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  • Oversight board blasts NASA

    Members of board overseeing NASA blast space agency
    Robyn Shelton
    Sentinel Staff Writer

    August 18, 2005

    NASA remains plagued by the flawed leadership style and engineering practices that led to the Columbia disaster, according to seven members of an independent group that monitored the agency's safety efforts after the tragedy.

    Overall, the watchdog panel's 26 members concluded in their final report Wednesday that NASA had made significant strides to correct the conditions that led to the 2003 accident.

    But a separate and blistering assessment from the group of seven described lingering problems in every aspect of NASA's efforts to return the space shuttle to flight.

    The agency continues to put schedule ahead of safety, follows lax engineering practices and exhibits an unwillingness to learn from its previous mistakes, they wrote. The members included a former astronaut and others from various fields of expertise including nuclear safety and public policy.

    They devoted more than 19 of the report's 216 pages to the bruising critique that blamed a lack of "focused, consistent leadership and management" within NASA.

    "It is difficult to be objective based on hindsight, but it appears to us that lessons that should have been learned have not been," they stated. "Perhaps we expected or hoped for too much."

    One finding -- that NASA never developed a clear understanding of why the shuttles' external fuel tanks keep shedding foam during launch -- was underscored when Discovery lifted off July 26 in the first mission since Columbia.

    Late in Discovery's climb to orbit, a nearly 1-pound chunk of foam flew off the tank, missing the orbiter. The event stunned NASA managers, who suspended further flights until they could determine why it happened. Columbia was doomed in 2003 when a large piece of foam punched a hole in its left wing during its launch.

    The seven members do not address Discovery's problems specifically, but they fault NASA heavily for failing to adequately understand the dangers of their spaceships and for taking a piecemeal approach to problem-solving.

    "Throughout the return-to-flight effort, there has been a reluctance to appropriately characterize the risks inherent in the Space Shuttle program," they wrote. "As an example, it has proven irresistible for some officials to characterize the modified External Tank as 'safer,' the 'safest ever,' or even 'fixed,' when neither the baseline of the 'old' tanks nor the quantitative improvement of the 'new' design has been established."

    3 recommendations unmet

    Their observations appear in the final report from the "Return to Flight Task Group" that was created in 2003 by former NASA Administrator Sean O'Keefe to look over the agency's shoulder after Columbia. O'Keefe, who left NASA in February to become chancellor at Louisiana State University, said the task group fulfilled its mission.

    "You've got to be pretty thick-skinned with this stuff," O'Keefe said Wednesday. "You don't learn anything by everybody saying you did a great job. If continuous improvement is part of the objective, you won't get there if you just sit back and rest on your achievements."

    A NASA spokesman said current Administrator Michael Griffin was not available to discuss the report Wednesday but that the agency was taking all of the task group's findings into consideration.

    The group's purpose was to track whether NASA complied with the safety recommendations made by the Columbia Accident Investigation Board. To that end, its report concluded NASA met or exceeded 12 of 15 recommendations that were supposed to be in place before shuttle Discovery launched.

    The three that NASA missed included eliminating foam debris; hardening the orbiter to protect against possible damage; and being able to repair the shuttle during missions.

    The panel's co-chairs, Thomas Stafford and Richard Covey, said Wednesday that they think the shuttle is safer than in 2003. They said NASA's attempts to reshape the agency after Columbia were commendable, if imperfect.

    Both men, former astronauts themselves, cautioned against giving too much credence to the separate views expressed by the seven other group members.

    "Everyone's going to have a different perspective," Covey said. "If you watch sausage being made, it's not always pretty, and some people are going to find it uglier than others. I personally did not find the process unusual. It's easy to look from hindsight and say this could have been done better."

    Foam loss called inevitable

    The final report concludes that some foam loss from the external tanks -- even large chunks that could do catastrophic damage to the orbiters -- is inevitable. But the agency has taken steps, such as detailed imagery and inspection of the shuttles in orbit, to detect damage so repairs can be tried, the report stated.

    Covey said his group, which was not asked to critique Discovery's mission, is not surprised by the foam problems on the recent flight.

    "We knew there was potential for foam loss on the tank," Covey said. "We didn't know where it was going to be, or we would have been smart enough to tell the agency what it was they had to go fix."

    In stark contrast to the group's overall report, the views expressed by the seven members are blunt and scathing. They appear at the end of the document in a section devoted to comments from individual members. The seven writers did not respond to interview requests or could not be reached Wednesday.

    The seven members faulted the agency for being driven by impending launch dates, which were reset nearly two dozen times from 2003 to 2005.

    "The constant setting of a launch date only a few months away never allowed the development efforts to take full advantage of the ultimate two-year stand-down; we heard several times that different solutions to problems would have been selected if launch had not been 90 days away," they noted.

    As an example, they cited the managers' initial plans to launch Discovery in May without new heaters on the external tank that are meant to discourage ice from forming. Continued questions about the risks eventually drove NASA to roll Discovery off its launchpad and give it a new tank that included the heaters.

    In addition, the seven members said, the agency developed flawed models when assessing various flight risks, such as the likelihood of errant foam striking the orbiter and the extent of damage that might cause.

    They also found many problems in NASA's mind-set or culture, with strong personalities within the agency sending signals that procedures can be circumvented. Saying the agency lacks individual accountability, the members said NASA is hobbled simultaneously by arrogance and acceptance of what they called a "best effort" mind-set.

    "A general attitude within the space shuttle program seems to be that best-effort is a satisfactory substitute for meeting technical requirements," the members said. "Parts of the agency seem to have forgone their traditional engineering rigor in favor of 'when you have done your best effort, you are good to go.' This is not an appropriate philosophy for a high-performance organization that routinely puts the lives of its employees into high-risk situations."

    'An informed decision'

    O'Keefe said he couldn't address the specific criticisms because he had not read Wednesday's report fully. But he did defend NASA's overall approach in returning to flight, pointing out that the agency even halted one of Discovery's launch attempts because of a technical glitch with a fuel sensor.

    The same problem might not have gotten such attention earlier, he said. NASA's leaders are sending the right signals and establishing a healthy mind-set that acknowledges the unavoidable dangers, O'Keefe said.

    "Let's never lead anybody to believe for a minute that we can eliminate the risk or, for that matter, drive it down to dust," he said. "Your objective is to understand the risk that's involved and make an informed decision."

    Robyn Shelton can be reached at [email protected] or 407-420-5487.
    June 9, 1973 - The day athletic perfection was defined.

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