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Columbia Report: Background

An independent board announced that flawed practices at NASA and falling foam debris contributed to the space shuttle Columbia disaster last February.

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  • RAY SUAREZ:

    Hours after the space shuttle Columbia disintegrated in the skies over eastern Texas on Feb. 1, NASA tapped retired Navy Adm. Hal Gehman to head an independent investigation board charged with figuring out why the shuttle broke apart on reentry. All seven astronauts on board perished.

    From the beginning, the leading theory was that a piece of hard foam insulation broke off the external fuel tank and struck the shuttle's left wing during liftoff on Jan. 16. Over seven months, the Columbia investigation board conducted extensive tests and interviews.

    With the release of its 248-page report today, the investigation board confirmed its earlier theory. MIT professor and former Air Force Secretary Sheila Widnall:

  • SHEILA WIDNALL:

    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.

  • RAY SUAREZ:

    The report also concluded that NASA's management and its self-protective culture were to blame for the Columbia accident as well. George Washington University professor John Logsdon:

  • JOHN LOGSDON:

    One was the budget pressures and workforce 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 workforce was cut by 40 percent. That left too little margin for robust operation of the system, in our judgment. It was operating too close to too many margins.

  • RAY SUAREZ:

    The board found that NASA turned over too many of its safety responsibilities to independent contractors. Steven Wallace is the head of the Federal Aviation Administration's Accident Investigation Office. He added that the culture inside NASA caused clear signals to be missed.

  • STEVEN WALLACE:

    Foam was coming off the orbiter from the very first mission. NASA requirements dictated that this not happen and nothing ever strike the orbiter that 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. And the question we all asked is, the machine was talking but why was nobody hearing. How were the signals missed?

  • RAY SUAREZ:

    The board made 29 recommendations in the report, including: redesign the section of the tank where foam broke off during Columbia's liftoff; find ways to better inspect the shuttle's protective shielding in advance, and to then repair potential damage while still in orbit; and make sure that images of the shuttle are taken from numerous angles on every flight. Engineers hope those images would allow them to better see any damage done while in orbit.

    In a statement, NASA's Administrator Sean O'Keefe said the agency has already begun implementing some of the recommendations. He spoke to NASA employees today.

  • SEAN O’KEEFE:

    We must go forward and resolve to follow this blueprint and do our very best to make this a much stronger organization. We are, all of us at NASA, a part of the solution.

  • RAY SUAREZ:

    Earlier today, I talked about the investigation board's report with its chairman, Hal Gehman.

  • RAY SUAREZ:

    Well, Admiral Gehman, welcome.

    ADM. HAL GEHMAN (Ret.), Chairman, Columbia Accident Investigation Board: Thank you very much. Glad to have an opportunity to tell the story.

  • RAY SUAREZ:

    Well, your report points out that foam strikes have been known about and pretty well understood for a long time. How did it happen that they weren't really examined in the kind of depth you've done until now?

  • ADM. HAL GEHMAN (Ret.):

    Over the years, the space shuttle program has changed its organizational structure due to outside forces and some inside forces in which they emphasized effectiveness and efficiency. Essentially they emphasized cost and schedule and things like that.

  • RAY SUAREZ:

    Over safety.

  • ADM. HAL GEHMAN (Ret.):

    And de-emphasized good engineering and research and development and safety but not just safety, research and development into understanding why things are happening. And, as that process kind of morphed itself over the years, questions like why is this happening and this is a violation of our rules but should we continue to live with it, those questions aren't even asked anymore. Instead questions like are you going to make the schedule and can you get the cost controls — and those are the kinds of questions that will get asked.

    This process took a long time. But that is the answer to why they allowed things that weren't supposed to happen to happen.

  • RAY SUAREZ:

    If you were a person in the apparatus, raising questions, sharing your concerns with other people involved in the mission, what did your investigation find what happened to those misgivings?

  • ADM. HAL GEHMAN (Ret.):

    It's a complex question with complex answers but to summarize it as best I can, we found that there are traits and characteristics at work in the NASA space shuttle management system which were unhealthy and unhelpful to safety and to good engineering. These traits and characteristics we call culture. It's kind of a buzzword to capture how people behave outside of the formal rules of the organization.

    And what we found was we found some cultural traits which worked against people speaking up, to get at the questions that you asked. For example, where you worked made a difference as to whether or not you were believed or whether you were credible or not. Now, many people at NASA will say, no, no, that's not true, admiral. That is not true. It doesn't make a difference where you work. We found it does make a difference where you work. Whether you were in the space shuttle program or not in the space shuttle program made a big difference. Whether you worked at Marshall or Kennedy makes a big difference whether you work at Johnson. These are the cultural things which were interfering with the communications that you were asking about.

  • RAY SUAREZ:

    The report makes it clear that some of these tendencies are as old as the shuttle itself. You say that the program has never met any of its original requirements for reliability, cost, ease of turn-around, maintainability or safety. That's 25 years.

  • ADM. HAL GEHMAN (Ret.):

    The board felt that in order to understand this accident that you have to understand the history of the shuttle. The board felt very strongly that this accident was not a random anomalous event. This accident actually, when you put it in the context of the shuttle's history, kind of fits into a plot that's predictable; in order to understand that plot you have to start at the beginning.

    At the beginning, the shuttle program was oversold and over-marketed. And it was sold on a — on the basis that they could never fulfill, that it would be economical, it would be reliable, it could be launched on schedule, it was going to be routine access to space. That's why it was called a shuttle. It never was any of those things. It never was from the first day to today. So in order to what we've got today, you have to start with what we built. It's a marvelous machine. It's an engineering marvel but it was an engineering machine that had to meet too many competing requirements in its original design.

  • RAY SUAREZ:

    Aren't many of the points you're making in this report and your colleagues are making in this report echoes of things that were understood about the way the shuttle was designed and got into space after the Challenger disaster?

  • ADM. HAL GEHMAN (Ret.):

    Yes. The board was disappointed to draw, to be — we were disappointed when we drew an analogy between the engineering and the management and the fault mechanisms having to do with the Challenger accident and the Columbia accident to find a disturbing number of parallels. In the case of Challenger, the solid rocket booster joint which failed and caused the Challenger disaster had been failing before the Challenger. And the engineering system and the management system decided to take their time about fixing it. Well, the foam, which caused this accident, had failed before and had been failing routinely.

    And they came to the conclusion that they didn't need to make this a big deal based on faulty engineering analysis, just like they did in Challenger and a number of other things. So, yes, there were a number of disturbing similarities, and the connection between the two is one of the reasons why the board wrote a report that's relatively hard-hitting because we were afraid if they didn't get it the first time and they don't get it the second time, then they may not get it at all.

  • RAY SUAREZ:

    What does NASA have to do and what has to be changed about the craft itself for the shuttle to head to space again?

  • ADM. HAL GEHMAN (Ret.):

    After a very, very lengthy and in-depth technical review, the board is quite convinced that the shuttle itself is not inherently unsafe. It's risky. It always will be risky. We all need to recognize that. This is a risky enterprise. But the shuttle itself in its design is not impossibly unsafe.

    However, the management system that operates it is not up to managing that risky technology. And we have great — gone to great length in the report to outline what we think needs to be done both in the short term to kind of get the thing flying again, which has to do with fixing the foam and better inspections and making the Orbiter tougher and giving you a chance to make some repairs and things like that. But that won't make it safe to operate for another 10 or 15 years. They're going to have to change their management scheme to eliminate these unsafe practices.

  • RAY SUAREZ:

    NASA has already talked or certain people inside NASA have already talked about a March '04 launch of a shuttle. Can they do that?

  • ADM. HAL GEHMAN (Ret.):

    I see no reason why they cannot. We have not done a — we have not done an in-depth engineering study of how NASA is going to go about implementing our 15 return-to-flight recommendations, but we don't think that any of our 15 return-to-flight recommendations are extraordinarily hard or extraordinarily expensive. The most difficult one is the on-orbit inspection and repair. They're well along on that one.

  • RAY SUAREZ:

    Admiral Gehman, thanks a lot.

  • ADM. HAL GEHMAN (Ret.):

    My pleasure, glad to be here.

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