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Chronicles of the Long Climb Back

 

Two Years Before Columbia, Jim Pointed to Flawed NASA Safety Culture

In Scientific American, February 2000, he wrote:
"Many observers have been alarmed at the apparent increase [of failures], which could be a symptom of deeper problems that could lead to more failures in the future. . . . NASA will have to address its systemic weaknesses if it is to avoid a new string of expensive, embarrassing and perhaps in some cases life-threatening foul-ups."

In New Scientist, April 15, 2000, he wrote:
"Critics say that a number of accidents, oversights and failures in other NASA programs indicate that other parts of the organization are stretched to breaking point. NASA, they say, is repeating the errors that led to the Challenger disaster. The consequences of a future accident could, also, be fatal.. . . The cost of forgetting is now measured in hundreds of millions of dollars, years of delay and public humiliation. So far, no more human lives have been lost but the question NASA must answer is whether this will continue."

Criticism of NASA’s “Safety Culture” in the late 1990’s

“Chapter 8 // The Mir Safety Debate, from ‘Star Crossed Orbits: Inside the US-Russian Space Alliance”, James Oberg, 2002, McGraw-Hill, NY”

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    Shuttle ‘Columbia’ and its seven astronauts were lost on February 1, 2003
    (following are articles written by Oberg for NBC, or other publications where specified):

    February 3, 2003 // USA Today
    Past disasters show NASA can learn and endure

    “….It remains to be seen whether this was a true, unavoidable accident or the consequence of human errors that NASA should have known how to avoid. If, as with the two earlier tragedies, this was not an accident, and if handled right, then we can get the space program back on track.”

    2003 Feb 09
    Corrosion suggested in shuttle crash

    “Undetected corrosion that had weakened Columbia’s left wing could be the still-sought “missing link” between the otherwise-harmless debris impact during launch and the eventual vehicle loss during descent, a veteran shuttle engineer claims.”

    2003 Feb 18
    Could shuttle crew have been saved? What might NASA have tried?

    “As hindsights and “what-ifs” about the Columbia disaster continue to accumulate, questions just won’t go away about what, if anything, NASA might have been able to do to prevent the catastrophe had it known in advance how bad was the damage to the wing.”

    2003 Feb. 20
    Columbia’s final readings deciphered
    Data analysis sheds new light on problems before breakup
    MSNBC STAFF AND WIRE REPORTS
    “The final seconds of flight data from the space shuttle Columbia, transmitted even after contact was lost with Mission Control, indicate that the crew members were likely aware they were in serious trouble, NBC News reported Thursday.”

    Feb. 25
    Analysis hints at shuttle’s last seconds

    “New analysis of the garbled last 32 seconds of radio signals from the space shuttle Columbia has raised the possibility that the crew survived up to a minute after the spaceship began tumbling out of control and breaking up. This reconstruction of the tragic end of the mission on Feb. 1 contrasts sharply with most preliminary assessments that the craft disintegrated suddenly and totally.”

    Feb. 28
    A patchwork plan for space rescue
    ‘What-if’ scenario might have employed payloads and second shuttle for survival


    “The dramatic video from the flight deck of the space shuttle Columbia, shot just minutes before it was destroyed, has sparked new interest in a nagging question: What could NASA have dreamed up to save the astronauts?”

    March 2003 // IEEE Spectrum magazine// pp. 22-24
    Commentary: The Shuttle Puzzle [written Feb 5, 2003] -- Will the Columbia catastrophe prove to have been an "accident" in the strict sense of the word?

    “One word I’ve never applied to the Challenger shuttle disaster in 1986 is "accident". I consistently call it a "consequence", and when asked, detail the reasons why it should be considered a preventable result of a string of bad human choices. The wrongness of those choices ought to have been known when they were being made, since they clearly violated classic principles of sound engineering judgment.”

    March 16
    Shuttle probe follows a trail of data
    Detailed timeline of last moments could shed light on causes


    “Investigators looking into the loss of the shuttle Columbia and its seven astronauts on Feb. 1 are putting the finishing touches on the collection of raw data from the final moments of flight. Now their analysis is shifting to interpreting those findings and “walking back” the reconstruction of these events to try to find the cause of the catastrophe.”

    March 18
    Was ‘mystery object’ a shuttle clue?
    Investigators paying more attention to radar blip on 2nd day


    “Frustrated investigators of the Columbia tragedy are still trying to find a connection between apparently minor launch damage to the shuttle’s wing and the subsequent failure of that wing on return to Earth. They are now paying more attention to one potential gap-bridging clue, and some observers are dismayed that the clue was not recognized soon enough to do some good for the doomed shuttle and its crew. This clue is the small “mystery object” that apparently detached itself from the shuttle after about 24 hours in space, on Jan. 17.”

    March 27
    High-tech sensor in the shuttle search
    Military imaging system may be withdrawn from debris hunt


    “The search for debris from the space shuttle Columbia is receiving valuable support from a classified U.S. Army sensor program whose important role has remained unsung, probably due to security concerns connected with the sensor’s primary mission to detect land mines in combat zones such as Iraq. However, the future of this effort is now in doubt, and the equipment may be withdrawn from the search as early as next week.”

    March 27
    Tape contains mystery shuttle data
    Technicians find new data from final seconds of Columbia flight


    “A flight data recorder from the space shuttle Columbia, recovered last week in East Texas, contains readings that continue 14 seconds later than any previously studied data, sources familiar with the investigation told NBC News on Thursday. Those readings are likely to play a crucial role in determining the cause of the shuttle's catastrophic breakup on Feb. 1.”

    April 22
    Columbia debris search nears end
    Large-scale sweep to end this month, investigators say

    “…Seventy-nine thousand pounds of Columbia debris — about 36 percent of the vehicle by weight — has been found in East Texas, according to the latest tally. Much of the remaining material was not located in the three-month search and may remain on the ground, or under it, in the search area. A significant fraction of the vehicle — perhaps as much as 20 percent, according to some experts — was pulverized or burned up in the tremendous heating that accompanied the spaceship’s disintegration.”

    2003 April 25
    MSNBC.COM (Oberg): "Shuttle investigators are zeroing in"
    But they haven't yet completed cause-and-effect links in tragedy


    “Like two tunneling teams digging a railway route through a mountain from opposite sides and aiming to meet "close enough" in the middle, groups of space shuttle accident investigators have created two very credible chains of evidence - but the critical juncture still eludes them.”

    April 30
    NASA mulls in-space options for shuttle repairs
    Top strategies described in internal report


    “Throughout the investigation of the Columbia disaster, the question of why the shuttle astronauts had so little ability to inspect and repair the exterior of their own spacecraft has never gone away. So even as the independent investigation board has been narrowing down the exact cause of the Feb. 1 tragedy, NASA engineers have been working to solve the inspection and repair issues.”

    May 12
    USA Today (Oberg): Space officials can't dismiss shuttle caution signs

    “Little more than three months ago, seven astronauts paid with their lives to remind space officials that spaceflight is unforgiving. Tolerance of any level of malfunction is a recipe for eventual disaster. Now it appears that this lesson still hasn't soaked into the consciousness of some top officials.”

    May 23
    Shuttle 'what-ifs' raise bigger issues
    Chairman hints that rescue scenario sparks 'ominous' questions about NASA leadership


    “A NASA study demanded by the independent board investigating the Columbia disaster has confirmed earlier assessments that technically there was a fighting chance to save the seven astronauts, if only management had been aware of their mortal danger in time. Although most commentators have focused on the Hollywood-style details of the theoretical rescue mission, the board's chairman seemed much more interested in what the failure to exercise this option implied about NASA's leadership.”

    June 2
    NASA wrestles over timeline for shuttle flights
    Dates under debate range from December to mid-2004


    ”More than four months after the Columbia catastrophe and the grounding of the three remaining space shuttles, NASA officials are wrestling with the question of when flights can resume. Estimates and guesses range from “the end of the year” through mid-2004.”

    July 8
    "The Hole in NASA's Safety Culture".

    “The foam impact test on Monday that left a gaping hole in a simulated space shuttle wing also graphically unveiled the gaping hole in NASA's safety culture. Even without any test data to support them, NASA's best engineers who were examining potential damage from the foam impact during Columbia's launch made convenient assumptions. Nobody in the NASA management chain ever asked any tough questions about the justification for these feel-good fantasies.”

    July 10
    Shuttles to fly no earlier than March
    NASA revises timeline for return to flight
    “The space shuttle fleet will return to flight no earlier than next March, more than a year after Columbia’s loss, according to a revised NASA timeline obtained by MSNBC.com Wednesday. Earlier timelines had indicated flights might resume as early as December, but most experts never expected the space agency to meet that schedule.”

    July 23
    Post-Columbia NASA hunkers down

    Officials’ view of shortcomings is a bad omen for future clash
    “NASA spaceflight operations officials argued Tuesday that the loss of the space shuttle Columbia was nobody’s fault, and that they couldn’t have done anything wrong because of their pure intentions. They couldn’t think of anything they did wrong, but they also promised to do better in the future.”

    2003 July 30 // USA Today
    Costly astronauts wield too much clout

    “A recent NASA inspector general's report criticized the inefficient use of highly trained astronauts. It confirmed the view of many space workers that there are too many — perhaps twice as many — astronauts than are really needed, costing the program too much money.”

    August 21, 2003 // USA TODAY
    NASA REQUIRES OVERHAUL AT THE TOP,

    “As NASA prepares to respond to the sweeping criticisms contained in the report on the Columbia shuttle disaster that will be released Tuesday, it still hasn't caught on to the fact that merely moving managers around and issuing rousing pep talks to workers won't be enough. New faces at the very top - either in the administrator's office or in the close circle of his top advisers - are going to be needed. Nothing less will be adequate to set NASA on a course toward healing itself and regaining the nation's confidence.”

    Aug. 25, 2003 //
    NASA’s culture of denial
    Real change needed if space agency to reform ways


    “Why did the Columbia astronauts die? To answer this question, the Columbia Accident Investigation Board has gone far beyond the technical issues of what went wrong. Harold Gehman, the retired admiral who chaired the independent commission, has made no secret that his intent was to find out WHY the technical decisions were wrong, and for that, his group has attacked the issue of NASA’s culture of decision-making. In fact, WHEN ASKED at a press conference how much of his final report could have been written BEFORE the disaster, Gehman thought momentarily and replied, “Probably most of it.” Why NASA — and its supposedly independent watchdog teams — failed to see the patterns is still another issue of “culture.”

    Sept. 15
    Expert warns of future shuttle woes
    Suggestions in shuttle report must be made mandatory, panelist says


    “A member of the Columbia Accident Investigation Board is warning that another shuttle accident could occur unless the board’s “suggestions” and “observations” are upgraded to mandatory recommendations and put into effect before the shuttles fly again. The warning appears in a not-yet-published supplement to the board’s final report that was obtained by MSNBC.com. “History reveals NASA has repeatedly demonstrated a lack of regard for outside studies and their findings,” the addendum states.”

    Sept. 18
    NASA returns to roots for tile repair
    Engineers coming up with shuttle fix learn from past tests


    “NASA showed off its current ideas for in-flight repair of space shuttle tiles this week, a demonstration that went a long way toward finally explaining why the space agency canceled its first tile repair efforts a quarter century ago.”

    Sept. 22
    “NASA adds extra shuttle mission
    Plans call for first mission no earlier than July, crew reshuffle

    “NASA is settling on a plan for the space shuttle’s “return to flight” next year, internal documents obtained by MSNBC.com show. These plans include moving the launch date for the flight, called STS-114, from the unrealistic “no earlier than March 11” into July 2004 or later. They also involve a major overhaul in the mission objectives and the addition of an extra shuttle mission two months later, to precede an ambitious rapid-fire sequence of space station expansion flights now planned for 2005.”

    September 29,2003 SPACENEWS Page 13
    Shuttles Should Keep Eyes Open In Orbit

    “To minimize the chances of being blindsided by future disasters, NASA needs to open all of its eyes. But one set of visual sensors still has not been activated.”

    October 2
    Shuttle flights may be delayed again    
    Sources say September is new target; safety concerns cited
    “NASA mission planners are proposing that the space shuttle fleet's return to flight be pushed back to no earlier than September 2004, sources told MSNBC.com Thursday. The space agency said there were concerns about whether the nose cap of the shuttle Atlantis was inspected properly for corrosion.”

    November 15 New Scientist magazine (London)
    Shuttle Tile Repair Kit

    “Next to a giant vacuum chamber for testing spaceships is a semicircle of tables covered with hands-on demos. Samples of rubbery pink “goop” are being handed out as souvenirs. It feels like a school excursion to a science museum, but the scene is actually a special media workshop to showcase NASA’s efforts to get the shuttle back to flight.”

    2003 Dec. 2 // NASA split over space station noise
    Incident hints at culture clash that shuttle probe didn’t fix

    ”The loud crunch that startled the crew of the international space station last week is still echoing through the halls of Mission Control in Houston. And it seems to have sparked a culture clash between those who have learned the lessons of the Columbia catastrophe, and those who apparently haven’t.”

    2004 Jan. 21
    NASA details new space goals to staff
    Employee presentation stresses affordability of plan


    “In a presentation now being delivered to NASA employees across the country, the space agency is providing details of how it plans to implement the broad new space goals announced by President Bush last week. The presentation, a copy of which was obtained by MSNBC.com, includes a list of guiding principles, specific program plans and details of budgetary rearrangements.”

    Jan. 28, 2004
    Shuttle manager reflects on mistakes
    In letter to employees, Hale reviews vision and shortcomings


    “Marking the first anniversary of the loss of the shuttle Columbia and its seven astronauts, a newly promoted NASA shuttle official has called on all space workers to adjust their thinking in preparation for resuming shuttle missions and going beyond them to meet the new goals recently set by the White House. And in a break with past NASA practices, he explicitly listed the mistakes he personally made that contributed to last year's disaster.”

    July 19
    The secret formula for going to the moon
    Fear played a role in 1960s, and may do so again


    “Over the three and a half years from July 1969 to December 1972, six teams of astronauts walked on the moon. They went from “We came in peace for all mankind” to the parting words, “We’ll be back.” But decades passed, and nobody came back..”

    2004 Oct. 21
    ‘Murphy’s Law’ rules outer space
    ... And NASA still needs to learn how to evade it


    “In outer space, many earthly rules and standards don’t apply. But if space exploration has proved anything, it is that like the universal Law of Gravity, the Law of Murphy also extends throughout the known universe.”

    2004 Oct. 28
    NASA mulls early retirement for space shuttle
    Preliminary studies look at off-loading station building to rockets


    “Even as NASA gears up for the space shuttle's return to flight next year, officials at the space agency are quietly studying the possibility of cutting back its number of missions and retiring the spacecraft years ahead of schedule, MSNBC.com has learned.”

    2005 January 8 // ‘New Scientist’
    2005: a tough year ahead for NASA

    “THE year 2005 is set to be one of the toughest for the US space agency NASA. It must deliver on its promise to get the space shuttle fleet back into the air by the middle of the year. With its international partners, it must find a way to keep the International Space Station functioning with a skeleton crew. And it needs a new leader, following the surprise resignation in December of its chief, Sean O'Keefe.”

    2005 Jan. 26
    Deadly space lessons go unheeded
    Apollo 1, Challenger, Columbia tragedies have much in common


    “At the end of January, NASA faces a triple anniversary of space catastrophes: the three times that astronauts have been killed aboard space vehicles. On January 27, 1967, during a pre-launch test, an unexpectedly ferocious fire suffocated Grissom, White, and Chaffee. On January 26, 1986, an unexpectedly brittle booster seal destroyed shuttle Challenger and killed Scobee, Smith, Resnik, Onizuka, McNair, Jarvis, and McAuliffe. And on February 1, 2003, unexpectedly severe heat shield damage destroyed the shuttle Columbia and killed Husband, McCool, Chawla, Clark, Anderson, Brown, and Ramon. As with the disasters themselves, this calendric coincidence was created by the confluence of independent trends and conditions that conspired to set the stage for disaster. But in each space case, these impersonal forces were merely backdrop to the human decisions that through their flaws were the immediate causes.”

    2005 February 7 // The Space Review:
    What does a sick “space safety culture” smell like?

    “In the months following the Columbia shuttle disaster two years ago, the independent Columbia Accident Investigation Board (CAIB) sought both the immediate cause of the accident and the cultural context that had allowed it to happen. They pinpointed a “flawed safety culture”, and admitted that 90% of their critique could have been discovered and written before the astronauts had been killed—but NASA officials hadn’t noticed.”


    2005 April 6
    Shuttle panel divided over NASA compliance
    A case of late paperwork or something more serious?


    “After a week of private and often heated internal debate, the independent panel appointed to oversee NASA's relaunch of the space shuttle appears unable to complete its final report on whether the agency has complied with safety recommendations.”

    2005 April 25
    NASA managers insist books aren’t cooked
    Complexities of shuttle risk explained amid debate


    “Safety standards for the next space shuttle launch are not being relaxed through mathematical manipulation, NASA shuttle managers insisted Friday, in response to a New York Times article that cited internal agency reports to raise that possibility. The managers denied that they were trying to “cook the books” about safety tests in order to force a foregone conclusion.”

    2005 Jun 13 // The Space Review
    Academic honors for a spaceflight prophet

    [Re Dr. John Houbolt, who invented the Apollo flight plan:] “…unless today’s space experts learn to emulate his vision, courage, and soft-spoken stubbornness, the grandiose “Vision for Space Exploration” plans for resuming human flight beyond low Earth orbit may fail to be realized.”

 

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