CAIB Press Briefing Transcript 29 Apr 2003 (part 1)
ADM. GEHMAN: Good afternoon. I’ve got a couple of short announcements to make.
The debris search is winding down as per the schedule that we approved. The ground area of primary search is 99 percent finished, and the organized large-level-of-effort debris-searching will cease on the 30th of April, as we indicated.
The board is quite pleased with how much of the orbiter has been recovered. We’re sneaking up on 40 percent. We won’t quite get to 40 percent, but it will be 38 or 39 percent of the dry weight of the orbiter will have been recovered, including a number of significant pieces, which has helped the investigation considerably. There will still be a debris recovery office located at JSC which will remain open for weeks and months, for anyone who happens to find debris; and also there will be an occasional debris search located at various high-probability areas, particularly out west as time goes on.
During this week we did find another tile in the vicinity of Granbury, Texas, which at one time, remember, was the westernmost tile at one time. So that piece of tile has not yet been identified as to where it came from, but that makes now three pieces of debris that have been found significantly west of the Dallas/Fort Worth area. So as we examine that piece of tile and find out where it came from, I’m sure we’ll learn more.
The U.S. Forest Service and the Texas Forest Service, who have been providing most of the manpower, of course, are repositioning themselves for what they do most of the time, which is fight forest fires. They’re from all over the country, including Alaska, and they are now going to their home bases and getting a little time off and preparing themselves for their season. We are very grateful to them and to everybody else that participated in this very important piece of the investigation. The importance of debris will be brought home later in this briefing when Mr. Tetrault gets to talk to us about debris; and you’ll see why we keep bringing debris up over and over again because it’s one of the things that really helps us with this.
This has been a big week for the board in that we did some heavy lifting this week in two areas, none of which are newsworthy; but in both areas, at least to me as the chairman, I think it’s significant.
The first one is in the development of what I call a working hypothesis or a working scenario. We released a little press release on Thursday afternoon after we had a very long and detailed meeting with everybody that’s involved with this, both our own staff and the NAIT, the NASA Accident Investigation Team, everybody who knows anything about this. They briefed us. We had several briefers to the board, and we made some progress in agreeing on something which I am calling our working hypothesis.
We are not finished with that. We have appointed a subcommittee to continue to refine the details of this working hypothesis, but we made a lot of progress and did quite a bit of hard intellectual work in order to narrow down choices and eliminate some choices and satisfy ourselves that we know enough to agree on a working hypothesis without inadvertently eliminating something which might be important later. That work will continue and in the near future, I hope, seven to ten days, we will announce what is our working hypothesis. I can’t tell you what it is right now because we’re still working on it, but I can tell you in general terms it is a hypothesis which narrows down the options of how heat got into the left wing and the process by which the left wing of the orbiter was damaged. We have mountains of data and mountains of debris, and what we have to do is see if that debris agrees or conflicts and come up with a hypothesis that agrees with most of the things but for which there are no conflicts.
The test that we have is that not all the data have to agree with our hypothesis but there can be no conflicts. So we can’t have any evidence which says that our hypothesis is no good. So that the board worked on for hours and hours, continues to work on very, very hard, and we will press that with some degree of urgency.
The second area that we did a considerable amount of work on, hard work, is in the area of risk assessment and understanding safety engineering and safety systems engineering. The board is satisfied that we have adequately founded our work in thermodynamics and aerodynamics and things like that with subject matter experts which are world recognized, world-class experts, and the board is satisfied that we are not likely to be challenged on any conclusion that we make as to an aerodynamic event or a thermodynamic cause or effect or something like that.
If the board is going to make some recommendations or some findings related to management, safety, risk assessment, or anything along those lines, the board feels that it needs to be equally well founded in that area of expertise. So what we’ve done this week, both in our public hearing which we held on Wednesday at which you heard about risk and various types of risk and different ways to look at risk and how the original designers of the shuttle looked at risk and how theorists like Diane Vaughan and other people look at risk — we also had in conversations and briefings and meetings with the board, about a day and a half of more experts from industry, from the academic world, from the National Safety Council, in which we were apprized of other ways to study, measure, analyze, and make comments on risky activities in high-reliability organizations.
You might call this an education process. We were not evaluating NASA. We were putting ourselves into a position in which, when we do write something about risk management, that we can do so with some authority and we can do so with some knowledge — once again, to put ourselves in a position like we are in the area of aerodynamics or debris reconstruction or something else where we have sufficient expertise that we are not likely to be challenged by somebody who has a different opinion. This is very hard work. It takes a lot of time. It takes a lot of patience. Sometimes I, for one, get a headache doing it; but it’s very important.
We had four visits by members of Congress at our headquarters this week, and they are always welcome. The four members were all from the House, and they were all from the oversight committees, either the House Science Committee or the Subcommittee on Space and Aeronautics, and it’s extraordinarily helpful to me to have this dialogue with members of Congress because we want to make sure that our report hits the bulls-eye when we write it. To so some degree, Congress determines where the bulls-eye is. So if they move the bulls-eye on me a little bit up or a little bit to the left, I need to know that so that I can structure the report that way.
In addition to that, I am leaving later this week to go make some more calls on Capitol Hill, again with the chairman and the ranking minority members of the oversight committees on both the House and Senate side, just to make sure that the work of the board meets the expectations when we get finished. As you probably are aware, the chairman of the Senate Commerce, Science, and Transportation Committee, Senator McCain, has called for a hearing on the 14th, at which I will be appearing.
Lastly, again, board-wide activities, is the board has just initiated — and we don’t have anything more to say about this than the fact that we’ve initiated it — a line of inquiry into the ascent phase of the flight. That we intend to be as detailed and as rigorous as is the inquiry into the entry. There are a few things in the ascent phase that are interesting to look. One thing, of course, is the foam strike; but there are other things in there like aerodynamic forces and control surfaces which moved not out of limits but right up to the edge of what has ever been seen before. So we would like to examine those and some other things with the degree of intensity and the degree of detail that we have picked apart the entry scenario. I’ll let my colleagues talk a little bit more about that, but I’m just going to say that we’re just starting that and we find it to be interesting.
Let’s see. I think that that’s it. We’re up to 78,000 pieces of debris now, for people who are keeping track; and they still come in at the rate of several hundred a day. So I will now call on my colleagues to talk about what their groups are doing.
General Barry, you have the floor.
GEN. BARRY: Good afternoon. I’ve just got a few things to talk about this morning. First of all, on Group 1, Maintenance, Management, and Materiel. Rear Admiral Steve Turcotte and Brigadier General Duane Deal will be going to KSC this week. They’ll be leaving tomorrow, following up on some interviews and some other working investigation down there.
We’ve got a couple of subgroups that are being worked. We’ve got Bob Ballister and Commander Mike Francis who are working on the ascent time line, as the Admiral mentioned, and we’ve got another subgroup, Colonel Nakayama and Colonel Beer, who are going to be as KSC for follow-on interviews and infrastructure investigation.
We also hired a Dr. Roger Staley. He’s a former professor at the University of Minnesota and Ohio State University, for corrosion analysis; and he’s going to be down at the debris site and doing some work for us on some of key items down there.
A couple of things. Maintenance. On the maintenance effort, the next closeout fault tree that we are going to be examining will be on the solid rocket booster. Estimates right now is that’s to be done in the middle of May. There will be one unresolved area that the NAIT, the NASA Accident Investigation Team, will be bring forward; and that will be on the bolt-catcher. So outside of that, they will bring everything forward about the middle of May.
Can I have the first slide. I want to talk about Day 2 debris. I know there’s been a lot of debate in the press about. I’ll give you the current debate from where we are. Right now, as has been mentioned before, the post-flight analysis really was after, of course, the mishap. We went back and examined the data.
There are two qualifying gates to figure out if this, in fact, was a valid debris that we saw on the second day; and those two gates have to be with the radar cross-section. There are 26 items that have been looked at. I will show you. There will be five more added and then, of course, the area-to-mass ratio. The radar cross-section is done at Wright Patterson Air Force Base. Dr. Brian Kent and Dr. Bob Morris at Colorado Springs for Space Command does the area-to-mass ratio.
So we’ve got two candidates that are still out there, and I will show you the next five. The RCC T-seal and the wing leading edge insulator.
Next slide, please. You can see over here; these still are not excluded. So we’re still holding them as potential candidates. There’s a lot written on the T-seal. Right now we’ve got Roger Tetrault who will be talking a little bit more about that in regards to what T-seals we think and the areas insofar as where the heat might or might not have come in.
The other five listings there are additional candidates. Those are all from the debris field that we have down at Kennedy Space Center, and those will be examined not only for RCS but also for area-to-mass ratio. So you can see a couple of those. There’s another T-seal section. There’s some RCC fragments that we want to look at and another carrier panel. This is the upper carrier panel. So we’ll continue on this detective story as we continue on the investigation.
Next slide. This is just to show you an example. This happens to be the T-seal that you can see over on the left-hand side and how it fits in within the parameters as listed from the Wright Patterson laboratory. So we’re trying to narrow this down as best we can; and as we get better information on what’s going on with the debris, we’ll be able to maybe zero in on this. It’s like a sine curve, you know, and then eventually it gets kind of dampened out and we finally figure out where it is that we want to have on the final part and hopefully we’ll conclude or give our best example of what we think that second day debris is.
Okay. Slide down, please.
A couple of other announcements just to make. We’ve got notification from U.S. Strat Com. They were put in charge of the DOD Columbia Investigation Support Team, and we’ve been in contact with them since Day 1. We were notified by letter that the DCIST or DOD Columbia Investigation Support Team has completed their collection and analysis of DOD information related to the flight, STS 107, and all analysis has been provided to the Cape. They’re unaware of any further data or information relevant to the Columbia accident, but they’re on call to continue to expert us as needed. So we’ve run that to ground, full circle.
The other one I want to announce also is we’re getting a briefing today from Ralph Roe, and he’s going to outline for the board the RCC NDE plan. That’s non-destructive evaluation for the reinforced carbon-carbon. As you know, we’ve put out a preliminary finding; and that finding called for a more detailed NDE evaluation of the leading edge and the RCC in general.
A final point is on the management and human factors. We have a team made up of multiple groups within the board, subgroup members who were at Huntington Beach this week, and they are going to be concluding the investigation on crater and the transition of the Boeing Huntington Beach shuttle analyst support that moved from California mostly to JSC, but some to KSC.
That concludes my remarks.
ADM. GEHMAN: Thank you very much.
Dr. Ride.
DR. RIDE: Thank you. I’m here representing Group 2. Steve Wallace also and General Hess are both in town this week, and we’re all pretty heavily involved in the aspects that I’ll discuss.
We’ve finished the assessment of launch controller training and have found that not to be a contributing factor, not to be an issue. We’ve uncovered nothing remarkable in that training activity. We’re right now deep into two other activities that you have heard something about. One is documenting the analysis and the disposition of the foam events. These are preceding and including STS 107. We’re going to start with STS 32, a major bipod foam event; then skip to STS 50, another one; and then do 50 through 107, looking at the major events. For each, what we’re interested in, our particular group, is how that event was handled through analysis, through briefings at the various reviews after the event, how it was taken up through the chain, was it declared an in-flight anomaly or not, was it briefed at the FRR or not, was a hazard analysis done. We’re still in the middle of gathering information.
As you can imagine, this is a fair amount of information. You’ve seen briefing charts at some of our public meetings that showed the cataloged number of hits per flight. We’re going quite a way beyond that, into the briefing charts after each flight and the minutes of meetings and that sort of thing, to really try to put together the story of how foam strikes were handled through the relatively recent history of the program.
That history of the foam strikes and the response to them kind of sets the stage for the decision-making that took place during STS 107, and that’s the other principal area that we’re involved in at the moment. We’re continuing what is really very time-consuming work in documenting that decision-making process. We’ve nearly concluded but not concluded a pretty extensive set of interviews in this particular area and we’re just at the stage where we’re now starting to assess how the organization functioned and we’re going to try to, in the next week or two, be stepping back to be able to take a look at the organization and how it responded to this. We think we have a fairly good understanding now of what happened, but what we really want to get at and what we think is the important piece of this is how did the organization function, because that’s something that we can hope to make some constructive comments on.
As a part of this, we’re bringing in some experts to help us develop the context and how to analyze and assess these processes. As Admiral Gehman said, we’ve got good grounding in aerodynamics and thermodynamics and we want to make sure that we avail ourselves of expertise in the safety and risk assessment area. So that’s what we’re starting to reach down to gather right now. You’ve heard from Diane Vaughan last week, who we had in. We also, as the Admiral mentioned, had a group of safety and risk assessment experts, accident investigation experts in yesterday. Allen McMillan from the National Safety Council, Jim Wick from Intel, Deb Grubbe from Dupont, Sam Mannan from Texas A&M, Nancy Leveson from MIT, and David Woods from Ohio State. So it was a good representation of industry corporate safety culture, safety organizations, and also academia; and we’re really trying to understand what they can teach us and how they can help us to develop some methodology and constructs to make sense of what we’re seeing and to, as I said, try to say something intelligent and constructive about the organization and the decision-making process.
The things that we saw in this accident, we’re learning, are not different from things that are seen in other accidents or other areas of investigation, whether they be in health care incidents or whether they be in chemical industry accidents. So we’re really trying to learn from the experience that they’ve got. We also want to get a perspective on safety and risk from recognized experts in corporate America and academia, how do they deal with safety through their cultures, and all of this is really to help us get a perspective on how does a large institution instill a safety culture, how does an organization approach developing metrics and using metrics that serve as advance indicators that there may be potential issues that should be paid attention to as they go forward.
We also got what we think is a pretty important briefing and reminder about hindsight bias. Hindsight is always 20/20, whether you’ve been watching a football game or analyzing a space shuttle accident; and it’s very, very important for us to take advantage of some of the literature and some of the expertise that’s out there on how to avoid hindsight bias and the importance of putting yourself in the place of the people who were involved in these decisions at the time. There’s quite a bit of literature about that that we’re getting some good insight into.
Again, we had some introduction to different sort of accident investigation models that we hope to use to be able to get at generalizing that we found in this investigation and pull, you know, kind of the gems on the organization. Perhaps it’s processes. Maybe it’s bias. Maybe it’s tendencies. We don’t know, but we think there are models out there that can actually help us, instead of trying to reinvent the wheel from a bunch of physicists and technical folks, but take advantage of a lot of rich work that’s been done over the last several decades to help us make sense out of it.
I’ll just add as an aside that one of the briefers that we had, David Woods, has done extensive work in analyzing decision-making in mission control, as well as in health care and other areas, and he in the past has found mission control to be the positive example in terms of how to handle decisions in real time and crisis decision-making. So he’s got a lot of insight into the way that decisions occurring during a space flight are normally handled. So we expect to get quite a bit of help and insight from him.
