On Day of Remembrance, NASA and Its Advisors Have Safety Top of Mind

Today is NASA’s annual Day of Remembrance honoring the nation’s fallen astronauts. This year it is commemorated on the 55th anniversary of the first U.S. human spaceflight tragedy, the fire that killed the Apollo 1 crew during a pre-launch test. As NASA readies its new Artemis system to return astronauts to the Moon while increasing its reliance on commercial partnerships for other human spaceflight missions, the agency’s safety advisors are urging caution.

Over the past several weeks, NASA’s Aerospace Safety Advisory Panel, created by Congress in the wake of the Apollo fire, and the NASA Advisory Council’s Human Exploration and Operations Committee, have been raising flags about both near-term and long-term issues.

The concerns seem especially timely today. The Day of Remembrance honors “all astronauts and astronaut candidates who lost their lives while furthering the cause of space exploration,” including the crews of Apollo 1, the Space Shuttle Challenger STS-51L, and the Space Shuttle Columbia STS-107.

On this day in 1967, Virgil “Gus” Grissom, a veteran of Mercury-Redstone 4 and Gemini 3, Ed White, the first American to make a spacewalk on Gemini 4, and rookie Roger Chaffee died when fire broke out in their Apollo capsule on the launch pad. Apollo 1, the first launch of an Apollo capsule on a Saturn rocket, was scheduled for February 21 to test the Command and Service modules in Earth orbit. The crew was in the capsule performing pre-launch tests with the spacecraft’s atmosphere 100 percent oxygen at 16.7 pounds per square inch. An electrical spark is thought to have started the fire. The hatch swung inward and the crew could not open it with the pressure higher inside than outside. They could not escape and died from asphyxiation by toxic gases and burns. Subsequently, the hatch was redesigned to open outwards and ground tests were no longer conducted in 100 percent oxygen, along with many other changes. Formally known as Apollo-Saturn 204 (AS-204), or just Apollo 204, NASA officially designated it Apollo 1 in the crew’s honor even though it never launched.

Almost exactly 19 years later, on January 28, 1986, the country experienced its second human spaceflight tragedy when the Space Shuttle Challenger broke apart 73 seconds after liftoff from Kennedy Space Center. An O-ring in one of the Solid Rocket Boosters failed due to very cold weather at the launch site allowing hot gases to escape from the SRB and causing the subsequent failure of the other SRB and the External Tank. Aerodynamic forces destroyed the vehicle.

Almost exactly 17 years later, on February 1, 2003, a third tragedy occurred when the crew of the Space Shuttle Columbia was returning from a 16-day science mission in orbit. Superheated gases (plasma) that surround the shuttle during reentry entered a hole in the wing that had been created during liftoff by foam falling from the External Tank. The wing deformed and aerodynamic forces tore the shuttle apart.

NASA Associate Administrator Bob Cabana, a former astronaut and former Director of Kennedy Space Center, drew attention to the intervals between the accidents today. Artemis I, the first launch of NASA’s new Moon rocket, the Space Launch System, and Orion crew spacecraft is expected in a few months, 19 years after Columbia. Cabana pointed out that while no one will be aboard this flight, they will be on the next and the time intervals between the accidents is relevant because they illustrate periods of turnover that could result in lessons being lost.

“From ’67 to ’86 was 19 years, from ’86 to 2003 was 17 years, from 2003 till now it’s 19 years.We’re in that same time period. Why is that? Well, we’ve had a huge turnover of personnel, we have new people, we have different people in leadership positions. I don’t want to forget the lessons learned in the past. OK? And we’re in a time of great change right now. We’re building new spacecraft. I don’t want to see us complacent with the commercial vehicles that we’re flying. We have to pay attention all the time.” — Bob Cabana

Cabana, NASA Administrator Bill Nelson, and Deputy Administrator Pam Melroy discussed the agency’s “core value of safety” during a televised event at NASA headquarters this afternoon after a wreath-laying ceremony at Arlington National Cemetery. They were joined on the panel by the head of NASA’s Office of Safety and Mission Assurance, Russ DeLoach. All sounded the same theme. Safety.

Nelson flew to space when he was a member of the U.S. House of Representatives on the shuttle flight immediately before Challenger and had come to know all the Challenger crew members very well. Melroy, one of only two women to command a space shuttle mission, was a NASA astronaut at the time of the Columbia tragedy and part of the Columbia Reconstruction Team literally piecing the remnants together to determine what happened. On that fateful day in 2003, Cabana was Director of Flight Crew Operations.

Cabana pulled out his copy of the Columbia Accident Investigation Board (CAIB) report saying he does it so often his copy is falling apart. “I’ve got all the key sections highlighted, and I’ve got notes that I’ve taken, and I refresh myself, I want to make sure that we are doing the right thing.”

Just an hour earlier, members of NASA’s Aerospace Safety Advisory Panel urged NASA officials to do just that, relook at the CAIB report and the Rogers Commission report from the Challenger tragedy.

Two other former astronauts, Sandy Magnus and Susan Helms, are members of ASAP.

Helms, who returned to the Air Force after leaving NASA and rose up the ranks to Lieutenant General, called on NASA to produce a written “leadership intent document” similar to a Statement of Commander’s Intent in the military to ensure clarity of communications. NASA has “a very full plate with countless and sometimes competing technical, management, political challenges and all levels of the workforce appear to be noticing those tensions” making clear communications critical.

“However, the panel has noted in our multiple engagements that we often hear differing interpretations about leadership priorities from various NASA managers and various NASA disciplines, sometimes notably different. There’s been a lot of verbal communication from the top level, no doubt, but the panel would suggest that something is being lost in translation through solely verbal guidance statements that disseminate to the workforce. We believe that utilizing the tools of a written statement of leadership that conveys the forward vision for NASA, the rationale for that vision, and the guiding principles, priorities and general strategies that execute that vision would help alleviate the varying interpretations across the NASA enterprise and what it is leadership has in mind. A written leadership intent statement from the top of the administration or the top of the Artemis leadership level, or both, will help allay some of the misperceptions we have observed regarding the interpretation of the administration’s priorities and guiding principles.”  –Susan Helms

Magnus focused on NASA’s recent decision to reorganize its human spaceflight enterprise. Four months ago Nelson split the Human Exploration and Operations Mission Directorate (HEOMD) into two, one for operations and one for development. Kathy Lueders, who used to be Associate Administrator (AA) for HEOMD, now is AA for the Space Operations Mission Directorate and Jim Free is AA for the Exploration Systems Development Mission Directorate.

Today Magnus urged NASA leadership to re-read Chapter 7 of the CAIB report, “The Accident’s Organizational Causes.” She read excerpts about how organizational barriers prevented effective communication, stifled professional differences of opinion, and led to the lack of integrated management and “the evolution of an informal chain of command and decision making processes that operated outside the organization’s rules.” She hopes NASA will be guided by CAIB’s warning that organizational changes be made “only with careful consideration of their effects on the system, and their possible unintended consequences. Changes that make the organization more complex may create new ways that it can fail.”

Those comments echo concerns raised by the NASA Advisory Council’s Human Exploration and Operations Committee last week. Doug Ebersole, formerly with the Air Force Research Laboratory, said that having two AAs instead of one “creates a seam” and “how they manage that seam is my question.” Jim Voss, another former NASA astronaut, said he sees it not as a seam, but a “crack that things could fall through.”

Former space shuttle program manager Wayne Hale, now Director of Human Spaceflight and Energy Services at Special Aerospace Systems and chair of the committee, agreed.

This is of great concern to me. … Can almost trace the accidents to where integration didn’t work. Most accidents happen at the interfaces.

— NAC/HEO Chair Wayne Hale

For the longer term, today and in its annual report issued earlier this month, ASAP called on NASA to “urgently” define its role in human spaceflight as it relies more and more on public-private partnerships where companies control the design and NASA only controls the requirements.

ASAP Chair Patricia Sanders said today her panel’s recommendations on NASA’s evolving role involve “clear accountability for risk management.”

“As NASA enters into acquisition strategies with providers who may have different risk management processes, it will remain imperative that NASA and the provider maintain a shared and consistent view of those risk management priorities. … Considering an initiative as complex as Artemis, with a multitude of commercial and international providers, a clear process for shared understanding of the risks, priorities, and focus will be critical to success.” ASAP Chair Patricia Sanders