Probe hits NASA in crash of shuttle

Agency called reckless, in need of reform

By Raja Mishra, Globe Staff, 8/27/2003

A persistent recklessness at the nation's space agency bears as much blame for the destruction of the space shuttle Columbia as the foam insulation that fatally damaged the craft's left wing, the final crash investigation report concludes. It also warns that only sweeping reforms at NASA could make human space flight safer.

The scathing 248-page report, released yesterday, described an agency so emboldened by previous successes that shuttle damage caused by chunks of insulation falling from the fuel tank was routinely ignored. Had NASA been more vigilant, the Columbia Accident Investigation Board said, the seven doomed astronauts might have been rescued during flight.

Instead, NASA managers dismissed concerns about the insulation that struck Columbia on liftoff, and the crippled shuttle fell apart over Texas on Feb. 1. The investigators identified eight "missed opportunities" when NASA officials suggested using spy satellites or other methods to investigate the wing damage, but the agency didn't follow through.

"NASA's safety culture has become reactive, complacent and dominated by unjustified optimism," said the report, which was written by a 13-member panel of safety and space flight specialists independent of NASA. "NASA's organizational culture and structure had as much to do with this accident as the (loose) foam."

While the report was unflinchingly critical at points, Retired Admiral Harold Gehman, who chaired the investigation, said a report on NASA's accomplishments would run far longer than the one on the accident. All members of the board endorsed a continuation of the nation's manned space flight program.

Still, NASA as characterized in the report seems a far cry from the triumphant space program that placed men on the moon in 1969 or even that sent a much-acclaimed unmanned mission to Mars six years ago.

Instead, an agency in decline emerged: The report cited pervasive safety lapses throughout NASA that echoed the conclusions issued by the panel investigating the crash of the shuttle Challenger 17 years ago.

"It didn't get fixed last time and there has to be a different approach," said Federal Aviation Admistration accident specialist Steven B. Wallace, a panel member.

The panel noted that various NASA officials raised concerns about Columbia's safety during the doomed flight, but met with inaction or bureaucratic opposition when they sought to investigate. The investigators identified six occasions when NASA officials discussed the possibility of using satellites to analyze the left wing, but there was either no follow-through or supervisors rebuffed the idea.

"We shouldn't just trust NASA" to reform itself, said team leader Gehman. Left uncorrected, NASA's problems, he said, "might contribute to a future accident."

Gehman's panel yesterday delivered copies of the report to the Bush administration and Congress, who control NASA's fate. Gehman called for congressional hearings to determine when NASA should be permitted to send its remaining three shuttles back into space, and to examine broader questions about the agency's mission and relevance.

President Bush said yesterday that NASA's future "must be determined after a thorough review of the entire report, including its recommendations."

But Bush sounded an optimistic note that echoed his address to the nation the day the shuttle disintegrated in a white streak over Texas: "Our journey into space will go on. The work of the crew of the Columbia and the heroic explorers who traveled before them will continue."

NASA officials promised to follow the report's recommendation, announcing the creation of the NASA Engineering Safety Center, based in Hampton, Va., to scrutinize the agency's programs for safety flaws.

"We have accepted the finding and will comply with the recommendations to the best of our ability," said NASA administrator Sean O'Keefe, who called the report "an important road map, as we determine when we will be `fit to fly.' "

The report did not call for O'Keefe's ouster, although Gehman hinted yesterday that change at the top might help, saying complex organizations can reform only when "a new boss comes in and he changes the way the organization operates or talks or thinks, or its attitudes and things like that."

The report outlined immediate fixes needed before the fleet, now grounded indefinitely, could be considered flight-worthy, beginning with a thorough review of all potential risks to the shuttles, from space debris to ill-designed parts.

It also urged that NASA explore safety options for astronauts, such as escape pods.

Investigators concluded months ago that the Columbia accident was caused by foam shaken loose from the shuttle's massive external tank 81.7 seconds after takeoff. The 2-foot slab of foam smashed into the shuttle's left wing with enormous force, tearing a 6-inch hole into protective carbon coating on the leading edge of the wing.

NASA officials did not regard the insulation strike as a safety threat because such strikes had happened on other shuttle flights with no great harm. As a result, the Gehman report found, NASA managers were uninterested in employing US spy satellites to get a closer look at the damaged wing, as some engineers suggested.

In fact, neither the crew nor mission control showed concern as Columbia began its descent to earth two weeks later even as ultra-hot gas from the planet's atmosphere seeped in, melting the infrastructure of the left wing.

Had NASA realized the danger Columbia was in, the report suggests the possibility of a midflight rescue mission that recalled the 1970 Apollo 13 drama, when mission controllers improvised a successful midflight rescue that saved that crew.

Two risky but realistic options were available then, the investigators learned. The shuttle Atlantis, which was scheduled to launch a month later, could have flown up to ferry the Columbia crew home. Or, the Columbia astronauts could have tried to stuff the 6-inch hole in the wing with metal and titanium parts scavanged from the cargo hold; a water bag could have been pushed in on top of the metal, freezing in the chill temperatures of space and creating a second protective layer.

"If we had gone out there and seen a hole in the wing and knew it was life-threatening, we would have done something," Gehman said yesterday, adding that the Bush administration disclosed to the panel that it would likely have ordered a rescue attempt had the extent of the wing damage been discovered.

Tragically, the report found, the damage was ignored: "'Overwhelming evidence indicates that program leaders decided the foam strike was merely a maintainance problem long before any analysis had begun."

The panel suggested the creation of an independent safety agency to constantly review NASA safety procedures, but the report did not offer firm recommendations for changing NASA's culture. Panel member John M. Logsdon, professor at George Washington University, said the problems were deep: "The accident is rooted in the history of NASA."

But the blame does not rest entirely with NASA, the panel found, noting that Congress and the White House put budgetary and political pressure on the agency, openly questioning the need to repeatedly send humans into orbit as early as 1970. NASA responded by arguing the shuttle was economically beneficial because it could ferry military satellites into space, initiating an era when the agency would constantly have its eye on the bottom line when planning missions, the report said.

During the last decade, as public and congressional interest in the shuttle waned, NASA shifted its money elsewhere, to marquee projects like the Hubble space telescope and unmanned Mars landings, cutting 40 percent of the shuttle program's budget and 40 percent of its work force. Many of the shuttle program's crucial components were turned over to private contractors. At the same time, it sought to maintain an ambitious series of shuttle launches.

"NASA had conflicting goals of cost, schedule, and safety," said panel member Major General John Barry. "Unfortunately, safety lost out."

The report detailed the final moments in the lives of the seven crew members. The cockpit began coming apart at 140,000 feet. Still, it took at least 24 seconds -- hurtling, tossing through the air -- before they perished as a result of oxygen loss and blunt trauma.

Material from the Associated Press was used in this report. Raja Mishra can be reached at rmishra@globe.com.