Panel criticizes NASA culture for shuttle loss
Report offers blueprint for return to flight
By Richard Stenger
(CNN) -- A space agency bureaucracy compromised by lax safety standards, slipshod management and dwindling funds were a major culprit in the loss of the space shuttle Columbia and its crew, an independent investigation panel concluded Tuesday.
Following a painstaking, seven-month examination, the final report of the Columbia Accident Investigation Board said that the U.S. space agency had done little to improve shuttle safety since it lost the shuttle Challenger in 1986.
"NASA's organizational culture had as much to do with this accident as foam did," the report said, referring to debris from an external fuel tank that struck and damaged Columbia soon after launch on January 16.
The board offered dozens of recommendations before the shuttle program returns to flight. Without major changes, the panel warned, NASA risks losing another one of its remaining three shuttles.
"If we thought the shuttle was unsafe, we would have said so. Now, that is not to say, there are not a lot of things they need to do to improve the safety of the shuttle," retired Adm. Harold Gehman Jr., the board chairman, told reporters Tuesday.
"But if we thought this shuttle was just inherently unsafe, we would have said so." (Gehman transcript)
NASA would like to return the shuttles to flight as early as the spring of 2004, primarily to send crews and equipment to the international space station.
Organizational flaws at NASA cited
Among the organizational cultural traits that contributed to the loss, according to the 248-page Gehman report:
• Reliance on past success as a substitute for sound engineering practices.
• Organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion
• The evolution of an informal chain of command of decision-making progresses that operated outside the organization's rules.
The February 1 disaster, which took place shortly before the shuttle was to land, claimed the lives of seven astronauts.
Minutes before the orbiter broke apart over Texas, it developed serious trouble in its left wing, the same one struck 16 days earlier by a piece of launch debris seconds after liftoff.
After conducting countless tests, interviews, and debris and data reconstructions, the board concluded Tuesday that the foam was indeed to blame. It ripped a hole in the left wing, which during re-entry allowed superheated gases into the wing interior, where they melted the wing frame, investigators said.
The day after launch, shuttle managers became aware of the foam strike, but a computer analysis done by an independent contractor predicted little flight risk, and NASA decided not to request satellite or ground-based pictures to assess possible damage.
Despite top shuttle management determination that there was no danger, low-level engineers fretted during the two-week mission over whether the foam chunk, the largest known to strike a shuttle, could have fatally punctured Columbia, the oldest and heaviest shuttle in the fleet.
NASA chief vows to accept recommendations
On Tuesday, NASA Administrator Sean O'Keefe said the report would "serve as NASA's blueprint. We have accepted the findings and will comply with the recommendations to the best of our ability."
On Monday, O'Keefe admitted his agency "just plain missed" the seriousness of the foam that hit the wing.
Besides NASA, the board placed blame on the White House and Congress. Over the past decade, the space agency has seen a steady decline in its budget, with adjustments for inflation. The trend forced the agency to cut its work force and rely heavily on outside contractors.
Moreover, U.S. commitments to build the international space station squeezed millions out of NASA's already tightened manned spaceflight budget.
"The White House, Congress and NASA leadership exerted constant pressure to reduce or at least freeze [space shuttle] operating costs," the report said.
Consequently, "safety and support upgrades were delayed or deferred, and shuttle infrastructure was allowed to deteriorate."
The board suggested 29 courses of action to return the shuttle fleet to flight for another decade or two.
"The changes we recommend will be difficult to accomplish," the report said, "and will be internally resisted."
The suggestions included preventing foam pieces from falling off external fuel tanks during launch, conducting an exhaustive safety recertification of all shuttle systems by 2010, improving imaging systems on the shuttle and ground for better launch and post-launch pictures, and exploring options to save stranded crews.
Had NASA known the probable extent of the damage to Columbia, for example, another shuttle could have been dispatched on an emergency mission before the Columbia crew ran out of air, investigators said.
Other recommendations include earmarking more funds for NASA, developing an orbital space plane to replace the shuttle and creating a new overall safety program, which would answer to Congress and the president.
"There will be so much vigilance, so much zeal, 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 NASA will naturally be putting in to making the first couple of flights safe," Gehman said.
"Over a period of a year or two, the natural tendency of all bureaucracy, not just NASA, to migrate away from that diligent attitude is a great concern to the board because the history of NASA indicates that they have done it before."