Posted: Tuesday, August 26, 2003
GEHMAN: Good morning. We will follow the same process that we follow at all of our press conferences. I have a short opening statement. I will ask my colleagues to each make a statement about their part of the investigation. I'll summarize. And then we'll open the floor to questions.
I'd like to start off by saying that we are here nearly seven months since the tragic loss of Columbia, and our efforts, the intent of our report and all of the many hours that we put into this investigation were done to reflect favorably and to reflect with honor on the efforts of the crew--Rick Husband, Willie McCool, Mike Anderson, Dave Brown, K.C. Chawla, Laurel Clark and Ilan Ramon.
The lives of these people are very precious to us, and the board considered that a very serious matter, that these brave people thought that what they were doing was important, that it was significant, that it was part of human space exploration, that the things that were going to be learned from this mission were worth the risk that they were taking.
GEHMAN: And if this board has any impact whatsoever, we felt that the loss of their lives had better make a difference or both them and us have wasted our time.
The board also would like to express it's, and I as the chairman would like to express our most profound thanks to a lot of people. I'd like to express my profound thanks to my 12 fellow board members, who essentially gave up their lives for six and a half months to put an awful lot of effort into this report.
We essentially worked seven days a week as you're aware, but most of these people either one, they put their previously life aside and devoted 100 percent to this investigation, or two, some of them began leading two lives and keeping two jobs. And they did the investigation in the daytime and they did their other duties at night.
We had a staff of about 120 people on the investigation team, to them I owe a lot. They worked very, very tirelessly. They did brilliant work. They probably will never get their names in the newspapers or on television, but they did a wonderful job and we as a board are indebted to them.
To the hundreds and hundreds of NASA employees who assisted us with this, we are indebted to them. They also made a great contribution.
And lastly, as I have mentioned in almost every press conference that I have taken part in, the 25,000 to 30,000 private individuals who helped us, mostly in the area of the debris collection but in lots of other ways too, we owe a great debt to all of them.
As you may be aware, for example, we had over 3,000 unsolicited public inputs either in the sense of letters or e-mails to our Web site. We had all those debris collectors who marched shoulder to shoulder through the state of Texas picking up that debris which turned out to be so significant. We had pictures of people who contributed photography and videography, all of which contributed to this accident investigation. So we owe a lot of people thanks, and we are the first to acknowledge we could not have done this by ourselves.
GEHMAN: Let me say at the outset that this board--and I think I can speak pretty confidently for the 13 members, or the other 12 members of the board--this board comes away from this experience convinced that NASA is an outstanding organization.
It's full of wonderful people who are trying very, very hard to do very unique and very special things; things that are not done any other place in the world and, for the most part, have never been done by mankind before. And we would like to make sure that the American people realize that they have an institution of which they should be very, very proud in the form of NASA.
If this board had set out to spend seven months listing all the good things that NASA does, the report would be thicker than this. Unfortunately, that's not what our task was. And the nature of these investigations, it causes all of the good work and all of the wonderful things that are accomplished to get lost. And I think it's worth that we take a second and say that we are impressed by the work force. We are impressed by the people. And we are impressed by what NASA has accomplished.
Nevertheless, there are some things they can do better. It is our intent, by the publishing of this report, that those things that they need to do better get documented and that we provide the impetus for those changes.
Next, I think I speak confidently for the board in which we can state a conclusion that the space shuttle is not inherently unsafe. And that this board was under no pressure to say anything to the contrary.
The fact that the International Space Station is up there, the fact that the United States has obligations to finish the International Space Station, and that lots of other factors like the sunk costs that are already in the shuttle, et cetera, I can speak confidently for myself, and I think I can speak confidently for the 12 members that this board was under no pressure to say that the shuttle could continue to be operated. If we thought the shuttle was unsafe we would have said so.
GEHMAN: Now, that's not to say there aren't a lot of things they need to improve the safety of the shuttle. But if we thought that this shuttle was just inherently unsafe, we would have said so.
However, that does not mean that there are lots of things they should do to operate this thing more safely, and that's essentially the context of our report.
There are some things that need to be done immediately. We have listed those, and we call those return-to-flight items. We'll be glad to talk about them as the time goes on. And then there's a second group of recommendations, which we call, continuing to fly. The board feels that there will be so much vigilance and so much zeal and so much attention to detail for the next half dozen flights that anything we say probably is an understatement compared to the energy and the diligence that will be--that NASA will naturally put into making the first couple flights safe.
The board, however, is concerned that over a period of a year or two, the natural tendency of all bureaucracies, not just NASA, to morph and migrate away from that diligent attitude is a great concern to the board because the history of NASA indicates that they've done it before.
Therefore, we have a group of recommendations that are designed to prevent that, that backsliding or atrophy of energy and zeal. And those are the second group of recommendations that we call continuing to fly. And those are more fundamental and harder to do, but they are just as important--perhaps more important--than the return-to-fly recommendations.
And we are careful not to create any hierarchy of recommendations. We don't have a set of recommendations which are more important than others and a second group that's less important, and a third group which is third important. We were careful not to make that distinction.
You will not find in this report terms like ``contributing factors'' or ``underlying causes.'' We don't believe in those terms. We believe that these other organizations--these other organizational kinds of recommendations are just as important as the return-to-fly ones.
And then there's a third group of findings, observations and recommendations that consists of all the things that we observed or noted that we were not particularly pleased with, but didn't have anything directly to do with this accident. But they might contribute to a future accident and we strongly recommend that NASA pay attention to them, too.
We, once again, suggest to our readers of this report that you not mentally categorize these three categories of findings and recommendations in any kind of hierarchal order.
GEHMAN: To us, the golden nugget which may prevent the next accident could be in that third group. Just because it didn't have anything to do with this accident, you should not prioritize them in any other way. We feel very strongly about that.
I will stop talking here because I get the last word, and I will ask my colleagues here to say in just a few minutes to talk about their contribution to the report and the section that they're willing to--that they're ready to talk about.
I would like to have the boards put up, if we could have the board putter upper put up the boards over there. That'll happen while we're speaking. And I will then come back, say the last few words, which will be some words about the future, and then we'll open it up to questions.
So I'll turn to my colleague here, Dr. John Logsdon, in group four.
Go ahead, John.
LOGSDON: Thank you, Admiral.
The STS-107 accident happened at a particular time in history, but the history part of it the board decided very quickly after it started its investigation was important. We looked at this as an accident rooted in the history of NASA and the history of the space shuttle program.
We've given equal weight to the organizational causes that come out of the history of NASA and the program, and you've seen in the report, you'll see in these storyboards the statement of the organizational cause. So I'm not going to repeat that.
But as I was added to the board about a month after it started, I was given the mandate to try to trace that history and we did that, the history of the original decisions that shaped the shuttle program, which are in chapter one of the report, and then the history from Challenger to Columbia, which are in chapter five of the report.
I think we can summarize what's there in terms of three main points. One was the budget pressures and work force pressures. In order to fund other parts of the NASA program, the shuttle program was squeezed during the '90s. Its budget was cut by 40 percent. Its work force was cut by 40 percent. That left too little margin for robust operation of the system in our judgment.
LOGSDON: It was operating too close to too many margins. There was a mischaracterization, maybe even a misunderstanding of what the shuttle was as a mature and reliable system, about as safe as today's technology will provide, to quote out of a 1995 report.
Based on believing that the shuttle was a mature system, NASA turned a lot of its operations over to a single contractor. But importantly, turned a lot of NASA responsibilities in safety and mission assurance over to that contractor and backed off, did insight rather than oversight of the program. And we believe that was a mistake and that there needs to be stronger technical oversight by civil servants, by government employees of the program.
NASA acted as if you could count on the shuttle to carry out operational missions from '98 on, mainly space station assembly and supply, while not also collecting the engineering information that is associated with its developmental status. We believe that was a mistake.
There's a great deal of uncertainty about how long the nation would use this shuttle. And sometimes it was being treated as a going out of business program, sometimes it was being treated as central to the long-term future. Just in the '90s, the replacement date went from 2006 to 2012 to now 2015, 2020, maybe beyond. That made it very difficult to decide how much to invest in the system, invest in the ground infrastructure which was deteriorating.
So the whole system was operating in ways that were characterized by uncertainty, by stress, by tension. It's hardly an environment for effective safe operation as a program, the board concluded.
Underpinning all of this was what we characterized as NASA's human space flight culture--that word has been in the news a lot--we provide a definition of culture as the basic values, norms, beliefs and practices that characterize the functioning of a particular institution. We go into some detail in discussing the particular NASA human space flight culture, and come to the conclusion that it must be modified for success in the future.
LOGSDON: Thank you.
GEHMAN: Thank you very much.
HUBBARD: Thank you.
In four simple words: The foam did it. I refer you to the physical cause statement over here. I'm not going to read it. But after months of inquiry, after a lot of analysis, after a series of tests, we concluded that the falling foam impacting the leading-edge of the wing was the cause of the breach that ultimately led to the destruction of the orbiter and the loss of the crew.
I'll point out one thing about the statement, which is that we do not include the words ``probably, likely, most probable.'' All of this exhaustive work that we've done, all the discussion and the testing have led us to the simple statement that the foam was the result--the foam resulted in the breach that led to the loss of the orbiter.
My personal involvement has been very deeply engaged with the impact testing. I feel that testing accomplished three things. First of all, it provided the experimental evidence that corroborated the lines of analysis--these five lines of analysis that Sheila Widnall will describe in a few minutes. It provided an explanation point to the directions that the analytical work was pointing to.
Second thing is that, of course, it added to the body of knowledge about this reinforced carbon material that turns out to be a lot tougher than anybody thought it was, a lot tougher than the original specification, but unfortunately not tough enough to withstand an impact of this piece of foam at 500 miles an hour.
And finally, I think the tests accomplished a third psychological or sociological accomplishment, which is to remove any lingering doubt that, indeed, this light material could break open the leading-edge and could lead to the loss of the orbiter.
I think all of this work by our group in establishing the physical cause brings us to the point now, where coupled with the organizational cause, we're able to make a series of recommendations that you'll hear about later, that includes my statement.
GEHMAN: Thank you very much.
WIDNALL: OK. Well, many of you have been with us since the beginning, and you followed in great detail the analysis and the work that has been going on. So as you know, the board conducted an in-depth investigation of the various events that occurred, primarily focusing on those events that occurred during re-entry.
At the very beginning we had data from on board the shuttle that was telemetered (ph) to the ground. And this time line gave very important clues as to what had happened. You also know that in the midst of our investigation, what might be called the flight data recorder--we call it the OEX recorder--was found which, again, gave us a wealth of data from on-board sensors that provided information about temperatures and pressures and locations of various things that were going on.
We did have these five parallel lines of work. We had extensive wind tunnel tests and extensive analysis of the aerodynamics of this vehicle, including its aerodynamic response, its flight controllability. There were detailed thermal analysis to look at the affects of heat in various parts of the structure.
WIDNALL: And then, basically, burning through or melting through or breaching of various parts of the structure. But we had video and photo analysis, much of it taken by the public, which indicated the various events, flashes, debris pieces that occurred during the flight and these were all pieced together to give a fairly accurate indication of what had happened.
The debris was absolutely invaluable. The debris told us a lot about the direction of the flow at various critical areas, about temperatures. Chemical analysis of the debris told us about deposits of various kinds of metals--whose melting point we know--that were deposited on the various pieces of debris that were recovered.
And in all of that, we were able to derive a very self-consistent picture that, as Scott mentioned, we really have a very high degree of confidence in. I think one of the important things that was demonstrated from the on-board data was that the breach in the leading edge was pre-existing. In other words, we had thermodynamic events that occurred on re-entry that occurred at a time when the aerodynamic forces were insignificant. So it leads strong belief to the fact that the breach in the wing was there before re-entry occurred.
We were able, through these analysis, to document and time line the various flight events that occurred. Ultimately, the vehicle, because of structural damage, essentially became uncontrollable. Up to that point, the flight control system had managed to keep the vehicle flying, the planned trajectory. But finally, it could no longer keep the vehicle flying.
And I think the other thing to mention is that, at that point, the vehicle was so damaged that there would not have been a possibility of successfully, you know, continuing the re-entry of this vehicle, even if the vehicle had progressed into a region where the heating was reduced.
So this was, obviously, a catastrophic event that determined that the vehicle would be lost. That's basically...
GEHMAN: Thank you very much.
WALLACE: I'm going to talk a little bit about--sort of the part of the story that fits between the physical and organizational cost statements. Chapter 6 of the report is entitled ``Decision Making at NASA,'' and there are sort of four stories told in there. A couple of them are fairly familiar.
The foam story, you've kind of lived through that with us. Foam was coming off the orbiter from the very first mission. NASA requirements dictated that this not happen, that nothing ever striking the orbiter could possibly damage it, but it happened on every flight.
It actually happened that there was an average of 30 or so dings in the thermal protection tiles on all flights. Seven occasions of bipod ramps falling and, of course, a severe bipod ramp failure then, just two flights before STS-107. I know that's a familiar story. And the question we all asked is--the machine was talking, but why was nobody hearing, how were the signals missed.
The imaging story, the request for imaging on orbit, the related decision making, all the e-mails that you've all seen and printed--that story is laid out in great detail in Chapter 6 as well, also with information gained from other sources, interviews and various records.
WALLACE: The third story in there to actually come second is the schedule pressure story which has not been quite as extensively discussed during the course of the investigation. And I would say that the schedule pressure story is laid out in great detail in the report. I think it's fair to say that opinions can easily differ, they have among us on the importance of this issue and it's not easily quantifiable. There are a lot of subtleties in the schedule pressure. We're not talking about fists banging on tables, we've got to launch on this date, but rather more subtle pressures and influences.
And I would encourage you all to read that part of the report carefully and I think you'll conclude that it's thorough and probably that it's fair. And like the entire report, we hope that this entire story is thorough, that it's fair, and that it really helps the human space flight program in the long term.
The fourth story in chapter six is about the repair and rescue possibilities. We asked NASA to do a study on this which we think they did very, very forthrightly and thoroughly. I think there are two reasons to look at that: one is to simply know if it was possible or what were the probabilities of being able to affect the repair or rescue mission; and the other is to analyze how it affected the thinking on the mission, whether that possibility if it had been better understood might have altered some of the decision making during the mission.
From chapter six we go into chapter seven and eight, which discusses in context of organizational theory more of the relationship of this decision making and studied in the context of other high reliability organizations. Other organizations which do very high-risk work and quite successfully--naval reactors, substate programs--different programs are analyzed in there and the entire accident and also the Challenger accident are really evaluated in a thorough historical context in chapter eight.
I think it's important, although it's a daunting task, to read this report from one end to the other and then you come away with the entire story.
BARRY: Thank you, Admiral.
Now, my comments will be on safety culture.
Now, as the admiral has said, we've met some fantastic and outstanding NASA employees all the way through. You talk about safety, industrial safety is world renowned. However, it's our view that the broken safety culture resides in the human space flight.
Now, I refer to our organizational chart where we talk about the cause, but clearly there is still evidence of a silent, safety program with echoes of Challenger. And here's the Challenger report.
NASA had conflicting goals of cost, schedule and safety, and unfortunately safety lost out in a lot of areas to the mandates of operational requirements. So what we went through in our analysis is trying to figure out how we can fix the culture, and it's not an easy task. In order to do that, you have to do some organizational changes and clearly we have made some of those recommendations in this report.
But the second part of that recipe is leadership, and that is where NASA has to do its role. We can only provide recommendations on some of the changes, but the leadership is clearly key to that.
The other thing I want to mention is that we had some concerns about safety regarding independence, and you'll see that as one of the key recommendations when you get to the organizational part. There was and has been evident a lack of integrated safety functions, but more importantly, a lack of integration within the space shuttle program itself.
We have evidence and interviews and our research has shown that the integration office was not truly an integration office.
BARRY: And that compounded the safety culture problems--I'm trying to get one story for the whole program.
There also is barriers to communication and some of them that are cited are lack of shuttle--ineffective information systems, databases. And finally going back to the silent safety program issue, we found evidence of silent safety in not only the program, the flight readiness review, the debris assessment team and the mission management team.
So, ladies and gentlemen, it is still there.
That concludes my remarks,sir.
GEHMAN: Thank you very much.
I'd like to talk a little bit today to you about my experience, primarily my focus in the investigation and my good friend, Brigadier General Duane Deal, who's not here today, who's on his way from Houston to this location. The two of us spent the majority of our time getting very close to the people that maintained the orbiter and also built the various other pieces (inaudible), the external tank and the solid rocket booster.
That was primarily our focus. And in chapter 10 I'm going to talk to you a little bit today about some other significant observations that we found in the course of the investigation. We naturally went through the maintenance records of Columbia 100 percent. We went through all of the existing maintenance records all the way back to day one. We went back through every maintenance period that it had, and then every single major gripe that we could focus in on that had anything to do with TPS or the thermal protection system.
Then we looked at a random sampling of all of the other orbiters and looked at how they did maintenance, whether it was a NASA employee, or a contractor employee, it didn't matter. We went through the depth and breadth of this. So I'd like to throw out, in our time on the shop floor those are good people. The people that are down there working, they're working their hearts out. They've got the right idea, the right mind set. They're trying to do the best they can.
These observations I'm going to show out today are indicative of something that you could walk into a lot of organizations, but in particular we found some things that are different from the aircraft industry standard or the military industry standard, and those are what I would like to just throw out.
First off is the QA program. QA program, they went through a series of down sizing, took their inspection points and made them a number of 85. They left them pretty stagnant. Well, as you know, this is an aging orbiter. If you look inside that airplane, airplanes that I flew 25 some odd years ago, it's very similar to that. The problems that we had with corrosion are ongoing.
TURCOTTE: The problems as this air frame changed, also the inspection points will change, and that's an industry standard. As an aircraft ages, the maintenance changes, the inspection points changes. We found that to be lacking in the QA program.
We found out in the corrosion program, a lot of hard things to do there. There is, for example, the capsule. There are some points that we'll, short of taking the orbiter apart, never be able to get to look at. So NASA has to figure out some ways to get in there and look at those and find out the true age of the orbiter.
We looked at a lot of the test equipment that was used in the industry today. A lot of the equipment that is used on that program is 22 years old. It's frozen in time. It's just as it was when that thing was built. There is a lot of good test equipment out there that is in use in the industry and we've made several recommendations to incorporate that.
There are some other anomalies that we saw looking at--you've heard of the famous hold-down cable, or hold-down bolt cable problem. Just the way that that problem was treated, and if you apply the technical wiring and the engineering, the way that problem was treated does not meet industry standards.
Classification of FOD (ph)--my good friend General Deal dealt a lot with this. If you look at the way an aircraft on the flight line versus the way an aircraft in a factory are treated, they are two different entities. With the space shuttle, it's pretty hard to tell the difference because you're looking at one hangar, you're doing a major maintenance where you have to open this thing up to the world and do some very major repairs. Then you look right next to it, you have somebody working in an operational mode where the rules are different.
So we're making some recommendation that de-standardized the classification of FOD (ph) across the board for both of those.
Generally, all in all, I want to refer back to my first statement and what I said, the people on the shop floors putting this orbiter together and maintaining it have the best heart and souls. They are absolutely wonderful people, and it's been a pleasure working with them.
And I just want to leave that final thought to you, that on the shop floor they are looking forward to getting this thing and as the cry from one of the supervisors when I left, he said, ``Sir, we hope you find it, you fix it and you fly it.''
And with that I would like to conclude my remarks.
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