Foam Was to Blame, Says Shuttle Study

The Columbia investigation concluded Tuesday that the accident that killed seven astronauts was indisputably caused by foam debris, but it also blamed NASA for squelching internal critics, cutting inspections and hewing to an unrealistic launch schedule.

The 248-page final report issued a broad indictment of NASA’s safety compromises and flawed internal culture, which it said played an equally important role in the tragedy on Feb. 1 that destroyed the $2-billion spacecraft.

By the time Columbia lifted off and was struck on its left wing by a 1.67-pound chunk of foam, NASA managers had become blinded to the fact that the shuttle’s delicate thermal protection system was never designed to withstand such impacts, according to the report.

“NASA has lost all of its checks and balances,” said Harold Gehman Jr., chairman of the Columbia Accident Investigation Board. “The second problem is that NASA has been told this 10 times.”

The foam punched a hole in the leading edge, which allowed superheated gases to burn up the wing’s internal structure during reentry into the atmosphere and caused the orbiter to break up over Texas.

The report documents the analytical errors made by NASA managers during the Columbia mission, saying they missed eight separate opportunities to have possibly prevented the accident. Engineers knew that Columbia could have been damaged, but at each step they pulled back or were blocked from efforts to further investigate the risk, the report said.

“We need to stop stifling communications and stomping on engineers,” Gehman urged at a news conference Tuesday morning.

Though it said the shuttle is “not inherently unsafe,” the board issued 29 recommendations meant to help fix the specific causes of the accident and improve internal management at the space agency.

Fifteen of those recommendations must at least be started before the shuttle resumes flying, the board said, meaning that NASA will face serious challenges to its prediction of resuming flights by next spring.

For more than 20 years, NASA considered foam debris falling off the shuttle’s external tank and damaging the orbiter’s thermal protection system as simply a maintenance nuisance. Now, it must finally address the problem, the board said.

However, it did not tell NASA to eliminate all of the foam debris. Instead, it told NASA to “initiate an aggressive program” to deal with the problem over the long term, meaning that when the shuttle resumes flying, it may again encounter falling foam.

Similarly, it recommended that NASA toughen the leading edge and heat-resistant tiles, but not necessarily before flights resume. It did require NASA to find a way to inspect and then repair any damage on the shuttle while in orbit.

“For the next flight, we are saying cross your fingers and hope it doesn’t happen again,” said John M. Logsdon, a board member. “But you would have a repair and inspection capability just in case. That’s as realistic as you can be.”

The 13-member accident board was appointed by NASA in February to investigate the Columbia accident and make recommendations, although NASA and Congress will make the final decisions about what changes they adopt.

The board is chaired by Gehman, a retired admiral who was NATO supreme allied commander in Europe. It includes three other military aviation experts, a former astronaut, a top NASA official, a retired corporate executive, several senior civil accident investigators and two distinguished engineering professors.

Accident board members said they expect NASA to adopt their recommendations. On Tuesday, agency chief Sean O’Keefe told a standing-room-only crowd at NASA headquarters in Houston that he accepted the report’s finding and that the recommendations would serve as a “road map to fix ... problems.”

Even while officials praised the report, the Bush administration and members of Congress refrained from wholeheartedly embracing the recommendations or pledging any funding increases for safety enhancements outlined by the board.

“The next steps for NASA under Sean O’Keefe’s leadership must be determined after a thorough review of the entire report, including its recommendations,” President Bush said in a statement. Similarly, House Science Committee Chairman Sherwood L. Boehlert (R-N.Y.) said he would not write a blank check to pay for the shuttle fixes.

Sen. Bill Nelson (D-Fla.), a former shuttle astronaut, sharply criticized the funding cutbacks for NASA, citing reports the agency recently requested $1.6 billion in supplemental funding to help deal with the Columbia accident and was turned down by the White House.

“You can’t do spaceflight on the cheap,” Nelson said in an interview. “President Bush has shown little interest in the space program.”

The report places significant blame for the accident on underlying problems at NASA.

“The organizational causes of this accident are rooted in the space shuttle program’s history and culture, including the original compromises that were required to gain approval for the shuttle program, subsequent years of resource constraints ... and lack of an agreed national vision,” the report said.

Although NASA engineers at centers across the country were exchanging e-mails that raised concerns about the foam that struck the Columbia, the agency’s internal culture and its management practices prevented those from ever reaching the key decision makers.

When engineers proposed using military spy satellites to get photographs of possible damage on Columbia, the requests first failed to reach top managers and then later were mishandled through the agency’s cumbersome bureaucracy.

Although the report does not contain any stunning surprises after the board’s seven-month investigation, it does disclose unusual internal pressures on NASA to maintain the space shuttle’s flight schedule.

During 2002, NASA faced an escalating crisis in its efforts to build the often-delayed international space station. The goal to complete the station’s basic configuration by Feb. 19, 2004, “seemed etched in stone,” the report said.

Columbia investigators thought originally that the deadline was unrelated to the accident, but as they delved into the details of NASA’s actions in 2002, they discovered the agency was being forced to compress the shuttle’s schedule and reduce safety margins to keep the space station program on track.

At one point, NASA headquarters shipped a computer screen saver to NASA’s shuttle managers, depicting a clock counting down to Feb. 19, 2004, even showing the number of seconds they had left to accomplish their goal.

But with one orbiter in overhaul and Columbia unable to ferry heavy loads to the space station, NASA was attempting to complete five consecutive missions with just two orbiters in 2003. “By December 2002, every bit of padding in the schedule had disappeared,” the report found.

Any delay or any new technical problem threatened to exacerbate the already-tight schedule, investigators found.

For example, after foam debris struck a part of the shuttle’s solid rocket boosters during a flight in October, shuttle managers elected not to classify the incident as an anomaly, because it could have caused further delays, the report found.

Linda Ham, who chaired the management team that ran the Columbia mission, also employed such a rationale. The report found that most of her inquiries about the foam strike were to determine how it would affect the next shuttle flight rather than its implications for Columbia.

“NASA had conflicting goals of cost, schedule and safety. Unfortunately, safety lost out,” said Maj. Gen. John Barry, a board member.

The report provides an exhaustive examination of the budgetary cuts imposed on NASA by Congress and the White House that forced space engineers into compromises that affected safety.

The seeds of the accident go back to the design of the shuttle in the 1970s, when budgetary constraints forced NASA to make many compromises in the basic safety of the system, the report said.

Former NASA chief Daniel Goldin’s 10-year tenure at the agency was “one of continuous turmoil,” the report said. During his years, the shuttle work force dropped 42%, to 17,462 by 2002.

At one time, NASA conducted 40,000 inspections of the shuttle before each flight, but by the time of Columbia’s last flight, that was reduced to just 8,500, Barry said. One recommendation calls on NASA to increase its supervision of its employees and contractors when it involves safety issues by forming an “independent technical engineering authority.”

In making other recommendations, the panel included changes that it said NASA must make before flying the shuttle again and long-range changes to address lingering internal management problems.

Among the “return-to-flight” recommendations, the panel said NASA should implement a comprehensive plan to inspect the leading-edge panels and thermal tiles and to repair them in orbit. It also should improve photography of the external tank and wings during launch, the panel said.

The recommendation was based on the finding that the shuttle’s leading edges, which are made of a heat-resistant material known as reinforced carbon carbon, have sustained frequent impact damage and have also deteriorated as they age.

For example, the board found that paint primer used on the launch towers leaked zinc on the panels and eroded their protective coating. The board suggested improving maintenance at the towers.

The panel also recommended that NASA develop a computer system to better evaluate damage to tiles and panels and develop equipment that can inspect all shuttle wiring, including segments that have been inaccessible.

If NASA continues its plan to use the shuttle beyond 2010, it should completely recertify that the shuttle’s systems are safe, a monumental undertaking that could prove very expensive, Gehman acknowledged.

The board said NASA should consider replacing the shuttle as soon as possible and called three unsuccessful attempts to design a new space launch system “a failure of national leadership.”

The Columbia investigation examined shuttle safety well beyond the specific causes of the accident, finding a number of serious problems, including:

* At Kennedy Space Center, it found corrosion on the launchpads, holes in the roof at the vehicle assembly building and other antiquated facilities.

* The system that allows the solid rocket boosters to detach two minutes into the launch has serious safety defects that could allow heavy debris to threaten orbiters. The so-called “bolt catchers” that capture the debris should be redesigned, it recommended.

* Even the blueprints and drawings for the shuttle fleet are outdated and stored on paper, rather than electronically. It recommended NASA get a new digital system for keeping track of the drawings.

* NASA needs to consider whether to equip the shuttle with a crew ejection or escape system that could save astronauts’ lives in a future accident, though the board elected not to make a recommendation.

* The board also raised new concerns about the potential for injuries to the public if an orbiter should ever again break up over the U.S. on its way back to Kennedy Space Center. A study commissioned by the board found a 9% to a 24% probability that someone would be injured by debris, and that if a breakup occurred over Houston, at least one or two people would become casualties. NASA is believed to be studying requiring future shuttles to land at Edwards Air Force Base in California.