BLAME for the loss of the shuttle and its seven crew in February rests with NASA鈥檚 management culture. These failings extended to or even emanated from NASA chief Sean O鈥橩eefe, says the final report of the Columbia Accident Investigation Board (CAIB), published this week.
In one of its sharpest criticisms, the CAIB says that time pressure imposed by O鈥橩eefe to appease Congress played a significant role in causing managers lower down the line to downplay risks and sweep aside clear warning signs. In particular, pressure to complete the core of the International Space Station by February 2004 left NASA engineers feeling 鈥渦nder the gun鈥� 鈥� and led one to warn that 鈥渨e had a train wreck coming鈥�.
It was partly as a result of that pressure, the board concluded, that after a serious foam-insulation strike during a launch of the shuttle Atlantis in October 2002, managers classified the strike as an 鈥渁ction item鈥� rather than a more serious 鈥渋n-flight anomaly鈥� that would have grounded the fleet. That decision allowed Columbia鈥檚 fatal mission, STS-107, to go ahead.
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And, as the board鈥檚 hearings over the past 7 months had already made clear, it was a similar impact by falling foam 鈥� only this time an even larger piece 鈥� that blew a dinner-plate-sized hole in Columbia鈥檚 wing and allowed hot gas to penetrate and tear the craft apart during re-entry.
The CAIB says cultural problems extended through NASA鈥檚 upper management, whose attitudes throughout the Columbia flight, and the months leading up to it, showed clear signs that schedule pressures were forcing ever-greater compromises and leading managers to override their own engineers鈥� judgement.
The report reveals no less than eight 鈥渕issed opportunities鈥� after Columbia鈥檚 launch to understand the damage. As early as the mission鈥檚 second day, requests were passed up through the line of command to get satellite images to assess the damage caused by the foam impact, but every request was blocked. Inspections by the crew were also ruled out.
This attitude stemmed in part from a belief that nothing could have been done about a wing breach. But the CAIB strongly disputes this, believing it would have been 鈥渃hallenging but feasible鈥� to launch a rescue mission and save the entire crew (New 杏吧原创, 22 March, p 36).
The report鈥檚 language is often scathing. It says that NASA is 鈥渋n denial鈥� that its safety panel was understaffed, underfunded and ineffective, and that the agency did not even follow its own rules. Its meetings 鈥渟tifled professional differences of opinion鈥�. NASA鈥檚 view of its own culture and procedures, it found, 鈥渄id not reflect reality.鈥� And, in words that echo physicist Richard Feynman鈥檚 comments on the 1986 Challenger accident, it says 鈥渂ureaucracy and process trumped thoroughness and reason鈥�.
The CAIB declares NASA incapable of policing itself. Its 鈥渉istory of ignoring external recommendations鈥�, the CAIB says, left it with 鈥渘o confidence鈥� the shuttle can be operated safely without outside supervision.
Legislators will begin hearings on NASA next week, and requests for funds to improve the shuttles will face heated debate.