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Board rips NASA on management, safety

By Associated Press
© St. Petersburg Times
published August 27, 2003

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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 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.

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 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.

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.

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 decisionmaking, 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.

The board refused in its report to blame any one individual for the tragedy, a view it has maintained since the beginning.


A 11/2-pound chunk of foam insulation that broke off the external fuel tank just over a minute into launch made a crack in the left wing that led to the ship's destruction.

The shuttle is not "inherently unsafe," but efforts should be made:

To reduce fuel-tank foam shedding.

Toughen thermal shielding on the wings.

Find a way to do in-orbit inspections.

Create a means of repairing damage.

The report also focused on management failures at NASA, saying the agency lacks "effective checks and balances, does not have an independent safety program and has not demonstrated the characteristics of a learning organization." Therefore, NASA should:

Better train managers to handle emergencies.

Establish an independent board to identify and analyze any possible hazards during a shuttle system's life and have sole authority to grant waivers for technical standards.

Give NASA's safety office direct authority over the entire safety of the shuttle program.


f,9,hr0 Launch shuttle Atlantis sometime between March 11 and April 6.

Replace NASA's aging space shuttle fleet, now reduced to three, as quickly as possible.

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