From: NASA HQ
Posted: Wednesday, August 27, 2003
Wednesday, August 27, 2003, 11:02 a.m.
MR. MAHONE: Good morning, and thank you for joining us here in Washington and from the centers across the country at our various NASA field centers.
Before I introduce the NASA Administrator, I want to go over a few guidelines for this morning's press conference. We'll begin with questions here in Washington, and then go to the various NASA centers. Please wait for the microphone before asking your question, and don't forget to tell us your name and affiliation.
Because of the large number of reporters who want to participate in today's briefing, please limit your inquiries to one question and one follow-up, and, please, please, no multi-part questions.
Again, thank you for taking the time to join us today, and allow me to introduce the NASA Administrator, Sean O'Keefe.
MR. O'KEEFE: Thank you, Glenn, and good morning. Thank you all for spending time with us here this morning.
Yesterday, we received the report of the Columbia Accident Investigation Board run by Admiral Hal Gehman, and shortly thereafter I had the opportunity to speak to several of our colleagues here throughout this agency to describe those initial findings and recommendations as well as to offer some views of what the direction will be from this point forward. And so if you'll permit me, let me draw a little bit from some of those comments here in the context of today's discussion with you, as well, as we start this and, of course, respond to your questions.
This is, I think, a very seminal moment in our agency's history. Over the 45 years of this extraordinary agency, it has been marked and defined in many respects by its extraordinary successes and the tragic failures in both contexts. And in each of those, in a tracing of the history of that 45 years, there is always an extended debate and discussion of the national policy as well as the focus of the charter and objective of exploration of what this agency was chartered and founded to do in 1958. And I expect that in this circumstance it will be no different. This is one of those moments in which there will certainly be a very profound debate, discussion, and I think a very inward look here within the agency of how we approach this important charter that we've been asked to follow on behalf of the American people to explore and discover on their behalf.
In each of these defining moments as well, our strength and resolve as professionals has been tested, and certainly that will be the case in this circumstance, and it has been for these past seven months, to be sure.
On February 1st, on the morning of that horrific tragedy that befell the NASA families and the families of the crew of Columbia, we pledged to the Columbia families that we would find the problem, fix it, and return to the exploration objectives that their loved ones had dedicated their lives to.
The Board's effort and the report we received yesterday completes the first of those commitments and does it in an exemplary manner. They have succeeded in a very, very thorough coverage of all the factors which caused this accident and that led to this seminal moment, which is marked by a tragic failure. And their exceptional public service and their incredible diligence in working through this very difficult task I think will stand us in good stead for a long time to come as we evaluate those findings and recommendations as carefully as we know how.
As we begin to fulfill the second commitment that we made to the families to fix the problems, the very first important step in that direction is to accept those findings and to comply with the recommendations, and that is our commitment. We intend to do that without reservation. This report is a very, very valuable blueprint. It's a road map to achieving that second objective, to fix the problem.
They've given us a head start in the course of their discussions over the last several months and in the course of their investigation, in the public testimony, in their press conferences, in all of their commentary, which has been very, very open in an extremely inclusive process as they have wrestled with the challenges of finding the problems that caused this particular horrible accident.
And that candor, that openness, that release of their findings and recommendations during the course of the investigation has given us a very strong head start in the direction of fulfilling that second commitment.
At this point, we have already developed a preliminary implementation plan, and we will update that, and we're about that process right now of updating to include all the findings and recommendations included in the report, in addition to those that were released and described very specifically during the course of their investigative procedures.
But, again, must as the Chairman, Admiral Hal Gehman, observed throughout the course of those proceedings, what we will read and what we did read as of yesterday was precisely the same commentary that we had heard during the course of their investigative activities and in all of their public testimony that they've offered, which has been considerable and, again, very extensive, exhaustive.
So as we implement those particular findings and recommendations, our challenge at this point will be to choose wisely as we select the options that are necessary to fully comply with each of those recommendations. We'll continually improve and upgrade that implementation plan in order to incorporate every aspect of knowing what's in the report, but also so much of what we have determined and seen as factors that need improvement and consistent upgrading throughout our own process within the NASA family.
It's going to be a long road in order to do that, but it is necessary in order to fulfill that second commitment we've made to the families.
Now, the report covers hardware failures, to be sure, but it also covers human failures and how our culture needs to change to mitigate succumbing to these failings again. We get it. Clearly got the point. There is just no question that is one of their primary observations, that what we need to do, we need to be focused on, is to examine those cultural procedures, those systems, the way we do business, the principles and the values that we adhere to as a means to improve and constantly upgrade to focus on safety objectives as well as the larger task before us of exploring and discovering on behalf of the American people.
But they've been very clear in their statements throughout the report in several instances, repetitively, and in the public commentary that the Chairman and members of the Board have offered following their efforts yesterday after the release of the report, that these must be institutional changes. And that's what we're committed to doing, and that will assure that over time those changes will be sustained, as those process, procedures, and systems are altered in order to reinvigorate the very strong ethos and culture of safety and exploration, those dual objectives that we have always pursued. That is what's going to withstand the test of time if we are successful in this effort, and we fully intend to be.
So we will go forward now and with great resolve to follow this blueprint and do our best to make this a much stronger organization. In the process of doing so, it will involve the capacity and capability of all of us within this agency. This is not about an individual program. It's not about an individual aspect or enterprise of what we pursue. It is about everything we do throughout this agency. There is so much of what has been observed in this report that really has tremendous bearing and tremendous purpose in defining everything we do throughout the agency. And so, therefore, we will approach it and have considered this to be an agencywide issue that must be confronted in that regard.
Now, this is a very different NASA today than it was on the 1st of February. Our lives are forever changed by this tragic event, but certainly not nearly as much as the lives of the Columbia families. This is forever for them. And so that resolve to find the problem which we have successfully done, thanks to the extraordinary efforts on the part of this Board, to fix those problems which we are now in pursuit of as the second commitment, and to return to the exploration objectives that their loved ones dedicated their lives to is something we take as an absolute solemn promise. We have to resolve and be as resolute and courageous in our efforts as they have been in working through this horrible tragedy.
The time that we have spent, I think, over the course of since the accident, and certainly well before, in trying to work through those particular questions, again, are focused on institutional change. Since I arrived a little less than a year and a half ago, we have almost completely rebuilt the management team, and so it is a new, fresh perspective in looking at a range of challenges that we currently confront, and those changes have been ongoing of a management team as well as the institutional changes we have implemented and will continue to do in full compliance with this report.
The new management team began I think by evaluating initially on the first day that I arrived here the contingency planning effort that was necessary in the event of such a tragedy. It was the first thing I did on the first morning I arrived at this agency. And in reviewing that contingency plan of how we would respond to a disaster, to a tragic event, which I had hoped and was in the expectation and fond hope that I would never, ever have to utilize, we nonetheless improved that contingency planning effort by doing two things:
First of all, reaching back to the Rogers Commission, the Challenger incident and accident, to incorporate in that contingency plan all the changes necessary in order to respond definitively. The second step we went through was to specifically benchmark it against best practices of any comparable organization, of which there are very, very few. And the only one that in my personal experience that I was aware or felt had any direct comparability to the risks and the stakes involved was the Navy nuclear program. And so from that first day, we upgraded that particular contingency plan based on the benchmarking procedures that we followed through with them.
We then began a very vigorous effort by late spring, early summer of last year to begin a comprehensive benchmarking procedure against the submarine service as well as the naval reactors community, to, again, pick up best practices as well as to institutionally change the way we do business. And that process is ongoing as it had been a year ago as we continue to make those changes.
That was a lesson I learned very specifically in my tenure as Navy Secretary better than ten years ago, was to look at those particular procedures and assure that we have incorporated as much of that, and that was a work in progress that will continue.
But, again, the observation by Admiral Gehman and the members of the Board yesterday and replete throughout the report, it is not about changing boxes or individual faces in each of those positions. It is about the longer-term institutional changes that must be made. And, again, to that point we get it. It is about the culture of this agency, and we all throughout the agency view that as something that's applicable to the entire agency, not any individual element thereof.
With that, I thank you again for the opportunity to get together this morning and, again, look forward to your questions and comments.
MR. MAHONE: Yes, sir?
QUESTION: Mr. Administrator, Matt Wald, New York Times. There are other organizations that have gone through this kind of change. Most have called for some outside help. I'm tempted to ask if you're read Diane Vaughn's book or called her up or if there are other specialists in safety culture who you would be bringing in at this time to help transform yourself, your agency.
MR. O'KEEFE: I appreciate that. Yes, indeed, we have read Dr. Vaughn's book, and there have been several folks here in headquarters as well as Johnson who have been in touch with her. Dr. Michael Greenfield spoke to her I think initially about four months ago, three months ago, shortly after her testimony before the Columbia Accident Investigation Board's hearings.
The primary source of safety experts that we have been trying to encourage and have requested come in to assist with us, again, are from the naval reactors community. This is a very specific set of procedures they follow. It's a very exhaustive effort that they have gone through over a comparable period of time as the span of this agency, in order to upgrade their procedures as a consequence of incidents in the early phases of that program that gave them great pause. And so there's a report that I think was released about a month and a half ago which was the second step in that benchmarking procedure with the submarine service, which is the operational community, and the naval reactors community, which is the disciplinaires, if you will, over the technical requirements side, that we continue to solicit.
Beyond that, there are certainly a number of folks that we have invited in and will continue to do so. I spent the better part of four hours last night with Admiral Gehman and most of the members of the Board asking them specifically for the folks that they had brought in as advisers to the Board on this particular question so we may be in contact with them in order to ask for their advice and assistance and contributions in this regard as we implement these recommendations on that front as well. So, yes, we're about that as well.
MR. MAHONE: Keith?
QUESTION: Keith Cowing, Nasawatch.com. Yesterday you read Gene Kranz's inspiring words that were issued to his troops after another accident. And, you know, that was then and this is now. You've got a workforce that has been downsized, bought out, they're jaded by innumerable management fads, and clearly it hasn't worked.
I got an e-mail from somebody yesterday saying, "What's he going to do, actually make us--write this on the white board?" I mean, the cynicism is that high.
What are you going to do this time that is demonstrably different than all these attempts before it, getting the agency motivated and beyond the cynicism and malaise that seems to have beset it?
MR. O'KEEFE: Well, it's going to require leadership at every level. This is not something that you direct or dictate. Again, in my experience, in my prior life as the Navy Secretary confronted with an incident, an event that really rocked that institution at that time, when I came in in the post-Tailhook incident, it's not about just walking around telling everybody shape up or ship out. It really takes persistent, regular, constant leadership focus, and I think the folks that we have recruited and are in place now as the senior management team that, again, have been over the course of certainly this last seven months, to be sure, but over the previous year, have been recruited to those capacities specifically for that, are the kinds of people, I think, who not only get it but also are going to be the first start at that leadership objective.
Throughout the agency we're going to have to persistently move through that, but I think it is staying with a very set of clear principles and values that we will continue to work through, and it's going to take time, but the time begins right now. And it has been in process, I think, for some period before this, but we will continue to redouble our efforts of that. But it's something that there is no one trick pony at this. It is not something that happens simply because I send out a memo. I'm not a Pollyanna on that point at all. It is something that really requires, I think, constant, unrelenting diligence, and that is another theme that I think comes out very resolutely in the Accident Investigation Board report, which is consistency as well as persistence and vigilance in the leadership direction in that regard. And that's what we are committed to doing.
MR. MAHONE: Yes, sir?
QUESTION: Thank you. I'm Larry Wheeler with Gannett News Service. I want to get back to the leadership question a little bit. I was wondering if you could share with us your thinking about how you motivate your leaders to follow through on this point that you said they get it.
Two weeks ago, one of your senior managers had a press conference at Kennedy Space Center in which he, if I understand--if I recollect correctly, he denied that there was a culture in NASA or that he was aware that there was a culture in NASA. And this is the same senior manager who ran the Safety and Mission Assurance Program throughout the '90s, which has been highly criticized by the CAIB.
Can you give us your thinking? How do you turn around that kind of thinking?
MR. O'KEEFE: Well, first of all, I think it's a--it's always a challenge to define with common specificity to which all accept of what the term "culture" means. And in my experience, again, as Navy Secretary, there were multiple cultures. There's the culture--there's a Navy culture, to be sure, and a naval service ethos. But there's also a surface sailor culture, an aviator's culture, a submariner's culture. And then, just to really get some extraordinary oomph into it, let's get the Marine Corps involved. They're part of the Navy Department as well. And the common distinctions between those are born of years of history as well as deep tradition.
It is also true here. There is every single aspect of how this agency has formed over its 45 years and well before when at the beginning of the last century the NACA was formed to respond to aeronautics challenges at that time that were to be advanced. Every one of the centers, every one of the elements of what you see throughout this agency, can reach back and trace historical roots to each of those individual moments.
And so in that regard, there are lots of different ways in which folks respond, but the overall, overarching, overriding NASA culture for this agency overall is a set of principles and discipline in order to pursue safety of program consideration, which has always been the case, in pursuit of those exploration objectives.
Those are the kinds of things we need to redouble, and, again, as you define it very specifically in that regard, there is importance that I think we get great clarity of exactly what the definition is, and that's the part we get. There is an overriding culture which must dominate, and certainly we celebrate the history and traditions of every aspect of this agency, much as any other storied agency or institution does.
MR. MAHONE: Yes, sir?
QUESTION: Earl Lane with Newsday. A lot of what the report spoke about on culture, though, I think dealt with attitudes as much as institutions and talked about how lower-level engineers were reluctant to come forward with the concerns. And I'm wondering how you deal with that to get that message out, and is it perhaps time for a stand-down like the Navy sometimes does?
MR. O'KEEFE: Well, it is--to be sure, that's one of their findings and views, is that there is--there was evidence that they saw, even in the course of their investigation, in which reluctance dominated. And I think part of that is--or the two things we've really got to focus on in that direction is, first of all, reinforce that principle, which, again, we articulate regularly and I think we see evidence of all the time.
There was a stand-down in June through October of last year in which an individual observed an anomaly on the fuel line for Atlantis. There was a crack on the fuel line that in turn stood down the fleet for that period of four months as we ran that to parade rest and determined exactly what the conclusions and solutions needed to be. So we've got to, again, continually identify that as the kind of behavior we want to encourage, and to the extent we do not see it evidenced or there is evidence in the opposite direction, to assure that we motivate and encourage folks to feel that sense of responsibility.
And that's the second part as well, is that there is, I guess, a renewal of the view that I heard expressed best by Leroy Cain, the Flight Director on STS-107, who observed this is all of our responsibility. And so for those who are part of this agency, we have to renew that view, and for those we recruit to that have to have it understand as the first principle that we all must adhere to.
MR. MAHONE: Yes, Tracy?
QUESTION: Tracy Watson with USA Today. Administrator, did you have any hints before the accident that you had this kind of serious attitude and value problem at the agency?
MR. O'KEEFE: Well, to be sure, there's always cases in which there are folks who feel like there are certain aspects of what has occurred in the course of our history or in the course of events that are not as advantageous as others. And so I've had a very open policy of let's communicate whatever those concerns are, let's have an open dialogue throughout the agency on every matter. I've tried to be as open about that to include encouraging e-mails, of which I get lots of from lots of folks. So I've seen, I think, lots of evidence of folks who are feeling, you know, very empowered to offer their view and their concerns. And at the same time, I think it's also evidence of the fact that the process or the systems to permit that discussion isn't happening at every level.
So there's two things you can draw from that that I have taken away, which is those who feel that it's necessary to respond in that regard really require other means because the systems may have broken down. So there is certainly some indicator of that, but certainly this was a wake-up call in yesterday's report to see how extensive that communications link that contributed during the course of this mission and operation needed to be improved to deal with precisely that set of problems.
It wasn't for lack of people talking. It was for lack of people, I think, coordinating those observations effectively to serve up appropriate decisionmaking about the challenges we were confronting at that time. And I think that's--you know, the upside of that is that there's ample evidence to suggest that folks are feeling like there is an opportunity to communicate and speak. It is also another question, though, of exactly at what level can they do so, and I think that's the point and the communications breakdown that is part of the culture and is part of the observation that was made by the Board, and the findings and recommendations speak to that very effectively.
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