NASA’s habit of relaxing safety standards to meet financial and time constraints set the stage for the Feb. 1 loss of the space shuttle Columbia and its seven astronauts, investigators said Tuesday. They warned that the agency’s “broken safety culture” would lead to tragedy again unless fundamental changes are made.
In a wide-ranging analysis of decades of NASA history, the Columbia Accident Investigation Board said the space agency’s attitude toward safety hasn’t changed much since the 1986 Challenger disaster, which also killed seven.
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,” the board said in a stinging 248-page report.
“The board strongly believes that if these persistent, systemic flaws are not resolved, the scene is set for another accident,” the report said.
Retired Navy Adm. Harold Gehman, the board’s chairman, told reporters at a Washington briefing that NASA tends to follow safety procedures diligently at first, then “morph or migrate away” from that diligence as time goes on.
“The history of NASA indicates that they’ve done it before,” Gehman said. Some of the report’s recommendations were aimed at fixing that organizational flaw, he said.
Responding to the report, NASA Administrator Sean O’Keefe noted that the board’s preliminary recommendations were already being adopted, and said the full report would serve as “NASA’s blueprint” for returning the three remaining space shuttles to flight operations.
President Bush said NASA’s next steps “must be determined after a thorough review of the entire report, including its recommendations.”
“Our journey into space will go on,” he said during a stop in St. Paul, Minn. “The work of the crew of the Columbia and the heroic explorers who traveled before them will continue.”
Jonathan Clark, the husband of Columbia astronaut Laurel Clark, said he thought the report was “extremely thorough.”
“From my perspective, it certainly hits right on the money,” he said.
An ‘Echo’ of challenger
In addition to detailing the technical factors behind Columbia’s breakup, just minutes before its scheduled landing at the end of a 16-day science mission, the board’s report laid out the cultural factors behind NASA’s failings. It said NASA mission managers fell into the habit of accepting as normal some flaws in the shuttle system and tended to ignore or not recognize that these problems could foreshadow catastrophe. This was an “echo” of some root causes of the Challenger accident, the board said.
“These repeating patterns mean that flawed practices embedded in NASA’s organizational system continued for 20 years and made substantial contributions to both accidents,” the report said.
During Columbia’s last mission, NASA managers missed opportunities to evaluate possible damage to the craft’s heat shield from a strike on the left wing by flying foam insulation. Such insulation strikes had occurred on previous missions, and the report said NASA managers had come to view them as an acceptable abnormality that posed no safety risk.
This attitude also contributed to the lack of interest in getting spy satellite photos of Columbia, images that might have identified the extent of damage on the shuttle and came to incorrect conclusions.
But most of all, the report noted, there was “ineffective leadership” that “failed to fulfill the implicit contract to do whatever is possible to ensure the safety of the crew.”
Management techniques in NASA, the report said, discouraged dissenting views on safety issues and ultimately created “blind spots” about the risk to the space shuttle of the foam insulation impact.
Throughout its history, the report found, “NASA has consistently struggled to achieve viable safety programs” but the agency effort “has fallen short of its mark.”
‘Safety lost out'
The board made 29 recommendations, including changes it said NASA must make to start flying again and long-range changes that will alter the space agency culture.
“The changes we recommend will be difficult to accomplish — and will be internally resisted,” the report said.
The board said it supports launching the next shuttle at “the earliest date” consistent with safety. It established a series of requirements before the next launch to focus more on threats to the shuttle, including a “relentless” hunt for the next dangerous failure and examining ways to help the crew escape.
The board concluded that the shuttle is “not inherently unsafe,” and outlined other recommendations that it said should allow NASA to continue flying shuttles for another 10 or even 20 years. Among those recommendations is a costly and time-consuming complete recertification of all shuttle systems.
Maj. Gen. John Barry, a member of the board, told journalists that NASA’s safety mission has conflicted with the goals of reducing costs and meeting flight schedules. “Unfortunately, safety lost out,” he said.
To address that failing, the board called on NASA to create an arm of the shuttle management program devoted to safety, separate from the functions concerned with cost and schedule. The space agency said it was already moving in that direction by creating a safety center and setting up an independent task force to monitor the shuttle fleet’s return to flight.
Congress, White house share blame
Some blame in the report was shifted to Congress and the White House, because for almost a decade NASA lived on a lean budget that actually lost 13 percent of its purchasing power from 1993 to 2002.
At the same time, NASA was under pressure to build the international space station. To cut costs, the agency reduced its staff and contractor work force from about 32,000 in 1991 to just over 19,000 in 1997.
“The White House, Congress and NASA leadership exerted constant pressure to reduce or at least freeze operating costs (for the space shuttle),” the report said. As a result, “safety and support upgrades were delayed or deferred, and shuttle infrastructure was allowed to deteriorate.”
At another point, the report noted: “Little by little, NASA was accepting more and more risk in order to stay on schedule.” Also: “The program was operating too close to too many margins.”
Scenario reaffirmed
The report reaffirmed the board’s conclusion that Columbia was destroyed as the result of a breach in the heat shield on the craft’s left wing. The board said that foam insulation peeled from the external fuel tank during launch in January and struck the wing at a high speed.
“In four simple words, the foam did it,” Scott Hubbard, a NASA representative on the board, said during Tuesday’s briefing.
When Columbia re-entered the atmosphere on Feb. 1, superheated air penetrated the wing and melted it from the inside, causing the spacecraft to break apart and scattering debris over parts of Texas and Louisiana.
Columbia’s crew died within seconds after Mission Control lost signals from the shuttle.
“The destruction of the crew module took place over a period of 24 seconds beginning at an altitude of approximately 140,000 feet,” the report said. Death was attributed to blunt trauma and loss of oxygen.
A final video from inside the crew compartment, just minutes before the breakup, showed that three crew members were not wearing the pressure suits, gloves and helmets prescribed for re-entry. However, this oversight “did not affect their chances of survival,” a the report said.
The 13-member investigation board was announced by NASA within hours of the accident. The board members spent almost seven months reviewing evidence, talking to engineers and conducting experiments that proved fast-flying foam could damage the heat shield on the wing of a space shuttle.
NASA responds
Gehman said copies of the report were delivered in advance of Tuesday’s public release to the astronaut corps and families of the astronauts, to the White House and Congress, and to O’Keefe at NASA Headquarters.
In a statement, the administrator said NASA was already following up on five preliminary recommendations released during the investigation, and the agency intended “to comply with the full range of recommendations” in the final report.
“The findings and recommendations of the Columbia Accident Investigation Board will serve as NASA’s blueprint,” O’Keefe said. “We have accepted the findings and will comply with the recommendations to the best of our ability. The board has provided NASA with an important road map, as we determine when we will be ‘Fit to Fly’ again.”
He is expected to provide additional reaction to the report during a briefing at 11 a.m. ET Wednesday, which will be streamed over the Internet by MSNBC.com and other news outlets.
Key members of Congress are promising close scrutiny during a round of hearings that 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.
MSNBC’s Alan Boyle and The Associated Press contributed to this report.