Posted: Tuesday, August 26, 2003
I'll wrap up here and we'll get to the questions.
As we indicated when we started this investigation six and a half months ago, this board has five constituencies. And at ten o'clock this morning, Eastern Daylight Time, our report was delivered personally to all five constituencies simultaneously. Three board members who are not here are in Houston and they personally delivered the same report that you're receiving here along with copies of the report to our two constituencies in Houston, that is the astronauts, the astronaut corps and the families of the astronauts who lost their lives in this accident.
Meanwhile, here in Washington at ten o'clock this morning, the report was delivered to representatives from the White House, the Congress and to the administrator of NASA.
GEHMAN: As a matter of fact, three of the board members, the reason they're not here is because they're down in Houston doing that, and they will be joining us. They're flying back this afternoon.
So I'll just close by saying that the board is quite convinced that most accident investigations do not go as far as we did, in that most accident investigations find the widget that broke. They find the person in the cause chain closest to the widget that broke, require that the widget be redesigned or replaced, and the person fired or retrained, and then call it a day. And they do not go far enough to find out why would this happen.
And the failure of that is that you really haven't fixed the problem which caused the problem. You really are setting yourself up for a repeat if you have other organizational or systemic problems. And because it took the board a considerable amount of time to convince itself that the foam did it, we had ample time to look into these other causal categories. And we are quite convinced that these organizational matters are just as important as the foam.
Our recommendations, which I will now ask that the board--that was very good, you were there ahead of me--our recommendations could be roughly organized along the following kind of logical lines.
What we said is what we would like to do, in the sense of our recommendations, is we would like to break up or loosen the close coupling between debris hitting the orbiter and losing the lives of astronauts. In order to do that you have to take several steps, not one step, but several steps.
The first step you have to take is you have to understand and reduce the amount of debris that the stack sheds, whether it be foam or ice or whatever.
The second step is you have to toughen the orbiter so that it can, indeed, fly through a cloud of debris without doing itself some damage.
The third step is you have to provide a system by which the orbiter can be inspected and repaired in case it did get a little ding or something like that and so that it does not become a life-threatening event.
And the fourth step is you have to do something to enhance the crew's survivability.
Now, we addressed the first three completely in our report. The fourth step, enhancing the crew's survivability, we've decided to arbitrarily leave that up to NASA, and they have done some work in that area.
We organized our recommendations into three categories. As I indicated before, short-term fixes, which you might call return to flight; mid-term, by mid-term we mean something like two to 10 or two to 15 years or what I call continuing to fly recommendations.
And then, a long-term, and there the board has written editorial comments about what the nation should do about human space flight, about replacing the shuttle as our human-carrying vehicle. And we have editorialized about what we should do long-term.
Therefore, the intent of this report is that this report, in our words here, should now be the basis for what we hope will be a very vigorous public policy debate about what do we do now. How soon do we replace the shuttle? What is the United States' vision for human space flight? And once you answer the question, ``What is our vision?''; you have to then answer the next question, ``Are you willing to resource that vision?''; because this stuff is not cheap.
GEHMAN: And what should be the balance between human space travel and robotic space travel? And a number of other public policy issues which are not the purview of this board to answer. These questions are the purview of the government of the United States and its agencies.
So we aren't ducking anything here, what we have done is we have established all the facts, we have characterized NASA and the space flight program in a way that's not been done in this depth before. We have characterized the risk. We have characterized their strengths and their weaknesses.
And now we turn this report over to the people in the United States who establish public policy, who is not us.
So with that I would then conclude and I will turn it over to Ms. Brown, who will orchestrate some questions.
MODERATOR: I'd like to take questions for about half an hour. The way I'd like to do that is to try to do it geographically just so our guys with the microphones can maximize their maneuverability. So if we can take questions to the right over here first.
QUESTION: On the organizational managerial problems, I was struck in reference to the STS 113, Flight Readiness Review, a reference to the slight of hand in calculating the foam loss, making it seem not as bad as it was. And also, during the Columbia flight, Linda Hamm's (ph) comments that the rationale was lousy to keep flying and it still is.
This sounds more than overconfident, it almost sounds negligent, and could you address that? And why wouldn't you want these kinds of problems fixed before we turn to flight?
GEHMAN: The role of establishing judgments on personal performance is not one that we set out to do. We have said since the first week that we'll put the facts in the report and we'll let the proper authorities determine whether or not that is a matter of performance or not. To us, statements like that are data and we use them to determine how the system operates, not how the individuals operate.
Steve Wallace, you want to follow up on that?
WALLACE: Well, and I think they are both certainly being corrected. The slight of hand refers to a calculation about falling bipod ramps which sort of use the fact that there were two bipod ramps. One that had never ever fallen off, over there, the right hand one by the locks line which--probably aerodynamic reasons or whatever.
So we thought that the probability calculation didn't--if it were accounting, I'd say it wasn't done according to generally accepted accounting principles, and an engineer would say something roughly equivalent to that.
And yes, the lousy then, lousy now, and the report of course includes the view graph which details the decision making on launching 113. I think that's all in the context of the greater story of sort of the normalization of foam. And then 107 is launched subsequently and the issue is no longer even on the table. So those are--as the admiral said, that's data which forms a part of the larger story.
GEHMAN: And, John--very quickly, John?
LOGSDON: Yes, sir.
Just to answer the question about the recommendation, if you look down on the bottom organization, one is RTF. And that is to develop a plan to get a technical, independent review capability, to develop an independent safety and to develop a better integration. So that is a return to flight requirement, that we're asking for organization.
GEHMAN: OK, thank you.
MODERATOR: OK, thanks.
QUESTION: I think this is probably for General Barry. On the technical engineering authority, could you explain a little bit more what you would envision accomplishing by stripping NASA management from operational or separating the operational decision making about just shuttle processing from, like, the technical requirements of the shuttle and how you would see that working in a real-time scenario?
BARRY: Well, the recommendation you're referring to--as Steve has just pointed out to me--establish an independent technical engineering authority that is responsible for technical requirements and all waivers to them and will build a disciplined systematic approach. What that really means is we're trying to separate the requirements from the program.
If the program is competing cost and schedule and they still own the requirements and the waiver authority, you will sometimes find that you will compromise the waiver and the safety precaution schedule. So what we've found by looking at best business practices, particularly sub-safe in the Navy and the aerospace organization is that by separating this out, you put a check and balance in the system that clearly allows the system to work in a more fair basis. You don't put safety and waiver and technical requirements at risk with the same organization that is compelled to work schedule and schedule pressures and the ability to launch operationally.
MODERATOR: OK, in the blue, Richard?
QUESTION: You have focused a great deal on culture and the need for NASA to change culture. But how can an organization like that change culture, particularly when you look back at Challenger, you see a lot of the things that were said pre-Challenger exists today. Is it possible to change culture?
GEHMAN: Well, we--I'm going to repeat what General Barry said in his introductory remarks. We thought a lot about this. We thought long and hard about this. We discussed it for hours and hours. And we have come to the conclusion that there are two steps into changing the culture--part of the culture that needs to be changed.
Now, first of all, keep in mind there's good culture and there's bad culture. You know, you can have a culture of safety and you can have a culture of openness and you can have a culture of honesty and all that good stuff. So you know, culture is not a bad word.
As John Logsdon indicated when he defined culture, culture is the way that the organization habitually acts absent rules. In other words, this is the way the people kind of intuitively act regardless of what the rules say. We think that there are two steps to changing--to weeding out the bad parts of the culture and changing the culture that needs to be changed.
One is you can take some organizational steps that help a little bit, but you--we believe that you can change a bad organization by reorganizing it, but you cannot change bad culture by reorganization. It takes both reorganization and leadership.
The leadership, not just the administrator, all levels of leadership are going to have to actively drive the bad cultural traits out of the organization. And it's something they're going to have to buy into personally, they are going to have to accept it in their gut, and in their daily reactions, they're going to have to look for these traits that we have carefully enumerated in our report like stifling communications and stomping on engineers and things like that. And they are going to have to drive it out.
And it is not simple, and that is why we did not make it a return to flight issue, because we know it can't be done between now and the next flight. It will take a long time.
QUESTION: Admiral Gehman, I believe it's Dr. Logsdon who has called NASA culture a fortress mentality. Am I right?
QUESTION: Somebody has.
Anyway, given the loss of the Cold War impetus that you cite in the report, and given that the public and the Congress seem to have indicated a desire for a space flight program but not a great willingness to pay more for it, what are your comments on continuing to fly under those very same circumstances?
GEHMAN: You are edging up toward the answer to the public policy debate that we are challenging the government of the United States to have.
I think that in the sections that John referred to, chapters one and chapter five of the report, in which we establish a historical context of how we got to where we are, it paints the picture that there's two sides to this issue.
That is, one side is that NASA over the years has over-marketed, over-promised and underestimated what these things cost, and therefore we've gotten ourselves in a position to where we have programs now that we own that are extraordinarily expensive and they never, ever have achieved either the goals or the cost goals that they set for themselves.
But that doesn't mean they can't be done. I mean, that doesn't mean that space travel can't be done relatively safely.
So it seems to me that the answer to your question is perhaps some renewed honesty on both sides of the equation here in which NASA doesn't over-market programs in an effort to get program and that also the branches of our government don't require unrealistic goals that can't be achieved. And I believe that's laid out in our report.
John, you want to say something about that?
LOGSDON: Well, I think the only thing I'd add to that is that the people that provide the resources for human space flight--the White House, the OMB, the congressional authorization and appropriations committees--all certainly believe that they're providing adequate resources. Nobody is trying to squeeze the program below an adequate level.
On the other hand, human space flight has had to compete within NASA. The shuttle's had to compete with the cost of the station. Human space flight has had to compete with robotic space flight. NASA's activities have had to compete with other science and technology areas.
And the country has been kind of ambivalent about how serious it is about its long-term space program and has done it, I think in our judgment, at a budget level not adequate to have a robust program.
And you can't draw a causal line that says, ``Budget constraints caused accident.'' We don't go there. We say it created an environment in which some things that could cause accidents could emerge. So it's a multi-layer kind of causality that we're talking about.
GEHMAN: And in our report we try and establish in chapter nine, in kind of the editorial section of our report, we suggest a way out of this dilemma. And without prescribing what the next program should look like or what the next vehicle should look like, we suggest that what really needs to happen is that we need to decide as a nation what it is we want to do.
We shouldn't start off by trying to design the next vehicle. That's a trap, and it's a trap we've fallen into three or four times in the last 15 years. We should decide what it is we want to do.
And the board suggests that what it is we want to do is to get humans in and out of low earth orbit routinely and safely.
GEHMAN: That's what it is we want to do. Not add a whole lot of bells and whistles to this thing, like single-staged orbit and build it out of the famous unobtanium (ph) material that floats around here and get on then with a program to support an agreed concept of operations or whatever it is we want to do.
In other words, reign in our appetite, properly fund the program and develop a program that is executable within what the nation wants to pay for it. It's in our report how to do this. Now, we didn't design the vehicle for the nation, but we told them how to get out of this dilemma.
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