Nasa accused of negligence in Columbia shuttle disaster

By DAVID USBORNE in NEW YORK

Nasa stood accused today of complacency and negligence in a damning final report into the Columbia shuttle disaster six months ago.

Independent investigators slammed the organisation's flawed safety procedures, finding that those were as much to blame for the calamity in which seven astronauts died, as technical faults.

They highlighted Nasa's failure to heed warnings that insulation had broken away, damaging one of the shuttle's wings shortly after take-off. Sixteen days later, on February 1, the craft broke-up on re-entry over Texas, sending shockwaves through America.

The 248-page report, the product of a $20 million investigation, castigates Nasa for failing to learn the lessons of the Challenger disaster 16 years ago in which seven astronauts also died.

It focused on a "self-protective' culture at the heart of an organisation which sends human beings on the most perilous journeys known to mankind.

That culture meant that its managers accepted increasing levels risk to the point where they accepted some flaws as normal in the shuttle system.

"Nasa's organisational culture and structure had as much to do with this accident as the external tank foam," the board said.

In devastating terms, the investigators condemned Nasa top officials for showing a "lack of concern" about the technical problems engineers brought to their attention.

"From the beginning, the board witnessed a consistent lack of concern about the debris strike on Columbia".

Nasa managers told the investigation that 'there was no safety-of-flight issue' and 'we couldn't have done anything about it anyway.'

But the probe found that they also failed to heed specific and repeated warnings about the possibility of calamity for the Columbia after foam from its fuel tanks struck a wing after its lift-off.

The mechanical cause of the disaster was long ago identified: that a piece of foam on an external tank, the size of a suitcase, broke off 81 seconds after lift-off and punched a hole in the heat-shielding leading edge of the left wing. Upon reentry, the gash allowed superheated gases to invade the craft's structure and start to melt it.

Moreover, the flaws in the culture of Nasa and the attitude of its senior managers seen by the board "echo" those identified after the Challenger crash so many years ago.

If lessons were learned then, apparently many of them were swiftly forgotten.

Devastatingly, it accused the agency of "ineffective leadership" that "failed to fulfill the implicit contract to do whatever is possible to ensure the safety of the crew."

"At Nasa's urging, the nation committed to building an amazing, if compromised, vehicle called the Space Shuttle. When the agency did this, it accepted the bargain to operate and maintain the vehicle in the safest possible way. The Board is not convinced that NASA has completely lived up to the bargain" the report said.

The board stops short of suggesting that actions could have been taken to scoop the crew from the damaged shuttle, even if Nasa had understood the gravity of the situation during its flight.

"Given the current design of the orbiter, there was no possibility for the crew to survive," it said.

Nasa, for itself, has insisted that a rescue operation would have been impossible.

The most specific charge made by the investigators was that engineers at the agency repeatedly raised questions about the possible implications of the debris strike once the shuttle was in orbit.

On three occasions during the 16-day mission, they asked for satellite photographs of the craft to allow them to check for possible damage to its skin. Those pictures were never made available to them.

The report does not go so far as to say Nasa was blase about safety. Yet a final video inside the crew compartment shows that three crewmembers had failed to don their prescribed pressure suits, helmets and gloves for re-entry.

The board specifically did not argue that the remaining shuttles are inherently unsafe and should be grounded for good. In fact Nasa is hoping to resume flights next spring and astronaut training is under way.

Yet, the investigators did offer a slew of recommendations for reform at the agency, including a shake-up of its managerial structure, in the hope of curbing the risk of a third fatal accident.

Among the 29 recommendations:

* That Nasa create separate safety agencies that will be able to get the attention of top officials whenever a possible cause of future peril is uncovered.

* That pictures are routinely taken of the fuel tanks after separation from the shuttles to check for foam breakage.

* That further work is done to determine the quality of heat shielding reinforced carbon materials, before the fleet is allowed to fly again.

* And that photographs of orbiting craft are routinely taken by satellites.
Perhaps most devastating is the allegation that NASA, admittedly under crushing budget pressure from Washington, had slumped back into the practices found wanting after the 1986 accident.

"By the eve of the Columbia accident, institutional practices that were in effect at the time of the Challenger accident -- such as inadequate concern over deviations from expected performance, a silent safety program, and schedule pressure -- had returned to Nasa," the report bluntly asserted.

"These repeating patterns mean that flawed practices embedded in Nasa's organisational system continued for 20 years and made substantial contributions to both accidents," the text went on.

Moreover, the board darkly warned that unless those flaws are addressed at once more such tragedies are likely to re-occur.

"The board strongly believes that if these persistent, systemic flaws are not resolved, the scene is set for another accident," the report said.

Nasa was well prepared for the harshness of the report. Its head, Sean O'Keefe, told space workers in the summer that it was certain to be "really ugly". But just this week, he told members of the agency, "we need to not be defensive about that and try to not take it as a personal affront." Mr O'Keefe was to speak to all agency staff in a video address.

Some blame, meanwhile, is placed on the politicians in Washington. NASA has been under consistent pressure both to maintain its schedule to keep up with the construction plans for the International Space Station and to cut costs. Its budget lost 13 per cent of its purchasing power from 1993 to 2002.

"The White House, Congress and Nasa leadership exerted constant pressure to reduce or at least freeze operating costs," the report said. As a result, "safety and support upgrades were delayed or deferred, and Shuttle infrastructure was allowed to deteriorate."
It added: "Little by little, Nasa was accepting more and more risk in order to stay on schedule." Also: "The program was operating too close to too many margins."

- INDEPENDENT

The Columbia Accident Investigation Board report