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Concerns raised that changes in NASA won't lastReport: Fix lax safety standards, slipshod management
(CNN) -- Without a huge commitment to change, NASA might again repeat practices that led to the loss of the space shuttle Columbia and its crew, according to the husband of one of the seven astronauts who died and a report released Tuesday. After conducting countless tests and interviews, and reviewing debris and data reconstructions, the Columbia Accident Investigation Board concluded that a piece of Columbia's foam insulation that fell off during launch January 16 was indeed to blame. It ripped a hole in the left wing, which during re-entry February 1, allowed superheated gases into the wing interior, where they melted the wing frame, investigators said. The board's final report also said that NASA had done little to improve shuttle safety since it lost the shuttle Challenger in 1986. "I think we are really going to have to look very carefully at what lessons we didn't learn from Challenger and make sure we absolutely learn them this time," said Jonathan Clark, a NASA flight surgeon and widower of Columbia astronaut Laurel Clark. He was not involved in preparing the report. Jonathan Clark referred to Diane Vaughn's book on the previous shuttle loss, "The Challenger Launch Decision," adding, "You could almost erase the O-ring problem and put in the tile shedding, and put 'Columbia' instead of 'Challenger.' " (Full story) A day before the report was released, NASA Administrator Sean O'Keefe acknowledged that his agency "just plain missed" the seriousness of the foam striking the wing. Tuesday, O'Keefe said the board's report would "serve as NASA's blueprint. We have accepted the findings and will comply with the recommendations to the best of our ability." The Columbia report comes after a painstaking, seven-month examination by the independent investigation panel and describes a space agency bureaucracy compromised by lax safety standards, slipshod management and dwindling funds as significant factors in the disaster. "NASA's organizational culture had as much to do with this accident as foam did," the report said. The day after the 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, lower-level engineers fretted during the two-week mission over whether the foam chunk, the largest known to have struck a shuttle, could have fatally punctured Columbia, the oldest and heaviest shuttle in the fleet. A congressman said the new report was reminiscent of NASA's internal analysis on the Challenger disaster, which also cited poor communication and an ineffective management structure at the space agency. "How can we put more brave astronauts in harm's way solely on NASA's assurance that this time they'll get it right?" said Rep. Anthony Weiner, a Democrat of New York. Among the organizational cultural traits that contributed to the loss, according to the 248-page 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. Without significant 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 next spring, primarily to send crews and equipment to the international space station. "It's hard to believe that's true," former astronaut Norm Thagard said, "because you've either got to correct one or both problems. You've either got to beef up the structure so that it's not so susceptible to damage from foam or whatever else might hit it, or you've got to eliminate the foam-shedding problem. Hard for me to imagine that's going to occur that soon." Although everyone might be vigilant on the next few flights, former NASA engineer and current editor of nasawatch.com Keith Cowing warns, "It's just in human nature to sort of slack off after a while." Board offers 29 steps to return shuttle to flightThe 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 postlaunch 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 into 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." Besides NASA, the board placed blame on the White House and Congress. During 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 budget for manned space flight. "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." With Congress on its August recess and President Bush on the road in Minnesota and Missouri, initial political reaction in Washington to the report was muted. Still, some lawmakers made a point of voicing their commitment to NASA and space exploration. "It is imperative that America remains at the forefront of space exploration and discovery, said Sen. Sam Brownback, chairman of the Senate Subcommittee on Science, Technology and Space. "It is our job here in Congress to take this report and move forward expeditiously in getting Americans in space safely aboard an American vehicle." Jonathan Clark said his late wife would have agreed. "I think she would say, "Learn what you can, be as safe as you possibly can, but don't give up space exploration, especially human space exploration." CNN.com's Richard Stenger contributed to this article.
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