Investigators say flawed NASA culture led to Columbia accident

0 Comments | Deseret News (Salt Lake City), Aug 26, 2003 | by Paul Recer AP science

WASHINGTON -- A long-term relaxation of safety vigilance at NASA culminated in the loss of the space shuttle Columbia and its seven- member crew, investigators said today, warning that without sweeping changes, "the scene is set for another accident."

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," the board said in a stinging 248-page report.

"NASA's organizational culture had as much to do with this accident as foam did," the 13-member board said of the Feb. 1 disaster. Officials have known for months that a piece of insulating material broke away from the orbiter's fuel tank during launch struck the leading edge of the left wing and left it vulnerable to disintegration from the heat of re-entry.

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

At a news conference, one board member, Maj. Gen. John Barry, referred to a "silent safety program with echoes of Challenger," a reference to the shuttle that blew apart on launch in 1986, killing all seven astronauts aboard.

NASA Administrator Sean O'Keefe issued a statement saying that the agency already had begun to implement some of recommendations the board issued earlier. "And we intend to comply with the full range of recommendations released today."

He said the agency already has established a group to oversee the return to flight, and another "to change the culture" of NASA.

The board raised fundamental questions about the future of the nation's space program -- an effort whose lofty goals often collide with sober budget realities.

"NASA had conflicting goals of cost, schedule and safety," Barry said, "Unfortunately, safety lost out."

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The board issued three series of recommendations -- 29 in all. They included steps necessary before the shuttle flies again, those needed to make the shuttle inherently safer in the longer term and those that Gehman said consisted of "all the things we noted not pleased with."

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

At the same time, Gehman said a report on the accomplishments of NASA would run far longer than the one issued on the accident, and all members of the board endorsed a continuation of the nation's apace flight program.

In events leading up to the loss of Columbia, the report said, NASA mission managers fell into the habit of accepting as normal some flaws in the shuttle system and tended to ignore or not recognize that these problems could foreshadow catastrophe. This is an "echo" of some root causes of the Challenger accident, the board said.

"These repeating patterns mean that flawed practices embedded in NASA's organizational system continued for 20 years and made substantial contributions to both accidents," the 248-page report said.

During Columbia's last mission, NASA managers missed opportunities to evaluate possible damage to the craft's heat shield from a strike on the left wing by flying foam insulation. Such insulation strikes had occurred on previous missions and the report said NASA managers had come to view them as an acceptable abnormality that posed no safety risk.

This attitude also contributed to the lack of interest in getting spy satellite photos of Columbia, images that might have identified the extent of damage on the shuttle, and led to incorrect conclusions.

But most of all, the report noted, there was "ineffective leadership" that "failed to fulfill the implicit contract to do whatever is possible to ensure the safety of the crew."

Management techniques in NASA, the report said, discouraged dissenting views on safety issues and ultimately created "blind spots" about the risk to the space shuttle of the foam insulation impact.

Throughout its history, the report found, "NASA has consistently struggled to achieve viable safety programs" but the agency effort "has fallen short of its mark."

The board said it supports launching the next shuttle at "the earliest date" consistent with safety," and said the shuttle is "not inherently unsafe."

Some blame in the report was shifted to Congress and the White House because for almost a decade NASA lived on a lean budget that actually lost 13 percent of its purchasing power from 1993 to 2002.

At the same time, NASA was under pressure to build the International Space Station. To cut costs, the agency reduced its staff and contractor work force from about 32,000 in 1991 to just over 19,000 in 1997.

"The White House, Congress and NASA leadership exerted constant pressure to reduce or at least freeze operating costs (for the space shuttle)," the report said. As a result, "safety and support upgrades were delayed or deferred, and Shuttle infrastructure was allowed to deteriorate."

At another point, the report noted: "Little by little, NASA was accepting more and more risk in order to stay on schedule." Also: "The program was operating too close to too many margins."