Shuttle Board Cites Critical Lapses at NASA

Times Staff Writer

NASA managers failed to identify serious risks facing space shuttle crews, significantly reduced important safety inspections at Kennedy Space Center and created a culture that failed to pay attention to safety concerns, Columbia investigators said Wednesday.

The criticism of NASA was some of the most pointed since the Columbia Accident Investigation Board began examining the causes of the Feb. 1 shuttle tragedy.

As the board gets closer to identifying the technical causes of the accident, it has begun to bore deeply into the underlying management and cultural issues that may have contributed to it. The climate inside NASA tended to isolate engineers who had specific and persistent safety concerns, board members said.

“There is ample reason for us to be concerned,” said Harold Gehman Jr., the board chairman. “People who had doubts about anything were outside the circle and had to work their way in, rather than the doubters being inside the circle. Of course, there are a lot of reasons for this.”


Gehman promised Wednesday that he would produce a “voluminous” report that goes back to day one of the shuttle program and provides a road map for all future use of the shuttle. The report is scheduled to be completed by late July, before the August congressional recess, he said.

A number of important tests in the next few weeks will help investigators reach their final conclusions about the technical failures on the flight. At the same time, the pace is picking up on efforts to put the NASA culture under a microscope.

Gehman said he plans to take the testimony of former NASA chief Daniel S. Goldin, whose long tenure at the space agency in the 1990s left an indelible imprint on its programs, outlook and management. It is not yet clear whether Goldin will testify in public or in a confidential interview, Gehman said.

Investigators are still learning of more incidents in which foam debris fell off the shuttle’s external tank and damaged the orbiter -- the scenario that still represents the most likely cause of the Columbia accident.


For years, NASA had accepted foam debris damaging the delicate thermal protection system on the orbiter fleet, board member Kenneth W. Hess said. In the process, the agency had blurred the distinction between safety problems and maintenance problems. Foam has fallen off during every shuttle launch since the first one in 1981, Hess said.

“There was a lack of appreciation of the total risks involved,” he said at a news briefing.

On seven and perhaps eight previous launches, major pieces of foam fell off an area of the external tank known as the bipod attachment. After a major foam impact during a launch Oct. 7, NASA began an independent assessment of the risks, Hess said. But that assessment was not due back until a week after the Feb. 1 Columbia accident.

The board also examined NASA’s performance in some other critical areas that were related to the Columbia accident, including a sharp reduction in the number of employees who performed safety inspections at the launch site.


NASA will need to improve the quality of its hands-on inspections, which have dropped sharply as the agency has come to rely on aerospace contractors to perform the bulk of such work, said Air Force Brig. Gen. Duane W. Deal, a board member.

Space agency employees were performing 40,000 inspections for each shuttle mission until the mid-1990s, when the program’s budget started to be cut. By earlier this year, those inspections had been reduced to just 8,500, Deal said.

No one in the space agency is satisfied with the adequacy of those inspections now, Deal said, adding that responsibility for at least some of the inspections performed by contractors should be turned back over to NASA.

Although the board’s assessments of NASA were frank, Gehman tempered his remarks by saying that it’s easier to draw conclusions after the fact.


Gehman called it “unfair and hypocritical” to suggest that NASA should have known that the foam debris could cause an accident on Columbia or that defective O-rings would have caused the Challenger accident 17 years ago.

The challenge today is to identify potential causes of future accidents."It is easy to find these flaws in hindsight,” Gehman said.

In other technical developments, the board is coming closer to identifying an object that floated away from the shuttle and was observed on the second day in orbit by powerful ground-based radars, said board member Sheila Widnall.

The object twirled as it fell to Earth, she said. Sophisticated aerodynamic analysis done at the Lincoln Laboratory, a federal facility, shows that such behavior could have been exhibited by a section of T-seal, the reinforced carbon carbon material that fits between panels of the leading edge of the wing.


The mystery object could be the piece of the left wing first damaged by the falling foam debris. Investigators have said they believe it somehow may have managed to reach space and then floated away, leaving behind a breach in the wing.