The hard-hitting final report of the Columbia Accident Investigation Board, released on Tuesday in Washington DC, makes one thing abundantly clear: the accident was caused in large part by the way NASA manages its operations. And this NASA 鈥渃ulture鈥�, as the 248-page report terms it, extended to, and to some extent emanated from, the very top: NASA chief Sean O鈥橩eefe.
In one of its sharpest criticisms, which had not been detailed prior to the final report, the CAIB makes it clear that schedule pressure imposed by O鈥橩eefe in order to appease the US Congress apparently played a significant role in causing managers all the way down the line to downplay risks and sweep aside clear warning signs.
Pressure to complete the core of the International Space Station by 19 February 2004 left NASA engineers feeling 鈥渦nder the gun鈥� and led one to warn that 鈥渨e had a train wreck coming.鈥�
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That pressure, the CAIB concluded, also affected the response to a serious foam-insulation strike during a shuttle launch in October 2002. Instead of grounding the fleet to study the problem, managers took the unprecedented step of classifying that strike as an 鈥渁ction鈥� item rather than a more serious 鈥渋n-flight anomaly鈥�, which would have required some resolution prior to a return to flight.
That decision allowed the fatal Columbia mission to go ahead as planned in February. And, as the CAIB鈥檚 hearings over the last seven months had already made clear, it was a similar impact by a piece of falling foam that blew a hole in the Columbia鈥檚 wing. This allowed hot gas to penetrate during reentry, eventually tearing the shuttle apart and killing the seven crew.
Missed opportunities
According to the CAIB, the cultural problems extended through most of NASA鈥檚 upper management. The 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 the judgment of their own engineers.
The report reveals no less than eight 鈥渕issed opportunities鈥� after Columbia鈥檚 launch to gain understanding of the damage. Beginning on the mission鈥檚 second day, requests were passed up through the line of command to get spy-satellite images of the shuttle to assess the foam impact鈥檚 damage 鈥� every one of these requests was blocked by management. Requests to ask the crew to perform an in-orbit inspection were also ignored.
In part, this stemmed from an attitude that even if a breach of the wing鈥檚 thermal insulation had been discovered, nothing could have been done about it. The board strongly disputes that notion, concluding that with timely information, it was 鈥渃hallenging but feasible鈥� to launch a rescue mission and save the entire crew (New 杏吧原创 print editions, March 22, p 36).
鈥淚n denial鈥�
The board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 the agency did not even follow its own rules. Its meetings 鈥渟tifled professional differences of opinion鈥�, and NASA鈥檚 view of its own culture and procedures, the board found, 鈥渄id not reflect reality.鈥�
And, in words that echo physicist Richard Feyman鈥檚 comments on the 1986 Challenger accident, it concludes that 鈥渂ureaucracy and process trumped thoroughness and reason鈥�.
What remains to be seen is what impact this report will have on the future of the US human space flight program. Legislators have already announced they will begin a series of hearings on NASA next week, and that requests for additional money to improve the shuttles and keep them flying longer will face heated debate.
NASA鈥檚 response is also uncertain, and the board made it clear that it does not think the agency is capable of policing itself. Because of 鈥淣ASA鈥檚 history of ignoring external recommendations,鈥� the CAIB said it 鈥渉as no confidence鈥� the shuttle can be operated safely for the long term without outside supervision that has real authority.
The board stopped short of providing 鈥渁 wiring diagram鈥� for the new structures that are needed. After seven months of penetrating investigation, that is where the hardest work must now begin.