Top-Level Report Cited Safety Fears

A top-level NASA report three years ago warned that the space shuttle fleet was facing serious safety problems, including faulty wiring on the ill-fated Columbia and corrosion on all the orbiters, but the agency failed to carry out many of the key recommendations, according to a former senior NASA official.

The recommendations raised alarms about crucial shuttle safety issues, such as sloppy workmanship, lost paperwork and reduced inspections of heat protection tiles, the component that is a focus of the Columbia crash investigation. The report also cited inadequate inspection staffs and the problem of physically strained workers reporting a high use of hypertension drugs.

Several studies critical of shuttle safety have come to light since Saturday’s accident, but this March 2000 assessment contains the most detailed documentation of potential problems. It also was produced under the authority of one of NASA’s highest-ranking officials.

The author of the report, Henry McDonald, former director of NASA’s Ames Research Center in Mountain View, Calif., said Monday in an interview that the space agency let him go two months ago when top officials elected not to renew his employment contract. He has since returned to the engineering department faculty at the University of Tennessee at Chattanooga.

It is unclear whether his advocacy on shuttle safety led to his dismissal, but the report’s criticism of personnel cutbacks on the shuttle program and his advocacy for reforms in shuttle management contradicted the policies of NASA Administrator Sean O’Keefe, he said.

NASA officials said Monday that most of McDonald’s findings were put into a so-called action plan, which they said was not immediately available. Nonetheless, they said this action plan has been carried out, though it is unclear to what extent recommended changes occurred.

NASA officials said plans include new training for employees to inspect wiring systems and improving the exchange of data with other government agencies. They declined to comment on the reasons for McDonald’s departure. But McDonald said other NASA officials had downplayed his findings and acted on only a few of the more than 100 recommendations.

The report was sent to various NASA research centers and to the space shuttle office, where staffers argued they had already taken care of issues in McDonald’s report or that he did not understand their processes.

“Do I think the recommendations were followed appropriately? No, I don’t. It is clear to me that the cost got in the way,” McDonald said. “I wasn’t too happy about it, but it wasn’t our duty to police the recommendation.”

Whether the report identified issues that could have prevented the Columbia loss is unclear, because the crash investigation is at a preliminary stage and little is known about the fundamental causes. NASA officials said Monday they are searching for a “missing link” that would help explain some of the conflicting information about the accident.

During the 1990s, a growing number of investigations focused on shuttle safety, including examinations by the General Accounting Office, the inspector general and Aerospace Safety Advisory Panel.

Although outside groups had expressed growing concerns about budget reductions in the program, McDonald’s recommendations were far more extensive and represented the agency’s own leadership raising a red flag. Ames is one of NASA’s eight major research centers, and McDonald’s role as center director placed him among the senior leadership.

A separate 1997 report by a NASA inspector -- cited on the agency’s Web site -- detailed concerns about the potential impact of insulation debris on shuttle tiles.

McDonald said efforts to quash his report went even further, with NASA officials attempting to persuade the agency’s technical staff to disagree with the conclusions.

“They called in a number of people we interviewed, and while there was no overt pressure, it was clear to the technicians that there was only one right answer if they wanted to keep their job,” McDonald said. The investigating team subsequently received calls from employees at NASA’s Michoud, La., and Palmdale facilities complaining about their treatment.

McDonald’s recommendations were first reviewed by then-NASA Administrator Daniel S. Goldin and former NASA chief engineer W. Brian Keegan. Keegan said in an interview Monday that the report, which he described as “far-reaching,” was discussed and debated intensely among top managers before it was sent to shuttle managers.

“It’s fair to say that they were comprehensive recommendations and that they had potentially significant implications,” said Keegan, a 36-year NASA veteran who retired last April.

But Keegan said the recommendations came at a time when the agency was under pressure to cut costs, which included having to reduce personnel. “The question was not whether we should do something but how do you do it,” Keegan said.

Keegan said NASA eventually drafted a plan for addressing “each and every one of the recommendations,” but he could not say whether any were carried out. Still, Keegan said he doesn’t believe any of the concerns raised in the report directly contributed to the Columbia disintegration, although he questioned whether budget constraints may have had an indirect bearing.

“The question is whether there may have been, in trying to accommodate the budget reductions, some trade-offs made where something could have been overlooked,” Keegan said.

McDonald said that as far as he knew only two recommendations were adopted: increasing some inspectors and improving wiring insulation on the Columbia while it was undergoing an 18-month modification in Palmdale beginning in September 1999.

The investigation that resulted in the 144-page report was undertaken after several mechanical problems delayed shuttle launches and raised safety concerns during flights. At that time, the agency had discovered some exposed wires in Columbia and a loose engine part that caused a premature engine shutdown on the launch of Columbia in 1999. Columbia’s damaged engine leaked explosive hydrogen fuel all the way to orbit. It would later be considered “a near-disastrous launch,” according to a Smithsonian Institution history of the shuttle.

The group McDonald chaired included experts from throughout NASA, the Air Force, Navy and private industry. The report examined staffing issues and specific technical areas. It repeatedly raised broad concerns about cutbacks of shuttle safety inspections and safety staffs.

“A reduction of workforce may also lead to a reduction in capabilities as expertise and experience are lost,” the report said. The remaining workforce, the team found, felt it was overworked and stressed out.

“Four of six people within this [interview] group were taking medication for hypertension,” it said. “They felt that the number of their peers who have retired, obtained jobs elsewhere, medically retired or suffered heart attacks or strokes was very high.”

Personnel cuts, McDonald said, had contributed to “increasing occurrences of stumble-ons, diving catches and escapes” that indicated narrowly missed serious accidents. The report noted, for example, that the program’s safety and mission assurance staff had been cut from 150 to 80 at its Marshall Space Flight Center. In all, space shuttle maintenance personnel were cut from 3,000 to 1,800 between 1995 and 1999, according to a Rand Corp. study.

The report dealt at length with degraded wiring on the shuttle fleet, noting that each orbiter contained 200 miles of wiring that was often difficult to inspect and maintain. The report noted instances of wiring insulation that had been burned off by electrical sparks, for example. It also raised serious concerns about the aging structure of the orbiters and corrosion that was never anticipated early in the program. The report said NASA would need to develop methods to inspect and monitor the growth of cracks in the orbiters’ aluminum structures.

“To date, much of the corrosion damage discovered has been largely unanticipated in the design of the shuttle and results from extending its operational life,” the report said. “Furthermore, about 10% of the structure is inaccessible” for inspections. The shuttle fleet was designed for a 10-year operational life, though it is being flown less often than expected.

Nonetheless, the fleet is more than 20 years old and could continue to fly until it is 40 years old. As a result, corrosion represents a serious concern, particularly because it can occur underneath heat tiles. Such corrosion, McDonald said, could directly affect the ability of the tiles to remain bonded to the spacecraft and should be an issue under investigation in the Columbia crash.

Spot checks for corrosion were conducted during Columbia’s refurbishing, McDonald said, but it was unclear whether any was discovered.

The report drew the attention of members of Congress in September 2001.

“I fear that if we don’t provide the space shuttle program with the resources it needs for safety upgrades, our country will pay a price we can’t bear,” Sen. Bill Nelson (R-Fla.), a former astronaut, told a shuttle safety hearing. “The proposed budget abandons some of the most critical safety upgrades for our aging fleet.”

McDonald said he blames the failure to carry out his report on the Office of Management and Budget, the White House office that reviews funding for the federal government. At the time McDonald’s report was issued, O’Keefe was the deputy director of OMB and had become a staunch advocate for reducing spending on the space shuttle program.

Other reports also indicated concerns about safety -- including the potential impact of insulation debris on shuttle tiles.

For example, after a post-flight inspection of a 1997 Columbia shuttle mission, NASA mechanical systems engineer Greg Katnik reported “significant damage to the tiles.” Katnik, who wrote of his inspection on a NASA Web site, said that up to 40 tiles are typically damaged on a shuttle launch. But the 1997 damage was “abnormal.”

“The pattern of hits did not follow aerodynamic expectations, and the number, size and severity of hits were abnormal,” he wrote. His team counted 308 “hits,” 132 greater than 1 inch. He said more than 100 tiles had to be removed from the shuttle because they were irreparably damaged.

Most recently, former NASA engineer Don Nelson wrote to President Bush in August 2002 urging suspension of shuttle flights out of concern for safety. He cited a number of dangerous conditions, including episodes of tile damage from insulation strikes.

“Your intervention is required to prevent another catastrophic space shuttle accident,” Nelson wrote the president. The 1999 retiree said NASA management had failed to respond to growing signs of danger.

On Dec. 4, 2002, Nelson received a reply from the White House saying that it was not appropriate “for the President to issue a moratorium on Space Shuttle launches at this time.”

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Times staff writers Lisa Getter, Judy Pasternak and Usha Lee McFarling and researcher Nona Yates contributed to this report.

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(BEGIN TEXT OF INFOBOX)

Internal friction

A 144-page NASA report on the safety of the space shuttle fleet warned agency officials of major problems three years ago. The trouble spots included:

* Reduced inspections of protective thermal tiles.

* Faulty wiring.

* Airframe corrosion.

* Reduction in technical workforce through cost reduction.

* A lack of oversight and backup inspections.

* A “false sense of security” with shuttle risk assessments.

Source: Space Shuttle Independent Assessment Team

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Memorial service

Cable and broadcast networks will provide live coverage of today’s memorial service for the seven Columbia astronauts, to be held at 10 a.m. PST at Johnson Space Center in Houston. All times PST:

* ABC -- Beginning at 10 a.m.

* CBS -- 10 to 11 a.m.

* NBC -- Beginning at 9:30 a.m.

* CNN -- Beginning at 9 a.m.

* Fox News Channel -- Beginning at 10 a.m.

* MSNBC -- Beginning at 9:30 a.m.

From Associated Press