Posted: Tuesday, August 26, 2003
GEHMAN: Let Richard Turcotte try a shot at this.
TURCOTTE: Let me give you an example from the aspect of the Navy and the Air Force, and the way we've run our programs. I'll give you an example of a squadron commander, or a commander of a ship, wants to make a modification or has a failing part that's in some way failing.
He does not have the decisional authority as that entity to do that. He has to go to an engineering authority commonly referred to as our system commands, separate authority that owns the technical requirements, submits a request, and if in fact the technical authority says it's good to go, then you can either fly that aircraft, or steam that ship, or that reactor, or that part, or dive that submarine, or jump out of that airplane, or whatever.
Unlike in NASA, the decisional authority for that waiver resided with the program. So our goal here is to have the program operate, maintain, fly the shuttle, but have the technical requirements reside separately so that the program has to go to another entity and is not deciding its own margins to operate.
GEHMAN: Mr. Wallace?
WALLACE: Well, just to clarify, I think one of your questions was not separate from NASA, not separate. Separate from the program that has the schedule that we got to get this built by this date.
Separate from the schedule, and I think the related recommendation also that follows that one is is the independent safety program. Again, not separate from NASA, but the safety organizations that we found to be sometimes in sort of an undecipherable matrix, and we wanted a much more straight line authority on that.
QUESTION: The sixth chapter, I think, has a pretty strong indictment of the scheduling pressures that were put on the program. I think at one point you say that as a result, the reaction to the
foam strikes focused, probably as a result focused less on safety than on keeping to schedule.
QUESTION: And the fact is that that, as you say, the schedule came right from the top from Sean O'Keefe. I mean, how big a factor was that? And how would you describe the relationship between the scheduling pressures and the decisions that were made about the foam?
GEHMAN (?): I think it's impossible to quantify it. Again, we tried to tell that story very thoroughly. I think you can see in there it's important to read the scheduling part of that chapter and then read what immediately follows it, which is the imaging request story. And it's in a logical sequence there because you see two things.
You see a concern about how this might affect the next mission, 114. And then I think you also see in there also a suggestion that well, there's nothing we can do about this on this flight. And so it gets to be a turnaround issue. And then there's the discussion about the flight readiness review criteria on the prior flight, 113.
So I think you read that entire story together, read the imaging story which follows it, and you can't put a number on this but you can get a sense for the schedule pressure.
QUESTION: We've talked a lot today, and you certainly discuss in your report a lot about NASA's culture. Several of you have stressed the point that when you deal with folks on the manufacturing fold (ph), when you deal with other personnel at NASA there is no lack of dedication, there is no lack of commitment to the program.
But it seems to me that culture is people. So at what level do you think NASA should attack this cultural problem? If it's not at the lowest level and we don't know if it's at the highest level, where should they be looking?
GEHMAN: Well, let me start off by trying to answer that and then I'll ask my board members to correct me if I get it wrong.
First of all, we in our report did not exactly equate culture to people as you did in your question. We equated culture as how people behave. And you can't change people's philosophies and attitudes, but you can change people's behaviors. And it's up to leadership at all levels to do that.
Now, I have some personal experience with this and many of our board members do too, in which a new boss comes in and he changes the way the organization operates or talks or thinks or its attitudes and things like that. And that's really what needs to happen is that they have to believe it in their gut and they have to say it every single day. And every time they deal with subordinates, every time there's any kind of a give-and-take going on or anything like that, they have to reinforce the kind of traits, attributes and characteristics that they want their organization to follow.
I mean, I'll give you a case in point. If you say that safety is the most important trait and characteristic in this organization, but then you require a person who's in charge of some program to come and travel to your office every month and report on how the schedule is coming, well, you're saying one thing and you're sending another message.
GEHMAN: So that's why we say that this is a difficult, challenging job. It's got to be done by the top level leadership, not just the administrator. He can't do it by himself, but at all levels of leadership, but we view it to be extraordinarily important.
Scott, did you want to jump in on this or--no?
OK, all right. Let us--all right, go ahead to the next question.
QUESTION: For Mr. Wallace, on the scheduling issue, the scheduling pressure came from the demands of the International Space Station program. The space station is still up there and occupied, and I think maybe even exerting some pressure today on the return to flight. How did your recommendations mitigate that pressure, particularly in the near term?
WALLACE: Well, I think we've made a strong story about the source of pressure, which you specifically identified, which was the node (ph) to complete and even--you might even argue that, gee, what's wrong with the screen saver? But you know, there's--I guess--a line between what's morale building and encouraging the work force and what actually then becomes another subtle form of pressure.
I think that the entire tragedy here is a massive stop and rethink point, a turning point for NASA, as it says in the board statement, which I think that the whole schedule gets kind of zero-based at this point.
GEHMAN: I think I'd like to add that the ISS does add schedule pressure, as it should. And oh, by the way, schedules are not bad, they're good managing tools. There's nothing wrong with using schedules as a good management tool. Everybody does it. I have been accused by this board of exerting schedule pressure on them.
(UNKNOWN): Yes, sir.
(UNKNOWN): 3:30 in the morning.
GEHMAN: But our concern is that various places in the organization are denying that there was any schedule pressure. And other places in the organization were screaming that there was schedule pressure. And it's that disconnect is what we're concerned about.
Of course there is schedule pressure with the ISS, because a crew has got to go up and a crew has got to go down, and supplies have got to go up and every once in a while the ISS has got to be boosted, et cetera, et cetera, et cetera. But we've found that the use of schedule pressure as a positive instrument was being misapplied and it was not turning into a positive reinforcement issue.
QUESTION: For Admiral Gehman, I wanted to ask you a question about your thermal protection system return-to-flight recommendations. When you issued your preliminary recommendations, it appeared to me that it called for before returning to flight, that you have a TPS inspection and repair capability. And as I look at the recommendations and the way that they're written now, it does not appear that it is a return to flight requirement.
And I wanted to sort of clarify that and ask you also how important is it to you that you do have a TPS repair capability in place before you fly again, given the fact that if you have an engine out on the way to the station or you undock, another crew could find itself in the same sort of predicament that Columbia was in?
GEHMAN: OK. I think it's just a misunderstanding. Recommendation 6.4.1 contains four provisions, all
of which are return to flight.
QUESTION: So developing an RCC repair is a prerequisite...
GEHMAN: Is correct.
QUESTION: ... of return to flight.
GEHMAN: That is correct. Exactly as we issued it. It's just--we put RTF after the recommendation. We only put it once in there, and there are four provisions to it. But, yes, we are sticking by our interim recommendation that you must develop before return to flight an on-orbit inspection and repair for both the TPS and the RCC.
QUESTION: For the admiral or whoever would like to take it. You note in the report that managerial and organizational problems echo back to Challenger, that these same types of problems are still there and there are many parallels. And you also note that NASA has a history of not fixing that type of problem of getting back to business-as-usual after a short period of diligence after an accident. What do you think will happen if NASA neglects to or fails to fix their institutional problems as they exist today?
GEHMAN: Well, NASA is an independent agency responsible to the Congress and to the administration. There is no Cabinet officer overseeing NASA. Therefore, the enforcement mechanism must come from those two branches of government.
So we are putting a little bit of a burden here on both the Congress, the oversight committees and on the White House to put in some kind of a follow-on mechanism to make sure that these changes are implemented. And there's lots of ways to do it. You can establish review panels and blue ribbon panels and annual reports, and all that kind of good stuff, all of which we think should be done.
But I don't believe that we should just trust NASA to do this. I think there needs to be some follow up.
QUESTION: You talk about the cultural changes and the need for leadership to do that. Does that imply that there's a need for new leadership?
And what's the role--the Rogers commission talked a lot about astronaut leadership. There's also a question of engineering skills at the top leadership level. How much of a change needs to be put at the very top leadership of NASA, especially when you say they're not the ones--they say they didn't see any schedule pressures.
GEHMAN: We don't have any opinion, one way or another, about the individuals at the top leadership of NASA. We've gotten nothing but cooperation from NASA. We've heard all the right words from NASA leadership.
But we, as a board, set a long time ago an internal rule that we were not going to try and chase the rabbit here. That is, as NASA changes and as they do things, we aren't going to be continuously trying to comment on the things that they've said or done or implemented.
So as we like to say, ``T equals zero.'' T equals zero is 1 February for us, as we are reporting on this event as of the date and time of the crash.
So I have no reason to believe that there is anything in this report that cannot be implemented by the leadership of NASA if they choose to do so. So I think it's more of a philosophical thing than a competency thing.
QUESTION: And that segues, Admiral--segues right into the question that I had, and I'd like for you and maybe Mr. Wallace to answer this.
And that is, yes, they can do these things if they do do. You guys believe in your heart of hearts that NASA will, in fact, be able to effect these kind of changes, because several places in the report you point out: We have no confidence. That other corrective actions will improve this. And changes we recommend will be difficult to accomplish, and they will be internally resisted by NASA.
So I'm wanting a personal opinion from both of you, will they do these things?
GEHMAN: We'll let Mr. Wallace go first.
WALLACE: My confidence is fairly high. I don't see that we draw--I mentally sort of can't draw a sharp line between some of the organizational changes and some of the cultural changes.
WALLACE: I think they go hand in hand. So if you, you know--an empowered independent organization that owns the technical qualifications and requirements and the waiver authority, coupled with a really empowered safety organization, and we're talking about organizations which all have a final signature on the certificate of flight readiness, I think those--the evolution of that organization which then sort of takes the authority away, to some extent, from the program that's really got--trying to meet the schedule and build the thing.
So I also think that the fact that this is the second loss and we've evaluated the accident in the historical context, including a very point-by-point comparison of the Challenger, a lesson we learned here is we got a--it didn't get fixed last time, there has to be a different approach now and I really think there will be.
GEHMAN: I think it's fair even though we didn't write this down in our report to say that we find two problems in this area. The first problem is that NASA has--NASA management over the years--and over the years, due to external influences, as well as internal influences--has morphed its management structure to where so much authority and power or so much responsibility has been put into one vertical chain--the program manager--and that they've lost all their checks and balances and independent research and independent engineering and the likely stuff. That's one problem.
The second problem is NASA's been told this 10 times, so they're guilty of two things. And we put that in there for emphasis, to get out an order to satisfy ourselves, that we have enough emphasis in here to satisfy ourselves that they will change, and that the system will make them change and that they will buy into it. So, yes, we've added some of those things for emphasis, as I said in my opening remarks.
QUESTION: Admiral Gehman, would you talk a little bit about the rescue scenario? Do you believe that with normal and reasonable procedures that the MMT should have arrived at that EVA on Flight Day 5?
GEHMAN: I would separate in my mind your question. Whether or not an EVA to inspect the wing was prudent or not from the rescue thing, I consider that to be two different things. From my understanding, to go out and take a walk and lean over the wing to see if you had a hole in the RCC is not very risky. It's well within the capability of the training of the astronauts.
If they were really curious and really had a lot of engineering curiosity, they were really suspicious and they were really concerned about pinning down everything that might be wrong with the orbiter, they would have attempted, first of all, to get some imagery. And if the imagery was inconclusive--which it may have been, by the way, you know, they may have gotten the imagery in and it proved nothing--I consider that going out and taking a look at the wing to be relatively a prudent thing to do.
The rescue thing--and you used the word rescue in your question--that's a whole 'nother enterprise and the risk goes way up when you do that and I wouldn't want to comment on whether or not it was something that they would have really, no kidding, chosen to do.
GEHMAN: The only thing we do know, and everybody has agreed upon this, the Congress, the president, the administrator of NASA, is that if we had gone out there and if we had seen a hole in the wing and we knew that it was life-threatening, we would have done something.
We wouldn't have sat here and done nothing and wish them, you know, wish them bon voyage. So I consider those two parts of your question to be two separate, two completely separate things.
MODERATOR: OK, thank you for coming. That's going to be the last question, and we are not doing the table rush we normally do, so forget about that, and we're going to do some one-on-one interviews with some of the board members in two rooms that are set up in the other room.
I've got a schedule for the admiral, and we'll have some interviews with the other board members as well.
GEHMAN: Thank you very much.
// end //