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Flawed NASA culture led to shuttle accident, report says AP August 26, 2003 < < Back to Start of Article WASHINGTON The destruction of space shuttle Columbia and the death of its seven astronauts were caused by a NASA culture driven by schedule, starved for funds and burdened with an eroded, insufficient safety program, investigators said Tuesday. . 몣The board strongly believes that if these persistent, systemic flaws are not resolved, the scene is set for another accident,'' the report said. . The Columbia Accident Investigation Board, in a wide-ranging analysis of decades of NASA history, said the space agency뭩 attitude toward safety is little improved since the 1986 Challenger disaster, which also killed seven, and that without fundamental changes more tragedies will occur. . In events leading up to the loss of Columbia, the report said, NASA mission managers fell into the habit of accepting as normal some flaws in the shuttle system and tended to ignore or not recognize that these problems could foreshadow catastrophe. This is an 몣echo뮃 of some root causes of the Challenger accident, the board said. . 몣These repeating patterns mean that flawed practices embedded in NASA뭩 organizational system continued for 20 years and made substantial contributions to both accidents,뮃 the 248-page report said. . During Columbia뭩 last mission, NASA managers missed opportunities to evaluate possible damage to the craft뭩 heat shield from a strike on the left wing by flying foam insulation. . Such insulation strikes had occurred on previous missions and the report said NASA managers had come to view them as an acceptable abnormality that posed no safety risk. . This attitude also contributed to the lack of interest in getting spy satellite photos of Columbia, images that might have identified the extent of damage on the shuttle, and led to incorrect conclusions. . But most of all, the report noted, there was 몣ineffective leadership뮃 that 몣failed to fulfill the implicit contract to do whatever is possible to ensure the safety of the crew.뮃 . Management techniques in NASA, the report said, discouraged dissenting views on safety issues and ultimately created 몣blind spots뮃 about the risk to the space shuttle of the foam insulation impact. . Throughout its history, the report found, 몣NASA has consistently struggled to achieve viable safety programs뮃 but the agency effort 몣has fallen short of its mark.뮃 . Sean O묷eefe, who heads the National Aeronautics and Space Administration, had warned space workers earlier this summer that they should prepare themselves for a report that will be 몣really ugly뮃 as it outlines flawed engineering decisions that led to the destruction of Columbia as it returned to Earth following a 16-day mission. . O묷eefe said Monday that he was telling space workers 몣we need to not be defensive about that and try to not take it as a personal affront.뮃 Rather, he said, they should view it as a roadmap for getting the shuttle back into orbit. . The board made 29 recommendations, including changes it said NASA must make to start flying again and long-range changes that will alter the space agency culture. 몣The changes we recommend will be difficult to accomplish ?and will be internally resisted,뮃 the report said. . The board said it supports launching the next shuttle at 몣the earliest date뮃 consistent with safety.뮃 It established a series of requirements before the next launch to focus more on threats to the shuttle, including a 몣relentless뮃 hunt for the next dangerous failure and examining ways to help the crew escape. . The board concluded that the shuttle is 몣not inherently unsafe,뮃 and outlined other recommendations that it said should allow NASA to continue flying shuttles for another 10 or even 20 years. Among those recommendations is a costly and time-consuming complete recertification of all shuttle systems. . Some blame in the report was shifted to Congress and the White House because for almost a decade NASA lived on a lean budget that actually lost 13 percent of its purchasing power from 1993 to 2002. . At the same time, NASA was under pressure to build the International Space Station. To cut costs, the agency reduced its staff and contractor work force from about 32,000 in 1991 to just over 19,000 in 1997. . 몣The White House, Congress and NASA leadership exerted constant pressure to reduce or at least freeze operating costs (for the space shuttle),뮃 the report said. As a result, 몣safety and support upgrades were delayed or deferred, and Shuttle infrastructure was allowed to deteriorate.뮃 tle by little, NASA was accepting more and more risk in order to stay on schedule.뮃 Also: 몣The program was operating too close to too many margins.뮃 . The report reaffirmed the board뭩 conclusion that Columbia was destroyed as the result of a breach in the heat shield on the craft뭩 left wing. The board said that foam insulation peeled from the external fuel tank during launch in January and struck the wing at a high speed. . When Columbia re-entered the atmosphere on Feb. 1, superheated air penetrated the wing and melted it from the inside, causing the spacecraft to break apart and scattering debris over parts of Texas and Louisiana. . Columbia뭩 crew died within seconds after Mission Control lost signals from the shuttle. . 몣The destruction of the crew module took place over a period of 24 seconds beginning at an altitude of approximately 140,000 feet,뮃 the report said. Death was attributed to blunt trauma and loss of oxygen. . A final video from inside the crew compartment, just minutes before the breakup, showed that three crewmembers were not wearing the pressure suits, gloves and helmets prescribed for re-entry. . However, this oversight 몣did not affect their chances of survival,뮃 a the report said. . The 13-member investigation board was announced by NASA within hours of the accident. Led by retired Navy Adm. Harold Gehman Jr., the board members spent almost seven months reviewing evidence, talking to engineers and conducting experiments that proved fast-flying foam could damage the heat shield on the wing of a space shuttle. . Five preliminary recommendations were released during the investigation, and O묷eefe said those are already being acted on by the agency. WASHINGTON The destruction of space shuttle Columbia and the death of its seven astronauts were caused by a NASA culture driven by schedule, starved for funds and burdened with an eroded, insufficient safety program, investigators said Tuesday. . 몣The board strongly believes that if these persistent, systemic flaws are not resolved, the scene is set for another accident,'' the report said. . The Columbia Accident Investigation Board, in a wide-ranging analysis of decades of NASA history, said the space agency뭩 attitude toward safety is little improved since the 1986 Challenger disaster, which also killed seven, and that without fundamental changes more tragedies will occur. . In events leading up to the loss of Columbia, the report said, NASA mission managers fell into the habit of accepting as normal some flaws in the shuttle system and tended to ignore or not recognize that these problems could foreshadow catastrophe. This is an 몣echo뮃 of some root causes of the Challenger accident, the board said. . 몣These repeating patterns mean that flawed practices embedded in NASA뭩 organizational system continued for 20 years and made substantial contributions to both accidents,뮃 the 248-page report said. . During Columbia뭩 last mission, NASA managers missed opportunities to evaluate possible damage to the craft뭩 heat shield from a strike on the left wing by flying foam insulation. . Such insulation strikes had occurred on previous missions and the report said NASA managers had come to view them as an acceptable abnormality that posed no safety risk. . This attitude also contributed to the lack of interest in getting spy satellite photos of Columbia, images that might have identified the extent of damage on the shuttle, and led to incorrect conclusions. . But most of all, the report noted, there was 몣ineffective leadership뮃 that 몣failed to fulfill the implicit contract to do whatever is possible to ensure the safety of the crew.뮃 . Management techniques in NASA, the report said, discouraged dissenting views on safety issues and ultimately created 몣blind spots뮃 about the risk to the space shuttle of the foam insulation impact. . Throughout its history, the report found, 몣NASA has consistently struggled to achieve viable safety programs뮃 but the agency effort 몣has fallen short of its mark.뮃 . Sean O묷eefe, who heads the National Aeronautics and Space Administration, had warned space workers earlier this summer that they should prepare themselves for a report that will be 몣really ugly뮃 as it outlines flawed engineering decisions that led to the destruction of Columbia as it returned to Earth following a 16-day mission. . O묷eefe said Monday that he was telling space workers 몣we need to not be defensive about that and try to not take it as a personal affront.뮃 Rather, he said, they should view it as a roadmap for getting the shuttle back into orbit. . The board made 29 recommendations, including changes it said NASA must make to start flying again and long-range changes that will alter the space agency culture. 몣The changes we recommend will be difficult to accomplish ?and will be internally resisted,뮃 the report said. . The board said it supports launching the next shuttle at 몣the earliest date뮃 consistent with safety.뮃 It established a series of requirements before the next launch to focus more on threats to the shuttle, including a 몣relentless뮃 hunt for the next dangerous failure and examining ways to help the crew escape. . The board concluded that the shuttle is 몣not inherently unsafe,뮃 and outlined other recommendations that it said should allow NASA to continue flying shuttles for another 10 or even 20 years. Among those recommendations is a costly and time-consuming complete recertification of all shuttle systems. . Some blame in the report was shifted to Congress and the White House because for almost a decade NASA lived on a lean budget that actually lost 13 percent of its purchasing power from 1993 to 2002. . At the same time, NASA was under pressure to build the International Space Station. To cut costs, the agency reduced its staff and contractor work force from about 32,000 in 1991 to just over 19,000 in 1997. . 몣The White House, Congress and NASA leadership exerted constant pressure to reduce or at least freeze operating costs (for the space shuttle),뮃 the report said. As a result, 몣safety and support upgrades were delayed or deferred, and Shuttle infrastructure was allowed to deteriorate.뮃 . At another point, the report noted: 몣Little by little, NASA was accepting more and more risk in order to stay on schedule.뮃 Also: 몣The program was operating too close to too many margins.뮃 . The report reaffirmed the board뭩 conclusion that Columbia was destroyed as the result of a breach in the heat shield on the craft뭩 left wing. The board said that foam insulation peeled from the external fuel tank during launch in January and struck the wing at a high speed. . When Columbia re-entered the atmosphere on Feb. 1, superheated air penetrated the wing and melted it from the inside, causing the spacecraft to break apart and scattering debris over parts of Texas and Louisiana. . Columbia뭩 crew died within seconds after Mission Control lost signals from the shuttle. . 몣The destruction of the crew module took place over a period of 24 seconds beginning at an altitude of approximately 140,000 feet,뮃 the report said. Death was attributed to blunt trauma and loss of oxygen. . A final video from inside the crew compartment, just minutes before the breakup, showed that three crewmembers were not wearing the pressure suits, gloves and helmets prescribed for re-entry. . However, this oversight 몣did not affect their chances of survival,뮃 a the report said. . The 13-member investigation board was announced by NASA within hours of the accident. Led by retired Navy Adm. Harold Gehman Jr., the board members spent almost seven months reviewing evidence, talking to engineers and conducting experiments that proved fast-flying foam could damage the heat shield on the wing of a space shuttle. . Five preliminary recommendations were released during the investigation, and O묷eefe said those are already being acted on by the agency. WASHINGTON The destruction of space shuttle Columbia and the death of its seven astronauts were caused by a NASA culture driven by schedule, starved for funds and burdened with an eroded, insufficient safety program, investigators said Tuesday. . 몣The board strongly believes that if these persistent, systemic flaws are not resolved, the scene is set for another accident,'' the report said. . The Columbia Accident Investigation Board, in a wide-ranging analysis of decades of NASA history, said the space agency뭩 attitude toward safety is little improved since the 1986 Challenger disaster, which also killed seven, and that without fundamental changes more tragedies will occur. . In events leading up to the loss of Columbia, the report said, NASA mission managers fell into the habit of accepting as normal some flaws in the shuttle system and tended to ignore or not recognize that these problems could foreshadow catastrophe. This is an 몣echo뮃 of some root causes of the Challenger accident, the board said. . 몣These repeating patterns mean that flawed practices embedded in NASA뭩 organizational system continued for 20 years and made substantial contributions to both accidents,뮃 the 248-page report said. . During Columbia뭩 last mission, NASA managers missed opportunities to evaluate possible damage to the craft뭩 heat shield from a strike on the left wing by flying foam insulation. . Such insulation strikes had occurred on previous missions and the report said NASA managers had come to view them as an acceptable abnormality that posed no safety risk. . This attitude also contributed to the lack of interest in getting spy satellite photos of Columbia, images that might have identified the extent of damage on the shuttle, and led to incorrect conclusions. . But most of all, the report noted, there was 몣ineffective leadership뮃 that 몣failed to fulfill the implicit contract to do whatever is possible to ensure the safety of the crew.뮃 . Management techniques in NASA, the report said, discouraged dissenting views on safety issues and ultimately created 몣blind spots뮃 about the risk to the space shuttle of the foam insulation impact. . Throughout its history, the report found, 몣NASA has consistently struggled to achieve viable safety programs뮃 but the agency effort 몣has fallen short of its mark.뮃 . Sean O묷eefe, who heads the National Aeronautics and Space Administration, had warned space workers earlier this summer that they should prepare themselves for a report that will be 몣really ugly뮃 as it outlines flawed engineering decisions that led to the destruction of Columbia as it returned to Earth following a 16-day mission. . O묷eefe said Monday that he was telling space workers 몣we need to not be defensive about that and try to not take it as a personal affront.뮃 Rather, he said, they should view it as a roadmap for getting the shuttle back into orbit. . The board made 29 recommendations, including changes it said NASA must make to start flying again and long-range changes that will alter the space agency culture. 몣The changes we recommend will be difficult to accomplish ?and will be internally resisted,뮃 the report said. . The board said it supports launching the next shuttle at 몣the earliest date뮃 consistent with safety.뮃 It established a series of requirements before the next launch to focus more on threats to the shuttle, including a 몣relentless뮃 hunt for the next dangerous failure and examining ways to help the crew escape. . The board concluded that the shuttle is 몣not inherently unsafe,뮃 and outlined other recommendations that it said should allow NASA to continue flying shuttles for another 10 or even 20 years. Among those recommendations is a costly and time-consuming complete recertification of all shuttle systems. . Some blame in the report was shifted to Congress and the White House because for almost a decade NASA lived on a lean budget that actually lost 13 percent of its purchasing power from 1993 to 2002. . At the same time, NASA was under pressure to build the International Space Station. To cut costs, the agency reduced its staff and contractor work force from about 32,000 in 1991 to just over 19,000 in 1997. . 몣The White House, Congress and NASA leadership exerted constant pressure to reduce or at least freeze operating costs (for the space shuttle),뮃 the report said. As a result, 몣safety and support upgrades were delayed or deferred, and Shuttle infrastructure was allowed to deteriorate.뮃 . At another point, the report noted: 몣Little by little, NASA was accepting more and more risk in order to stay on schedule.뮃 Also: 몣The program was operating too close to too many margins.뮃 . The report reaffirmed the board뭩 conclusion that Columbia was destroyed as the result of a breach in the heat shield on the craft뭩 left wing. The board said that foam insulation peeled from the external fuel tank during launch in January and struck the wing at a high speed. . When Columbia re-entered the atmosphere on Feb. 1, superheated air penetrated the wing and melted it from the inside, causing the spacecraft to break apart and scattering debris over parts of Texas and Louisiana. . Columbia뭩 crew died within seconds after Mission Control lost signals from the shuttle. . 몣The destruction of the crew module took place over a period of 24 seconds beginning at an altitude of approximately 140,000 feet,뮃 the report said. Death was attributed to blunt trauma and loss of oxygen. . A final video from inside the crew compartment, just minutes before the breakup, showed that three crewmembers were not wearing the pressure suits, gloves and helmets prescribed for re-entry. . However, this oversight 몣did not affect their chances of survival,뮃 a the report said. . The 13-member investigation board was announced by NASA within hours of the accident. Led by retired Navy Adm. Harold Gehman Jr., the board members spent almost seven months reviewing evidence, talking to engineers and conducting experiments that proved fast-flying foam could damage the heat shield on the wing of a space shuttle. . Five preliminary recommendations were released during the investigation, and O묷eefe said those are already being acted on by the agency. |
