ORB,FWD"

¶"Crushed Foam Testing." CAIB document CTF059-10561058.¹²¹² Howard E. McCurdy, Inside NASA: High Technology and Organizational 27 Demingʼs management philosophy was not the only new notion that Change in the U.S. Space Program (Baltimore: The Johns Hopkins Goldin attempted to apply to NASA. He was also an advocate of the University Press, 1993), p. 24. "Total Quality Management" approach and other modern management 13 schemes. Trying to adapt to these various management theories was a Garry D. Brewer, "Perfect Places: NASA as an Idealized Institution," in Radford Byerly, Jr., ed., Space Policy Reconsidered (Boulder, CO: source of some stress. Westview Press, 1989), p. 158. Brewer, when he wrote these words, 28 For a discussion of Goldinʼs approach, see Howard McCurdy, Faster, was a professor of organizational behavior at Yale University with no Better, Cheaper: Low-Cost Innovation in the U.S. Space Program prior exposure to NASA. For first-hand discussions of NASAʼs Apollo-era (Baltimore: The Johns Hopkins University Press, 2001). It is worth noting organizational culture, see Christopher Kraft, Flight: My Life in Mission that while the "faster, better, cheaper" approach led to many more Control (New York: E.P. Dutton, 2001); Gene Kranz, Failure is Not an NASA robotic missions being launched after 1992, not all of those Option: Mission Control from Mercury to Apollo 13 (New York: Simon & missions were successful. In particular, there were two embarrassing Schuster, 2000); and Thomas J. Kelly, Moon Lander: How We Developed failures of Mars missions in 1999. the Apollo Lunar Module (Washington: Smithsonian Institution Press, 29 2001). Lambright, Transforming Government, provides an early but 14 comprehensive evaluation of the Goldin record. The quote is from p. Brewer, "Perfect Places," pp. 159-165. 28.Show full note

Minutes of Orbiter Structures Telecon meeting, June 19, 2001, held with NASA, KSC, USA, JSC, BNA-Downey, Huntington Beach and Palmdale. CAIB document CAB033-38743888.

¶NASA Report NSTS-37398. 14

¶Standard Operating Procedure, Foreign Object Debris (FOD) Reporting,

Revision A, Document Number SOP-O-0801-035, October 1, 2002, United Space Alliance, Kennedy Space Center, pg. 3.

¶Ibid, pg. 2. 16

"An effective FOD prevention program identifies potential problems, corrects negative factors, provides awareness, effective employee training, and uses industry "lessons learned" for continued improvement. There is no mention of Processing Debris, but the guidance does address potential Foreign Object Damage and Foreign Object Debris. While NASA has done a good job of complying with almost every area of this guideline, the document addresses Foreign Object investigations in a singular sense: "All incidents of actual or potential FOD should be reported and investigated. These reports should be directed to the FOD Focal Point who should perform tracking and trending analysis. The focal point should also assure all affected personnel are aware of all potential (near mishap) and actual FOD reports to facilitate feedback (ʻlessons

¶learnedʼ)." 17

Space Flight Operations Contract, Performance Measurement System Reports for January 2003, February 2003, USA004840, issue 014,

¶contract NAS9-2000.

¶Installation Of The –Y Bipod," August 8, 2002.

¶Part Two

¶Why The Accident Occurred

¶Many accident investigations do not go far enough. They identify the technical cause of the accident, and then connect it to a variant of "operator error" – the line worker who forgot to insert the bolt, the engineer who miscalculated the stress, or the manager who made the wrong decision. But this is seldom the entire issue. When the determinations of the causal chain are limited to the technical flaw and individual failure, typically the actions taken to prevent a similar event in the future are also limited: fix the technical problem and replace or retrain the individual responsible. Putting these corrections in place leads to another mistake – the belief that the problem is solved. The Board did not want to make these errors.

¶Attempting to manage high-risk technologies while minimizing failures is an extraordinary challenge. By their nature, these complex technologies are intricate, with many interrelated parts. Standing alone, the components may be well understood and have failure modes that can be anticipated. Yet when these components are integrated into a larger system, unanticipated interactions can occur that lead to catastrophic outcomes. The risk of these complex systems is increased when they are produced and operated by complex organizations that also break down in unanticipated ways.

¶In our view, the NASA organizational culture had as much to do with this accident as the foam. Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of an institution. At the most basic level, organizational culture defines the assumptions that employees make as they carry out their work. It is a powerful force that can persist through reorganizations and the change of key personnel. It can be a positive or a negative force.

¶In a report dealing with nuclear wastes, the National Research Council quoted Alvin Weinbergʼs classic statement about the "Faustian bargain" that nuclear scientists made with society. "The price that we demand of society for this magical energy source is both a vigilance and a longevity of our social institutions that we are quite unaccustomed to." This is also true of the space program. At NASAʼs urging, the nation committed to building an amazing, if compromised,

¶vehicle called the Space Shuttle. When the agency did this, it accepted the bargain to operate and maintain the vehicle in the safest possible way. The Board is not convinced that NASA has completely lived up to the bargain, or that Congress and the Administration has provided the funding and support necessary for NASA to do so. This situation needs to be addressed – if the nation intends to keep conducting human space flight, it needs to live up to its part of the bargain.

¶Part Two of this report examines NASAʼs organizational, historical, and cultural factors, as well as how these factors contributed to the accident. As in Part One, this part begins with history. Chapter 5 examines the post-Challenger history of NASA and its Human Space Flight Program. This includes reviewing the budget as well as organizational and management history, such as shifting management systems and locations. Chapter 6 documents management performance related to Columbia to establish events analyzed in later chapters. The chapter reviews the foam strikes, intense schedule pressure driven by an artificial requirement to deliver Node 2 to the International Space Station by a certain date, and NASA managementʼs handling of concerns regarding Columbia during the STS-107 mission.

¶In Chapter 7, the Board presents its views of how high-risk activities should be managed, and lists the characteristics of institutions that emphasize high-reliability results over economic efficiency or strict adherence to a schedule. This chapter measures the Space Shuttle Programʼs organizational and management practices against these principles and finds them wanting. Chapter 7 defines the organizational cause and offers recommendations. Chapter 8 draws from the previous chapters on history, budgets, culture, organization, and safety practices, and analyzes how all these factors contributed to this accident. This chapter captures the Boardʼs views of the need to adjust management to enhance safety margins in Shuttle operations, and reaffirms the Boardʼs position that without these changes, we have no confidence that other "corrective actions" will improve the safety of Shuttle operations. The changes we recommend will be difficult to accomplish – and will be internally resisted.

¶The Board is convinced that the factors that led to the Columbia accident go well beyond the physical mechanisms discussed in Chapter 3. The causal roots of the accident can also be traced, in part, to the turbulent post-Cold War policy environment in which NASA functioned during most of the years between the destruction of Challenger and the loss of Columbia. The end of the Cold War in the late 1980s meant that the most important political underpinning of NASAʼs Human Space Flight Program – U.S.-Soviet space competition – was lost, with no equally strong political objective to replace it. No longer able to justify its projects with the kind of urgency that the superpower struggle had provided, the agency could not obtain budget increases through the 1990s. Rather than adjust its ambitions to this new state of affairs, NASA continued to push an ambitious agenda of space science and exploration, including a costly Space Station Program.

¶If NASA wanted to carry out that agenda, its only recourse, given its budget allocation, was to become more efficient, accomplishing more at less cost. The search for cost reductions led top NASA leaders over the past decade to downsize the Shuttle workforce, outsource various Shuttle Program responsibilities – including safety oversight – and consider eventual privatization of the Space Shuttle Program. The programʼs budget was reduced by 40 percent in purchasing power over the past decade and repeatedly raided to make up for Space Station cost overruns, even as the Program maintained a launch schedule in which the Shuttle, a developmental vehicle, was used in an operational mode. In addition, the uncertainty of top policymakers in the White House, Congress, and NASA as to how long the Shuttle would fly before being replaced resulted in the delay of upgrades needed to make the Shuttle safer and to extend its service life.

¶The Space Shuttle Program has been transformed since the late 1980s implementation of post-Challenger management changes in ways that raise questions, addressed here and in later chapters of Part Two, about NASAʼs ability to safely

¶hallenger Columbia operate the Space Shuttle. While it would be inaccurate to say that NASA managed the Space Shuttle Program at the time of the Columbia accident in the same manner it did prior to Challenger, there are unfortunate similarities between the agencyʼs performance and safety practices in both periods.