When all is said and done, it comes down to this: NASA lost 7 of its employees as they returned from work in outer space. As the investigation proceeded towards determining the cause, a broad panoply of more pervasive, systemic issues quickly became evident. At the end of the day, the technology only performs as well as humans understand its operations - and limitations. The CAIB report pointed out a number of problems and suggested an equal number of solutions to resolve - or at least ameliorate these areas of concern. Moreover, fixes are needed in all parts of the agency - not just within human spaceflight.
That not withstanding, NASA failed - in a big way. It failed in a way, which, while manifesting itself in the loss of a vehicle flying a human mission, has repercussions and relevance to everything NASA does.
Just as NASA was preparing to release its recovery plan for the Shuttle program a NASA contractor dropped a perfectly good quarter-billion-dollar satellite and broke it. The hardware didn't fail: someone took a bunch of bolts out of a test stand and didn't bother to let everyone else know. Such an unfortunate event serves to show that the greater NASA family - civil service and contractor alike - has a long way to go in cleaning up its act.
Meanwhile, a glance at the ISO9000 charts created to advise NASA employees - specifically the team at GSFC which oversees the NOAA-N activity - included the following advice (advice seen on identical charts all over the agency):
Some Audit No-No's!
As such, NASA is still formally advising its own people not to "volunteer information not asked for". Unbelievably, they are doing so 6 months after a fatal accident wherein precisely this behavior helped keep potential problems and solutions - "missed opportunities" as the CAIB calls them - from reaching those people who could have at least tried to do something. Didn't anyone see these charts and think that this was just contradictory to all that was being said - not just in the CAIB report - but in Congress and on TV?
When asked if this accident spoke to the broader issues raised by the CAIB as they apply to the agency as a whole, O'Keefe readily agreed. As such, anyone at NASA who hasn't read the CAIB report needs to do so. How they will be doing their job will depend on how they integrate the observations and recommendations the CAIB went into great detail to produce. Whether the workforce at NASA "gets it" as Sean O'Keefe likes to put it, only time will tell.
At least the words coming out of the mouths of its senior-most officials seem to point to personal progress down a multistep path. At a press conference to discuss the Return to Flight Plan, Associate Administrator for Space Flight Bill Readdy said "quite frankly, we missed something. We screwed up. The burden is on us."
The road to recovery is not going to be easy. Everyone is going to have to prove themselves worthy. In a memo to all his employees in July, Readdy said "the jury is still out with regard to NASA's conduct of human space flight. Let there be no misunderstanding on this: we are not out of the swamp yet - nor will we be even after we return to flight. This will be a process that we will need to recalibrate and recertify each and every day. We will have to earn it back one day at a time, one launch at a time, one mission at a time and one landing at a time."
A hundred or so emails have been received at NASA Watch regarding the CAIB report from people all over NASA - civil service and contractor personnel alike. Virtually all (more than 90%) requested anonymity. The bogey man (Dan Goldin) is gone. You can speak out. Your boss has told you so. Yet you don't. It is time to take some personal responsibility, folks. Until such time as individuals are willing to speak out - with full attribution - things at NASA will not change. NASA Watch, and its long-standing willingness to post commentary anonymously, is just a crutch for what a truly healthy organization - and its people - should be able to do by itself.
At the most recent House Science Committee hearing, Sean O'Keefe closed his opening statement by saying: "to the families, we sincerely apologize for our failures. It will be with them for the rest of their lives. By committing ourselves to this report, we know that how we respond in the days and weeks ahead must be an institutional change. Of that there is no doubt. We will honor our commitment to fix the problem and return to the exploration effort their loved ones committed their lives to."
O'Keefe then quoted Oliver Wendell Holmes: "I find the great thing in this world is not so much where we stand, as in what direction we are moving: To reach the port of heaven, we must sail sometimes with the wind and sometimes against it, but we must sail, and not drift, nor lie at anchor."All too soon after the Rogers Commission pronounced its findings about the Challenger accident, NASA promptly forgot many of the lessons it had learned.
Now the Gehman Board has spoken. At least two people at NASA have publicly admitted that NASA failed - and that NASA must do better from now on. That's 2 down, 17,998 to go. The more people who make this admission and commitment, the harder it will be to forget this new set of hard-earned lessons. Conversely, the more of you who sit on your hands and do nothing, the sooner something like this is bound to happen again.
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