Understanding Columbia - and Fixing NASA

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Seven months after her crew perished over Texas, the final report chronicling Columbia's demise has been released. This is not your every day accident report, for it reaches into the very soul of NASA. NASA will not be able to ignore this report.

Already, NASA Administrator Sean O'Keefe has stated categorically that NASA will implement the report's recommendations and that it won't be picking which ones it wants to implement. That said, this is going to be a long, difficult road for the agency.

The mechanical cause of the accident has been known for months. In the words of panel member Scott Hubbard "the foam did it." In that regard, this report serves to document the previously revealed cause of the accident in great detail. Yet, the cause of this accident was not simply a failure of hardware. Rather, the hardware was just the physical manifestation of a human process which had failed to learn from previous experience. As portrayed by the report, such an accident was almost inevitable. And, unless NASA makes some dramatic changes, its likely to happen again.

There is something for everyone in this report: chronic under funding of the agency, lack of a clear compelling overall goal for America's space program, dysfunctional internal communications, rigid management, inability to spot trends, ambivalence to external advice, and a propensity to accept anomalies rather than fully understand them. Moreover, the CAIB makes it very clear that many lessons the agency should have learned after he Challenger accident either went unlearned, or were forgotten once learned.

Is the cure worse than the illness?

One fear many had is that the report would simply attack the agency with no thought of the consequences of such an indictment. That did not happen. Rather, as the report systematically chronicles the agency's failings, it also provides a path toward fixing these problems:

The report sets the tone of its findings by noting that "NASA is a federal agency like no other. Its mission is unique, and its stunning technological accomplishments, a source of pride and inspiration without equal, represent the best in American skill and courage. At times NASA's efforts have riveted the nation, and it is never far from public view and close scrutiny from many quarters. The loss of Columbia and her crew represents a turning point, calling for a renewed public policy debate and commitment regarding human space exploration. One of our goals has been to set forth the terms for this debate." [p 6]

The path, however is a steep one -and it is not a given that the agency will be able to climb that path without a substantial commitment from the White House and congress. While the CAIB doesn't simply advocate throwing money at problems, the solutions they recommend will certainly come only at considerable expense.

"At NASA's urging, the nation committed to building an amazing, if compromised, vehicle called the Space Shuttle. When the agency did this, it accepted the bargain to operate and maintain the vehicle in the safest possible way. The Board is not convinced that NASA has completely lived up to the bargain, or that Congress and the Administration has provided the funding and support necessary for NASA to do so. This situation needs to be addressed - if the nation intends to keep conducting human space flight, it needs to live up to its part of the bargain."[p 97]

Cut Cut Cut

NASA has done what has been on its plate for many years without a budget commensurate with these tasks. This fact was not lost on the CAIB.

"During the past decade, neither the White House nor Congress has been interested in "a reinvigorated space program." Instead, the goal has been a program that would continue to produce valuable scientific and symbolic payoffs for the nation without a need for increased budgets. Recent budget allocations reflect this continuing policy reality. Between 1993 and 2002, the government's discretionary spending grew in purchasing power by more than 25 percent, defense spending by 15 percent, and non-defense spending by 40 percent (see Figure 5.3-2). NASA's budget, in comparison, showed little change, going from $14.31 billion in Fiscal Year 1993 to a low of $13.6 billion in Fiscal Year 2000, and increasing to $14.87 billion in Fiscal Year 2002. This represented a loss of 13 percent in purchasing power over the decade." [p102-103]

"Faced with this budget situation, NASA had the choice of either eliminating major programs or achieving greater efficiencies while maintaining its existing agenda. Agency leaders chose to attempt the latter. They continued to develop the space station, continued robotic planetary and scientific missions, and continued Shuttle-based missions for both scientific and symbolic purposes. In 1994 they took on the responsibility for developing an advanced technology launch vehicle in partnership with the private sector. They tried to do this by becoming more efficient. "Faster, better, cheaper" became the NASA slogan of the 1990s." [p 103]

"The squeeze on the Shuttle budget was even more severe after the Office of Management and Budget in 1994 insisted that any cost overruns in the International Space Station budget be made up from within the budget allocation for human space flight, rather than from the agency's budget as a whole. The Shuttle was the only other large program within that budget category." [p 104]

Lessons Unlearned -1

NASA did not arrive at its current predicament overnight. Rather, this is a process that has its roots in the agency's origin and subsequent history. This history has been punctuated by a series of accidents. The environment that led the agency down the path towards the Columbia accident began after the agency retuned to flight following the previous shuttle accident. Indeed the phrase "Echos of Challenger", mentioned in the report, was uttered by CAIB - and Challenger Commission member - Sally Ride.

After Challenger, the agency was warned that the Shuttle fleet was not composed of operational vehicles, but rather that they were still - and would likely always be - experimental vehicles. With the pressure to complete the International Space Station on an aggressive time table the Shuttle fleet all too soon fell back into a mindset that can only be called "operational".

Moreover, NASA sought to derive fiscal benefits from this program by utilizing contractual mechanisms that work only on operational programs - not on programs with an inherent experimental aspect such as the shuttle program. One report which symbolized this shift in mindset form experimental to operational was the Kraft Report , which, according to the CAIB "characterized the Space Shuttle in a way that the Board judges to be at odds with the realities of the Shuttle Program" [p 108]

"Although the Kraft Report stressed that the dramatic changes it recommended could be made without compromising safety, there was considerable dissent about this claim. NASA's Aerospace Safety Advisory Panel - independent, but often not very influential - was particularly critical. In May 1995, the Panel noted that "the assumption [in the Kraft Report] that the Space Shuttle systems are now "mature" smacks of a complacency which may lead to serious mishaps. The fact is that the Space Shuttle may never be mature enough to totally freeze the design." The Panel also noted that "the report dismisses the concerns of many credible sources by labeling honest reservations and the people who have made them as being partners in an unneeded "safety shield" conspiracy. Since only one more accident would kill the program and destroy far more than the spacecraft, it is extremely callous" to make such an accusation." [p 108]

Chop Chop Chop

All of this occurred while the agency's Administrator, Daniel Goldin, cheered on this fiscal straight jacket, equating it with the agency's ability to do more with less. When critics would raise the possibility that such cuts were going to affect safety the CAIB notes "Goldin described himself as "sharp-edged" and could often be blunt. He rejected the criticism that he was sacrificing safety in the name of efficiency. In 1994 he told an audience at the Jet Propulsion Laboratory, "When I ask for the budget to be cut, I'm told it's going to impact safety on the Space Shuttle ... I think that's a bunch of crap." [p 106]

The effect Goldin's relentless cutting had on the NASA workforce is legendary. Looking back, it is also an exercise in "I told you so" since his cuts eventually led the agency to a point where it is not always capable of doing all that has been set before it:

"Workforce reductions instituted by Administrator Goldin as he attempted to redefine the agency's mission and its overall organization also added to the turbulence of his reign."... " By the end of the decade, NASA realized that staff reductions had gone too far. By early 2000, internal and external studies convinced NASA leaders that the workforce needed to be revitalized. These studies noted that "five years of buyouts and downsizing have led to serious skill imbalances and an overtaxed core workforce. As more employees have departed, the workload and stress [on those] remaining have increased, with a corresponding increase in the potential for impacts to operational capacity and safety." NASA announced that NASA workforce downsizing would stop short of the 17,500 target, and that its human space flight centers would immediately hire several hundred workers." [p 110]

CAIB panel members have been careful to caution that a direct line of causality cannot be drawn between budget or personnel cuts and the Columbia accident. However, when you have fewer safety people on the job, you have fewer safety people on the job.

Culture Culture Culture

The "culture" word has been tossed around at one point or another by everyone on the CAIB and the media covering the CAIB. In my opinion the word is used far too often to cover far too many things. I feel that it is often used by reporters and others when they want to assign a problem to something inside NASA an they can't quite understand what it is they are referring to. None the less there is a "culture" at NASA that is at the core of all it does - efficiently and otherwise. Having worked at NASA myself , I have to agree with many that pinning it down can be difficult but "I know it when I see it."

All of the budget and personnel cuts not withstanding, the people at NASA who run the Shuttle program were ultimately responsible for how the program ran - and accepting the risks associated with the operation of this program. Over the decades a very unique "culture" has developed at NASA - one that is, on one hand, adept at orchestrating the myriad of systems required to make a Shuttle launch happen. On the other hand, it can be xenophobic and resistant to criticism or change.

It is this culture at whose collective feet the CAIB lays blame for the events leading up to the Columbia accident: "In our view, the NASA organizational culture had as much to do with this accident as the foam. Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of an institution. At the most basic level, organizational culture defines the assumptions that employees make as they carry out their work. It is a powerful force that can persist through reorganizations and the change of key personnel. It can be a positive or a negative force." [p 97]

You Just Don't Understand

NASA is famously capable of circling the wagons whenever external criticism mounts about a mission failure or cost overrun. Moreover, the agency's instinctual response is often to ignore criticism rather than heed it since the NASA family often thinks that anyone who hasn't done what they do can't truly understand what they agency does: "External criticism and doubt, rather than spurring NASA to change for the better, instead reinforced the will to "impose the party line vision on the environment, not to reconsider it," according to one authority on organizational behavior. This in turn led to "flawed decision making, self deception, introversion and a diminished curiosity about the world outside the perfect place." The NASA human space flight culture the Board found during its investigation manifested many of these characteristics, in particular a self-confidence about NASA possessing unique knowledge about how to safely launch people into space." [ p 102]

In addition to a broken feedback loop with external input, the internal communication system at NASA has a very efficient feedback loop - however it is one that is so closed off that one's output is quickly reused as input, thus providing a false sense that one is getting all the facts when indeed you are talking to yourself.

"Communication did not flow effectively up to or down from Program managers. As it became clear during the mission that managers were not as concerned as others about the danger of the foam strike, the ability of engineers to challenge those beliefs greatly diminished. Managers' tendency to accept opinions that agree with their own dams the flow of effective communications." [p 169]

Lessons Unlearned - 2

Foam strikes were nothing new to NASA. They had been happening for decades. While duly taking not of each incident in great detail, no one thought to stop and look at whether these strikes had a potential for damage. Moreover, they also didn't connect what they were seeing with the fact that the tank was never supposed to be shedding foam in the first place - certainly not such that the orbiter was being hit. Even when the issue was raised in the media after the accident, this view persisted. The Administrator of the agency was apparently provided with a technical briefing such that he would often refer to the media as "foamologists" and repeated a description of the foam strike , somewhat dismissively, as being "like a cooler coming off of your car in a parking lot".

Several months later several definitive tests put the issue to rest. As Scott Hubbard said "the foam did it".

The CAIB noted that:

"While the debris strike was well outside the activities covered by normal mission flight rules, Mission Management Team members and Shuttle Program managers did not treat the debris strike as an issue that required operational action by Mission Control. Program managers, from Ron Dittemore to individual Mission Management Team members, had, over the course of the Space Shuttle Program, gradually become inured to External Tank foam losses and on a mental level did not believe foam striking the vehicle posed a critical threat to the Orbiter. In particular, Shuttle managers exhibited a belief that RCC panels are impervious to foam impacts. Even after seeing the video of Columbia's debris impact, learning estimates of the size and location of the strike, and noting that a foam strike with sufficient kinetic energy could cause Thermal Protection System damage, management's level of concern did not change." [168-169]

In an interview with CNN the other day Sean O'Keefe's response to the whole situation was much more sober: "This was a case where we missed it. You know, just flat missed it."

Moreover, when analysis was eventually done, the tools used were not appropriate for the task - and yet even when these tools still gave an indication of a potential concern, NASA ignored it:

"An inexperienced team, using a mathematical tool that was not designed to assess an impact of this estimated size, performed the analysis of the potential effect of the debris impact. Crater was designed for "in-family" impact events and was intended for day-of-launch analysis of debris impacts. It was not intended for large projectiles like those observed on STS-107. Crater initially predicted possible damage, but the Debris Assessment Team assumed, without theoretical or experimental validation, that because Crater is a conservative tool - that is, it predicts more damage than will actually occur - the debris would stop at the tile's densified layer, even though their experience did not involve debris strikes as large as STS-107's." [ 168]

The CAIB goes on, in excruciating detail, illustrated with emails and memos, to chronicle repeated instances where NASA could have understood the damage to the orbiter - and possibly had enough time to do something about it - but rather "missed opportunities" to get at the true nature of the damage to Columbia:

"Management decisions made during Columbia's final flight reflect missed opportunities, blocked or ineffective communications channels, flawed analysis, and ineffective leadership. Perhaps most striking is the fact that management - including Shuttle Program, Mission Management Team, Mission Evaluation Room, and Flight Director and Mission Control- displayed no interest in understanding a problem and its implications. Because managers failed to avail themselves of the wide range of expertise and opinion necessary to achieve the best answer to the debris strike question - "Was this a safety-of-flight concern? - some Space Shuttle Program managers failed to fulfill the implicit contract to do whatever is possible to ensure the safety of the crew. In fact, their management techniques unknowingly imposed barriers that kept at bay both engineering concerns and dissenting views, and ultimately helped create "blind spots" that prevented them from seeing the danger the foam strike posed." [p 170]

Even when information was gleaned from these analyses - or the need for photographs of the Shuttle by military assets arose, this information never made it to the parts of the agency where a fully informed decision could be made. Instead, a decision was made with the best information available - and that information was not complete.

"NASA's bureaucratic structure kept important information from reaching engineers and managers alike. The same NASA whose engineers showed initiative and a solid working knowledge of how to get things done fast had a managerial culture with an allegiance to bureaucracy and cost-efficiency that squelched the engineers' efforts. When it came to managers' own actions, however, a different set of rules prevailed. The Board found that Mission Management Team decision-making operated outside the rules even as it held its engineers to a stifling protocol. Management was not able to recognize that in unprecedented conditions, when lives are on the line, flexibility and democratic process should take priority over bureaucratic response." [P 202-203

In perhaps one of the most poignant references to the similarities between the Challenger and Columbia accidents, and the dysfunctionality of the management hierarchy and the information that made its way though channels, the CAIB says:

"perhaps the ultimate example of engineering concerns not making their way upstream, Challenger astronauts were told that the cold temperature was not a problem, and Columbia astronauts were told that the foam strike was not a problem." [p 202]

Replace the Shuttle - now

The CAIB minces no words when it comes to expressing its estimation of the Space Shuttle program's ability to resume flying soon:

"Based on NASA's history of ignoring external recommendations, or making improvements that atrophy with time, the Board has no confidence that the Space Shuttle can be safely operated for more than a few years based solely on renewed post-accident vigilance." [p 13]

The board also wastes few words in expressing their need for a replacement for the shuttle:

"... based on its in-depth examination of the Space Shuttle Program, the Board has reached an inescapable conclusion: Because of the risks inherent in the original design of the Space Shuttle, because that design was based in many aspects on now-obsolete technologies, and because the Shuttle is now an aging system but still developmental in character, it is in the nation's interest to replace the Shuttle as soon as possible as the primary means for transporting humans to and from Earth orbit. At least in the mid-term, that replacement will be some form of what NASA now characterizes as an Orbital Space Plane. The design of the system should give overriding priority to crew safety, rather than trade safety against other performance criteria, such as low cost and reusability, or against advanced space operation capabilities other than crew transfer."

In making these recommendations, the CAIB also makes it very clear that simply replacing the Shuttle with another launch system without calibrating that system to the agency's stated goals would be a mistake. This assumes that the agency actually has a set of overarching goals in the first place such that they can be used to drive the design.

Where do we go from here?

All of the reforms and funding increases in the world mean nothing if they are done in support of a program that is meandering due to a lack of a consistent overall focus. Attempts to replace the shuttle have fallen flat on their face - partially because they were developed under wholly unrealistic expectation - as well as being done with out a long term view in place to determine what was needed and when. The CAIB makes some rather expansive observations in this regard:

"The Board in its investigation has focused on the physical and organizational causes of the Columbia accident and the recommended actions required for future safe Shuttle operation. In the course of that investigation, however, two realities affecting those recommendations have become evident to the Board. One is the lack, over the past three decades, of any national mandate providing NASA a compelling mission requiring human presence in space. President John Kennedy's 1961 charge to send Americans to the moon and return them safely to Earth "before this decade is out" linked NASA's efforts to core Cold War national interests. Since the 1970s, NASA has not been charged with carrying out a similar high priority mission that would justify the expenditure of resources on a scale equivalent to those allocated for Project Apollo. The result is the agency has found it necessary to gain the support of diverse constituencies. NASA has had to participate in the give and take of the normal political process in order to obtain the resources needed to carry out its programs. NASA has usually failed to receive budgetary support consistent with its ambitions. The result, as noted throughout Part Two of the report, is an organization straining to do too much with too little.

A second reality, following from the lack of a clearly defined long-term space mission, is the lack of sustained government commitment over the past decade to improving U.S. access to space by developing a second-generation space transportation system. Without a compelling reason to do so, successive Administrations and Congresses have not been willing to commit the billions of dollars required to develop such a vehicle. In addition, the space community has proposed to the government the development of vehicles such as the National Aerospace Plane and X-33, which required "leapfrog" advances in technology; those advances have proven to be unachievable. As Apollo 11 Astronaut Buzz Aldrin, one of the members of the recent Commission on the Future of the United States Aerospace Industry, commented in the Commission's November 2002 report, "Attempts at developing breakthrough space transportation systems have proved illusory." The Board believes that the country should plan for future space transportation capabilities without making them dependent on technological breakthroughs." [p 209]

Final Thoughts

Much will be written in the days and weeks ahead about this report. After Labor Day, a non-stop series of Congressional hearings will commence wherein all of the issues raised by this report - plus many others - will be hotly debated.

NASA personnel will find themselves in a hot seat the likes of which many have never experienced. Many within the agency will take solace in the realization that at least some of the systemic problems are now going to be addressed. The cynical among them will expect no change. Others will work to make certain that change does occur. Still many others will be confused given that the past decade at NASA has been marked with one management fad or change in guiding philosophy after another.

Some within Congress will pursue a longstanding pattern of NASA bashing armed with fresh ammunition while others will jump to the agency's defense in ways many would have not expected. All will seek to exact some amount of contrition from the agency in the process.

The media will attempt to chronicle all of this as best they can - some will take the time to understand the technology and the politics, others will simply shoot from the hip with little thought of whether they got it right.

And in the White House, the President and his advisors will sit and take all of this in. At some point they will be called upon to respond, for in this report is not only a diagnosis - but also a prescription for what currently ails NASA and America's space program. While many will be involved in fabricating the cure, only the White House can set the nation down a committed path.

A small tidbit emerged today from the White House: "Our journey into space will go on. The work of the crew of the Columbia and the heroic explorers who traveled before them will continue.". What this means is uncertain. As the President also said "The next steps for NASA under Sean O'Keefe's leadership must be determined after a thorough review of the entire report, including its recommendations." In other words: stay tuned.

While the mechanical fixes to NASA's shuttle fleet are straightforward, the human fixes that are needed will require persistence from everyone involved. The question before America is not just whether human space flight is worth the risk, but also whether NASA - and the nation - are up to the task.

Everyone needs to get it right this time. Everyone.


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