Transcript (Part 4): Hearing on the Space Shuttle Columbia Investigation Before the Senate Committee on Commerce, Science & Transportation 14 May 2003

SENATOR BROWNBACK: — Which one didn’t?

ADMIRAL GEHMAN: In my opinion, because the Board hasn’t spoken on this yet. In my opinion, both the Boards that asses the condition of the orbiter before it’s launched, which are Boards and Committees set up by the Program Manager, and the Boards and Committees that run the mission after it’s flying, are ill-served by a system — by an imperfect system of checks and balances. And by that I mean specifically, the Safety Organization sits right beside the person making the decision.

But, behind the Safety Organization there’s nothing back there. There’s no people, money, engineering, expertise, analysis. The engineers sit right to the other side of them. But the engineering department is not independently funded. The engineers all have to charge to a program or something like that, so their allegiance is to the program. And we find that to be an imperfect system. The Boards are ill served. You’re going to get the same wrong answer no matter how many times you convene this Board. It doesn’t make a difference who the Chairman is.

SENATOR BROWNBACK: Now, this is a very troubling point that you make. They’re going to get the same wrong answers, why are we going to get the same wrong answers? These are good people. They’re all well-meaning people, why are we going to get the same wrong answers?

ADMIRAL GEHMAN: Once again, I’m kind of a little bit out in front of my headlights here, because the Board has not completely spoken on this. But giving my own personal view of it. We have availed ourselves of a very, very rich and deep academic world who studies in these kinds of things as well as industries, like nuclear power plants and petrochemical plants and things like that, about how do they do safety and how do they build in checks and balances, so that the people who are making a decision are getting good contrary opinions. And to us, it seems that this is the flaw in the system. That unless you change the management techniques and unless you change the procedures, you can change the people sitting at the seats and they’ll still not get good advice.

SENATOR BROWNBACK: Well, what you’re describing to me is a Committee without a head, or a process without a design, that just communicates a lot back and forth, but it doesn’t come to a — there’s not a responsible point at which this person is responsible for the decision making that takes place.

ADMIRAL GEHMAN: No, sir, I wouldn’t agree with that. There’s a Chairman and there’s someone responsible and everybody knows who that is. But the process is not serving that person very well.

SENATOR BROWNBACK: How is the process not serving that person specifically? How is the process not serving that person well?

ADMIRAL GEHMAN: Because the key advisors, the people who would bring up alternative points of view, the people who would say, wait a minute, this is not safe or they’re in the room, but they aren’t supported by — they can’t come argue their cases with 18 inches worth of documentation, because they aren’t funded well enough. They’re not independently funded, there aren’t enough people in there to do that independent research, in order that they can come to the table and make a persuasive argument. They’re just kind of there by themselves.

SENATOR BROWNBACK: They’re without backing?

ADMIRAL GEHMAN: They’re there without backing. And when you get into these very technical issues about whether this is safe, or whether or not this signal is important, or whether or not this little anomaly need paid attention to, you have to come with data. These are engineers. You have to come with facts and data and studies. You can’t just get in there and wave your arms and beat your breast. You’ve got to come armed with ammunition. And so the safety — we find the safety organization is on paper, perfect.

But, when you bore down a little bit deeper, you don’t find any there, there. And the Engineering Department looks precisely organized exactly right. But then when you go bore down and find out what these 600 engineers are doing, you find that three-quarters of them are funded by the program. And so you know where their allegiance is, etc.

So, we are going to try and make some recommendations to improve the process of safety, but don’t mislead — don’t — that’s why I’m giving this unsatisfactory answer — I know the Chairman’s still looking at me. But, that’s why we are trying to find a way to fix this and fix it right, but it isn’t necessarily any individual one person’s responsibility.

SENATOR BROWNBACK: So you need — excuse me for interrupting. So, you need internal muscle that’s separate and distinct from the program that can effectively argue within the structure –.

ADMIRAL GEHMAN: — Yes, sir, that’s correct –.

SENATOR BROWNBACK: — For the change that would need to be addressed. Is that correct?

ADMIRAL GEHMAN: That is correct. And we now, the Board is loathed to make specific organizational management recommendations, for the fear of the law of unintended consequences. We aren’t going to be around to manage these things and steer them. But I believe that when we write out report, we are going to give quite direct and specific guidelines on how this process ought to operate.

SENATOR BROWNBACK: Thank you, Mr. Chairman.

MR. O’KEEFE: Mr. Chairman, may I comment?

CHAIRMAN McCAIN: Sure. Could I comment first? When I was a young lad, the USS Missouri ran aground not too far from here. The Captain was asleep in the cabin, and the navigator ran it aground. The Captain was relieved immediately. But now, since there seems to be an interesting situation. No one is responsible for 9-11. No one is responsible. Excuse me, we’re all responsible, so therefore no one is responsible. No one’s responsible for 9-11, no one’s responsible for Khobar Towers, no one is responsible for a whole bunch of other bad things that have happened. We’re all responsible, so therefore no one is responsible. Go ahead.

MR. O’KEEFE: Thank you, Mr. Chairman. That is a perfect prelude to my respectful disagreement with my friend, the Chairman of the Columbia Accident Investigation Board. There is no ambiguity on who’s responsible. There are two folks who sit at the Flight Readiness Review. The Associate Administrator for Space Flight and the Safety Administrator for Safety and Mission Assurance. They sign the order that says, we certify this is ready for flight.

The argument that’s being advanced here is that the quality of advice they’re receiving, in the opinion, I think, of the Chairman of the Columbia Accident Investigation Board, needs further support. That’s a point that we’ve positively got to look at. But in terms of who is responsible, there is no question about it — who signs the certification on this case. There are identified, named individuals, who are part of this Mission Management Team.

Senator Snowe asked the question, how many people participated in that. Lots of engineers and so forth, you bet. Lots of folks participate there. But there are specified folk with name, faces, serial number, and you know, paychecks that are provided that are Chair of the Mission Management Team and members of it that make determinations and are responsible for that.

There will be accountability here. There is no question about it. This will not be ambiguous, about who is responsible at the end of the day. We’re awaiting the report. There are certain changes that have to be made. But in the end, there is no line or argument of a mush-mouth system here, of how these decisions are arrived at. There are individuals who you can identify and say, that is the responsible fish on it. I think the point that’s being made here is, the quality of advice that’s being rendered to them may not be as organized as it should be.

My attendance at flight readiness reviews in prior flights, and to include, you know, the most recently, I guess, 113, was you look in this room and everybody and anybody who has an opinion on the quality of the readiness of the orbiter to fly, are in that room. It’s a big confab. And anybody’s got the opportunity to step up and speak. And many of them are the functional equivalent in the space flight community of EF Hutton. Whenever they stand up, immediately everybody recognizes them, they stop everything until the issue is resolved. In the end, that judgment has to be rendered by two people. And that’s very clear in the way this process works. Same is true during an operation of Mission Management Team. And the issue, I think, that the Admiral Gehman was raising, is what is the quality of that advice, how is it organized and how do we make it more relevant for them to make the kinds of decisions they’re asked to make.

SENATOR BROWNBACK: Mr. Chairman, could I respond to this, because I want to bore in on this point, because it does seem to be very important one of it. What I hear the Admiral saying is that he’s saying there’s not a muscle, an independent muscle, behind this that’s challenging this process internally. But the people, the engineers and the others that are commenting, are part of a systemic system that’s funded, that’s one system. And it needs an independent muscle that’s there in the room that can speak from engineering data and specifics, that can challenge the decision making process. Is that correct, Admiral?

ADMIRAL GEHMAN: That is correct and by the way –.

SENATOR BROWNBACK: — Now if I could then — if I could — but Mr. O’Keefe — and I’m not here trying to point fingers, but I’m trying to figure out how we keep this from happening again. We don’t want any body to die. You don’t want anybody to. Do you agree with that assessment, that there’s not the independent muscle behind the challenge process internally in making these safety and engineering decisions?

MR. O’KEEFE: Again, I’m guided by this — by the view of the Board. If their view is, that it is inadequate, that’s the answer, it’s inadequate. And we will go fix that.

CHAIRMAN McCAIN: Thank you. Admiral Gehman, did you want to make an additional –?

ADMIRAL GEHMAN: — Thank you very much. As I indicated, we on the Board have grounded ourselves, we think, in aerodynamics and thermodynamics and physics, to the point where when we write what caused this accident, it’s unlikely that we’re going to get challenged on any of our findings. In order for us to write on this subject, we’ve had to ground ourselves in the — what we in the United States know about these very complex management techniques. And so we’ve done that to a great extent.

And two of the principles that have struck me, get to the point where indeed, the person who is the Chairman of this Board or the Chairman of this Committee, or the two people who have to sign the papers, they’re identified by name. We know who they are. And you know who they are. But so many of these experts in this area have told us, that just picking on those two people and firing them or something like that won’t prevent this from happening again. If you’ve got a flawed process, the next Chairman is going to make the same mistakes, probably. So, we’re quite driven by that.

The second thing that we’re quite driven by is writing out of a report, that I would like to acknowledge other people here, but the writing goes along the line of this — this way. That the wonderful engineers who give us all these magical things, also make a pact with the devil. I’m thinking about things like nuclear power plants and petrochemical plants and dams and things like that. But you get all these — and Space Shuttles. You get all these magical things from engineers, but the pact that you make with the devil is, you have to be vigilant forever. Because now you’ve got this dragon by the tail. And it could be that in the 25 years or 20 years of this program, as the conditions of Shuttle life change, the Board is looking at whether or not this vigilant forever law has been observed or somehow, have we migrated away from that. And the Board is going to try to write on that.

CHAIRMAN McCAIN: Very good.

Senator Nelson.

SENATOR BILL NELSON (D-FL): Thank you, Mr. Chairman.

Senator Brownback, I want to pick up on your line of questioning. But first, I want to say, Admiral, thank you for your public service. Thank you for the public service that you rendered even after your retirement with regard to the Cole investigation. Thank you for your public service for this. And it is this Senator’s hope that you are going to succeed. And that’s what we want to see, that you succeed.

In the line of questioning from Senator Brownback, and in your response earlier, with regard to the safety process that had been set up 17 years ago, and your quote was, there is no theres there. Now that makes my blood boil. Because, of the communication problems 17 years ago, with Challenger, which in large part, was that was the reason for the destruction of Challenger. That information could not flow from the bottom up. It was much easier flowing from the top down. And so, this process of safety was imposed, and the safety process was supposed to be an automatic fail-safe. But you say there’s no theres there. Why do you think we haven’t learned the lessons from Challenger, as painful as that was?

ADMIRAL GEHMAN: Senator Nelson, thank you very much for your vote of confidence. We’ll see whether or not that’s well-founded or not. But, the Board is going to spend an enormous amount of energy to answer that very question. It’s possible — it’s possible that we have the system that we have right now, because of Challenger. There were recommendations to consolidate, have a more formal chain of command, have a more strict and monolithic program, that were part of the Challenger recommendations. And once again, I don’t want to get ahead of myself.

But, we’re going to look at this in great detail. We have also looked at best business practices from other very, very risky communities. And have found how they do high reliability kinds of things. And the Board will attempt to write on an outline that will ensure that these kinds of safety issues do indeed get raised at the right level, and the people who have to make the judgments are advised well and that these issues are not submerged.

I don’t want to get into any more detail than to say that, at this time, preliminary — at this stage in our report, I am willing to volunteer that we are not completely satisfied that underneath the box that says safety at S&MA, that there’s a big robust organization which allows the person in the box to speak — come to the table with the same number of chips as everybody else. And under the box that says engineering director, that there’s not enough independent, good old engineering kind of think that NASA used to be known for, to come to the table and bang on the table and say, you’re wrong and I can prove it. That’s about as far as I’m willing to go at this point.

SENATOR NELSON: All right. Let me nail down something that the Chairman and Senator Hollings said earlier — ask you about, with regard to our Congressional oversight. I need to know specifically for the record, since you are trying to protect the identity of the witnesses, since you want to encourage people to come forth and tell the truth, without having to subpoena them for the truth, understandably, you want to protect their identity. What we need to know, is that testimony — that full testimony available to this Committee and our Congressional Oversight capacity?

ADMIRAL GEHMAN: The short answer is, we are in the process of working out an arrangement by which you will have access, by some process, to all that information. The short answer is, yes. If I may just say, that the purpose of giving witnesses guarantees of anonymity is not so they’ll tell the truth. That’s not the issue. They’ll tell the truth when they come up here and raise their hand. The purpose is to find out things that they would not volunteer under questioning. That’s this whole different range of information, a whole different body of insights, in which they may say something that they’re not fully sure of, for example. They just — or it’s a feeling that they have, or something they can’t prove, or something like that. Which they would not give to anybody which was doing this in a public forum.

SENATOR NELSON: Well, there was some question in Senator Hollings’s mind. I’m glad that you have clarified that, that the answer to the question is yes. All right, let me comment. I happen to agree with your statement about the old timers. That the old timers basically, if they knew there was the potential of a problem, they would have started working it. They’d have done photos immediately. They’d have started pulling out of their hip pocket every possible theory of changing anything that could be changed, as well as what Senator Hollings had said, coals soaking, no roll reversal to the left, maybe a different angle of attack.

What do you think — why did NASA and its leaders tolerate — I guess the question is, what is your report going to tell about reenacting this, of how you would do it, pursuant to the old timers?

ADMIRAL GEHMAN: The old timers certainly taught me something, which I find compelling. The business about photos for example, on over photography. They would say, it doesn’t make any difference whether you could have done anything to save this crew or not, we would have taken photographs, just so we would have known what happened.

I mean, the old timers are more flight test, test pilot kind of attitude, that even though the loss of the crew is terribly regretful, if you have a test pilot kind of an attitude, you always want to know what happened, so that they didn’t die in vain. So, of course they would have taken photographs. You wouldn’t have had to prove that there was a foam strike, all you had to do was scratch your head and say, hey, I don’t think I know what happened here and the next thing, all the lights would have gone off. And so that’s compelling to me. In other words, you don’t have to prove that somebody made a mistake or you don’t have to prove that an error in judgment was made.

The old timer attitude would have got your photographs just because. And maybe we couldn’t have done anything about it. But we would have — maybe we would have known what happened in this particular case. It’s more of an intellectual inquiry kind of an attitude.

Senator you weren’t in the room when I mentioned earlier that we and NASA have just begun, 10 days ago, a very in-depth and aggressive analysis of what could have been done. And I mentioned that we couldn’t have done this earlier, because there were too many emotions, everybody was too close to it. But now that we’ve got a little time separated, and we, the Board know a little bit more about this, together we are looking very, very hard at what might have been done.

But, I don’t really know that even if we find an answer, what, you know — put duct tape on it or something like that. I don’t know that it’s going to result in whether or not — whether it’s going to result in whether or not we could have saved this mission or not. I just don’t know.

The only thing I do know, and I know that the Administrator agrees with me, is we would not have done nothing. I mean that’s not the way we do things. We would have done something. And even if we only had a 10 percent chance of saving this, we would have done — there were two EPS suits on board. They could have gone out and taken a look at it. They could have put duct tape on the thing. I mean, I don’t know. I’m just making that up of course. But, they would have done something.

CHAIRMAN McCAIN: Senator Sununu.

SENATOR SUNUNU: I thank you, Mr. Chairman.

I want to begin by exploring this issue of accountability that the Chairman raised. Admiral, I think you said that, something to the effect that you don’t want to pick on those that are responsible for signing off on the flight security, because if there’s a flawed process, even if you have a replacement, you’ll still have a flawed process. And I would maybe differ with that just slightly.

The Chairman used an example of the Missouri, I think, that ran aground. Now, I don’t know that they changed the process or not, but my guess is, not only did the subsequent Captain not run aground, I bet the Missouri has never run aground since. So, we don’t want to single anyone out inappropriately. We want the criticisms to be based on good information, good analysis.

But I do think there’s something to be said for a system that does hold those in a position of responsibility, accountable. Even if there is a flawed process. And even if you’re not sure you’ve implemented a perfect process. Because a system that holds individuals accountable, will create an incentive for those in a position of responsibility, to do everything possible to make sure the support systems, the processes that help them make decisions are good ones. Would you agree with that?

ADMIRAL GEHMAN: I think you — I support your comments completely. I come from the system that that’s the way we do business. And I have no problem whatsoever with the process, the administrative processes of NASA and the Congress and the Administration, of taking whatever steps are necessary if you thing someone’s performance was lacking. It’s just not the function of this Board. Now, you will be able to tell from our report where to go looking. We’re not ducking the issue. It’s just not the function of this Board.

The function of this Board is to try and make space flight safer. Find out what happened and try and make space flight safer in the future, if we can. And we believe we will be able to do that for you. And if there are — if we found that someone had not executed their duties in accordance with NASA regulations, we will note that. But that’s not the purpose of this Board.