THE CULTURAL TALE OF TWO SHUTTLES
NASA’s habit of relaxing safety standards to meet financial and time constraints set the stage for the Feb. 1 loss of the space shuttle Columbia and its seven astronauts, investigators said Tuesday. They warned that the agency’s “broken safety culture” would lead to tragedy again unless fundamental changes are made.
In a wide-ranging analysis of decades of NASA history, the Columbia Accident Investigation Board said the space agency’s attitude toward safety hasn’t changed much since the 1986 Challenger disaster, which also killed seven.
The space agency lacks “effective checks and balances, does not have an independent safety program and has not demonstrated the characteristics of a learning organization,” the board said in a stinging 248-page report.
“The board strongly believes that if these persistent, systemic flaws are not resolved, the scene is set for another accident,” the report said.
Retired Navy Adm. Harold Gehman, the board’s chairman, told reporters at a Washington briefing that NASA tends to follow safety procedures diligently at first, then “morph or migrate away” from that diligence as time goes on.
“The history of NASA indicates that they’ve done it before,” Gehman said. Some of the report’s recommendations were aimed at fixing that organizational flaw, he said.
Responding to the report, NASA Administrator Sean O’Keefe noted that the board’s preliminary recommendations were already being adopted, and said the full report would serve as “NASA’s blueprint” for returning the three remaining space shuttles to flight operations. Advertise
President Bush said NASA’s next steps “must be determined after a thorough review of the entire report, including its recommendations.”
“Our journey into space will go on,” he said during a stop in St. Paul, Minn. “The work of the crew of the Columbia and the heroic explorers who traveled before them will continue.”
Jonathan Clark, the husband of Columbia astronaut Laurel Clark, said he thought the report was “extremely thorough.”
“From my perspective, it certainly hits right on the money,” he said.
An ‘Echo’ of challenger
In addition to detailing the technical factors behind Columbia’s breakup, just minutes before its scheduled landing at the end of a 16-day science mission, the board’s report laid out the cultural factors behind NASA’s failings. It 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 was an “echo” of some root causes of the Challenger accident, the board said.
“These repeating patterns mean that flawed practices embedded in NASA’s organizational system continued for 20 years and made substantial contributions to both accidents,” the report said.
During Columbia’s last mission, NASA managers missed opportunities to evaluate possible damage to the craft’s 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 came to incorrect conclusions.
But most of all, the report noted, there was “ineffective leadership” that “failed to fulfill the implicit contract to do whatever is possible to ensure the safety of the crew.”
Management techniques in NASA, the report said, discouraged dissenting views on safety issues and ultimately created “blind spots” about the risk to the space shuttle of the foam insulation impact.
Throughout its history, the report found, “NASA has consistently struggled to achieve viable safety programs” but the agency effort “has fallen short of its mark.”
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