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Retooling NASA's culture

Probe into the Columbia loss shows that managerial fixes are key to improving safety.

In a space agency where safety is typically gauged by statistics and flight experience, can managers make sufficient room for an engineer's hunch or intuition?

The answer to that question could be crucial in determining how successfully the National Aeronautics and Space Administration's human spaceflight program recovers from the February loss of the shuttle Columbia and its seven-member crew.

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This week marks a turning point in the shuttle program's road to recovery. The Columbia Accident Investigation Board is zeroing in on a triggering event behind the tragedy - loose foam that struck Columbia's wing shortly after launch, which appears to have dislodged a seal on the leading edge, leaving the shuttle's wing vulnerable to the intense heat of reentry. Meanwhile, shuttle-program director Ron Dittemore, credited for his public candor in the days following the accident, has announced his resignation. And NASA managers are discussing the possibility of launching new shuttle missions within a year, depending on how quickly the panel's final recommendations can be implemented.

The investigation board is expected to finish its work later this summer, but it has already offered some recommendations. Earlier this month, the board asked NASA to ensure that photographs of the shuttle are taken during missions. After Columbia's launch, some engineers were worried about the foam's effect on the tiles and asked their superiors for photos.

In addition, the board has asked NASA to use a more high-tech approach to inspecting heat-resistant panels that cover the leading edges of the orbiters' wings. Currently, the panels get close visual inspection, but the board found they can develop defects that inspectors can miss.

Eleven weeks into the investigation, however, analysts suggest that broader, management-related lessons are emerging - and that they bear an uncomfortable resemblance to lessons that many hoped would be drawn from the 1986 Challenger disaster. These may be the toughest to address.

"You can always come up with a technical fix," says William Kauffman, an aerospace engineering professor at the University of Michigan in Ann Arbor, Mich. "But can we come up with the management fixes needed?"

NASA's Aerospace Safety Advisory Panel has expressed concern that while the agency focuses on the safety of any given mission, its maintenance and upgrade program has failed to plan sufficiently for the aging shuttle fleet's future. Still, it recently praised NASA for extending the time frame for refurbishing the orbiters.

Yet other aspects of the agency's culture weigh against its efforts to bolster shuttle safety, according to Diane Vaughan, a Boston College sociologist who closely examined the Challenger disaster in a 1996 book, "The Challenger Launch Decision."

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During testimony before the investigation panel this week, she noted that engineers, worried about the foam after Columbia's launch, expressed concerns over e-mail about not having enough information to back them up. "Intuition and hunch didn't carry any weight," she said, adding that NASA's emphasis on hard numbers discourages people from speaking up "in critical situations."

Moreover, she maintained that - just as engineers failed to see scorched seals between solid-rocket-booster segments as show-stoppers before a seal failed completely, triggering the Challenger explosion - in Columbia's case, engineers failed to treat repeated foam-insulation strikes on past missions as serious, even though the agency strives to avoid collisions between the shuttle and debris. What should have been seen as a problem was seen as routine, until disaster struck.

At this stage of the investigation, the contribution that NASA's culture may make to the investigation board's final report is unclear. But Dr. Kauffman suggests that part of the solution may lie in ensuring that managers up and down the chain of command have "gotten kerosene on their boots" in some engineering capacity.

In addition, the Aerospace Safety Advisory Panel notes that while the agency has a safety division, working there often is viewed as a dead end. It recommends that before the agency appoints someone to head a major program, it makes sure the candidates have done a tour of duty in a safety-related division.


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