From: NASA HQ
Posted: Tuesday, August 26, 2003
MR. O'KEEFE: Good afternoon. Thank you all for taking the time to participate in this afternoon's discussion. After conclusion of the opening comments and presentations from myself and Scott Hubbard, we'll have an opportunity to dialogue a little bit here, as we typically do on the update discussions.
Over our 45 years of this great agency's history, we have been defined by our tremendous successes and our tragic failures. In each of these defining moments, our strength and resolve have been, as professionals, have been tested, and this is one of those moments, and it's one of the seminal moments in our history, and I would suggest in the time ahead.
On the 1st of February, we pledged to the families of the Columbia seven that we would find the problem, fix it, and return to the exploration objectives that their loved ones dedicated their lives to.
Today, the Columbia Accident Investigation Board has released its report, and the first of those three commitments has been fulfilled. We're indebted to the Board for their exceptional public service and diligence in this terribly difficult task.
As we begin to fulfill the second commitment to the families to fix the problems, our first step must be to accept the findings and to comply with the recommendations. This report should serve as a blueprint, as a road map to that second objective to fix the problems.
The Board has given us a head start as a consequence of their candor, their openness, and their release of the findings and recommendations during the course of this investigation. So what we read as a result of this report's release today is what we've heard in the last several months, and they have been true to that objective all the way through.
So we've gotten a pretty good head start I think in developing an implementation plan, and now it must be updated to include all of the findings and recommendations, in addition to the ones we've seen that they released to us, to now incorporate the ones they talked about and are now written and printed as part of this particular report.
The next task is we must choose wisely as we select options to comply with each of those recommendations, and we must continually improve and upgrade that plan to incorporate every aspect we find, as we have found in these last several months, in addition to the Board's findings, in this long road to fulfilling that second commitment to fixing the problem.
Now, the report, as we have heard the Board discuss in the course of their multiple public hearings, press conferences, public availabilities, and their very open discussion of what their conclusions would be, the report covers, as they had said, the hardware failures and the human failures and how our culture as an agency, as a group of people, as a community, as a family, dedicated to these important exploration objectives, need to change in order to mitigate against succumbing to these failings again. It's going to be a long road in that task.
But to describe for you the nature of those findings and recommendations, in very specific terms, we've asked a member of the Board to come join us here this afternoon to walk us through how they have gone about the process of deliberating here in these last seven months on the Columbia Accident Investigation Board, and to summarize those findings, which we will again all be reading here in the days and weeks ahead.
Now, Scott Hubbard is the only member of the Board who is a NASA member of the NASA family, and the rest of the members are from lots of different backgrounds, which he will describe for you. Scott, of course, is the Director of the Ames Research Center out in California and has lots of prior experience in dealing with a range of different programs and managing different activities, to include some of our past failures. So, therefore, he has incorporated and employed those extraordinary experiences in his contributions towards what has been a very, very comprehensive, extremely thorough effort on the part of the Columbia Accident Investigation Board's review.
So, with that, I'd like to ask Scott Hubbard to come join us and to describe the efforts of the Board in the course of this time.
MR. HUBBARD: Good afternoon. It's a pleasure to be here with the NASA family. My part of this journey started on February 1st, about 6:30 in the morning. We were listening to the radio at my house, and we heard the awful news that the Columbia was missing, it was long overdue. Jumped up, grabbed my clothes, grabbed my cell phone, for reasons I cannot fathom to this day why I did that, went upstairs, turned on the television to see what you all saw, which were the pictures of debris flashing across the sky of East Texas.
My cell phone went off. It was my good friend and colleague, Suzanne Hilding, who handed the phone off to Fred Gregory, and he asked me, on behalf of Sean and the Agency, if I would be willing to serve as the single NASA employee on this Accident Investigation Board. I was honored to be asked to do that. I did not hesitate to say, yes.
At 2 p.m. that day, the first telecon of the Board occurred. The next day we were in Barksdale, Louisiana. We began a seven-month odyssey of investigation and learning. The Board operated seven days a week for most of the time. It was a long and thorough effort, I believe, by all 13 members, and at times we got very tired, but every time I looked up in the hallway or in the conference room and saw a picture of the seven members of the crew, we realized that any sacrifice we made would be minuscule compared to the sacrifice that they made.
I'll never forget that moment, a few days after we arrived in Barksdale, when we stood at attention as the helicopters landed with the first crew members who were found. The Honor Guard carried them over to a simple ceremony, and that's when I realized what sacrifice truly means on behalf of this agency and the exploration of space.
I'd like to introduce you now to members of the Board and tell you just a little bit about each one. So, if we could show that slide, actually a series of slides I'll be happy to go through. First, Admiral Gehman, retired four-star admiral, the Chairman, an extremely capable man. I have a great deal of respect for his leadership abilities.
Next, Major General John Barry. He comes from Materiel Command, Wright Patterson Air Force Base, a real expert in components, materials, aging aircraft. He brought all of that experience to the table.
Next person, Brigadier General Duane Deal from Space Command, Colorado Springs--very familiar with our orbiting national assets, and he brought his knowledge of how that effort is carried out in the Air Force to the Board.
Next, Dr. Jim Hallock is from Volpe Center, part of the Department of Transportation. Jim is a physicist. We bonded right away. He and I had many, many discussions about the physics of this accident, and the engineering, and all of the different technical aspects that we had to investigate.
Next, Major General Ken Hess runs the Air Force Safety Center out in Albuquerque, New Mexico. He has deep experience in aircraft accidents, how they occur, why they occur, and was one of the prime movers in bringing to the Board a broader knowledge of high reliability, high-risk organizations, how they manage risk and so forth.
Next, me. We can skip me and go on to the next one.
Dr. John Logsdon. A lot of you know him. He's an expert in space policy. He's written extensively about the history of NASA, about all of the things that we've done, both the failures and the successes, and he brought his extensive knowledge of policy to the table. And I must compliment John on bringing in an open mind to what we were doing and tried very hard not to let his opinions that he has expressed in writing about policy to influence the conclusions of the Board, that we all signed up to.
Next, Doug Osheroff, a Nobel Prize in physics from Stanford. Doug became well-known for conducting some experiments, first, in his kitchen and then in his laboratory, to demonstrate that some of our ideas about how foam sheds were wrong. In a set of very simple experiments, he showed that notions of what are called cryo-pumping or cryo-ingestion cannot explain the way that foam pops off the external tank. So he made a very substantial contribution in investigation.
Next, Dr. Sally Ride. You're all familiar with Sally, the first woman astronaut. She brought her extensive experience and knowledge of how the astronaut system works, what flying in the Shuttle means, all of the aspects of operations that the Board needed to know in order to evaluate the accident and understand it from the astronaut's perspective.
Next, Roger Tetrault. Roger is former CEO of McDermott, former Chairman of the Board of McDermott Corporation. And Roger brought not only his understanding of business to the investigation, but he also brought some incredibly good engineering skills. He worked on nuclear reactors for a long, long time and truly and well understood what engineering in a high-reliability environment entails.
Next, Real Admiral Stephen Turcotte. He's the head of the Naval Aviation Center. You know that the Navy has aviators, and he brought his experiences and understanding how accidents occur from his perspective.
Next, Steve Wallace is the Director of Accident Investigations at the Federal Aviation Administration. He does accident investigation for a living, and he brought some extraordinary capabilities in evaluating the whys and wherefores of accidents to the Board,
And then, finally, I think there's one more--Sheila Widnall, former Secretary of the Air Force, now a Professor of Aeronautics and Astronautics at MIT. She brought not only her knowledge of large organizations and how they function, from the DOD perspective, but also a deep understanding of some of our aerodynamic questions.
So, initially, we were eight. We became 13 members within the first month or so, after we were established. We owe a great deal of thanks to 120 staff members that supported the Board, 400 NASA engineers at JSC, KSC and all over the Agency.
We went through 30,000 documents, did 200 interviews, conducted PN public hearings, and all of the time, all of the time, all of the time we had a picture of the crew in every conference room, and we constantly felt that we were serving in their legacy.
This Board was an independent Board. From the very beginning, we had diverse opinions, and no one hesitated to express them at any time. We felt under no pressure from anyone to come to any preordained conclusion.
Now, I'd like to talk just a little bit about the two pieces of the investigation--the physical cause and the organizational efforts.
The physical cause, this was a forensic investigation of unprecedented scale. We followed five analytic paths:
Aerodynamics, looking at how the yaw and roll of the orbiter as it reentered the atmosphere indicated damage in the left wing;
The thermodynamics, understanding the temperatures that were measured over the orbiter and what those were telling us;
The sensor data that allowed us to establish the time line of the accident and ultimately to calculate from first principles how big a breach there had to be in order to come up with that time line;
The imagery, both the imagery on ascent that showed the foam striking the left wing, as well as the many, many dozens of individuals that sent in videos that we were able to use to look at the breakup and understand what was going on;
And, finally, the debris. Twenty-five thousand people searched arm-to-arm through East Texas, recovering 40 percent, by weight, of the orbiter, 84,000 pieces, and that debris told us a great deal. It told us where the breach most likely occurred, it told us where the heat got in, and it told us how the left wing probably failed;
And, finally, the impact tests that I was personally involved in, and I think those showed three things:
One is it provided experimental evidence to support the analytic conclusions; the second thing is that it provided information for future engineering efforts to establish how tough is this material and what are its limits--that effort needs to go on more extensively; and, finally, I think it removed, in anybody's mind, any lingering doubt that foam of that size at that speed can, in fact, damage the reinforced carbon material.
The result of all of this was the statement of physical cause. I won't read it to you. It's in the report. But, in essence, we concluded that a 1.7-pound piece of foam from the left bipod ramp hit the reinforced carbon, Panel 8, 81.9 seconds into the launch, and created a breach that, upon reentry, allowed the superheated air to enter the wing, destroy the wing and ultimately cause the loss of the crew and the vehicle.
You'll notice that we did not include in here most probable, likely. We felt that the preponderance of this evidence, the weight of these five analytical paths, as well as the impact tests, gave us a very high degree of certainty that this is what happened.
But we didn't only look at that. We looked at the organization as well. Now, I should note that the Board studied the Shuttle organization. We looked a little bit at the edges of the International Space Station because it was related in certain schedule issues. We did not look at aeronautics, at planetary exploration, at Earth science and so forth. So the comments in the report, by and large, are directed at the Shuttle program, but I think there may be lessons in there for all of us.
We interviewed 200 individuals, on a privileged basis, so that people would feel free to say what was on their minds and to say what their role or observations might have been in the accident. We conducted a workshop by the National Safety Council. We brought in experts on high reliability, normal accident and organizational theory, as well as talking to practitioners that work in the fields of managing these types of organizations--the submarines, the Nuclear Navy, the certification for launch that the Air Force uses.
Throughout this analysis and study, we looked, in general, in four areas--the history of the Shuttle, what were the original requirements, what were the compromises, the budget and the workforce changes over the years, decisionmaking, the schedules that the orbiter was placed in, that the shuttle was placed in, in order to meet certain other programmatic requirements.
We looked at this thing called "culture." And I've worked with scientists and engineers for over 30 years, and I can say that if somebody came up to me and said "culture," they would say, "Ah, that's that fuzzy, icky stuff," you know. I didn't take sociology in college. I took physics. I took engineering, something I can get my arms around.
I think the point the Board is making is that the sociological and the psychologic parts of an organization are just as real as the physics and engineering, and how we interact as individuals, how we relate to each other, how we express information to one another, that's part of what we do as well, and that's part of what the Board looked into.
So, as a result of that, we came up with an organizational cause statement, and that's in the report. I won't read it. We put that, the Board, on a par with physical cause, in terms of contributing elements. And we found things that I'm sure you're all familiar with: budget reductions, putting a developmental vehicle, with only 113 flights, into an operational sequence and demanding that schedules meet that. We found some communication problems.
We found the belief, unfortunately, that past success guarantees future success. And when you're dealing with a vehicle where the probabilities of catastrophic failure are perhaps 1 in 200, 1 in 300, somewhere in that range, past success does not guarantee future success.
We found informal chains of command and people conducting discussions in the hallway that had enormous impact on decisions that were made later on.
And we found, at times, a seeming inversion of not prove it's safe, but prove it's not safe. To the extent that this exists, I think that we all need to examine what our approach is to proving that it's safe to fly in anything that we do, whether it be robotic, but particularly in human exploration.
We pride ourselves at NASA as being on the leading edge of science and technology, and I think we are, and we strive to be that every day. There's no reason that we can't be at the leading edge, as we have been in the past, of how to manage high-reliability organizations that deal with very high-risk ventures.
Now, there's a series of recommendations out of all of this. I'm going to walk through them at a very high level. So, if we put up the first recommendation slide.
There are 29 recommendations in all. Fifteen of those are considered return to flight. There are 23 recommendations I would call technical recommendations and 6 that I would call organizational recommendations. The other 14 are considered to be continuing to fly recommendations.
So, if we go to the next chart. Under technical recommendations, there are nine that deal with the thermal protection system. In general, these talk about eliminating damage to the thermal protection system, stopping the foam shedding, understanding the characteristics of the TPS, both by test and by modeling, inspecting this material, both on the ground in as sophisticated a way as we can, as well as being able to inspect it and repair it on orbit, if necessary.
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