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.