Why NASA must change

Published on Wednesday 27 August 2003 01:00

ONLY a revolution in NASA’s attitude towards safety will prevent another space shuttle disaster, a damning final report into the loss of the orbiter Columbia has concluded.

In a judgment that will have far-reaching implications for the space agency’s human space flight programme for years to come, the Columbia Accident Investigation Board (CAIB) blamed persistent flaws in NASA’s management culture for contributing to the fatal break-up of Columbia.

The board said NASA had grown complacent and had developed a self-protective culture that prevented it tackling safety problems head on. The board made 29 recommendations for improvement.

In a stark warning, it said: "If these persistent, systemic flaws are not resolved, the scene is set for another accident."

It added: "The changes we recommend will be difficult to accomplish - and will be internally resisted."

The 250-page report into the 1 February tragedy that claimed the lives of seven astronauts, said the foam cladding that broke away from a fuel tank and struck the orbiter on lift-off, creating a critical hole in the wing, was not the sole cause of the craft’s break-up.

"In our view the NASA organisational culture had as much to do with this accident as the foam," stated the CAIB’s chairman, retired United States navy admiral, Harold Gehman.

The report was the result of a seven-month-long investigation by the CAIB’s 13 independent board members, more than 120 investigators, 400 NASA and contractor employees, and more than 25,000 people who recovered Columbia’s debris.

"Management decisions made during Columbia’s final flight reflect missed opportunities, blocked or ineffective communications channels, flawed analysis and ineffective leadership," the report states.

"In the face of mission managers’ low level of concern and desire to get on with the mission, engineers found themselves in the unusual position of having to prove that the situation was unsafe - a reversal of the usual requirement to prove that a situation is safe."

Budget constraints and schedule pressure contributed to the problems.

"These little pieces of risk add up until managers are no longer aware of the total programme risk and are, in fact, gambling. Little by little, NASA was accepting more and more risk in order to stay on schedule."

Senior management, including the shuttle programme manager, Ron Dittemore and the mission management team chairman, Linda Ham, "displayed no interest in understanding a problem and its implications" and thereby "failed to fulfil the implicit contract to do whatever is possible to ensure the safety of the crew".

The report adds: "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 imposed."

The document was yesterday delivered to the White House and to Congress, both of which also come in for criticism for failing to deliver financial security to NASA, creating further pressures that impacted on the shuttle programme.

NASA administrator Sean O’Keefe issued a statement saying the agency has begun taking action on the board’s recommendations.

"We intend to comply with the full range of recommendations released today," he said.

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

Families of the victims were briefed on the report on Monday. Jonathan Clark, husband of astronaut Laurel Clark, said: "I think it’s very thorough, extremely thorough. From my perspective, it certainly hits right on the money."

The US president, George Bush, said the next steps for NASA "must be determined after a thorough review of the entire report, including its recommendations." He said the journey into space "will go on".

Yesterday’s report criticised NASA for failing to have learned the lessons of the past. It said "unfortunate similarities" existed between the Challenger accident of 1986 and February’s Columbia disaster, which killed Commander Rick Husband, pilot William McCool, payload commander Michael Anderson, mission specialists David Brown, Kalpana Chawla and Laurel Clark, and payload specialist Ilan Ramon.

"During Apollo, NASA was in many respects a highly successful organisation capable of achieving seemingly impossible feats. The continuing image of NASA as a ‘perfect place’ in the years after Apollo, left NASA employees unable to recognise that NASA never had been, and still was not, perfect," the report revealed.

Looking to the future, the CAIB called for a new "national vision" to direct the design of a new space transportation system.