NYT: NASA Management Failings Are Linked to Shuttle Demise

Link:
http://www.nytimes.com/2003/07/12/na...l?pagewanted=1


NASA Management Failings Are Linked to Shuttle Demise

The New York Times
By MATTHEW L. WALD and JOHN SCHWARTZ


WASHINGTON, July 11 Management failure at NASA was as important in
the destruction of the shuttle Columbia and the loss of its crew as
the chunk of foam that knocked a hole in its wing, the chairman of the
Columbia Accident Investigation Board said today.

As the board prepares its final report about what led to the breakup
of the shuttle over Texas on Feb. 1, people deeply involved in the
investigation say board members have become more concerned about
NASA's flaws in communication and in its evaluating and tracking of
problems before the Columbia's launching and during its flight.

At the last scheduled briefing before the report's release, the panel
chairman, Adm. Harold W. Gehman Jr., said today: "We have what we're
now calling either the physical or mechanical failure, and then we
have the systemic failures. And we're now putting them at equal
weight."

This approach replaces the board's initial belief that there was "a
hierarchy of factors" with the foam at the top, Admiral Gehman said.
"That's why we're being so cautious and careful about the management
sections and safety sections" of the report the board is writing.

His remarks suggest that the board will reach conclusions that
parallel those reached by the commission that investigated the
destruction of the shuttle Challenger 17 years earlier: that NASA knew
in advance that it had an engineering problem but did not appreciate
its significance.

At the briefing today, Admiral Gehman, who is retired, also hinted
that while the board had already discussed many of its findings, the
final report, now expected in late August, could have some surprises.
When all the elements are assembled in a single narrative, he said,
the tone may have "some news value."

Throughout the investigation, Admiral Gehman has said he was taking
care not to go beyond the position approved by his board. Today, a
person who has attended the board's deliberations said that at least
10 of its 13 members concurred with Mr. Gehman about the relative
importance of management issues.

Some management factors have been obvious for weeks. For example, NASA
knew that the shuttle was vulnerable to debris strikes and knew that
it was being hit by foam debris on nearly every flight, but left the
issue unresolved. That factor, board members have noted, resembles the
O-ring failure that destroyed the Challenger in 1986, when NASA knew
it had a component prone to problems but did not recognize the
potential for catastrophe.

Another management issue is that during the Columbia's 16-day flight,
after scientists realized that foam had struck the shuttle on liftoff,
some NASA engineers thought the agency should get spy satellite
photographs of the shuttle to look for damage, but managers decided
not to.

The person who has attended the board's meetings said that more
management problems would be listed in the final report, involving
other examples of "flying with things you shouldn't fly with."

Some of these problems were cited in e-mail correspondence or in the
minutes of the Mission Management Team meetings held during the
flight, the person said, and showed "a lack of foresight" by managers.

Another issue, this person said, was that managers were supposed to
meet daily during missions, but skipped meetings during the Martin
Luther King Jr. holiday weekend.

"It's just a mindset they got into, that this was an operational
vehicle, on an operational mission, and you don't have to worry about
it," the person said.

At the briefing today, Admiral Gehman said that NASA should stop
treating the shuttles as "operational," but instead consider them as
"developmental," even though they have been flying for 20 years.

This would mean, he said, "treat each launch as a first launch, each
orbit as a first orbit, each re-entry as the first re-entry."

Instead, he said, NASA had become less interested in some details; for
example, he said, it had allowed its capability to take photographs of
shuttles on launching to "gracefully atrophy over the years."

The pictures of Columbia's launch spotted the debris strike, but the
quality was poor, helping to mislead engineers into deciding there was
no major problem, the board has said.

At NASA headquarters, Robert Mirelson, a spokesman, said that it
should not come as a surprise that the board is taking management
issues seriously, since the board has discussed such issues
extensively and Admiral Gehman had made critical statements about the
agency's management during Congressional hearings.

"They've been talking about that for a long time," Mr. Mirelson said.
"How they word that as a recommendation or a conclusion, we'll have to
see."

Today the board also released a 189-page revised "working scenario" of
the flight, developed jointly with NASA. It showed that the foam that
hit the orbiter about 81 seconds after liftoff was a bigger chunk than
the six previous occasions that involved foam debris from the same
area of the external tank.

The board seems to be preparing a harsh assessment of NASA's
performance, but members indicated today it could be tempered.

Many conclusions about management problems will be based on
military-style "privileged" interviews, in which witnesses are
interviewed privately, individually and with a promise of
confidentiality.

Admiral Gehman said he would leave it to Congress or NASA to follow up
if the report uncovered an issue that required changes in personnel.

Also today, Scott Hubbard, another panel member, said that further
analysis of a test in which researchers shot a chunk of foam into a
shuttle wing panel at more than 500 miles an hour had yielded two new
clues about what happened.

In the test, a part called a T-seal was broken in a way that made it
likely to flap back and forth. That could account for wreckage that
shows a pattern of burns indicating the alternating presence and
absence of hot gases.

The other, he said, was the recognition that the target wing panel had
broken in a way that left a piece of debris with one thick edge. In a
radar image, that would match the "Day 2 mystery object," the
unidentified part seen floating away from the shuttle in a radar image
made during its second day in orbit.

"Recom" wrote in message
...

Link:
http://www.nytimes.com/2003/07/12/na...l?pagewanted=1

NASA Management Failings Are Linked to Shuttle Demise

The New York Times
By MATTHEW L. WALD and JOHN SCHWARTZ

snip

Another issue, this person said, was that managers were supposed to
meet daily during missions, but skipped meetings during the Martin
Luther King Jr. holiday weekend.

"It's just a mindset they got into, that this was an operational
vehicle, on an operational mission, and you don't have to worry about
it," the person said.

Beyond that operational mindset, whether NASA upper managers realized it or
not they were setting the example of a relaxed tone that lower management
naturally emulated for acceptance within the work group culture. The
degradation of concern can be a slow insidious process bolstered by each new
"successful" mission. What is a less experienced manager to think? "If it
is safe enough for the boss to go on vacation, surely he knows better."
"Should I call him"? "Will he think I am not up to handling the situation"?
Of course if the upper manager is present at every meeting and asking
probing questions, the message is that the level of concern is high and you
better come to each meeting and put all the cards on the table. The high
level of concern then trickles down and permeates the organization. With
Columbia it appears that most of the concern was trying to trickle uphill.

If you look back over the past few years here on SSS, you can even see a
similar almost cavalier swagger develop among some posters with actual
contempt in several instances for those who raised safety concerns on a
multitude of issues. I fear it will get much uglier before it gets better.
Congress will not likely be so kind the second time around.

Daniel

In news:Charleston typed:

If you look back over the past few years here on SSS, you can even
see a similar almost cavalier swagger develop among some posters with
actual contempt in several instances for those who raised safety
concerns on a multitude of issues.

You must be talking about the likes of CT/Stuf4 who felt the
grounding due to the cracks in the flow liners was unwarranted. You'll
remember how he was *roundly* and *severely* criticized around here for
that particularly head-in-the-sand view. I don't usually see much of a
"cavalier attitude" towards safety by most of the (saner) posters here.

Could you perhaps provide examples of this "cavalier swagger"
demonstrated by some of the posters here? And could you demonstrate
what posters to s.s.s have to do with NASA's safety program at all by
posting on little old usenet? Just curious about such a sweeping
statement like this. :-/

(Oh, and I'm completely eliminating for consideration any
conversations with hallerb as they are irrelevant to *actual*
discussions.) ;-)
--
Mike
__________________________________________________ ______
"Colorado Ski Country, USA" Come often, Ski hard,
Spend *lots* of money, Then leave as quickly as you can.

"Mike Speegle" wrote in message
...
In news:Charleston typed:

If you look back over the past few years here on SSS, you can even
see a similar almost cavalier swagger develop among some posters with
actual contempt in several instances for those who raised safety
concerns on a multitude of issues.

You must be talking about the likes of CT/Stuf4 who felt the
grounding due to the cracks in the flow liners was unwarranted. You'll
remember how he was *roundly* and *severely* criticized around here for
that particularly head-in-the-sand view. I don't usually see much of a
"cavalier attitude" towards safety by most of the (saner) posters here.

No I wasn't talking about CT. We have all received some criticism now and
then. I still have some small suction cup bruises on my forehead ;-)

Could you perhaps provide examples of this "cavalier swagger"
demonstrated by some of the posters here? And could you demonstrate
what posters to s.s.s have to do with NASA's safety program at all by
posting on little old usenet? Just curious about such a sweeping
statement like this. :-/

Gee, do you really, really mean that Mike? Do you really want me to go dig
up a bunch of posts with names on them? I would not have to go back very
far you know;-) As for how this little group might remotely relate to
NASA's safety program, let me see. How many here work for a NASA
contractor, NASA itself, or know someone at NASA or a NASA contractor. How
many here used to work for any of the above? How many owe there current
jobs to knowledge they gained when they used to work at any of the above?
How many here work at a college or University that gets any sort of grant
money from NASA, and of course how many are related to any of the
above....... Call it a reflection, if you'd like, but if NASA and even the
CAIB cast their eyes here, and if NASA status reports find their way here,
you'd have to be a little blind to miss some sort of loose semblance from a
*philosophical* perspective when it comes to safety issues.

(Oh, and I'm completely eliminating for consideration any
conversations with hallerb as they are irrelevant to *actual*
discussions.) ;-)

I am not sure that is completely fair. The Columbia accident affected all
of us, some more than others. Bob obviously took it pretty badly; however,
with a liitle help from the group he is beginning to bounce back to his good
ol' pre-Challenger Alfred E. Neuman "What me worry" approach to manned space
flight. ;-)

Daniel

I think the main thing here as far as management is concerned is to not make
the report read like an acusing finger or witch hunt, because it is, as has
been said here before, a culture that people slip into, and I'd say that
obviously nobody knowingly took what they thought were undue risk.

I do not know this, but is there a system of management evaluation that
goes on with these teams? We had that in the defence industry, from The Gov
dept we did projects for, and it spotted the slides into convenient
assumptions that seem to have gone on here.

It laid down procedures for correcting things. It was not handled in a
disciplinary way, more of a psycho behavioural way, and thus when things
slipped, procedures were created that plugged the 'hole' if you like in the
way things tended to be done. You learn a lot about the way we all think
after this, I can tell you. You also learn that there is no such thing as a
foolproof procedure!

Brian

--
Brian Gaff....
graphics are great, but the blind can't hear them
Email:
__________________________________________________ __________________________
__________________________________





---
Outgoing mail is certified Virus Free.
Checked by AVG anti-virus system (http://www.grisoft.com).
Version: 6.0.500 / Virus Database: 298 - Release Date: 10/07/03

In news:Charleston typed:
"Mike Speegle" wrote in message
...
In news:Charleston typed:

If you look back over the past few years here on SSS, you can
even
see a similar almost cavalier swagger develop among some posters
with actual contempt in several instances for those who raised
safety concerns on a multitude of issues.

You must be talking about the likes of CT/Stuf4 who felt the
grounding due to the cracks in the flow liners was unwarranted.
You'll remember how he was *roundly* and *severely* criticized
around here for that particularly head-in-the-sand view. I don't
usually see much of a "cavalier attitude" towards safety by most of
the (saner) posters here.

No I wasn't talking about CT. We have all received some criticism
now and then. I still have some small suction cup bruises on my
forehead ;-)

That *was* pretty funny. g

Could you perhaps provide examples of this "cavalier swagger"
demonstrated by some of the posters here? And could you demonstrate
what posters to s.s.s have to do with NASA's safety program at all
by posting on little old usenet? Just curious about such a sweeping
statement like this. :-/

Gee, do you really, really mean that Mike? Do you really want me to
go dig up a bunch of posts with names on them? I would not have to
go back very far you know;-) As for how this little group might
remotely relate to NASA's safety program, let me see. How many here
work for a NASA contractor, NASA itself, or know someone at NASA or a
NASA contractor. How many here used to work for any of the above?
How many owe there current jobs to knowledge they gained when they
used to work at any of the above? How many here work at a college or
University that gets any sort of grant money from NASA, and of course
how many are related to any of the above....... Call it a
reflection, if you'd like, but if NASA and even the CAIB cast their
eyes here, and if NASA status reports find their way here, you'd have
to be a little blind to miss some sort of loose semblance from a
*philosophical* perspective when it comes to safety issues.

Again, Daniel, I take extreme exception to the phrase "cavalier
swagger" with regard to most reputable posters in s.s.s. regarding
safety issues in the shuttle program. There is a lot of engineering
savvy here, especially in the aerospace field. Lot's of knowledge also
here regarding orbital mechanics and super/hypersonic travel. And
counting the folk that work/used to work for NASA and other aerospace
companies, there's a tremendous well of knowledge and experience in
s.s.s.

That said, despite all our reactions to Columbia, I still get a
realistic attitude towards the realities and dangers of space travel in
regards to the shuttle. Yes the shuttle is a conglomeration of
political and engineering trade-offs, but that's not the point. To
state a "cavalier swagger" exists by "some" posters, I assume you are
not speaking of the more enlightened and knowledgeable posters here.
'Cuz I don't see it and never have.

WRT NASA and management policies, that is an *entirely* different
subject than attitudes of posters here. I do believe NASA and their
safety programs have much work to do. Let's face it, it's a goddam
government bureaucracy. Without outside pressure, most bureaucracies
are too close to the trees to see the forest. Waste and procedures grow
imperceptibly, cost cutting measures are hard to implement, and
perspective is difficult to achieve. It's a large organization spread
across the country and subject to the whims of *politicians* (ugh!
ick!). It's a formula for a potential morass, what we might have today.

CAIB is doing NASA and us a huge favor with all these outside
investigators with oodles of years of experience outside the agency. I
do believe that much good will come out of whatever restructure and
rewriting of procedures that will come from implementing the boards
recommendations. NOW, will Congress allow it to happen properly? Well,
let's just say breath-holding is not on my list of my options. My
reaction to your post was strictly based on years of reading this
newsgroup and being enlightened by it and the general group of regular
posters here and your use of the phrase "cavalier swagger". Now
perception may be reality to each individual, but I have never seen what
you claim to see WRT shuttle safety programs. YM(apparently *does*)V.

(Oh, and I'm completely eliminating for consideration any
conversations with hallerb as they are irrelevant to *actual*
discussions.) ;-)

I am not sure that is completely fair. The Columbia accident
affected all of us, some more than others. Bob obviously took it
pretty badly; however, with a liitle help from the group he is
beginning to bounce back to his good ol' pre-Challenger Alfred E.
Neuman "What me worry" approach to manned space flight. ;-)

It was difficult for us all and the damage to sci.space.* goes on
and I hope we all get past this tragedy and move with greater resolve.
:-/
--
Mike
__________________________________________________ ______
"Colorado Ski Country, USA" Come often, Ski hard,
Spend *lots* of money, Then leave as quickly as you can.

Mike Speegle wrote in message
...
In news:Charleston typed:
"Mike Speegle" wrote in message
...
In news:Charleston typed:

If you look back over the past few years here on SSS,
you can even see a similar almost cavalier swagger
develop among some posters with actual contempt in
several instances for those who raised safety concerns
on a multitude of issues.

I don't usually see much of a "cavalier attitude" towards
safety by most of the (saner) posters here.
snip
Could you perhaps provide examples of this "cavalier
swagger" demonstrated by some of the posters here?

Gee, do you really, really mean that Mike? Do you really
want me to go dig up a bunch of posts with names on them?

Again, Daniel, I take extreme exception to the phrase
"cavalier swagger" with regard to most reputable posters
in s.s.s. regarding safety issues in the shuttle program.

You are without doubt one of the most disingenuous posters on
these sci.space.newsgroups. You demand cites, but you supply
none. You libel and defame those like myself who put crew lives
and space shuttle integrity/protection first. You add little of value
to intelligent and worthwhile discussions here. You act like a ski
bum looking for a vacation retreat from which to hurl school-boy
insults. You have a shallow understanding of shuttle disasters.

CAIB is doing NASA and us a huge favor with all these outside
investigators with oodles of years of experience outside the agency.

You have no concrete foundation upon which to make such a
judgement. It is strictly your uninformed opinion, worth about as
little in this forum as Dan's opinion about my book. You are the
last who should be taking "extreme exception" to opinions about
"reputable posters," since you are yourself so disreputable.

--
John Thomas Maxson, Retired Engineer (Aerospace)
Author, The Betrayal of Mission 51-L (www.mission51l.com)

"Charleston" wrote in message
news:kC7Qa.8124$zy.7185@fed1read06...

Of course if the upper manager is present at every meeting and asking
probing questions, the message is that the level of concern is high and
you
better come to each meeting and put all the cards on the table.

As several people have said here already, endless meetings *increase* the
chances that something will slip through the cracks. The attendees are so
busy sending emails about the meeting, checking their calendars,
rescheduling other stuff to attend the meeting, and preparing their
viewgraphs and thinking up ways to get noticed (or not) in the meeting, that
actual productive work gets shoved aside.

The fatal flaw that led to Columbia, in hindsight, had nothing to do with
who was in town or who attended what meeting. It was just that somewhere
along the line (probably many years before anybody in the shuttle program
management even took their jobs), nobody thought to actually test the damage
tolerance of RCC. They assumed it was safe, and down the years the favorable
tests on the tiles were transmogrified into also applying to the RCC.

Whose fault is that? I have not the slightest clue, although I'll bet you a
wooden nickel that it will ultimately be found to be people who have long
since left NASA or moved on to other fiefdoms. And that it wasn't negligence
or oversight on their part, just simple human error: thery were tasked with
testing the tiles but never got around to (or were never instructed to)
testing the RCC.

And I will bet you much more than a wooden nickel that in fifteen or twenty
years, we will be talking about *another* catastrophic failure that in
hindsight will be obvious but nobody in NASA ever anticipated.

--
Terrell Miller


"We pay for love, but the hate comes free"
-Gordon Sumner

"Terrell Miller" writes:

And I will bet you much more than a wooden nickel that in fifteen or twenty
years, we will be talking about *another* catastrophic failure that in
hindsight will be obvious but nobody in NASA ever anticipated.

I completely agree with the above paragraph and the rest of the
post that went with it.

--
J. Porter Clark

Terrell Miller spake unto the ether:

: And I will bet you much more than a wooden nickel that in fifteen or twenty
: years, we will be talking about *another* catastrophic failure that in
: hindsight will be obvious but nobody in NASA ever anticipated.

Didn't Admiral Gehman say at one point, "If you're so smart, tell
us about the *next* obvious failure, right now"? I give him enormous credit
for that statement.

*Rich*
--
Richard F. Drushel, Ph.D. | "Aplysia californica" is your taxonomic
Department of Biology, Slug Division | nomenclature. / A slug, by any other
Case Western Reserve University | name, is still a slug by nature.
Cleveland, Ohio 44106-7080 U.S.A. | -- apologies to Data, "Ode to Spot"