(Not) Learning From One's Mistakes
On September 10th Adm. Gehman was asked to describe how lessons were learned from accidents such as Columbia. Gehman said that other organizations often looked back at previous accidents as a guide toward dealing with a recent one. Such is the case in the nuclear Navy.
Not so with NASA. "NASA feels that bringing up past failures some how tarnishes employees. In our report we said that NASA is not a learning organization." said Gehman.
This has become abundantly clear as the CAIB revealed how NASA ignored trends that should have been apparent - in some cases, for decades - with regard to foam shedding. It was also manifested in NASA's inability to couple these shedding incidents with the real possibility that they could cause damage - serious damage - to a Space Shuttle.
It had never been a real issue before - so why should it be one this time? Or so went NASA's corporate logic. The contributing factor that this same sort of thinking played in Challenger accident seemed to be lost on NASA within a few years as the agency reverted to old, bad habits.
I can recount one experience that bears out what Gehman and his panel concluded - one that is embedded in NASA's ‘culture'. Back during NASA's 40th anniversary celebration, there was a large photo exhibit in a hallway at NASA Headquarters which chronicled the major events in the agency's history. Glaringly absent was any mention of the Apollo 1 fire, the Apollo 13 accident, or the Challenger accident. When I asked NASA's Associate Administrator for Policy and Plans, Lori Garver why there was no mention of these obviously important events, she said "we like to focus on positive things". The exhibit was never changed.
How can NASA learn from its past mistakes if those mistakes are hidden from view?
Oversight for NASA
Its one thing to go through the process of analyzing an accident and making recommendations. It is quite another for NASA to pay attention to the recommendations and learn from its past mistakes. It is even more difficult to get the changes to stick over time.
Much discussion has emerged about some sort of oversight body for NASA - one which would look to keep NASA focused on implementing the CAIB's recommendations. At hearings held on September 10th, Adm. Gehman has said that he'd be interested in reconvening the CAIB a year from now. O'Keefe expressed his enthusiasm for this.
Others have called for a more formal entity among them Sen. Barbara Mikulski (D-MD). Such an entity, although nebulously defined at this point, would apparently act as some sort of overall operations advisory board - and have some authority to tweak the agency's plans should they see fit.
In the interim, while the Shuttle program works to get back to flight status, NASA has appointed a Return to Flight Advisory Task Force co-chaired by former Astronauts Tom Stafford and Richard Covey. This panel will be in place to oversee all preparations for return to flight. While some have suggested that the panel is stacked with people who might be too close to NASA to be objective, words emerging from this Task Force suggests that a high level of healthy skepticism is alive and well among its ranks.
As for a more formal, permanent panel, some have suggested that the current charter of the Aerospace Safety Advisory Panel, put into place after the Apollo 1 fire, could be tweaked to enhance its oversight role.Foamology
On September 10th Rep. Rohrabacher brought up these issue of causality - and how NASA dealt with the fact that something that they had overlooked or not considered (foam impacts) eventually turned out to be the cause. When asked if he had any prior knowledge about foam issues O'Keefe said that he had none.
When asked if Dan Goldin had passed on any such concerns O'Keefe said "none that I recall". Rohrabacher then moved to O'Keefe's comments early on wherein he chastised those who were pointing to the foam as the cause of the accident as "foamologists". He asked O'Keefe who was giving him that advice.
O'Keefe replied that some people within the agency had taken it up on themselves to speak to the media and discount any possible role of foam in the accident. "These individuals were corrected." When pressed further on the reason why O'Keefe said this, O'Keefe replied that he had directed everyone at the agency not to "fall in love" with any particular theory and to let all options remain open until such time as the CAIB arrived at its own, formal conclusions.
O'Keefe said that he had uttered these words in an attempt to dissuade some reporters who were already (in O'Keefe's mind) arriving at the conclusion that the foam as the cause - when the CAIB had yet to begin its engineering deliberations.
Adm. Gehman added that the CAIB had done an analysis of some 50 reports that had looked into NASA including the Rogers Commission (Challenger accident) In none of these reports - including the Rogers Commission report - was foam identified as posing a potential threat to the shuttle.Dropping Satellites
After a decade of Faster-Better-Cheaper, TQM (Total Quality management), and ISO 9000 certification, you'd think that everyone at NASA and the aerospace contractor community would be thinking about how to do things better by now
On September 6th employees at Lockheed Martin were working on the NOAA-N satellite. As they began to tilt the spacecraft it fell off and dropped 3 feet (that's about 1 meter LockMart) and landed on a cement floor. The spacecraft is worth a quarter of a billion dollars. Just looking at the photos and reading the accident report shows that major damage was done.
An all too common refrain I hear from some folks in the space community is that the CAIB report addressed problems in the human spaceflight world - and that the folks operating in the space and earth sciences world did not have those problems. If ever that point could be nullified by a single act it was this act of satellite dropping.
I raised this event with O'Keefe in September 11th and asked him if indeed this accident was symptomatic of a more pervasive problem at NASA and its contractor family - one where not everyone thinks that the CAIB report had lessons for them as well as the human spaceflight community.
O'Keefe agreed that it did. He said that he has been "doing a lot barnstorming around to NASA's 10 centers. I was trying to prepare all of our folks that this report is something that has application to every aspect of what we do. The board articulated their views very succinctly. They were explicit about where they were going. This report was going to have application to everything we do. Are there folks that are still in denial about that point? Sure. In an a agency of 18,000 people it is inevitable that you are going to find someone who did not hear what was going on."
"This report has tremendous application to everything we are involved with" he continued. "We are seeing this played out in incidents like this. The satellite is being built for NOAA by Lockheed Martin - through NASA - but this has a bearing on the kinds of things that are called out in the report. It has tremendous application. Yes we are looking at how to identify issues in the report that have application across the agency as a separate matter of what the agency should be focusing on. So while we are implementing its recommendations [in the Shuttle program] there are issues that have application across the agency and we are looking at how we do that".
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