Columbia Accident Investigation Board Press Briefing May 28, 2003 (part 2)

A REPORTER: Associated Press. For General Hess. You sort of touched on this, but I’d like a little more information about the decision-making specifically after 112 and how a big piece of foam came off, struck one of the boosters, left evidence that it had struck, and yet the next flight goes off without this even being really seriously discussed. What have you found that allowed flights to continue rather than halt after 112 in particular?

GEN. HESS: Let me go back and kind of clarify one of the premises in your question here. First of all, there was some serious discussion about the foam loss from 112 in the flight readiness process for 113, and the program did direct a study to be done on the bipod foam loss. Now, the body of their knowledge at that time indicated that that had been the first time a significant bipod piece of foam had come off in, say, roughly a decade. So it was a "one of" kind of event in their memory, and they did direct that the appropriate people go back and study and make sure manufacturing processes and stuff like that hadn’t changed and take a look at it. And they moved right ahead into STS 113 and flew that mission and then apparently by what they knew did not have any trouble with the bipod foam. So when they got to 107, it really was not an issue anymore; but the study requirement was still outstanding.

ADM. GEHMAN: The due date on the study was?

GEN. HESS: Initially December, then February. After 107.

A REPORTER: Is this where you think a better archival system would have helped, because clearly this seems to be an issue that was discussed a couple of months ago in a public hearing actually, that a better archival system is needed so you don’t think you’ve just got a "one of" kind of event.

GEN. HESS: True. I think you have to look at the ability to retrieve the trend information from the various data bases that they have, and it’s a fairly mechanical process. It can be done, but it takes a lot of work to get the out. The other part of it is as we go back and take a look at the perception by management that losing foam had become an in-family experience because it was just going to cause them work to turn the shuttle around. At the same time, obviously by the discoveries that General Deal and his group have been making in terms of we found certainly two missions where they had bipod foam loss that they really didn’t know about, there was a lack of connection between the program and the people doing the maintenance turn-around and looking at the films to try to track it as an issue in the first place. I don’t view that necessarily as a critical failing, but it is certainly an influence on what we have to report, as far as the board is going to do, in terms of management decisions and how the program was approaching the issue overall.

A REPORTER: LA Times. I’ve talked to some NASA employees who say that the culture is not conducive to raising concerns or raising problems over and over again that they may have. I was wondering in this foam case whether you’re aware, as you’ve looked at the paper trail, of anybody who said we really need to pay closer attention to this and who wasn’t listened to and, secondly, if you have any feeling whether that there were cultural constraints that led people to not to want to raise the concern too loudly for fear of their career.

ADM. GEHMAN: Ken, why don’t you start out, then I’ll put in my 2 cents worth.

GEN. HESS: I think the answer to your question, in short, is, no, I haven’t found or seen or talked to anybody who felt that if they had thought that foam was a problem that they wouldn’t be listened to. The plain fact of the matter is there was a general understanding about foam within the organization at large.

Now, we have talked to you before about various barriers to up-channeling information about this particular foam loss on STS 107 that I think have at their basis a little bit of the culture that you’re asking your question about. The safety organization was quiet about the analysis that was being done and reporting through the safety channels that there may be a problem. The management channels were really concentrating on foam loss as a turn-around issue as opposed to a potential safety-of-flight issue in how they handled the STS 107. I think those kinds of attitudes and approaches do have at their heart a cultural appreciation for this particular event.

ADM. GEHMAN: I would add my 2 cents worth on the end of that that a considerable part of our report is going to be addressing this underlying and hard-to-pin-down attitude or climate that you were referring to in your question. We are going to be quite interested to speak on this subject; but we also want to speak on it with a good, firm basis that we know what we’re talking about. We’re not going to speculate about these things; but there is ample reason for us to be concerned and to look into it very, very carefully.

Some people have characterized it – not the way you characterized the question – but they’ve characterized it as a change in posture, from one in which you had to prove that it was safe to fly, to one in which you had to prove that it was unsafe to fly. In other words, the people who had doubts about anything were essentially outside the circle and had to work their way in, rather than the doubters being inside the circle and then you had to prove that it was safe to fly.

Of course, there’s a lot of reasons for this. This is not criminal activity or anything like that. You have 112 successful flights. You’ve got to assume you’re doing something right; and you’ve got thousands and thousands of dedicated people being very careful about what they do, catching many, many flaws before you launch. So they’ve got lots and lots of successes to prove that they’re doing a lot of things right.

There are a number of underlying issues that we’re going to attempt to address in this report, and we want to be sure that we’ve got them addressed in a responsible way. So we have to be a little bit guarded about what we’re saying here.

A REPORTER: Orlando Sentinel. Following up on that, the matter of underlying issues. I’ve heard in various conversations that the work of safety and mission assurance is not now a place in NASA where you become a rising star and there may be a tendency not to put the best and the brightest people in that realm. It’s not a place for achievers. Can you address that? Is that a factor you’ve delved into?

GEN. HESS: Yes, it’s a factor that we’re looking into; and we’ve heard the same sorts of reports that you have heard. I think really the approach that the board is going to take is, one, our interview process will ask those sorts of questions; but we’re looking at the mechanics of the organization. Is the organization created so that safety can have the appropriate influence on the process that it should have in a very high-risk venture like launching the space shuttle? I think that will be more of the context of how we will answer that particular question.

A REPORTER: Florida Today. For the Admiral. I am curious whether or not you are going to interview the former administrator – as you’ve said, you’re going to talk about context – and the circumstances under which you might do that. Is he going to be allowed testify in a privileged situation?

ADM. GEHMAN: It is our intention to interview the former administrator when we move to Washington.

A REPORTER: NBC. Back to the issue of the people who are watching safety. I was very dismayed to hear the comment that you didn’t find anybody in the safety office who thought that they were at 100 percent and yet NASA, which I think suspected that, set up independent organizations which were supposed to be watchdogs on their safety. They were supposed to remind them and kick them in the head when they detected things were not. But who was going to guard those guards? Are you going to look at the functioning of these independent groups and where they may have fallen short of what they were responsible for, which was catching this kind of thing in advance?

GEN. HESS: I think that’s kind of a combination answer from myself and General Deal. In short, yes, we have to take a look at the construct under which the safety program operates. You know, it’s one thing to look at the regulations and policy guidance and those kinds of things and evaluate safety as to whether or not they’re given the right parameters under which to operate but then to go out and test exactly how they’re doing it on a day-to-day basis. There may be another answer to how S&MA does their work.

I think most of us would agree that the independent nature of S&MA is probably with a lower-case "i" as opposed to a capital "I". We have to be able to put that in context. We can’t just, as a board, step back and say that they’re not independent enough, that they haven’t done this, that, and the other thing correctly, without being able to offer them an opportunity to look at it a different way. That’s what we are attempting to do is offer our constructive recommendation.

A REPORTER: Houston Chronicle. My question is for Admiral Gehman. You’ve mentioned over the last several weeks that you don’t want a scenario-dependent report in the end. You’ve mentioned also that you’ve seen other issues that may be as serious as the foam problem. I don’t want to assume that you haven’t brought some of these up, but could you elaborate on some of the other issues you may touch on in your report that you find great concern for with regard to shuttle operations?

ADM. GEHMAN: I can explain what I mean by we’re not going to write a scenario-dependent report. We may or may not be able to state with unequivocal, complete certainty that the foam strike, which obviously did happen, knocked a hole in the leading edge of the orbiter. There’s no question that the foam hit the orbiter, but we may not be able to prove that it actually caused some kind of a breach. Therefore because we’re working so hard on determining exactly what caused this shuttle not to return safely to earth and we’re looking at so many engineering and physical and mechanical processes and chemical processes that took place, it has caused us to look broader, much more broadly at the material condition and the operation of the shuttle program, probably more broadly than any review in the past. This probably is a blessing in disguise, particularly if you’re thinking about NASA’s thinking about operating the shuttle for another 20 years. It probably is a good thing that we’re doing such a broad review.

Therefore, our findings and our recommendations are going to be based on this very, very broad review and not based on a single, solitary initiating event like the foam hitting the orbiter. We’re not going to rule that out. I mean, the foam hitting the orbiter may have caused a breach and that may have been what allowed the heat to get into the wing, but since we can’t prove that and we can’t disprove, for example, orbital debris or micrometeorites – we can’t disprove that – we’re left with the position of having the report stand on its own weight and all of these other things that we’re looking into – like safety and management and risk assessment and work force issues and the stature of the S&MA organization – all of these other things are going to have to stand on their own. Our conclusions and findings will have to stand on the merits of our work, and we cannot refer back to the foam hitting the orbiter as proof of everything. That’s kind of what I meant.

Since it’s likely that we’re going to be able to say that the foam was the initiating mechanical or physical event in the terms of something like most likely or most probably or the board is confident but we can’t prove it, we have to allow for the possibility that something else initiated this event; and our report will have to take that into account. That’s the best way I can answer, I think, that question.

A REPORTER: NBC. On that answer. You gave NASA a hypothetical a month ago as to say if they had known immediately after the accident, what would they have done about a rescue mission. I would like to give you a hypothetical. If your panel had been called last year by NASA and told, "We are getting worried about keeping the shuttle running for a long time. We are getting worried about our own safety program. Will you all come in and spend 117 days or four months looking at what we’re doing?" How much of what’s going to be in your report would you have found before Columbia was lost?

ADM. GEHMAN: We actually have asked ourselves that question. That’s a very, very fair question; and the way I break it down, I break it down into two sections. The first section – and this by the way, this is not hypothetical; we’re actually doing this. As a matter of fact, the author here is sitting beside me. All this foam business, we’ve been saying that foam has been hitting the orbiter since the first flight. NASA is never not being reviewed by a blue-ribbon panel. NASA is being reviewed by somebody all the time. Well, what did all these other panels say about this? Is this just NASA’s fault alone that they’ve been ignoring the foam issue? What about all these other real smart people like the Rogers Commission and the Augustine Commission and the Aldridge Commission, et cetera, et cetera, and Harry McDonald and all this good stuff?

So we are actually conducting a review of the literature to see where all these other wise people were on this subject of foam and whether or not, if we had been called in before the Space Shuttle Columbia took off, whether or not we would have raised our alarm bells about this foam business or not ourselves. We actually are asking ourselves that question.

The second part of the question is – and I have said this before in public – I think it’s a bit unfair and hypocritical of us to say, "Look at the O-ring problem. You should have known that. Look at the foam problem. You should have known that." Okay. Give me another one.

I mean, it’s unfair to wait until the accident and then look back and say, "Oh, look at that problem. You should have known that." Tell me something else you should have known. Find me another one, if you’re so smart. We’ve actually challenged ourselves to answer that question before we set ourselves up in judgment over other people who are doing the very, very best they can.

In hindsight, it’s really easy to find these flaws. So if these flaws are out there laying around and everybody should have seen them, okay, well, tell me what the next one is if you’re so smart. Tell me the next one. So if we as a board can’t answer that question, we are very slow to sling spears at other people who also failed to answer that question.

Now, don’t misunderstand me. If there is a flaw in the system or there’s a better way to do it, we have going to document that and we are going to be quite straightforward in pointing it out; but if we can’t answer those two questions, we are going to be a little careful, judicious about sitting in judgment over other people who had to make these decisions not in hindsight but in foresight.

Now, let me just say that the answer to the first question about what’s the next one out there, what other ones are they calling within family which might go out and bite them, we actually are working on that question because we think that would be a great help. So that kind of gets to your question about if this board had been called to existence before the Columbia took off. We would have asked that kind of question also.

You know, I don’t want to belabor this; but a third very interesting question is suppose the Columbia had returned safely. I mean, suppose the foam had hit the Columbia and done some damage of undetermined origin and the Columbia returned safely. Okay. Now, we’ve got two major foam hits out of three flights. Now, would that have caused any policy changes or anything like that? That’s another way to get at asking the same kind of question.

So you take that third test I said. Suppose the Columbia had been struck by foam, some damage had been done, but she returned safely. Now you take the present NASA management systems, apply them to that question, and see what kind of an answer you get. That’s kind of the framework of how we’re approaching. If we take that test and apply the present NASA management system and we predict we come out with not the kind of answer we want, then we are going to be critical of the present NASA management system. So that’s three ways to get at the question that you asked.

Maybe my board members would want to share.

GEN. DEAL: I’ll add a fourth way. That’s through the interviews. When we talk to technicians all the way through management, we do talk about Columbia and STS 107, but we also give some more generic type of questions. You know, budgetary impacts to what you’ve been doing over the last few years. Have you been able to get the resources you need, the tools, the parts, the people? We ask questions about safety and about security, and we ask what I commonly call the "King for a Day" or "Queen for a Day" question: "If you were in charge of all of NASA, what’s been gnawing at you? What would you change if we gave you the right budget?" We get some pretty good answer out of those things, where they come forward with some of these things that they’ve said, well, you know, this is something we’ve brought up and we have not been able to fix due to such and such and such.

ADM. GEHMAN: This gets directly to the question of why we say over and over again that we’re not conducting a scenario-dependent investigation, because you ask people hypothetical questions like this: What’s bothering you? What would you change? We’re not asking them what would you change about foam strikes. We’re asking them about lots of things. Of course, once again, it proves the value of conducting privileged witness interviews.

What happened to the phone bridge?