Shuttle-crash report prods NASA management

Analysis due Tuesday bores in on administrative issues as well as technical ones, and the question of 'culture as cause.'

Tuesday the Columbia Accident Investigation Board (CAIB) is set to release what some dub an unprecedented report on the shuttle's breakup and the loss of its crew.

But the key question many analysts are asking is: What next? Will the report spur a few congressional hearings, a handful of firings or resignations - and then join the Rogers Commission's Challenger report on a dusty shelf? Or will it trigger reforms in the manned-spaceflight program, including an influx of money for shuttle-safety upgrades and the development of a new, cheaper way to launch people and cargo into space? "We're at that crossroads," says Howard McCurdy, a specialist in space policy at American University in Washington.

After a six-month probe, the panel identifies the most likely cause of the breakup as a foam block that broke free from the external fuel tank on launch, punching a six- to 10-inch hole in a heat shield on a wing. But unlike the 1986 investigation into the Challenger disaster, the CAIB elevates organizational flaws to a level of concern usually reserved for mechanical problems, notes Diane Vaughan, a Boston College sociologist and author of a book on the Challenger disaster.

Such shortcomings range from chronic federal underfunding of the shuttle program to managers' readiness to accept anomalies - such as foam striking the orbiter - as normal and not significant safety issues.

"This sets a precedent for future accident investigations," she says.

For months, NASA has steeled itself for this day. NASA administrator Sean O'Keefe has talked of donning Kevlar suits. In a letter to his return-to-flight team last month, William Readdy, associate administrator for the Office of Space Flight, warned that "Congress and the media will mount their bully pulpits and rail righteously at how careless, callous, and indifferent all of us must have been to allow Columbia and her valiant crew to be lost so needlessly."

But, he added, "The jury is still out with regard to NASA's conduct of human spaceflight. Let there be no misunderstanding on this: We are not out of the swamp yet."

But NASA is hacking at the undergrowth. Last month it set up an "engineering and safety center" at the agency's Langley Research Center in Hampton, Va. In announcing the move, Mr. O'Keefe noted, "among the things we've learned during the investigation ... is the need to independently verify our engineering and safety standards." The center, he said, "will have the capacity and authority" to influence mission operations.

Additionally, the agency is addressing five "preliminary" CAIB recommendations issued in the past few months. NASA engineers reportedly are narrowing options for in-flight repairs on fragile heat-shedding material on orbiter wings' leading edges.

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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