5.8 Conclusion

5.8 Conclusion

¶Over the last decade, the Space Shuttle Program has operated in a challenging and often turbulent environment. As discussed in this chapter, there were at least three major contributing factors to that environment:

¶
• Throughout the decade, the Shuttle Program has had to function within an increasingly constrained budget. Both the Shuttle budget and workforce have been reduced by over 40 percent during the past decade. The White House, Congress, and NASA leadership exerted constant pressure to reduce or at least freeze operating costs. As a result, there was little margin in the budget to deal with unexpected technical problems or make Shuttle improvements.
• The Shuttle was mischaracterized by the 1995 Kraft Report as "a mature and reliable system … about as safe as todayʼs technology will provide." Based on this mischaracterization, NASA believed that it could turn increased responsibilities for Shuttle operations over to a single prime contractor and reduce its direct involvement in ensuring safe Shuttle operations, instead monitoring contractor performance from a more detached position. NASA also believed that it could use the "mature" Shuttle to carry out operational missions without continually focusing engineering attention on understanding the mission-by-mission anomalies inherent in a developmental vehicle.
• In the 1990s, the planned date for replacing the Shuttle shifted from 2006 to 2012 and then to 2015 or later. Given the uncertainty regarding the Shuttleʼs service life, there has been policy and budgetary ambivalence on investing in the vehicle. Only in the past year has NASA begun to provide the resources needed to sustain extended Shuttle operations. Previously, safety and support upgrades were delayed or deferred, and Shuttle infrastructure was allowed to deteriorate.

¶The Board observes that this is hardly an environment in which those responsible for safe operation of the Shuttle can function without being influenced by external pressures. It is to the credit of Space Shuttle managers and the Shuttle workforce that the vehicle was able to achieve its program objectives for as long as it did.

¶An examination of the Shuttle Programʼs history from Challenger to Columbia raises the question: Did the Space Shuttle Program budgets constrained by the White House and Congress threaten safe Shuttle operations? There is no straightforward answer. In 1994, an analysis of the Shuttle budget concluded that reductions made in the early 1990s represented a "healthy tightening up" of the program.⁷⁷⁷⁷ General Research Corporation, Space Shuttle Budget Allocation Review, Volume 1, July 1994, p. 7. CAIB document CAIB015-0161. Certainly those in the Office of Management and Budget and in NASAʼs congressional authorization and appropriations subcommittees thought they were providing enough resources to operate the Shuttle safely, while also taking into account the expected Shuttle lifetime and the many other demands on the Federal budget. NASA Headquarters agreed, at least until Administrator Goldin declared a "space launch crisis" in June 1999 and asked that additional resources for safety upgrades be added to the NASA budget. By 2001, however, one experienced observer of the space program described the Shuttle workforce as "The Few, the Tired,"

¶and suggested that "a decade of downsizing and budget tightening has left NASA exploring the universe with a less experienced staff and older equipment."⁷⁸⁷⁸ Beth Dickey, "The Few, the Tired," Government Executive, April 2001, p. 71.

¶It is the Boardʼs view that this latter statement is an accurate depiction of the Space Shuttle Program at the time of STS- 107. The Program was operating too close to too many margins. The Board also finds that recent modest increases in the Shuttle Programʼs budget are necessary and overdue steps toward providing the resources to sustain the program for its now-extended lifetime. Similarly, NASA has recently recognized that providing an adequately sized and appropriately trained workforce is critical to the agencyʼs future success.

¶An examination of the Programʼs management changes also leads to the question: Did turmoil in the management structure contribute to the accident? The Board found no evidence that the transition from many Space Shuttle contractors to a partial consolidation of contracts under a single firm has by itself introduced additional technical risk into the Space Shuttle Program. The transfer of responsibilities that has accompanied the Space Flight Operations Contract has, however, complicated an already complex Program structure and created barriers to effective communication. Designating the Johnson Space Center as the "lead center" for the Space Shuttle Program did resurrect some of the Center rivalries and communication difficulties that existed before the Challenger accident. The specific ways in which this complexity and lack of an integrated approach to Shuttle management impinged on NASAʼs performance during and before the flight of STS-107 are discussed in Chapters 6 and 7.

¶As the 21st century began, NASAʼs deeply ingrained human space flight culture – one that has evolved over 30 years as the basis for a more conservative, less technically and organizationally capable organization than the Apollo-era NASA – remained strong enough to resist external pressures for ad- aptation and change. At the time of the launch of STS-107, NASA retained too many negative (and also many positive) aspects of its traditional culture: "flawed decision making, self deception, introversion and a diminished curiosity about the world outside the perfect place."⁷⁹⁷⁹ Brewer, "Perfect Places," pp. 159. These characteristics were reflected in NASAʼs less than stellar performance before and during the STS-107 mission, which is described in the following chapters.

ENDNOTES FOR CHAPTER 5

¶The citations that contain a reference to "CAIB document" with CAB or CTF followed by seven to eleven digits, such as CAB001-0010, refer to a document in the Columbia Accident Investigation Board database maintained by the Department of Justice and archived at the National Archives.

Chapter 6: Decision Making at NASA

¶The dwindling post-Cold War Shuttle budget that launched NASA leadership on a crusade for efficiency in the decade before Columbiaʼs final flight powerfully shaped the environment in which Shuttle managers worked. The increased organizational complexity, transitioning authority structures, and ambiguous working relationships that defined the restructured Space Shuttle Program in the 1990s created turbulence that repeatedly influenced decisions made before and during STS-107.

¶This chapter connects Chapter 5ʼs analysis of NASAʼs broader policy environment to a focused scrutiny of Space Shuttle Program decisions that led to the STS-107 accident. Section 6.1 illustrates how foam debris losses that violated design requirements came to be defined by NASA management as an acceptable aspect of Shuttle missions, one that posed merely a maintenance "turnaround" problem rather than a safety-of-flight concern. Section 6.2 shows how, at a pivotal juncture just months before the Columbia accident, the management goal of completing Node 2 of the International Space Station on time encouraged Shuttle managers to continue flying, even after a significant bipod-foam debris strike on STS-112. Section 6.3 notes the decisions made during STS-107 in response to the bipod foam strike, and reveals how engineersʼ concerns about risk and safety were competing with – and were defeated by – managementʼs belief that foam could not hurt the Orbiter, as well as the need to keep on schedule. In relating a rescue and repair scenario that might have enabled the crewʼs safe return, Section 6.4 grapples with yet another latent assumption held by Shuttle managers during and after STS-107: that even if the foam strike had been discovered, nothing could have been done.