Columbia Accident Investigation Board: Final Report

ssclift writes "After nearly 7 months the Columbia Accident Investigation Board has released its final report into the February 1st loss of the Shuttle Columbia and all 7 crew members. This is more than a technical assessment of the immediate causes of the accident. Once again, sadly, the world's flagship space agency gets a thorough and grim review. Press briefings will begin at 11:00 EDT along with a webcast."

Comments

The "Culture of NASA"????

[tha_mink]

I actually read that they are blaming this accident on the "Culture of NASA". Meaning, that if you were some small fry in the organization and you saw a problem with a process, you would be afraid to approach the 200 suits. Even though they stand there and say "Anyone have a problem with what we're doing?" "Our doors are always open.."

Sound familiar anyone?

Re:The "Culture of NASA"????

[the MaD HuNGaRIaN]

Where I work, the doors are always open...it's the ears that aren't.

I suspect it's the same situation at all large organizations.

You can lead a manager to an idea, but you can't make him/her think.

Re:The "Culture of NASA"????

[L0C0loco]

First a disclaimer: I work for NASA.

The small fry is not afraid of 200 suits, just two or three in the level or two of management above them. There are many levels of management in NASA and it is likely that someone somewhere in that chain of management (I was going to call it command, but frequently the managers high up have insufficient command/knowledge of the topic they manage) will not want to pass bad news along. They'll either decide to report nothing or spin it into something less distasteful. Generally there are two concerns: Somebody goofed or We need more time/money to do it right. The latter is not acceptable since NASA has a fixed budget and congress is already unhappy about the growing cost over-runs in some programs. It all really boils down to too much to do with too little resources. Just look at the way things worked under the moon program or the way it works under the dark side of DOD where money was/is frequently no object. Nowadays, everybody underbids to get the contract and then tries to do what they can with the money (not necessarily what was promised). Yes, checks and balances would help a little a few years down the road once the short-comings are caught and exposed, but by then any last shred of confidence in NASA by the public will have evaporated.

Bottom line here is that you get what you pay for.
Congress and the voters have to decide what they want to do given realistic costs. The costs are frequently adjusted by managers trying to get the program to boost their self esteem or pay-grade with little regard as to what will happen to the likelhood of success. The underlings are all too eager to try and make do for similar motivations. Now toss in contracting functions out to the lowest bidder and you're really asking for trouble.

Sorry if this borders on being a rant for some.

Re:The "Culture of NASA"????

[DrMorpheus]

The visible difference being that most large organizations are not funded by the government, and do not strap men and women to tons of explosives and try to get them back without any danger to the astronauts or the people of Earth.

When or not a large organization is or is not funded by the government makes no difference whatsoever, market arguments notwithstanding.

The key is, children, it's a large organization. Being so it's relatively immune to external forces, or rather it's got internal resources to withstand any outside pressures to change. Again, this is true whether or not it's a government body or a corporate body. Local government bodies, like town councils are much, much more flexible than their equivalent in state or federal levels.

This holds true in private organizations too where small businesses, or ones with a thin layer of management are much more responsive/sensitive to outside pressures than are those from hugh behemeths like Microsoft, etc.

That same flexibility is also a weakness in that when a small organization has a good idea, government body or not, and faces a hostile environment it's not likely to succeed in implementing that idea relative to a larger organization so it's a trade off. Small and responsive, but also vulnerable and weak versus large and strong, but also insular and bullying.

Bottom line is, there's no single organizational structure that works in all circumstances for all times.

At least they admit it...

[LordYUK]

"On Monday, NASA Administrator Sean O'Keefe told CNN's Miles O'Brien that the agency missed signs of trouble that led to the accident.

"This was a case where we missed it. Just flat missed it," he said of the significance of the foam strike. "

At least they arent trying to cover it up. Now they can move forward, and hopefully we'll continue to explore space even more proficiently than before.

Who knows, maybe our grandkids (or their grandkids) will get to land on mars!

A rare opportunity

[TopShelf]

I wouldn't say that it's "sad" that NASA gets a thorough review. Quite the contrary, I think it's a rare opportunity to make the case that cost-cutting measures involve tradeoffs that have a significant impact on how an organization like NASA operates. What is sorely needed is a public champion to advocate for increased NASA funding, as part of a commitment to keep America at the forefront of technological leadership worldwide. Particularly as other countries are stepping up their space efforts, this is going to be a growing concern in the years ahead.

Not having followed the eeaaarrrrllly presidential campaigning, are there any strong proponents for NASA out there?

Re:A rare opportunity

[RevMike]

What is sorely needed is a public champion to advocate for increased NASA funding....

I don't think it is a budget issue, though. Throwing money at this sort of problem rarely solves anything. The problem is a cultural one.

Organisations frequently have an upward focus. Too many people concentrate on what their boss wants to hear, instead of what needs to be said. Everything is about satisfying one's boss by helping them satisfy their boss, by helping them satisfy their boss, ad nauseum. It is more important that things look right the most senior administrator than that they are right.

An organisation that depends on highly skilled highly professional people at relatively low levels needs to have a downward focus. The most senior people need to focus on how they can help their direct reports do their job, and those people need to focus on helping their direct reports do their jobs, ad nauseum. In the end, this type of culture helps the engineers and technicians actually do their job.

The US military went through this kind of transition in the early 1980s. More and more command and control was moved lower and lower in the hierarchy. Tactics were left to the people on the scene. The senior personnel focused on strategy and logistics, coordinating and supplying, which enable the local personnel to do their jobs effectively. Taking out a machine gun nest is a job for a sargeant or lutenant on the scene - not a general in Washington.

Summary:

[RealityProphet]

"A terrible accident occured. It's nobody's fault, really. These things happen. We'll try to be more careful in the future. But, spaceflight is risky business, we can't make any guarantees."

Re:Summary:

[applemasker]

What I find most distressing is how the mission managers and program managers have all run for cover. There are people to blame, starting with the folks who never followed up on the previous foam issues; the managers who squelched engineers requests for imagery; and the mission team who met a handful of times during the flight (even though the regs require daily meetings) and never thought of what might happen if the foam had hit the RCC. Come on, it IS rocket science guys.

So, what they're saying is...

[gowen]

What they're saying is that

for a successful technology, reality must take precedence to public relations, for nature can not be fooled.

Well, surprise, surprise. Thats what Richard Feynman said is his minority report on the Challenger accident.

Plus ca change...

Re:Failure is not an Option?

[The Original Yama]

I don't blame them. Since the end of the space race with the USSR, NASA funding has been continually eroded over time. Understandably, NASA personnel have become more conservative and focused on keeping their jobs rather than taking risks. NASA isn't the problem, it's politics that's retarding their progress.

Feynman said exactly this 16 years ago

[Alrocket]

I don't seriously believe that the culture of NASA will change as a result of this report. Feynman noticed all of these issues and made sure that he met the engineers alone, without any management, when he needed to find out the real answers.

It didn't change since then, it's not going to change now.

Managed by accountants rather than engineers

[hughk]

In an engineering led process any engineer has the right to say "stop, I believe we have a problem". The problem may be proved to be non-existant, but someone must address it and escalate it.

Regrettably, many organisations insist that you be "Part of the solution" not "Part of the problem" (I think this was an AC buzz-phrase). This meant that unless you could deliver a problem with a solution, you were associated with failure. At the bottom engineers may gripe but unless the PHBs supervsing them help the problems be escalated, nothing will happen.

In the end if we want public money spent responsibly, then projects have to be managed and accountants must count the beans. However, engineering must have a voice that is equal to that of the manager and the accountant. It is right that an experimental program takes risks, but they must be informed.

Lastly, the space program has provided some very good examples of the managed delivery of quality projects. With Columbia and Challenger we have two major counter-examples. It is both useful and a good memorial to those who died if everyone, both inside and outside NASA learned from this.

Re:Failure is not an Option?

[stratjakt]

I realized how much different NASA is today. They have no fire in their belly, seems like they're more interested in keeping their jobs than anything

You know this how? You work at NASA? You were in mission control when Columbia went up?

About the only thing that's changed is that there's a no smoking rule. I live only a stones throw away from Gottard, and know dozens of people at various levels within NASA.

They are all extremely passionate about their work, and they all took Columbia very, very personally.

Dont make overly broad statements about a group of people you know absolutely nothing about.

NASA is no longer a flagship

[Mahrin Skel]

NASA hasn't been the leader in space technology for a long time. They spend too much, accomplish too little, and paradoxically they make it *too* safe. If we were throwing up a launch every other day, and losing a bird a year, we'd get used to it. Astronaut would be just another dangerous profession, like "test pilot", "commercial fisherman", or "underground coal miner".

But because we've lost only 3 crews, and spend over a billion on every launch trying to bring it to zero (and therefore don't get a lot of launches), people are able to delude themselves into thinking that space travel should be safe. So when we do have a problem, everyone looks for someone to blame, NASA writes a few more books of safety procedures, launches get more expensive and less frequent.

You know why we lost the Columbia? Because NASA regulations didn't allow anyone to go out and look at the damned wing in orbit without specific orders. If the astronauts weren't treated as remote voice-controlled drones by the ground crews, and the shuttle commander had the responsibility and authority that goes with that title in any other field, somebody would have put on a suit and taken a look. But an EVA requires the input of hundreds of desk jockeys, and an "emergency" EVA requires authorization from the agency director. What kind of bullshit way to run a railroad is that?

Disband NASA, turn over civilian spaceflight regulation to the FAA (after first burning every regulation NASA ever wrote), turn the shuttle over to the Air Force and unmanned launches over to the civilian companies that really run them already. Otherwise, get used to the idea that the good old USA is no longer a space-faring nation, and other countries with the stomach for it are going to take the lead.

--Dave

Re:Time to shrink NASA

[geekoid]

whew, I guess that explains why there budget doesn't get cut all the time... hmmmm

Private industry can not take up the flag for space exploration until a cheaper way is found to get there. In order for that to happen there must be central agency that focuses on this, and the agency must get government funding.
Nasa needs to keep doing what it has been doing, and it needs to be able to explore other RnD efforts.

The only company the could do priovate space launch successfully would be microsoft, and even there 40+billion wouldn't ge them far.

Actually, it doesn't have to get cheaper, but it oes have to get profitable.

once private companies do start backing manned space exporation, we had be damn sure there is a controlling body for safty, and launches. I do not want the space equivilent of baby bells.

Starved for money and lacking direction

[fmaxwell]

NASA is no longer the pride of the nation as it was in the Mercury, Gemini, and Apollo days. We no longer have a goal as we did after JFK's challenge to land a man on the moon. The budget at NASA has been cut over and over so that they now have far less purchasing power than they did decades ago -- despite the commitment to build the International Space Station. Starting with Reagan, NASA has increasingly been viewed as a way to orbit and service military payloads.

Want NASA to prosper?

1. Provide an inspiring goal. Choose one that average people can relate to. Landing men on Mars would be a good one.

2. Stop all use of NASA for military work. Pass legislation prohibiting NASA from military missions. It's demoralizing and tends to many of those who are excited by the exploration of space.

3. Fund NASA adequately. We've spent far more in IRAQ and Afghanistan than NASA has seen in recent years. Wouldn't you be more proud of your country if it put a man on Mars rather than bombing a third-world country?

4. Scrap the Space Shuttle. It's 1980's technology that was disappointing in its performance the day it was first launched. Even using NASA's own very low cost-per-flight figures in the 1980s, the cost to put a pound of payload into orbit on the shuttle was $6,000. That compares to an inflation-adjusted figure of only $3,800 for the Saturn V expendable launch vehicles that carried men to the moon.

NASA needs The Right Stuff in order to be something more than just another government bureaucracy.

Reduced Engineering Staff at NASA and Contractors

[LoneStarGeek]

I am a former Software Developer for a NASA contractor. In 2000, I left this job due to inpending cuts by the agency. I saw many talented developers, engineers and scientists do the same thing. NASA seems to cut the budget like this about every 10 years (once a decade). They are attempting to shift a lot of the day to day operations over to contractors and alleviate the need for in-house staff to handle the load. Unfortunately, with a reduced technical staff and unapproachable executive style directors they have let launch safety slip on the Shuttle once again. I am sad at the loss of the astronauts onboard this doomed craft and pray for the famlies that have lost more than NASA can repay.

Time to get out the broom and clean the house.

No news

[EinsteinWasRight]

My family has had several of its members working for NASA for the past 30 years. We have seen NASA locked in the same vicious cycle for the past 7 presidents, it goes something like this:

1. Congress tells NASA to cut budget.

2. Congress says no Centers, no matter how useless can be closed.

3. Directors of centers give actual job of cutting budget to middle managers(Who haven't done any engineering in decades)

4. Middle managers vote to fire everybody but themselves(What a surprise!) that is fire all the engineers under them and farm out the actual engineering to contractors.

5. Make wild claims of success

6. Repeat after next election cycle.

This has been repeated now so many times that NASA doesnt do any actual engineering any more. Furthermore many of these MMs farm out even the writing of the specs!

It is the opposite of what private industry does which is to fire the MMs and keep the engineers(Flatten the organizational chart, keep the Indians fire the chiefs, etc.)

There are so many reasons why this is bad that I wont list them all here (the average Slashdot reader knows them anyway) but the most devastating effect is zero accumulation of organizational knowledge. Constructing space vehicles is very technique oriented; the devil is all in the details. That is the difference between success and failure may be knowing that the lubricating grease on the control moment gyro needs to be of a specific viscosity and quality. (Speaking hypothetically, no slur to ISS, really). Going outside of these parameters means that the CMG fails which means that the spacecraft cant change attitude which means that you have a 100 M dollar piece of junk.

This has been has been documented at NASA ad nauseum but the basic organizational structure prevents accumulation of knowledge. Which means that we pay to reengineer every time will build something.

Now add in ?Low bid always wins? and see what happens. An experienced contractor who has built spacecraft now knows that they have NASA over a barrel because they are the only ones who know how to build what they want. So they jack up the price. The bid then is won by the inexperienced contractor who now has to learn everything all over again. Repeat.

The solution? Do the same thing private industry does: Keep the Indians, fire the chiefs. Prevent the loss of organizational knowledge at all cost. Begin the slow process of knowledge accumulation so that eventually the price of space vehicle construction will come down.

Naaah, makes too much sense.

EWR

NASA Has been in trouble for a while

[EvilTwinSkippy]

NASA more or less fell flat with the decision to persue the Space Shuttle. They did not have the backing to do the project right, so they ended up selling their soul to multiple competing interests and clodged together a camel of a spacecraft.

It was a big hauler for the Military, which required so much tweakage to the engines that they require complete rebuilds between flights. It contains parts made from congressional fiefdoms scattered around the country. For example, the O-Rings were needed because the boosters are built in Minnesota and flown in chunks to Florida. The size of the shuttle and short shrift Congress paid to its budget led to useful items like atmospheric propulsion for landing to be scrapped during development.

The best thing NASA can do for itself is to just let the Shuttles sit in a hanger. They cost too much to launch and keep running. If the money that went into keeping the fleet running went into R&D they could have a replacement in a few years.

What sort of replacement? The shuttle has 3 almost mutually exclusive roles.

• A manned orbital shuttle, needing proven engines, endless testing, and tons of life-safety equipment for takeoff and landing.
• A high-performance heavy-lifter, where every pound is accounted for.
• An orbital space platform for short term experiments.

NASA has no shortage of heavy lift rockets. What they can't hurl into space, the Russians surely can. The ISS is in orbit 24/7, it can take over the "can ants in space sort tiny screws" experiments. So the only the part that NASA needs is the getting people to and from orbit part.

Once you strip the need to carry cargo, the shuttle suddenly shrinks. Every pound you don't have to launch is 3 pounds of propellent. You also save weight on the structure of the craft itself, it's landing gear, brakes, etc. The engines can be de-rated back to a range where they don't tear themselves apart every liftoff. Or better yet, just design them to use a cheap, quickly replaced, and disposable motor.

Since you are not riding the edge of performance, you can also utilize easier to handle hydrocarbon based fuels like aircraft Kerosene. Sure it's not as efficient, but it is readily available and simpler to store.

Even though you do have a permanent orbital platform, I do see some merit to keeping the ability to orbit for several weeks, not to mention the robot arm. EVA protocols will have to be adapted working without the cargo bay, but it could be done.

In short, by reducing the requirements of the shuttle you end up with the very simple spacecraft NASA had originally intended.

Re:Oh so familiar...

[EvilTwinSkippy]

Don't forget:

• Modern weapon systems can detect, target, and prosecute a target before the pilot can even see it.
• An F-15 can carry more bombs (by weight) than any aircraft in WW-II.
• Modern aircraft have to fly well both below and above the speed of sound, which requires substantial ly more design and testing for the controls.
• WW-II aircraft were plagued with problems, to the point that crews created the legendary Gremlins to explain them.
• The most famous aircraft of the War took years to develop:
  • The B-29: 4 years (1940-Dec 1943)
  • The Spitfire: 4 years (1934-1938)
  • P-38 Lightning: 5 years (1937-1942)
  • Japanese Zero: 2 years (1937-1939)

  Given the increased complexity of modern fighter jets, 10 years for an F-22 seems about par for the course.