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Sequence of Events During Columbia Mission
applemasker writes "Today's NYT is reporting that NASA managers actively resisted requests from vehicle engineers for on-orbit imagery. This should answer Administrator O'Keefe's question of why no engineers 'spoke up' during the flight. Seems they did; managers just ignored them."
Engineers make recommendations. Managers disregard them. Things like impressing VPs, etc are way more important to get ahead in an organisation unfortunately.
...is that all of the managers on the mission, including Ms. Ham, have apparently been reassigned or they've retired. The behavior quoted in the article (assuming it's accurate), is inexcusable.
Tim
This sounds like what happens with any career where the management doesn't know as much as the subordinates. As such this should send the message out that when someone tells you that something is a bad idea then you might want to consider why they say its a bad idea. After all how many of us have had our boss(es) tell us to do something that is either technically not possible (for any reason), or is dangerous?
This is just another example of one of my favorite statements:
"A bad technical decision is never a good business decision!"
Regardless of the circumstances, a bad technical decision is never good from a business perspective. It never cost less in the long run. A mediocre decision may be a good one because of cost, but a bad one will fail, cost you more, and failure is never good for business. Unfortunately too often managers don't understand this until it's too late.
I'm sure the VPs were very impressed by the fireball over Texas.
Not that there's much that could have been done to fix the problem (is launching another shuttle on a rescue mission an option?), but it makes it more tragic nonetheless. When will the VPs learn to listen to the "little guys" who aren't jockeying for position?
Constitutionally Correct
The panel findings that NASA was starved for funds by congress and the White House. One congress man actually said that "The problems at NASA would still exists even if we gave them a blank check."
No they wouldn't.
The managers are told that they have to fly x number of missions on x number of dollars. If they fly less they get even less money.
Don't blame the managers blame congress and the last couple of Admins. Yes Billy Boy during a time of budget surplus never gave NASA a buget increase.
See my blog http://ilovecookes.blogspot.com/ for light hearted technical information.
Do you launch another shuttle mission, have both dock at the space station? Do you set up a moon base? Do you develop a new low-orbit rescue vehicle? Does everyone moonwalk from one shuttle to another? Do we redesign the shuttle to have a safty escape module that can blast loose of the mother ship and safely return to earth?
I bootleg Fizzy Lifting Drinks.
No, but the US Penal Code provides that they can be charged with murder in the third degree, negligent homicide. After knowing that there were significant structural problems, and then disregarding them, they were criminally negligent. It'd be moderately difficult to prove this beyond a reasonable doubt, which is why I'm guessing charges haven't been brought forth.
IAALS.
Probably not. If you could prove their behavoir was malicious, instead of merely stupid or calous, then maybe. People performing in their legal line of work are generally protected.
The main problem, I would guess, is that the managers didn't fully understand the job being done by the people that reported to them. I doubt a single manager said "Hey, let's kill some astronaunts."
Most likely, they performed their job to the best of their ability. Also most likely, is that their ability did not measure up to what the job required of them.
Even more as the problem, NASA is being run like a business. I'm a business guy at heart, but NASA is not a business. Its primary function, in my opinion, should be exploration. It doesn't have P&L, it has discoveries of intangible but emmense value. We should allocate tax money to NASA not because of ROI, but because of all of America's desire to explore and adventure.
If this is the way we looked at NASA, then the NASA managers would also be adventuring engineers, and perhaps would have made different decisions. All of the outsourcing and other business decisions at NASA have resulted in people looking at the bottom line instead of the people and the mission.
Sarcasm and hyperbole are the final refuges for weak minds
When I was taking the required Technical Communication course in college to finish my engineering degree, a major theme of the class was incidents such as Three Mile Island and the Challenger disaster. The professor said that while the public perception was that management had f***ed up, the engineers had to bear some responsibility because they were unable to adequately communicate the necessary conclusions in a manner that decision makers could understand. And we would look at copies of the memos, and think that, yeah, if the engineers had written more effectively, things may have been different.
In some ways, even though I don't enjoy writing specs and design documents for software (I don't work on mission-critical or life-critical systems), I try to write well, because I figure, "I'm an engineer, and I have a responsibility to do my job as a professional."
And then I read this article, and I think that maybe, after all, it doesn't matter what a competent, professional engineer says or does. I'm just saddened that NASA, an institution I loved growing up, did not change at all after Challenger. I wish I knew the answer.
Engineers make recommendations. Managers disregard them. Things like impressing VPs, etc are way more important to get ahead in an organisation unfortunately.
In a "normal" work environment, the corporate food chain annoys those of us with a clue (ie, non-management). Just one of the hassles they pay us to put up with. "Why did this project fail?" "Because you killed the single most important subproject associated with it" "Well, get to work on that, and don't let this happen again!" (mimes masturbating while walking away, disgusted).
In the case of NASA, however, they have a bit more on the line than the bottom line, good hair, and kissing VP ass - They have real, live humans risking their lives every time they climb up into the cockpit.
Sorry, but "the way we do things" doesn't cut it in this situation. I'd personally like to see some people go to prison over this one. They overruled the warnings of people with a clue, and as a result, people died. Totally unacceptible.
How about giving them an opportunity to say goodbye to their friends and family?
I'd say that's worth it.
If NASA managers listened to every issue brought forward by each of their thousands of engineers, spaceships would never leave the earth.
It's in each of these engineers best interest to list every problem that could possible occur in the systems they design and maintain. That way if the problem happens in one of their systems, they can cover their ass with paperwork. Just because they issued a low-level memorandum doesn't mean these engineers actually had any level of confidence that the problem would occur. It just meant they were covering their ass.
NASA has an escalation process, if these engineers *really* felt there was a problem, all they had to do was push that button. But to push the button is to put your clout on the line. Push it too often by mistake and you will rightly be taken out of the process. No company or organization can afford an employee that continually cries wolf.
So if anyone is to blame for this, it's not the managers. It's the engineers that wrote memo's about it to cover their ass but didn't think the problem was important enough to push the escalation button.
The managers are so inundated with engineers thinking up possible error scenarios they can't possible take them all seriously. Of course, when a shuttle goes down, those same engineers drag out the paper trail covering their butt and program managers are left to swing.
Congress should be ashamed of this inquiry and so should most of America. Space travel is dangerous. Live with the danger or get out of the business.
Absoltuly false. I am in a management profession, and I can tell you from experience that people that do this are only successful to a point.
What you said is the recipe to make it into middle managment (Director or VP level), but you will never get beyond that. Company Sr. Executives and Officers are expected to be frank and honest. Those that aren't generally don't fare well (yes, you can point out exceptions, but as a general rule, liars don't make it to the top).
Unfortunatly, honest senior managers often have kiss-ass middle managers working for them. Those middle-managers lie, cheat, steal, etc, and senior management is left holding the bag for their mistakes (which is the job of management, to take the fall when your subordinates screw up, in case any managers reading this have forgotten... ignorance is not\ excuse).
I made it into senior management very quickly in my career by having a policy of never breaking the law, never lying to my boss and never sucking up to anyone. Say what you want, but those simple ethics, combined with extremely hard work, are what put me on the fast track. Managers who will screw people to get ahead will find their careers never make it to where they could (but probably does go past where they should).
Sarcasm and hyperbole are the final refuges for weak minds
This results in a culture where we promote a weakness (no communication skills) as a virtue (disdain for politics). The only way to change this, I think, is to emphasize writing and communications coursework as well as courses where you learn how not to kill people by leaving a bolt off the diagram.
What's sad, is that this is NASA's second mistake of that sort. Anyone remember why Challenger went KABOOM!?
Engineer: "Uh boss, we really should look into the issue of attempting a launch in cold weather... The rubber seals will probably crack and send explosive fuel out the sides of the rockets - its supposed to NOT do this."
NASA management jerk: "What, do I look like a manager?! We don't need to worry about no freakin rubber seals, this is rocket science, not blender repair!!"
(time passes)
*KABOOOM*
Except that without knowing what the extent of the damage is in the first place, it's impossible to determine if it can be repaired in the first place. So perhaps there might have been a plausible repair scenario (or at least the opportunity to do something that didn't involve the death of a shuttle crew), but since no investigation was done while the opportunity was avaliable. NASA might be a godawful bureaucracy, but if you strip away the bureaucrats, you're left with people who have something of a clue and could have worked out something, instead of pretending that the problem didn't exist in the first place.
Dogma: Dead (mostly because your Karma ran it over)
What's most interesting to me about this story is that both the engineers and the managers were making the best decision based on their perspectives. The engineer's perspective is based on hard facts, information, and analysis. The manager's perspective is based on people issues: money, resource management, risk management, project deadlines, etc.
It's easy in retrospect to criticize managers who didn't want to be a "Chicken Little" or who, upon getting feedback from upper management, called it a "dead issue". But if they had gone ahead with the imaging, and the photos showed no damage and the shuttle had landed safely with no (or insignificant) damage to the wing, their reputation would have suffered. They would have been faulted for allocating valuable resources on something that turned out not to be an issue.
Part of a manager's job includes risk management and resource allocation. This means properly assessing the likelihood and impact of a risk. In this case, I would suggest that management considered the 'cost' of pursuing further investigation to be higher than the 'likelihood * impact' factor of doing nothing. They have probably made the same decision many times before, successfully, which would encourage them to make the same decision again. Only this time, they were wrong -- the statistics caught up with them.
-Thomas
The guilty managers will get promoted, their budgets will be increased, the bothersome engineers will get shuffled off into a dark and dusty corner where they can't make any more noise.
He who identifies the problem will be assigned the blaim and will be punished. If he actually fixes the problem, he will be fired for insubordination.
NASA gets rewarded for failure and punished for success. Success must be prohibited at all costs. The only thing that matters is pretty pictures and pretentious words.
That's how it worked when I worked with NASA a decade ago. Nothing has changed.
So an engineer saw a problem and was concerned. My question is how often does this happen. If after every launch there are 100 engineers who noticed a potential problem, then I'd have ignored this too (along with the 99 other potential problems that didn't kill columbia) If enginneers almost never see a potential problem then this should have been taken seriously.
Others have pointed out that there is an esclation process for problems belived to be serious, and that wasn't followed. In hind site it should have been, but they didn't have hind site to work with then, so we have to be realistic i our expectations.
Part of the problem is the damage caused to NASA by years of budget cuts. I saw this first hand. Due to a lack of funds, NASA adopted an attitude that sustaining engineering and operations costs could be substantially reduced by avoiding change whenever possible. Just keep the current system running with as little maintenance as possible. If nothing changes, you can get rid of most of the people who used to design, test, document and maintain the systems. If there is a problem with a system, you don't find the root cause and fix it, you develop a work-around. If new technology offers a better way to do something, you ignore it because the old system is "good enough" and you no longer have the money, infrastructure and people needed for major design changes and new systems development. The organization gets reduced to a caretaker for the engineering accomplishments of previous generations. It has just enough money and people to maintain the status quo.
Mea navis aericumbens anguillis abundat
This was NASA's chance to regain its former status. If the problem had been discovered, the nation would have been in the grips of the attempts to the solve the problem. Provided the threat to the astronauts' lives was made clear to the populace, a successful return would have guaranteed that NASA would receive the public support and possibly fnding that it needs to continue its exploration of space.
However, the engineers were ignored, the problem was serious, and tragedy was the result. NASA missed its chance to reclaim its glory days.
The issue is not "did NASA engineers raise concerns" but did they raise concerns above the level that usually triggers a more serious review. I am sure that on every single shuttle mission there were engineers that raised concerns about every single glitch, out-of-tolerance reading, or unusual occurence, etc. This is a good thing. It is also a good thing that other engineers and managers make informed cost-benefit decisions to either pursue, study, or ignore any raised concerns.
Hindsight is 20-20. Nobody remembers all the prior events in which engineers raised concerns that were ignored and nothing happened. Don't forget this was not the first time that insulation had fallen off the external tank. As an engineer myself, I know I can come up with all manner of "potential concerns." As an older engineer, I know that many of those concerns can easily fail a cost-benefit analysis or prove to be groundless on further study.
Tuning the process of raising and dispatching concerns is very hard -- being overly cautious is as damaging as being overly risky. It is especially hard with the extremely low sample sizes and highly complex systems that NASA faces when managing the shuttle. Personally, I am surprised that the shuttle is as reliable as it is.
I hope that NASA can keep flying because it is the only way that humanity can get the experience needed for truly reliable space flight in the future.
Two wrongs don't make a right, but three lefts do.
Say they did have some knowledge while in orbit that the shielding was damaged, and that Columbia probably could not come back. Their choices were extremely limited.
The crew didn't have the tools, training, materials, etc. to do any repairs in flight.
The arm wasn't installed for this shuttle flight.
There were only two eva capable space suits on board. The only eva training the crew had was to try manual methods of closing the cargo bay doors if the automatic methods failed.
The shuttle apparently didn't have enough fuel to reach & dock with the space station.
Would they have had any choices other than:
a. Tell the crew the situation, and let the crew decide whether to take a chance.
b. Breaking every single shuttle launch safety rule, try to launch another shuttle with 1-2 crew, and a bunch of space suits, before Columbia ran out of consumables.
Neither choice would look good to me.
Yes, I agree. It sickens me that it has been almost 40 years since people landed on the moon, and the human component of space exploration is barely out of the atmosphere, and only done by a poorly funded govt. organization. It sickens me to read about Software patents in Europe, the USPTO here, the way John Ashcroft wants to police america, and all the wars and conflict in the world that we have the resources to resolve, but don't.
It sickens me that people care more about their own self interest and their company or agency's PR, than advancing the human race. I really hope in the next election some of these issues come up, instead of being pushed behind the tired old debates about abortion and taxes.
The sending of this message pretty much inconveniences everyone involved.
I've just been reading "What do you care what other people think" by Richard Feynman, and it covers some of his life during the Challenger investigation. And it was the same then as it is now...The field techs and engineers saying "This is really dangerous" and the Suits in management saying "But it worked before, why is it not safe now?!?!". It is a sad story about our Western Civilization that communication between the top and bottom of companies is so bad it is non-existant. If people in Management went and read the Toffler's Future Shock, and the books that come after it, they would understand why it is so important esp. in today's ultra-fast communication age that the heirarchy between the top and bottom of companies be flattened.
...who happily works for a company where the management *are* engineers and still to engineering work, and thus will listen to their workers.
Of course, if it was just money, it might not be that important...but PEOPLE DIED because managment didn't listen...and every day PEOPLE DIE because management continues to be def to the information comming from below.
ttyl
Farrell
CAN-CON 2019 - Ottawa's only book oriented Science Fiction Convention! October 18-20, Sheraton Hotel, Ottawa, Canada h
the enguineers don't have that kind of access to the top level managment.
they were ignored by some folks in mid managment, like mission coordinator or some one like that.
I am the Alpha and the Omega-3
Just because most people treat risk analysis like some grade school math problem doesn't mean that there hasn't been lots of research on how to do proper risk analyses for complex systems. It isn't simple, but you can do a rigorous risk analysis based on uncertain information. Such an analysis would show which missing information is contributing the largest amount of uncertainty to the end result. In this case, the largest uncertainty was "WHERE DID THE FOAM HIT". Given that this most basic uncertainty was never resolved until much later, there was no way that a proper analysis could have said with any certainty as to the safety of the Columbia given the foam strike.
"We think the foam was this big, we think it didn't hit a critical tile and we think our computer program is too pessimistic so the shuttle is safe" is utter and complete BULLSHIT. It doesn't matter how many numbers you wrap around those words. A bullshit perspective is still bullshit. And no real engineering manager would have let the Lockheed engineers get away with presenting the crappy analysis report. I have another post from a Feburary shuttle story about this.
There is no trap so deadly as the trap you set for yourself
-Raymond Chandler, The Long Goodbye
Someone else brought up a good point: Engineers tend to seek out the worst possible situations (especially the best engineers). However, if you've predicted disaster on every mission and on the 100th time you predicted a problem something goes wrong, did you really "predict" the problem? After hearing that the sky is falling constantly for several years, managers naturally may begin to doubt some reports. The way the article was written (which wasn't a research paper - it was clearly crafted to make Mr. Rocha a potential, but unheard, hero) it doesn't sound like this was the case, but it's a good point when talking about this situation
Keep in mind, too, that falling foam was "normal" and Boeing's investigation determined that there was no serious damage to the shuttle. These guys probably weren't *all* the managerial demons that they're being made out to be.
There's probably little doubt that NASA's processes suck, these guys should have listened to Rocha (especially - what is it they say about hindsight again?), but this thing was more complicated than "a bunch of stupid-A$$ managers"...
Seastead this.
Engineers in the real world try to make things work. The biggest problem with this is managers who share your beliefs who believe that problems can be wished away by managerial fiat.
The escalation you whine about was blocked by the action of a bureaucrat at the wrong place and the wrong time, and people died.
This isn't an engineering problem, it's a business process problem and in general, the solution is finding management like you and terminating it and putting procedures in place which will make future managers of the type you support disappear. This is just as important as increasing the budget, because it makes sure that the new money goes into solving the real problems, not into management perks or bureaucratic empire building. The purpose of an organization is to get things done. To fulfill this purpose in a new technology organization which means making new things, the engineers must be supported by management. The engineers are the people who have to solve the problems. The proper place of management is to give them the tools and to fight for budget and priorities with upper management. Any other managerial function in an technology R&D organization that isn't concerned with sales and marketing is secondary at best and parasitic at worst.
Once upon a time, there was a political system whose management believed the country's problems could be solved by bureaucratic edict instead of with people finding out what the problems really were at an empirical level and solving them. The Soviet Union failed its reality check, just like NASA has repeatedly. The Soviet Union no longer exists. Perhaps it's time for NASA to follow it.
Space travel is dangerous. Live with the danger or get out of the business.
Ships were once dangerous. Automobile travel was once dangerous. Airplanes were once dangerous. Living in the America was once dangerous. Every new human domain has been paid for in blood. The problems were solved and now, kids can play outside in California suburbs without fear of being eaten by predators, they can fly in airliners without fear of following the trail of the Challenger astronauts.
The shuttle is not an example of how to deal with the dangers of space travel. Since it was designed, there have been 30 years of aerospace research and development. Can a new earth to LEO vehicle be designed with safety comparable to the DC-3? I think it's time to find out. Perhaps it can't be done, but we can't find out unless it's tried.
The DC-3 was a lot safer than anything that came before it. The modern jet airliner of today is a hell of a lot safer than the DC-3. It's called engineering progress, and that progress happens because engineers figure out what the problems are and their managers support them in getting the resources to implement the solutions. Not because PHMs attack them because they're saying things they don't want to hear.
Space travel is dangerous because Congress won't appropriate the funds to do what needs to be done to make it safe. This is largely because NASA management has not been able to make a case for it that Congress can understand. Even at the level of "if we don't, our astronauts will keep raining down on your constituents in barbecued chunks". Where is the engineering incompetence in this?
Where are the program directors with the integrity to say "We need this amount of money to put humans safely into space. If you won't give it to us, then you'll have to find other people willing to kill astronauts in order to give you guys good PR."
Either Congress should come up with the funds to develop a vehicle whose design takes into account what has been learned in the last 30 years or admit that America can't afford a real space program and leave the field to the private sector, the Indians, and the Chinese.
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