Shuttle-crash report prods NASA management

And NASA has established a return-to-flight team aiming to get shuttles off the ground - perhaps as early as spring of 2004.

Yet fixes for the physical cause of Columbia's loss and the adoption of technologies that could help identify problems on shuttle exteriors while in orbit are likely to be the easiest nuts to crack, analysts say, compared with changes to the manned spaceflight program's culture.

Ask any employee about his or her commitment to safety and, analysts agree, you'll hear sincere commitments to safe missions. But as organizations such as NASA grow in size and geographic spread, communications break down and boundaries arise. Some in Congress have taken issue with the notion of culture as cause. It's too fuzzy a concept, they argue, and it undercuts accountability. Even some within the agency acknowledge that they're not quite sure what it means.

But Dr. McCurdy counters that workplace culture has a simple definition: "assump-tions people make about their work." In the space program's early days, that assumption "was that things blew up," he says Roughly 3 of every 10 launches of rockets that were later used for human spaceflight failed. So engineers were attuned to danger - and built spacecraft with escape towers to blast capsules free. By comparison, McCurdy adds, although shuttles remain experimental, they lack comparable crew safety systems.

As with Challenger, NASA has maintained a belief in the shuttle's safety "inconsistent with the reality so far revealed" in operations, Vaughan adds. Other parts of the program's "culture" that could be addressed include those determined by ambitious flight schedules in the face of tight budgets.

Noting the impact of flat budgets on NASA's culture of safety, McCurdy continues, "over the last 30 years, no one in NASA has had the nerve to stand up to Congress and the White House and say, 'If that's all the money you've got, then we're not going to fly.'"

At another level, Vaughan adds, the shuttle program is a culture in which managers tend to ask engineers to prove something is unsafe rather than safe.

In working towards change, two approaches the agency could take include a military-like "red team," assigned the task of "challenging everything to prevent group-think," says Charles Perrow, professor emeritus at Yale University who has written widely on risky technologies and safety. Another approach involves an independent, anonymous hotline for reporting problems - then periodically publishing reports, with wide circulation among all levels of management. The Federal Aviation Administration, he notes, has done this. "The big challenge with high-tech systems is to keep people alert to all the things that can go wrong," he says.

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