Columbia Investigation Focuses on Problems At NASA

The investigation into what caused the tragic demise of the Space Shuttle Columbia plods along, with one member of the board feeling a touch of deja vu. Dr. Sally Ride, America's first woman in space, was a member of the Challenger investigation board in 1986. Now, she's on the board investigating Columbia's destruction as it re-entered the atmosphere on Feb. 1.

Ride said she's hearing what sounds a lot like what she heard 17 years ago: Serious problems with a particular component or components, repeatedly weathered by various shuttle missions, might have catastrophically failed because management misread the threats as maintenance headaches.

Is There An Echo In Here?

In 1986 it was leaky O-rings on solid fuel booster rockets; this time, it seemed, debris — perhaps the shuttle's own foam insulation — might have dealt the craft a fatal blow.

Another authority who drew similar parallels was Prof. Diane Vaughan of Boston College, whose scholarly review of the 1986 disaster in her book, "The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA," earned her a platform as an expert witness in the Columbia case. Professor Vaughan, a sociologist who is to testify this month, said in an interview that the similarities became obvious to her in early February, in reports that mentioned longstanding problems with falling foam and the shuttles' fragile insulating tiles.

She then watched NASA officials like the Columbia program manager, Ron D. Dittemore, explain at news conferences that the National Aeronautics and Space Administration had decided the occasional damage from dislodged foam and other liftoff debris was a risk NASA had grown comfortable with. To Professor Vaughan, Mr. Dittemore's assessment seemed evidence of something all too familiar: NASA management's "incremental descent into poor judgment."

Dr. Vaughn said she did not think that in either accident people had necessarily done their jobs improperly or had violated NASA procedures. Instead, Ms. Vaughan said she saw a flawed culture in which most participants gradually demoted their concerns, causing major problems to be pushed off as lower-level issues.

As she wrote of Challenger workers in her book: "Following rules, doing their jobs, they made a mistake. With all procedural systems for risk assessment in place, they made a disastrous decision."

Vaughan maintains the true error resided in the system. Once officials in the rocket booster program, including Lawrence Mulloy, the project leader, left NASA, the problem was treated as solved.

But Was It?

"That need to make individuals accountable can backfire, because once individuals are shifted out of their positions and the personnel are changed, it looks as if all of the problems have been cleared up," Professor Vaughan said. "That means that the organizational problems that shaped their decision making go unchecked."

In NASA's case, she said, one such problem is budgetary. In her opinion the agency does not have enough money to do its job over the long run without cutting corners.

"You have to look beyond individuals and look to the situation in which they work," Professor Vaughan added. "Otherwise you're just going to reproduce the problem. And that's what's happened — again."

Mulloy: "Challenger Scapegoat"

Mulloy, who has retired, says he was made a scapegoat. "That was their primary focus in 1986, to find somebody to put the public face on for blame," he said, "and I was the lucky nominee for that."

Whatever the physical cause of the Columbia accident is determined to be, it is clear that the space agency's decision making culture has become as important to the board as any falling foam or data recorder.

"We need to have the aperture of our focus opened up to see things the way she sees them," Adm. Harold W. Gehman Jr., chairman of the investigation board, said this week of Professor Vaughan.

At the hearings this week, the admiral sounded a lot like her. "We have not concluded that the analysis and the decision making was wrong," Admiral Gehman said. "They may have done everything they could with the information that they had available. They may have had all the right people in the room, and asked all the right questions, and considered all the right factors, and just come up with the wrong answer."

After the hearings, he explained why the board was taking this approach. "We have to have a better working theory than hindsight," he said. The no-fault approach bothers some at NASA, who say they think determining responsibility for mistakes is important. Professor Vaughan agrees that individual responsibility is important. But she draws a distinction between assigning responsibility and scapegoating, which she maintains does not fix the deeper problem. "You change the cast of characters, and you don't change the organizational context," she said. "And the new person can be under the same constraints and conditions that they were under before."

The board is still gathering and reviewing debris and data, digesting the discoveries it has made about NASA's responses to the blow from the foam chunk that occurred about 80 seconds into the Columbia's flight.

Software Misused?

The board has discovered that the software used by Boeing, a NASA contractor, to evaluate the damage had never been used during a mission before and was not designed as a predictive tool. In fact, it was little more than an Excel spreadsheet that described past strikes and damage.

Professor Vaughan, looking at the chain of events now, said that the seemingly hard numbers of the Boeing analysis appeared at the time to trump the gut feelings of the engineers. Admiral Gehman has said the board probably will not write its final report until June. But its charter, written by NASA, calls only for recommendations to improve safety and return to flight — in other words, prevention, not punishment.

That is the standard model for aviation and military "mishap investigations," like the one after the terrorist attack on the destroyer Cole in Yemen in October 2000. That inquiry was also conducted by Admiral Gehman.

But it remains to be seen whether this approach can break what Mulloy, for one, fears may be a pattern at NASA.

"The mistake in judgment we all made was accepting deviance in the performance from the hardware from what it was designed to do," Mr. Mulloy said of events before the Challenger disaster. Once the erosion in O-rings was tested and analyzed and accepted, "we started down the road to the inevitable accident.

"If — and this is a big if, with big capital letters in red — if the cause of the Columbia accident is the acceptance of debris falling off the tank in ascent, and impacting on the orbiter, and causing damage to the tiles — if that turns out to be the cause of the accident, then the lesson we learned in Challenger is forgotten, if it was ever learned."

FMI: www.caib.us