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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."
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?
You'll have that sometimes...
"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!
This is my sig. Its pathetic.
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?
Stop by my site where I write about ERP systems & more
"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."
Plus ca change...
Athletic Scholarships to universities make as much sense as academic scholarships to sports teams.
"The total blame for the Colombia accident rests squarly on the shoulders of Kim Johnson of Springfield, MO." Ever have one of those days?
These comments do express the opinions of my employers, and, personally, I think they're complete rubbish.
Funny how the History Channel special on the early space program came out this week. After watching it, 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. If we want to continue sending men into space, we had better start doing it right once again.
...for anyone to RTFA.
W00T! I married the geekiest guy I know (/.er #3115) on July 19, 2003! Who says nerds never find love?
"Hmm, I don't know, all this equipment is for measuring TV ratings"
Kick in the Head
It didn't change since then, it's not going to change now.
I used to be a big believer in the NASA Myth: that they were the only ones capable of doing big space launches and that space access for humans was inherently expensive.
Then I heard Jerry Pournelle speak a couple years ago at a convention. He said something that shook me: NASA has many good people and does many good things but needs to get out of the business of launching people and robots into space. It surprised me because here is a guy who is in favor of space exploration but against NASA.
NASA as an organization doesn't really care about cheap, reliable space launches, because that would mean that their budget would be cut! The shuttle accidents are a symptom of bureaucratic mentality. Think on this: the Russian space agency will charge you about $15M for a trip to the space station. It costs between $500M and $1 billion just to do a shuttle launch.
NASA does a great job building Mars rovers and such, let's keep them doing that. But we should turn everything else over to private industry.
Your design to a real part online: Big Blue Saw
It's interesting that the first thing they said about it was that there was only a tiny chance that the foam had anything to do with it. It's weird how things turn around like that.
6 72378.html
:-/
I think the bottom line behind all this is most likely money. They have cut so many budgets as far as space goes and forced them to do fewer and fewer pre-flight inspections that something like this was almost guaranteed.
"Confidential interviews with shuttle workers at NASA and its contractors, 'from line technicians all the way through management', found no one who believed that preflight safety inspections were adequate, a member of the independent board investigating the loss of the Columbia has said." Linkage (and more of the same): http://www.smh.com.au/articles/2003/05/29/1054177
It's sad that it had to come to something like this for a wakeup call to be heard, but i guess all they can get out of it is to be more careful and not let it happen again. what else can ya get i guess...
It seems to me that somewhere along the way NASA has changed from an operation mode where you had to prove that something was safe to proving that something is not safe.
Look's like a 10 megabyte pdf-- you can download chapters individually,but unless you're piqued by soul inspiring names such as "Chapter 3", Chapter Nine", and "Chapter Seven", it's a bit of a black box.
So, for handy reference, here are the chapter titles.
PART ONE THE ACCIDENT
Chapter 1 The Evolution of the Space Shuttle Program
Chapter 2 Columbia?s Final Flight
Chapter 3 Accident Analysis
Chapter 4 Other Factors Considered
PART TWO WHY THE ACCIDENT OCCURRED
Chapter 5 From Challenger to Columbia
Chapter 6 Decision Making at NASA
Chapter 7 The Accident?s Organizational Causes
Chapter 8 History as Cause: Columbia and Challenger
PART THREE A LOOK AHEAD
Chapter 9 Implications for the Future of Human Space Flight
Chapter 10 Other Significant Observations
Chapter 11 Recommendations
PART FOUR APPENDICES
Appendix A The Investigation
Appendix B Board Member Biographies
Appendix C Board Staff
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.
See my journal, I write things there
Also consider that that same week 90 people were roasted/squashed to death while attempting the life-altering experience of seeing "Great White" live on stage. Seems to me that space exploration is worth a bit more risk than that event.
sPh
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
Fuck all this talk about privatizing space exploration, you people HAVE seen the Aliens films, right?
NASA's problem is a reflection of the institutional behavior I have seen at my last 4-1/2 employers (the least recent morphed into a pathological organization while I was there); it has become more important to appear to have a product or strategy (or quality) than to actually have it. Nothing Scott Adams hasn't been saying for years.
BTW, the mindset did not start within NASA. In the 60's, the mandate was to spend what was necessary to build the best solution that could be conceived; starting in the 70's, it was all about compromises.
It Would Be Nice if NASA could be given a mandate and execute on it in such a way to once again set an example on How It Should Be Done, but I think we ultimately need to fix our broader culture about the standards of how we conduct business.
The shuttle is and was an experiment. It's effectively a very functional prototype, but the completion - or at least the ongoing refinement - of the shuttle program has been in stasis for too long. We're not driving Model-T's anymore for a reason.
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.
This is a little long, but it gets to the heart of the accident and why it happened:
Executive Summary: Paragraphs 2,3 and 4
The Board recognized early on that the accident was probably not an anomalous, random event, but rather likely rooted to some degree in NASAs history and the human space flight programs culture. Accordingly, the Board broadened its mandate at the outset to include an investigation of a wide range of historical and organizational issues, including political and budgeary considerations, compromises, and changing priorities over the life of the Space Shuttle Program. The Boards conviction regarding the importance of these factors strengthened as the investigation progressed, with the result that this report, in its findings, conclusions, and recommendations, places as much weight on these causal factors as on the more easily understood and corrected physical cause of the accident.
The physical cause of the loss of Columbia and its crew was a breach in the Thermal Protection System on the leading edge of the left wing, caused by a piece of insulating foam which separated from the left bipod ramp section of the External Tank at 81.7 seconds after launch, and struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel number 8. During re-entry this breach in the Thermal Protection System allowed superheated air to penetrate through the leading edge insulation and progressively melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused loss of control, failure of the wing, and breakup of the Orbiter. This breakup occurred in a flight regime in which, given the current design of the Orbiter, there was no possibility for the crew to survive.
The organizational causes of this accident are rooted in the Space Shuttle Programs history and culture, including the original compromises that were required to gain approval for the Shuttle, subsequent years of resource constraints, fluctuating priorities, schedule pressures, mischaracterization of the Shuttle as operational rather than developmental, and lack of an agreed national vision for human space flight. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing in accordance with requirements); organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion; lack of integrated management across program elements; and the evolution of an informal chain of command and decision-making processes that operated outside the organizations rules.
Ruby on Rails Screencast
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.
p.219: "While ISO 9000/9001 expressed strong principles, they are more applicable to manufacturing and repetitive-procedure industries, such as running a major airline, than to a research-and-development, non-operational flight test environment like that of the Space Shuttle"
And it goes on with interesting points regarding maintenance documentation, procedures, design flaws, and managerial training.
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
People are commenting that if 100 flights took place in a year instead of 4, we wouldn't worry about safety so much. But I think what's frustrating about the Columbia and the Challenger accidents is that they were caused by seemingly simple problems which were known before the accident occurred. Not a single astronaut has been killed by any of the things that make space dangerous: asteroids, radiation, etc. They have been killed by essentially terrestrial things that we expect to happen on a passenger car (leaky seals, cracked body panels) but not a multi billion dollar spacecraft. It's like sailing out of a storm alive and then drowning as you step off the boat.
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.
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.
"Learning is not compulsory... neither is survival."
--Dr.W.Edwards Deming
For my senior thesis, I helped design a proposed Mars mission. I was working at Johnson when Columbia broke up, but I've since graduated and am no longer associated with NASA, and can speak freely.
I'm not sure to start on what's wrong with NASA. Many other posters have covered that in detail, and I think many of them are spot on.
But there is one thing very, very right--the people. From janitors and groundskeepers, all the way to the directors of the various centers, NASA employees are passionately devoted to the job they do. Losing Columbia hurt like losing members of their families, hurt their professional pride, hurt that part of their souls where they keep their their dedication and hope. They will continue because there is still work to be done, because the journey is still unfinished, because that's what their fallen comrades wanted. This spark is fundamental to NASA--the institutional culture cannot extinguish it, but I fear that it may become impotent.
Space travel is costly and risky. It will be centuries before we can consider it routine. The people of NASA have the expertise and the will to carry on, but will they be permitted to do so? I say, Stand aside and let your scientists and engineers work. Let your astronauts fly. They may greatly fail, but it will be because they have greatly dared.
We've forgotten courage, I think.
-Carolyn
Like Daddy always said: if you can't dazzle 'em with brilliance, baffle 'em with bullshit.