SPACE CENTER, Houston - The space shuttle engineers who desperately wanted zoom-in satellite pictures of the damaged Columbia in orbit never spoke up at key meetings and never told the manager in charge of the flight.
They were too uncomfortable. Too afraid.
Whatever the reason for the chilling silence, NASA chief Sean O'Keefe is promising dramatic change. He told employees last week he is committed to "creating an atmosphere in which we're all encouraged to raise our hand and say something's not right or something doesn't look safe."
"We all have a responsibility," he said, "to redouble our efforts to create that atmosphere."
For starters, employees will be able to go to the NASA Web site and "file anything anybody sees as being off," O'Keefe said. "It will make it really easy for anybody to participate and voice their concerns anonymously or through any other means they want to," including NASA's longtime safety-reporting hot line and printed forms.
But James Oberg, a former shuttle flight controller, doubts that will solve the problem.
"I've heard that before. In fact, I heard that 17 years ago," Oberg said, referring to the 1986 Challenger accident.
To the Columbia Accident Investigation Board, the foul-up over satellite images is a prime example of what is wrong deep within NASA - and the 13 members intend to highlight management failures in their final report, due out in late August.
Board member John Logsdon blames the problem, at least in part, on so-called tribalism: "It's a particular culture, has its own rules and its own behavior patterns."
NASA's previous boss, Daniel Goldin, scared many workers with his abrasive, demanding demeanor, and the effects of that may have lingered after he left NASA in 2001, Logsdon noted. "There were people afraid to tell Mr. Goldin things he didn't want to hear," he said.
Jose Garcia, a retired shuttle operations manager, was one of the few who openly voiced his complaints about NASA safety cutbacks not only to Goldin, but to the White House.
What surprised the former Kennedy Space Center worker was not the loss of another shuttle - he predicted that back in 1995 - but the fact that he was not fired or even demoted for speaking out.
Oberg, too, spoke up when he was at Johnson Space Center in the mid 1990s, warning of the dangers of Mir and the Russian space program. He ultimately was right; a fire and decompression crippled the orbiting station. But he was shunned, taken off critical e-mail lists and hauled in for frequent job reviews. He quit in late 1997.
While acknowledging mistakes, a former flight director who served on Columbia's mission management team, Phil Engelauf, has "trouble accepting the idea that this flight failed because one individual was afraid to say something in one particular meeting."
"I wouldn't look at this case as being all of NASA was wrong except one guy who had the answer," Engelauf said. "There has to be a more fundamental structural problem with how the communication broke down here."