Adm. Harold (Hal) Gehman (Ret.), chairman of the Columbia Accident Investigation Board (CAIB) that determined the cause of the 2003 space shuttle STS-107 Columbia tragedy, says that he does not know if NASA’s culture changed as a result of the accident and CAIB’s recommendations because CAIB no longer exists and Congress never asked it back.
Columbia disintegrated as it returned to Earth on February 1, 2003 after a 16-day science mission. At a March 8, 2013 seminar sponsored by George Washington University’s (GWU’s) Space Policy Institute and the American Institute of Aeronautics and Astronautics (AIAA), Gehman and others who were involved in dealing with the aftermath shared stories and lessons learned from the disaster. They also raised questions about what lessons were unlearned or forgotten in the intervening 10 years.
CAIB determined the technical cause of the accident: a hole in the left wing created when foam liberated from the External Tank struck it during launch; this allowed the superheated gases surrounding the shuttle 16 days later as it sped through the atmosphere during its return to Earth to enter the wing. The superheated gases deformed the wing, creating aerodynamic forces that ripped the shuttle apart. Seven astronauts died: NASA’s Rick Husband, William McCool, Michael Anderson, Laurel Clark, David Brown, and Kalpana Chawla, and Ilan Ramon of the Israeli Air Force.
Gehman and fellow CAIB member John Logsdon, GWU Professor Emeritus, stressed that the accident had a more fundamental cause, however, rooted particularly in NASA’s culture. When asked if CAIB’s work was done, Gehman said “the work is never done.” He recounted that when he testified to committees in both the House and Senate in 2003, he was asked a similar question and he replied “wait a couple years and bring the CAIB back and we can tell you in 10 days whether or not the culture has changed. No one ever called us back.”
Other participants in the day-long symposium painted a detailed picture of the conditions prior to, during and after the disaster and several suggested that, 10 years later, several of the external and internal factors that – apart from the technical failure – led to the accident may once more be in place.
The agency’s actions immediately following the disaster, including their care of the crew’s families, are perhaps the silver lining in the story. Former astronaut Scott “Doc” Horowitz and former NASA Marshall Space Flight Center Director David King described in detail their respective roles in the monumental task of recovering the remains of the astronauts and the pieces of the shuttle scattered across East Texas and parts of Louisiana, a search area equivalent to the size of the state of Rhode Island. The undertaking involved 140 local and federal organizations, 25,000 people – including the National Guard – and ground, air and water searches. They succeeded in recovering the remains of the crew members within two weeks and in retrieving and cataloguing over 40% of the Shuttle (by weight) in just 100 days. The effort was impressive from a number of levels, not the least of which was the human aspect. King and Horowitz, who listed a number of elements that contributed to success of the recovery operation, highlighted the importance of sustaining morale in what was at times a very challenging emotional experience.
Former astronaut Pam Melroy was particularly effective in conveying the challenge of studying specifically what happened to her seven colleagues in order to better understand what might have been done to make the mission safer. She led the reconstruction efforts of the debris that was recovered, including that of the crew cabin, and successfully convinced the agency to publish a detailed report of the fate of the cabin and its occupants to help in design of future vehicles. She particularly thanked three people – former shuttle program manager Wayne Hale, former Johnson Space Center Director (and former astronaut) Mike Coats, and former NASA Administrator Mike Griffin – for their “moral courage” in getting her report published so that the lessons it contained would not get lost.
Driving their work in recovering the hardware was the goal of Return to Flight, said King. The information on what pieces of the shuttle were found, precisely where, and in what condition played a critical role in CAIB’s analysis. Logsdon described how the $17 million, six-month effort went beyond traditional investigations of technical failures to look at NASA as an organization and place the accident in the long-term historical context of the space program. He noted that several of the CAIB’s observations, such as the lack of a clearly defined long-term human spaceflight goal and the lack of sustained government commitment to the program, are just as relevant today.
Doug Cooke, who served as NASA’s technical advisor to CAIB and later became Associate Administrator for Exploration before retiring in 2011, walked through the reconstruction of events and how it was informed by the hardware recovery process. He commented on the importance of the discovery of the flight data recorder, which cemented the Board’s suspicion that a foam impact on RCC panel 8 had been the main cause. But the process also highlighted other vulnerabilities that Cooke said “might have caused the next accident” if STS-107 had survived. This “indicated the degree to which we misunderstood the vehicle we were flying,” he said, adding that “we were learning about the shuttle ‘till the day it was decommissioned.”
Cooke enumerated a number of concerns for today’s human spaceflight program, such as the extent to which NASA can or cannot impose requirements on commercial crew operators, the consequences of “overconfidence” born of success, and the effects of political influences on safety. He agreed with the sentiments of other speakers that NASA did indeed become stronger after the accident, but cautioned that as time goes by those lessons may become less relevant and safety can be compromised. “The consequences, we know, can be catastrophic,” he said.
Vice Admiral Joseph Dyer (Ret.), chair of NASA’s Aerospace Safety Advisory Panel (ASAP), expressed similar concerns. Dyer considered the legacy of the accident on the safety practices of the agency and said of the Columbia crew that “in their lives and in their loss they made NASA better.” He described the shuttle program as “significantly safer” after the accident, thanks in particular to the adoption of the concepts of rescue and launch-on-need, which relied on a back-up shuttle ready to launch in the event of an emergency, a practice that was kept until the last shuttle launch.
Yet looking at the agency now and, in particular, the future of commercial crew transport, Dyer expressed concern. Aside from the relationship between cost and safety and a question of requirements, budgetary pressures are a principal obstacle. He reiterated that we must learn from our mistakes and let them influence our future but “not limit our spirit or need to explore.”
The seminar looked at lessons learned, unlearned, forgotten, and in one case, wrongly learned from the Challenger disaster in 1986. Several speakers referenced the late Sally Ride’s haunting comment that she heard “echoes” of Challenger in the Columbia tragedy. Ride, the first American woman in space, served on the accident investigation boards for both Challenger and Columbia.
At Friday’s seminar, Wayne Hale, who served in several positions in the space shuttle program before becoming program manager several years after Columbia, said that the lesson he originally learned from Challenger was that “one venal, amoral manager made an improper decision and browbeat the troops” into supporting it. It was only after Columbia, he said, that he discovered that was not the lesson at all, that both tragedies were the result of NASA’s culture.
He came to that realization, he said, after reading The Challenger Launch Decision by sociologist Diane Vaughn, which came to prominence in the aftermath of Columbia. Hale said it was only then that he understood Vaughn’s central point that the Challenger disaster was the result of a “rule-based decision. It was not amorally calculating managers violating rules… It was conformity. They were following the rules.” Because he did not understand that at the time, he and others wrongly concluded that NASA was basically on the right track with Return to Flight, but they were not, as Columbia demonstrated.
That was a lesson wrongly learned that needed to be unlearned, he stressed. Prof. Julianne Miller of George Mason University, author of Organizational Learning at NASA: The Challenger and the Columbia Accidents, spoke at length about lessons learned, unlearned and forgotten. Lessons are forgotten unintentionally, she explained, but unlearning is when lessons are “intentionally jettisoned” because they are deemed to be no longer relevant or fall victim to budget cuts or management changes.
The impressive array of speakers – many of them former astronauts offering poignant stories of being on the front line of recovering their fallen comrades and shuttle fragments, piecing the fragments back together to determine what went wrong, and moving the shuttle program forward to Return to Flight – along with other former NASA officials, offered many of their own lessons learned. Scott Pace, who was Deputy Chief of Staff to then-NASA Administrator Sean O’Keefe and now heads GWU’s Space Policy Institute, said the lesson he took away was “have a degree of humility in front of the hardware.” Although the major shuttle components – the orbiter, SRBs and External Tank – were performing all right, he said, “the system as a whole was exhibiting dangerous behavior that we didn’t recognize. … We had failed to listen to the vehicle and what it was telling us.”
Former astronaut and former head of NASA’s Safety and Mission Assurance Office Bryan O’Connor offered the lesson to “look where you slipped, not where you fell.” Hale provided a cogent list of 10 lessons that enveloped many of those offered by other speakers:
- It can happen to you
- Focus
- Speak up
- You are not nearly as smart as you think you are
- Dissention has tremendous value
- Question the conventional wisdom
- Do good work
- Engineering is done with numbers
- Use your imagination
- Nothing worthwhile was accomplished without taking risk
He agreed with Gehman that the work is never done because there are new people designing new human spaceflight systems who did not live through the shuttle tragedies and need to understand what happened.
In the final analysis, did CAIB make a difference, Gehman asked rhetorically. He answered by saying it was forums like this that will keep the lessons alive.
The overarching point that he and others stressed, however, is that “there is no progress unless you do risky activity.” The key is knowing the risk, being honest about it, evaluating whether the risk is worth the reward, and, if it is, managing that risk.
Note: Marcia Smith also contributed to this article.
Last Updated: Apr 19, 2013 5:21 am ET