Transcript (Part 3): Hearing on the Space Shuttle Columbia Investigation Before the Senate Committee on Commerce, Science & Transportation 14 May 2003

And indeed, every once in a while, some of these panels are returned to the manufacturer, for example is there’s a visual flaw, and the manufacturer does this introspective, non-destructive kinds of testing and guess what? On occasion, we find flaws, serious flaws, which are not visible to the naked eye. That lead us to believe that we have a condition here — we have an unknown condition. The Board is not saying there’s anything wrong with those RCC panels. The Board is saying that NASA doesn’t know the condition of 25 year old panels and that this is a big flaw. And we, of course, wanted to make sure we didn’t say anything that was factually incorrect or anything like that, so we consulted experts inside, outside NASA. And oh, by the way, when we consulted experts in NASA, we got the same push back that the Administrator got. Oh, by the way, the systems are not perfect. Yeah, we’ll have to take them off in order to do this and we found that to be not relevant to our discussion. We cannot fly an orbiter with 25 year old pieces of equipment that you don’t know the condition of them.

SENATOR WYDEN: Mr. Chairman, thank you.

CHAIRMAN McCAIN: Senator Snowe.

SENATOR OLYMPIA SNOWE (R-ME): Thank you, Mr. Chairman.

How many people would have been involved in this whole decision making, once it was recognized, after the Shuttle launch, that damage had been done?

MR. O’KEEFE: Jeez, I’d have to get you a headcount for the record, but the Mission management Team is composed of folks from the Johnson Space Center, the Marshall Space Flight Center, Kennedy Space Center, and primarily at Johnson, because Mission Control is operated there, out of Houston. It is a fairly large number, but let me get you a precise one for the record here. I couldn’t give you –.

SENATOR SNOWE: — Could be as many as 100, you think?

MR. O’KEEFE: Less than that.

SENATOR SNOWE: Less than that.

MR. O’KEEFE: In terms of active members of that team, there may be that many or more folks, who are actually being tasked or required to participate or whatever else. But in terms of decision makers, you’ve got a very specified number of folks there.

SENATOR SNOWE: And how far up the chain of command does a safety-related question go, on the day of the mission?

MR. O’KEEFE: The Mission Management Team is run primarily by the Shuttle Program, which reports primarily to the Office of Space Flight in Washington, as well as to the Center Director in Houston. A safety issue would escalate all the way through that process quickly, if the Mission Management Team were of the mind that we had a safety of flight consideration.

SENATOR SNOWE: They didn’t, obviously, identify this as serious safety related issue?

MR. O’KEEFE: They did not determine that based on all the evidence that there was a safety of flight consideration during the 16 day mission. That was a judgment call made by the Mission Management Team, indeed.

SENATOR SNOWE: Yeah, it just seems to me, that there’s no question that the whole decision making process and communication and the bureaucratic structure that goes up through the chain of command, has to be significantly altered.

Admiral Gehman, you were mentioning that no one’s responsible. But that’s the problem. We have a Committee, 100 or less, no one’s — you know, if everybody’s responsible, no one’s responsible, it’s true. I mean there’s some — it has to change, I think, before any next launch, among other things, because we have to get to the root causes. It just appears to me that it was a very complicated decision-making environment, when it came to making these kinds of decisions. And red flags were not readily identified.

You couldn’t access previous records or abnormalities that were associated with the Columbia Shuttle. And that’s also a concern. You can’t have an antiquated system if there are problems that had been identified with Columbia Shuttle on previous flights, there was no way to access that previous experience, readily or quickly, and ascertain whether or not this was a serious problem. So, if there was a growing list of abnormalities, there were no red flags being raised, because you couldn’t access the list. And you have a very cumbersome, you know, bureaucratic environment that doesn’t raise a red flag with respect to this.

It’s disconcerting, because — and I don’t know if this is true. I read this in one of the newspaper accounts, talking about there was a memo that named over 30 high-risk concerns regarding tanks and foam. It identified the idea of, you know, foam shedding from the tank and causing damage to the thermal protection system of the tiles and panels. But over time, the Space Agency had come to classify the problem as a maintenance issue, and not a serious threat to the safety of the craft or its crew. But even though it might have been, you know, considered a maintenance issue or not, the fact that it was on a list of 30 high-risk concerns, should have raised a red flag.

MR. O’KEEFE: Senator, if I might. I want to disagree just a bit with the assertion that there were not — wasn’t enough dialogue or exchange or whatever else, during the courses. There was plenty of that and ultimately, there is accountability. There are people that can be identified, very clearly, as to who makes decisions about this during Mission Management activity, during on-orbit operations. And they are very clearly specified in terms of how they make those choices. The audit trail was pretty clear on this.

Having said that, it’s a judgment call. And what they came to was — and that’s the hard part of this. This is the much tougher conundrum about this than any other aspect. It’s not that the information wasn’t available. It was analyzed and deemed to be within the context of safety of flight considerations. That was a judgment call. And you’re right. There were several different high-risk items that were identified, and those were all identified as things that need to be treated. But during the course of operations, every previous flight — and yes, indeed, that information was available, that demonstrated, was reviewed during the course of flight readiness reviews and so forth, but determined to be not a safety of flight risk consideration. Needed to be fixed, but not something that would compromise the Mission.

It is just a — you know, last June, we shut down the operations of the Space Shuttle Program for the better part of 4.5 months, after identification of a hairline fracture in a fuel line. That was determined to be a safety of flight consideration on those kinds of high risk issues, therefore, stop everything until we fix that. And that’s the difference. In some cases, there are all kinds of different abnormalities that you’ll find on any commercial aircraft, on any military aircraft, no matter what it is, that are requiring of corrections, but not determined to be safety of flight. That was a judgment call, and we’ll find out, in this investigation whether that was an accurate judgment call. And certainly, there appears to be plenty of doubt on that.

SENATOR SNOWE: If the photos had been able to show damage to the carbon-carbon leading edge that Senator Wyden was referring to, would anything have changed?

MR. O’KEEFE: Absolutely. No question. If there had been something, any evidence at all, to suggest that there was a safety of flight consideration, it would have gone to, you know, five-alarm fire status, where everybody would have been absolutely beating the parade rest every possible idea of how to correct the problem, until there was nothing left –.

ADMIRAL GEHMAN: — Senator, may I comment?

SENATOR SNOWE: (Inaudible).

ADMIRAL GEHMAN: The Board is probably going to spend a good fraction of the time or the linear inches of our report on this subject. And we have looked really hard at the question that you asked, of why do we have all this dialogue going on but no transmission of any messages? There’s all this talking, but nothing’s being transmitted. And the Board has taken an interesting approach to this, and that is, the approach is, that if you look at the O-Rings on the Challenger and you kind of backtrack on how that decision failed to get made, and if you take the foam and the photographs in the Columbia and you backtrack and say oh look, they missed something, we find that to be kind of unfair, because hindsight is wonderful.

So, the Board has said, let’s look through all the waivers and all the anomalies and all the steps that NASA has weighed on all the flights, and see if there are other items like this, in which we continuously have these waivers and the acceptance of anomalies. And are there other things like this going on? And is it symptomatic of some process which is not working very well? Because, to pick these two incidents and work backwards doesn’t take a whole lot of introspection. That’s pretty obvious. So, the Board is interested, are there others out there? And if there are others out there, how did they come to be accepted? And how did they come to be — how come we’re still flying?

We have found those. And what we’re doing is we’re trying to find out whether or not there is a process flaw, which is not allowing safety items and engineering items to get up to the level that they should. We find that to be more intellectually honest, than to go back and thrash people for what they should have seen on this one. And we have found what we believe to be some good analysis and good data, which will help with this process in the future. Not just beat-up on people for the past.

SENATOR SNOWE: Yes, I couldn’t agree more. And I think looking prospectively and addressing the root cause so that it doesn’t happen again. I agree, thank you.

CHAIRMAN McCAIN: Senator Breaux.

SENATOR BREAUX: Thank you, Mr. Chairman. Thank the witnesses.

I have two points. First is, it seems that a great deal of the investigation leads to the conclusion, I guess, that damage to the leading edge of the left wing caused part of the problem. The question then becomes, what caused the damage to the leading edge of the left wing. And the speculation has been that the foam coming off of the — at the time of the launch, hit the leading edge and caused some deterioration to the panels. And I know that you all have been testing that theory by some type of a mechanism that threw or shot the foam towards the leading edge, to see if it could possibly do that type of damage. What can you tell us about the results of that test so far?

ADMIRAL GEHMAN: Yes, sir. The testing started last week. We are, indeed, shooting pieces of foam at test articles that are orders of magnitude larger than have ever been done before. This testing has been going on for years and years and years. But, the test — these shots have always been tiny little pieces of foam at tiles and all that kind of stuff. And of course, that then leads to this erroneous analysis of how much damage the tiles. But that’s another story. We started by shooting foam at — once again, this is the first time that foam of the size that came off this time, has ever been used as a test. We started shooting at the wheel well doors. Because as you may recall, six or eight weeks ago, we suspected that the heat was getting in through the wheel well door. The recovery of the onboard recorder changed all that. We are now building a leading edge test target. That will not be ready until the first of June.

The first couple of shots that were conducted by Southwest Research Institute, were very, very mild angle of impact kind of shots. Little or no damage was done. The angle of impact — the angle of impact underneath here was much shallower than was actually experienced in real life. As we start to crank the angle of impact around, the damage gets much more severe. And that’s the testing that’s going on now. We’re just now getting –.

SENATOR BREAUX: — That’s damage to the underbody?

ADMIRAL GEHMAN: To the tiles.

SENATOR BREAUX: To the tiles on the underbody, not the leading edge?

ADMIRAL GEHMAN: That’s correct. We have not started shooting at the leading edge yet. We will start shooting at the leading edge — to get to your question directly, around the first of June.

SENATOR BREAUX: But, the results of the test on the tiles of the undersurface of the Shuttle, indicated much more damage than had been experienced before on the test?

ADMIRAL GEHMAN: The damage is dependent on the angle of impact. And as we get up into angles of impact which are representative of what we think really occurs to the Shuttle, the damage is more severe than previously thought, that is correct. It’s dependent on the angle of impact.

SENATOR BREAUX: Mr. O’Keefe, how many times in previous launches has foam insulation separated from the fuel tank and broke off in launch or in other parts of emission?

MR. O’KEEFE: There were four observable events that were recorded and analyzed as the consequences. Going back to, I think, STS 7, I think was the first one. There were several other events of smaller pieces, apparently, that were documented as well. But the ones that were significantly analyzed, were these four different events. The most recent of which was on STS 112, which was launched in October.

SENATOR BREAUX: Is there any reports anywhere in NASA that raised a serious concern, red flag, alert, that this was a problem or could be a more severe problem?

MR. O’KEEFE: I think for the reasons Admiral Gehman just described, there were tests that were conducted thereafter, that led engineers to conclude that the impact was not, on those four significant events, was not considered a safety of flight compromise.

ADMIRAL GEHMAN: Senator, may I –?

SENATOR BREAUX: — You have any comment on that?

ADMIRAL GEHMAN: I would. I will respectfully disagree with the Administrator here. Foam coming off the external tank has hit every flight on every orbiter. If you want to measure total number of hits, it’s thousands. If you want to measure hits that have caused damage to the tiles of greater than an inch, it’s about 30 per flight.

What the Administrator was referring to, is this particular piece of foam that we’re talking about in this instance, which is a special piece of foam molding that’s hand molded to cover a certain connection point called the bipod. That particular piece of foam is known to have come off six total times, including this flight.

But, there are over 40 flights for which we have no information. For example, the ones launched at night. Or ones where we couldn’t photograph the external tank when it comes away. So, there are six that we know of, out of 40 minus 113, out of 70-some flights. And so, just to make the record straight, this particular big piece of foam, the Administrator is right, only half a dozen times. But foam hitting the orbiter occurs on every single flight.

SENATOR BREAUX: Well, I mean, I think that’s a significant piece of information for everyone to understand. I can’t draw any conclusions in my own mind, but it seems to me that that might be the smoking gun and the fact is, is that this isn’t the first time it happened. But that insulating foam was coming off on every flight and on thousands of hits, damage to the tiles had occurred. It just seems to me that it was only a question of time when one of those hits did the damage that ultimately was done to the Columbia. Thank you.

MR. O’KEEFE: Senator, if I could, again, I don’t disagree with Admiral Gehman at all. I apologize for having understated this at all. Because it is a very significant event, there’s no doubt about it. I was referring very specifically to the bipod section. And Admiral Gehman is precisely right. This is how this is happening in each and every case. And I don’t want to understate this.

The question that’s really being debated internally in NASA right now, is why did we permit a process that would tolerate any strike? That’s the really important factor, I think. That we’re really going through the soul search now, saying what is it that contented ourselves to believing that any strike should have been tolerated? And that’s a much deeper process issue that really is being examined, and there’s a lot of real soul search going on. It says, we rationalized, based on historical evidence of what we thought was acceptable damage. Why would we think any level of damage would be deemed acceptable.

SENATOR BREAUX: Well, you’ve just put your finger on the real question. Is this, you know, if it had been one hit at one time, I think you could have been — somewhat would be justified in saying well, you know, it happened once, that’s out of thousands of flights. But it happened thousands of times. And this was probably the last time. Thank you.

CHAIRMAN McCAIN: Senator Brownback.

SENATOR SAM BROWNBACK (R-KS): Thank you very much witnesses, and I appreciate the information you’re putting forward.

Admiral Gehman, has the Commission come up with any ideas on changing the decision-making process to see that a mistake that had been made in judgments this time around — Administrator O’Keefe has already said that we clearly should have gotten imaging and there was a mistake in judgment that was made. Has the Commission come up with any recommendations to change the decision making process yet, that they’re willing to put forward.

ADMIRAL GEHMAN: Senator, we have not come to any conclusions yet, but I will predict, that probably a third of our report is going to be on this subject. Because we believe that that is really the lasting and the significant legacy that we can leave here. Yes indeed. We think that this is a systemic problem. That if you just change the people or change the names of the Committees, it won’t do any good. That there actually is a process problem here. And we have options on how to go about this. We have availed ourselves of literally dozens of experts in the area of safety engineering, risk assessment, risk management, high reliability organizations, in order that we can write authoritatively on this subject.

I will add also, parenthetically, that you, in our opinion, neither the Congress nor this Board, could get at these very, very deep-rooted institutional problems, unless we availed ourselves of the investigating technique that’s associated with a safety investigation, which people can speak without the fear of retribution.

SENATOR BROWNBACK: Well, who was responsible for the mistake in judgment this time around? Particularly on the imagery. You said, clearly, well okay, there was a mistake in judgment made at this. We should have gotten imagery. Who made that determination? Who was responsible for that decision?

ADMIRAL GEHMAN: I would not characterize that decision as a mistake by any one individual. When you’ve got an organization which is run by Boards and Committees, and those Boards and Committees don’t work, I’m not sure you can blame an individual person. So, I’ll have to duck that question. I can tell you which Board or Committee didn’t work as designed. And I can tell you why –.