Shuttle report calls for NASA overhaul

Agency's culture blamed in part for Columbia tragedy

? The investigators have identified the causes. Now it’s up to NASA, Congress and the White House to fix them.

In a “damning” 248-page report released Tuesday, the Columbia Accident Investigation Board blamed the loss of space shuttle Columbia as much on weaknesses in the way NASA operates as on the breakaway piece of tank insulation that caused fatal damage to the left wing.

The physical cause will be the easiest to fix. NASA already has decided never to fly again with the foam that punched a hole in the wing’s heat shield, allowing the superheated gases of re-entry to destroy the shuttle over Texas on Feb. 1. All seven astronauts aboard died.

The board said it wants NASA to go much further — essentially, to re-invent itself, changing a culture that the board said ignored problems, made assumptions about safety based on incomplete data and stifled dissent within the ranks.

Without change, the board wrote, “the scene is set for another accident.”

Persistent oversight demanded

The board predicted that changing that culture would take months — if not years — and require persistent oversight.

“We have established all the facts. We’ve characterized their (NASA’s) strengths and weaknesses. And now we turn this report over to the people in the United States who establish public policy,” said retired Navy Adm. Hal Gehman, the board’s chairman.

Congress already planned hearings, starting next week, to begin considering what to do and how much it will cost. “There’s got to be some changes,” said Sherwood Boehlert, R-N.Y., chair of the House Science Committee. “You’ve got to re-energize the agency, get some different approaches.”

Space shuttle Columbia crew members strike a flying pose for their traditional in-flight crew portrait in the research lab aboard the shuttle in this photo from January. Clockwise from left are Kalpana Chawla, David Brown, William McCool, Michael Anderson, Ilan Ramon, Laurel Clark and Rick Husband. A report issued Tuesday said the destruction of Columbia and the deaths of its seven astronauts were caused by a NASA culture driven by schedule, starved for funds and burdened with an eroded, insufficient safety program.

The White House issued a statement reiterating President Bush’s promise at the Columbia crew’s funeral to find the problem, fix it and return to flight.

The investigation board indicated Congress and the White House were part of the problem but remain the highest authorities for making needed changes. The board blamed shrinking budgets and personnel, coupled with pressures to build the International Space Station, for helping set the stage for the accident.

NASA Administrator Sean O’Keefe, in a televised conversation with NASA workers, promised that the agency plans to follow each of the board’s recommendations.

“Do we intend to comply? You bet. Without reservation,” he said. To do so, he said, NASA must develop “a culture that tolerates absolutely no deviation” from good, safe practices.

O’Keefe has appointed a panel headed by former astronauts Richard Covey and Tom Stafford to assess NASA’s compliance and offer a recommendation about returning to flight.

Continued flight

The board expressed “strong support for return to flight at the earliest date consistent with safety” and took pains at a briefing after the report’s release to praise NASA employees and show pride in the agency’s accomplishments.

What happened:¢ About 81 seconds after launch, a piece of foam insulation smacked the shuttle’s left wing edge and opened a gash.¢ As the shuttle returned to Earth, it broke apart because heat entered through the gash. The seven astronauts died of blunt trauma and lack of oxygen.It could have been prevented:¢ Nine different times during Columbia’s 16-day flight, NASA managers could have done more to investigate damage from the falling foam.¢ By playing “sleight of hand” with statistics on past foam strikes, NASA officials had made the likelihood of certain types of dangerous foam impacts 10 times less likely than they actually were.Preventing future accidents:¢ Come up with in-flight repairs for all shuttle surfaces.¢ Photograph shuttles more — in flight and during launch.¢ Toughen the shuttle’s ability to withstand hits from space debris.

But board member John Logsdon said the report’s scathing tone was unmistakable. “I think it is frank, critical and, in some ways, damning,” he said.

“NASA’s safety culture has become reactive, complacent and dominated by unjustified optimism,” the report said. “Over time, slowly and unintentionally, independent checks and balances intended to increase safety have been eroded.”

The board expressed dismay that NASA, even after the fixes imposed following the loss of space shuttle Challenger on launch in 1986, had slid back into inadequate engineering, safety and management practices. The board noted that independent commissions since Challenger had warned NASA repeatedly that safety was again becoming a problem.

No confidence

“Based on NASA’s history of ignoring external recommendations, or making improvements that atrophy with time, the board has no confidence that the space shuttle can be safely operated for more than a few years based solely on renewed post-accident vigilance,” the report said.

Much of what the board reported Tuesday had been discussed in seven public hearings and numerous news briefings, but the narrative created a powerful story.

The board concluded that Columbia’s breakup on re-entry occurred because of a breach in the thermal protection system of the orbiter’s left wing. The breach, caused by a foam debris strike 82 seconds after launch Jan. 16, “allowed superheated air to penetrate the leading-edge insulation and progressively melt the aluminum structure of the left wing,” the board said. The structure weakened and ultimately succumbed to aerodynamic forces.

One new piece of information: A NASA Crew Survivability Working Group concluded that “the death of the crew members was due to blunt trauma and hypoxia (shortage of oxygen),” rather than an explosion. “It appears that the destruction of the crew module took place over a period of 24 seconds beginning at an altitude of approximately 140,000 feet and ending at 105,000 feet,” the group reported.