Sept. 15, 2003 — A member of the Columbia Accident Investigation Board is warning that another shuttle accident could occur unless the board’s “suggestions” and “observations” are upgraded to mandatory recommendations and put into effect before the shuttles fly again. The warning appears in a not-yet-published supplement to the board’s final report that was obtained by MSNBC.com.
“History reveals NASA has repeatedly demonstrated a lack of regard for outside studies and their findings,” the addendum states.
It warns, “If NASA settles back into its previous mindset of saying, ‘Thanks for your contribution to human space flight,’ summarily ignoring what it chooses to ignore, the outlook is bleak for the future of the program.”
The 10-page addendum, officially labeled pages 251-260 of the appendices section of the report, was written by Air Force Brig. Gen. Duane Deal. Deal is currently the commander of the 21st Space Wing at Peterson Air Force Base, Colo., which provides missile warning and space control for combat forces. He has a B.S. in physics, an M.S. in systems management and an M.S. in counseling/psychology.
Deal, who has presided or participated in a dozen space and aircraft accident investigations, writes that he “fears the [original] report has bypassed some items that could prevent ‘the next accident’ from occurring.”
Raising the bar
CAIB’s own original report lambasted NASA for its “history of ignoring external recommendations” and its culture of “self-deception, introversion, [and] diminished curiosity about the outside world.” It prescribed changing to “an organizational culture that reflects the best characteristics of a learning organization.”
In his response, NASA Administrator Sean O’Keefe promised the space agency would fully implement all of the recommendations of the report, plus unspecified reforms of its own that “raise the bar” higher. Deal’s report raises the bar even further.
Deal specifically addresses cases of overly “optional” wording found in the main report, such as this passage in Chapter 10: “The significant issues listed in this chapter are potentially serious matters that should be addressed by NASA because they fall into the category of ‘weak signals’ that could be indications of future problems.”
Deal recommends that the paragraph be rewritten in “sterner and more effective wording”, deleting the word “potentially,” replacing the word “should” with “must,” and replacing the final “could be indications” with “are indications.”
Deal conducted hundreds of hours of interviews with shuttle processing workers, mainly at the Kennedy Space Center in Florida. They provided him with a list of consistent concerns that seemed to have escaped the notice of NASA’s managers whom Deal also interviewed.
He did find that the stand-alone NASA “Safety Reporting System” was properly responsive, but often it was faced with complaints from workers that their managers would not validate.
“[Workers] have found they must occasionally go around their management” to get proper attention, he writes. And despite written requirements that the work of “Quality Assurance Specialists” be independently verified, Deal found that “surveillance is discouraged and essentially nonexistent.”
“Past reports (such as the 1986 Rogers Commission, 2000 Shuttle Independent Assessment Team report, and 2003 internal Kennedy Tiger Team) affirmed the need for a strong and independent quality program,” Deal wrote, “though the quality program management at Kennedy took an opposite tack.” He details staffing shortcomings and other effects of budget cuts.
Engineering issues raised
The first technical recommendation in Deal’s supplemental report deals with the issue of structural corrosion of space shuttles (first suggested on MSNBC.com a week after the disaster). Rather than merely making the “observation” that NASA ought to someday get around to developing techniques to inspect and repair internal shuttle structure, Deal said such a step should be mandatory: “Develop non-destructive evaluation inspections to detect and, as necessary, correct hidden corrosion.”
Deal also addressed engineering issues associated with mechanisms holding the shuttle to the launch pad and capturing explosive bolts on the solid rocket boosters.
Concerning an issue of tremendous concern to any pilot, that of crew survivability, Deal was not satisfied with mere “observations” concerning long-term studies of enhancing the chance of a crew to survive a future shuttle disaster. He insisted that NASA “must evaluate” the feasibility of improvements such as adding a small amount of ablative or insulating material around the cabin’s inner pressure vessel. Such a relatively low-cost measure, he wrote, “might provide the thermal protection needed for the cabin to retain its structural integrity in certain extreme situations.”
Deal described a special 300-page log of all recommendations of all previous independent safety advisory groups, along with NASA responses. He wrote: “In light of the reaction to past studies — even those following the Challenger disaster — my confidence disappears when we offer NASA items only as ‘observations.’”
Deal warned that the future of the entire NASA space program depended on NASA’s ability to follow the recommendations of the investigation board.
“If NASA will accept this prescription and take the ‘medicine’ prescribed,” he wrote, “we may be optimistic regarding the program’s future.”
But his report detailed how NASA has regularly failed to follow through on such outside advice in the past, painting a “bleak” picture of what could happen if history repeated itself.
James Oberg, space analyst for NBC News, spent 22 years at the Johnson Space Center as a Mission Control operator and an orbital designer.
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