive," the report said.

The report drew similarities between the Columbia and Challenger accidents, especially in the area of management failures.

NASA's space shuttle fleet, now reduced to three, has proven difficult and expensive to operate -- and more dangerous than expected, the report stated. Still, the investigators said they envisioned the shuttle returning to flight. They declined to say when that would happen, although NASA has said it hoped for a launch as early as next spring.