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Associated Press WASHINGTON (Aug. 26) - 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 1 1/2-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 place over a period of 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.
At the time of Columbia's doomed launch, the board said, NASA retained too many negative aspects of its traditional culture: ``flawed decision making, self deception, introversion and a diminished curiosity about the world outside the perfect place.''
Shuttle managers had become conditioned over time not to regard the loss of fuel-tank foam insulation as a safety issue, the board stated, and were facing intense pressure to complete the U.S. portion of the international space station by February 2004.
A significant piece of foam came off Atlantis' fuel tank during liftoff in October and struck one of the booster rockets. Yet, shuttle managers continued with the launch of Endeavour on a space station delivery mission in November and then with Columbia's scientific mission in January.
Five days after Columbia's liftoff, the head of the mission management team, Linda Ham, wrote in an e-mail to shuttle program manager Ron Dittemore: ``Rationale was lousy then and still is.'' Nonetheless, neither objected to the quick back-to-back launches after the Atlantis foam strike. The board said both officials - and many others at NASA - were influenced by the space agency's push to wrap up work on the American segment of the space station.
The board refused in its report to blame any one individual for the tragedy, a view it has maintained since the beginning.
Gehman said he hoped the report would spur ``a very vigorous public policy debate about what do we do now. How soon do we replace the shuttle? What is the United States' vision for human spaceflight? Once you answer the question, what is our vision, you have to answer the next question, 'Are you willing to resource that vision,' because this stuff is not cheap.''
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 1 1/2-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 place over a period of 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.
At the time of Columbia's doomed launch, the board said, NASA retained too many negative aspects of its traditional culture: ``flawed decision making, self deception, introversion and a diminished curiosity about the world outside the perfect place.''
Shuttle managers had become conditioned over time not to regard the loss of fuel-tank foam insulation as a safety issue, the board stated, and were facing intense pressure to complete the U.S. portion of the international space station by February 2004.
A significant piece of foam came off Atlantis' fuel tank during liftoff in October and struck one of the booster rockets. Yet, shuttle managers continued with the launch of Endeavour on a space station delivery mission in November and then with Columbia's scientific mission in January.
Five days after Columbia's liftoff, the head of the mission management team, Linda Ham, wrote in an e-mail to shuttle program manager Ron Dittemore: ``Rationale was lousy then and still is.'' Nonetheless, neither objected to the quick back-to-back launches after the Atlantis foam strike. The board said both officials - and many others at NASA - were influenced by the space agency's push to wrap up work on the American segment of the space station.
The board refused in its report to blame any one individual for the tragedy, a view it has maintained since the beginning.
Gehman said he hoped the report would spur ``a very vigorous public policy debate about what do we do now. How soon do we replace the shuttle? What is the United States' vision for human spaceflight? Once you answer the question, what is our vision, you have to answer the next question, 'Are you willing to resource that vision,' because this stuff is not cheap.''
If I remember right NASA knew the shuttle was damaged. But they let them try to bring it back in anyway. If that is the case then NASA should be held resopnsible.