This is an edited version of the Columbia Accident Investigation Board report released in August, 2003. It provides a comprehensive and often sobering example of management lapses that have severe consequences.

The original report was over 280 pages. This edited version eliminates the much of the technical discussion and focuses instead on the organizational factors that lead to the accident. You may obtain the entire report from http://www. caib. us/news/report/default.

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html I have included some sections for background. Read these sections to gain an overview of the accident and the report.I have included some pages simply to provide context for sections that relate to questions below.

I have placed arrows in the text to indicate those sections that are most important. Here Questions to Consider: 1. According to the report, what were the causes of the Columbia accident? 2. What were the essential features of the culture at NASA? 3. Which factors played the greatest role in the events leading up to the accident: logical factors, such as schedule, technicalities of the shuttle design, testing, or psychological, such as politics, the perspective of deadlines? 4. What was the meaning of February 19, 2004? . How did February 19, 2004 contribute to the Columbia accident? 6.

How did management and workforce differ in their perspective on the pressure to meet 2/19/04? Why did they differ? 7. What types of schedule management tools did NASA use? Were they effective? 8. What were the de facto priorities of the shuttle program leading up to the accident? 9. How did these priorities shape management’s perspective on “facts” presented by engineering after the launch of ST-107? 10. Which perspective on communication best explains the findings in the report: communication as information flow or communication as influence? 1. Which was most important in explaining the cultural factors leading up to the accident: a lack of management or a lack of leadership? Why? 12.

What role did the management’s perception of NASA’s history play in the events leading up to the accident? 13. What role did a willingness to learn from mistakes play in the events leading up to the accident? 14. Given the example of the Navy’s reactor safety program, how could NASA correct these organizational deficiencies? 15.

Could NASA managers have done a better job if they had followed Descartes’ four rules for thinking? Why? 6. What role did PowerPoint play in management’s failures? 17. How do the reports conclusions about leadership, culture, change, structure and risk apply to the management of everyday projects? COLUMBIA ACCIDENT INVESTIGATION BOARD Report Volume I August 2003 ACCIDENT INVESTIGATION BOARD COLUMBIA On the Front Cover This was the crew patch for STS-107. The central element of the patch was the microgravity symbol, µg, flowing into the rays of the Astronaut symbol. The orbital inclination was portrayed by the 39-degree angle of the Earth? s horizon to the Astronaut symbol.The sunrise was representative of the numerous science experiments that were the dawn of a new era for continued microgravity research on the International Space Station and beyond.

The breadth of science conducted on this mission had widespread benefits to life on Earth and the continued exploration of space, illustrated by the Earth and stars. The constellation Columba (the dove) was chosen to symbolize peace on Earth and the Space Shuttle Columbia. In addition, the seven stars represent the STS-107 crew members, as well as honoring the original Mercury 7 astronauts who paved the way to make research in space possible.

The Israeli flag represented the first person from that country to fly on the Space Shuttle. On the Back Cover This emblem memorializes the three U. S. human space flight accidents – Apollo 1, Challenger, and Columbia. The words across the top translate to: “To The Stars, Despite Adversity – Always Explore“ Limited First Printing, August 2003, by the Columbia Accident Investigation Board Subsequent Printing and Distribution by the National Aeronautics and Space Administration and the Government Printing Office Washington, D.

C. 2 Report Volume I August 2003 ACCIDENT INVESTIGATION BOARD COLUMBIA EXECUTIVE SUMMARYThe Columbia Accident Investigation Board? s independent investigation into the February 1, 2003, loss of the Space Shuttle Columbia and its seven-member crew lasted nearly seven months. A staff of more than 120, along with some 400 NASA engineers, supported the Board? s 13 members. Investigators examined more than 30,000 documents, conducted more than 200 formal interviews, heard testimony from dozens of expert witnesses, and reviewed more than 3,000 inputs from the general public. In addition, more than 25,000 searchers combed vast stretches of the Western United States to retrieve the spacecraft? s debris.In the process, Columbia? s tragedy was compounded when two debris searchers with the U. S. Forest Service perished in a helicopter accident.

The Board recognized early on that the accident was probably not an anomalous, random event, but rather likely rooted to some degree in NASA? s history and the human space flight program? s culture. Accordingly, the Board broadened its mandate at the outset to include an investigation of a wide range of historical and organizational issues, including political and budgetary considerations, compromises, and changing priorities over the life of the Space Shuttle Program.The Board? s conviction regarding the importance of these factors strengthened as the investigation progressed, with the result that this report, in its findings, conclusions, and recommendations, places as much weight on these causal factors as on the more easily understood and corrected physical cause of the accident. The physical cause of the loss of Columbia and its crew was a breach in the Thermal Protection System on the leading edge of the left wing, caused by a piece of insulating foam which separated from the left bipod ramp section of the External Tank at 81. seconds after launch, and struck the wing in the vicinity of the lower half of Reinforced CarbonCarbon panel number 8. During re-entry this breach in the Thermal Protection System allowed superheated air to penetrate through the leading edge insulation and progressively melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused loss of control, failure of the wing, and breakup of the Orbiter.

This breakup occurred in a flight regime in which, given the current design of the Orbiter, there was no possibility for the crew to survive. The organizational causes of this accident are rooted in the Space Shuttle Program? s history and culture, including the original compromises that were required to gain approval for the Shuttle, subsequent years of resource constraints, fluctuating priorities, schedule pressures, mischaracterization of the Shuttle as operational rather than developmental, and lack of an agreed national vision for human space flight.Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing in accordance with requirements); organizational barriers that prevented effective communication of critical safety information and Report Volume I d Here stifled professional differences of opinion; lack of integrated management across program elements; and the evolution of an informal chain of command and decision-making processes that operated outside the organization? rules. This report discusses the attributes of an organization that could more safely and reliably operate the inherently risky Space Shuttle, but does not provide a detailed organizational prescription. Among those attributes are: a robust and independent program technical authority that has complete control over specifications and requirements, and waivers to them; an independent safety assurance organization with line authority over all levels of safety oversight; and an organizational culture that reflects the best characteristics of a learning organization.This report concludes with recommendations, some of which are specifically identified and prefaced as “before return to flight. ” These recommendations are largely related to the physical cause of the accident, and include preventing the loss of foam, improved imaging of the Space Shuttle stack from liftoff through separation of the External Tank, and on-orbit inspection and repair of the Thermal Protection System.

The remaining recommendations, for the most part, stem from the Board? s findings on organizational cause factors.While they are not “before return to flight” recommendations, they can be viewed as “continuing to fly” recommendations, as they capture the Board? s thinking on what changes are necessary to operate the Shuttle and future spacecraft safely in the mid- to long-term. These recommendations reflect both the Board? s strong support for return to flight at the earliest date consistent with the overriding objective of safety, and the Board? s conviction that operation of the Space Shuttle, and all human spaceflight, is a developmental activity with high inherent risks.A view from inside the Launch Control Center as Columbia rolls out to Launch Complex 39-A on December 9, 2002. August 2003 9 ACCIDENT INVESTIGATION BOARD COLUMBIA CHAPTER 5 From Challenger to Columbia The Board is convinced that the factors that led to the Columbia accident go well beyond the physical mechanisms discussed in Chapter 3.

The causal roots of the accident can also be traced, in part, to the turbulent post-Cold War policy environment in which NASA functioned during most of the years between the destruction of Challenger and the loss of Columbia.The end of the Cold War in the late 1980s meant that the most important political underpinning of NASA? s Human Space Flight Program – U. S.

-Soviet space competition – was lost, with no equally strong political objective to replace it. No longer able to justify its projects with the kind of urgency that the superpower struggle had provided, the agency could not obtain budget increases through the 1990s. Rather than adjust its ambitions to this new state of affairs, NASA continued to push an ambitious agenda of space science and exploration, including a costly Space Station Program.If NASA wanted to carry out that agenda, its only recourse, given its budget allocation, was to become more efficient, accomplishing more at less cost. The search for cost reductions led top NASA leaders over the past decade to downsize the Shuttle workforce, outsource various Shuttle Program responsibilities – including safety oversight – and consider eventual privatization of the Space Shuttle Program. The program? budget was reduced by 40 percent in purchasing power over the past decade and repeatedly raided to make up for Space Station cost overruns, even as the Program maintained a launch schedule in which the Shuttle, a developmental vehicle, was used in an operational mode. In addition, the uncertainty of top policymakers in the White House, Congress, and NASA as to how long the Shuttle would fly before being replaced resulted in the delay of upgrades needed to make the Shuttle safer and to extend its service life.

The Space Shuttle Program has been transformed since the late 1980s implementation of post-Challenger management changes in ways that raise questions, addressed here and in later chapters of Part Two, about NASA? s ability to safely Report Volume I operate the Space Shuttle. While it would be inaccurate to say that NASA managed the Space Shuttle Program at the time of the Columbia accident in the same manner it did prior to Challenger, there are unfortunate similarities between the agency? s performance and safety practices in both periods. . 1 THE CHALLENGER ACCIDENT AND ITS AFTERMATH The inherently vulnerable design of the Space Shuttle, described in Chapter 1, was a product of policy and technological compromises made at the time of its approval in 1972. That approval process also produced unreasonable expectations, even myths, about the Shuttle? s future performance that NASA tried futilely to fulfill as the Shuttle became “operational” in 1982.

At first, NASA was able to maintain the image of the Shuttle as an operational vehicle.During its early years of operation, the Shuttle launched satellites, performed on-orbit research, and even took members of Congress into orbit. At the beginning of 1986, the goal of “routine access to space” established by President Ronald Reagan in 1982 was ostensibly being achieved. That appearance soon proved illusory. On the cold morning of January 28, 1986, the Shuttle Challenger broke apart 73 seconds into its climb towards orbit. On board were Francis R. Scobee, Michael J. Smith, Ellison S.

Onizuka, Judith A.Resnick, Ronald E. McNair, Sharon Christa McAuliffe, and Gregory B.

Jarvis. All perished. Rogers Commission On February 3, 1986, President Reagan created the Presidential Commission on the Space Shuttle Challenger Accident, which soon became known as the Rogers Commission after its chairman, former Secretary of State William Rogers. The Commission? s report, issued on June 6, 1986, concluded that the loss of Challenger was caused by a failure of the joint and seal between the two lower segments of the right Solid Rocket Booster.

Hot gases blew past a rubber O-ring in the joint, leading to a structural failure and the explosive burnAugust 2003 99 ACCIDENT INVESTIGATION BOARD COLUMBIA ing of the Shuttle? s hydrogen fuel. While the Rogers Commission identified the failure of the Solid Rocket Booster joint and seal as the physical cause of the accident, it also noted a number of NASA management failures that contributed to the catastrophe. The Rogers Commission concluded “the decision to launch the Challenger was flawed. Communication failures, incomplete and misleading information, and poor management judgments all figured in a decision-making process that permitted, in the words of the Commission, “internal flight safety problems to bypass key Shuttle managers. ” As a result, if those making the launch decision “had known all the facts, it is highly unlikely that they would have decided to launch. ” Far from meticulously guarding against potential problems, the Commission found that NASA had required “a contractor to prove that it was not safe to launch, rather than proving it was safe. 1 The Commission also found that NASA had missed warning signs of the impending accident.

When the joint began behaving in unexpected ways, neither NASA nor the Solid Rocket Motor manufacturer Morton-Thiokol adequately tested the joint to determine the source of the deviations from specifications or developed a solution to them, even though the problems frequently recurred. Nor did they respond to internal warnings about the faulty seal. Instead, Morton-Thiokol and NASA management came to see the problems as an acceptable flight risk – a violation of a design requirement that could be tolerated. During this period of increasing uncertainty about the joint? s performance, the Commission found that NASA? s safety system had been “silent.

” Of the management, organizational, and communication failures that contributed to the accident, four related to faults within the safety system, including “a lack of problem reporting requirements, inadequate trend analysis, misrepresentation of criticality, and lack of involvement in critical discussions. ”3 The checks and balances the safety system was meant to provide were not working.Still another factor influenced the decisions that led to the accident.

The Rogers Commission noted that the Shuttle? s increasing flight rate in the mid-1980s created schedule pressure, including the compression of training schedules, a shortage of spare parts, and the focusing of resources on near-term problems. NASA managers “may have forgotten–partly because of past success, partly because of their own well-nurtured image of the program–that the Shuttle was still in a research and development phase. ”4 The Challenger accident had profound effects on the U. S. pace program. On August 15, 1986, President Reagan announced that “NASA will no longer be in the business of launching private satellites.

” The accident ended Air Force and intelligence community reliance on the Shuttle to launch national security payloads, prompted the decision to abandon the yet-to-be-opened Shuttle launch site at Vandenberg Air Force Base, and forced the development of improved expendable launch vehicles. 6 A 1992 White House advisory committee concluded that the recovery from the Challenger 100 Report Volume I SELECTED ROGERS COMMISSION RECOMMENDATIONS “The faulty Solid Rocket Motor joint and seal must be changed. This could be a new design eliminating the joint or a redesign of the current joint and seal. No design options should be prematurely precluded because of schedule, cost or reliance on existing hardware. All Solid Rocket Motor joints should satisfy the following: • “The joints should be fully understood, tested and verified. ” • “The certification of the new design should include: • Tests which duplicate the actual launch configuration as closely as possible. • Tests over the full range of operating conditions, including temperature. • “Full consideration should be given to conducting static firings of the exact flight configuration in a vertical attitude.

” • “The Shuttle Program Structure should be reviewed. The project managers for the various elements of the Shuttle program felt more accountable to their center management than to the Shuttle program organization. ” • “NASA should encourage the transition of qualified astronauts into agency management positions. ” • “NASA should establish an Office of Safety, Reliability and Quality Assurance to be headed by an Associate Administrator, reporting directly to the NASA Administrator.

It would have direct authority for safety, reliability, and quality assurance throughout the agency. The office should be assigned the work force to ensure adequate oversight of its functions and should be independent of other NASA functional and program responsibilities. ” • “NASA should establish an STS Safety Advisory Panel reporting to the STS Program Manager. The charter of this panel should include Shuttle operational issues, launch commit criteria, flight rules, flight readiness and risk management. • “The Commission found that Marshall Space Flight Center project managers, because of a tendency at Marshall to management isolation, failed to provide full and timely information bearing on the safety of flight 51-L [the Challenger mission] to other vital elements of Shuttle program management … NASA should take energetic steps to eliminate this tendency at Marshall Space Flight Center, whether by changes of personnel, organization, indoctrination or all three. ” • “The nation? s reliance on the Shuttle as its principal space launch capability created a relentless pressure on NASA to increase the flight rate … NASA must stablish a flight rate that is consistent with its resources. ”5 disaster cost the country $12 billion, which included the cost of building the replacement Orbiter Endeavour.

7 It took NASA 32 months after the Challenger accident to redesign and requalify the Solid Rocket Booster and to return the Shuttle to flight. The first post-accident flight was launched on September 29, 1988. As the Shuttle returned to flight, NASA Associate Administrator for Space Flight August 2003 ACCIDENT INVESTIGATION BOARD COLUMBIA Richard Truly commented, “We will always have to treat it [the Shuttle] like an R&D test program, even many years into the future.

I don? t think calling it operational fooled anybody within the program … It was a signal to the public that shouldn? t have been sent. ”8 The Shuttle Program After Return to Flight After the Rogers Commission report was issued, NASA made many of the organizational changes the Commission recommended. The space agency moved management of the Space Shuttle Program from the Johnson Space Center to NASA Headquarters in Washington, D. C.

The intent of this change was to create a management structure “resembling that of the Apollo program, with the aim of preventing communication Read Here deficiencies that contributed to the Challenger accident. 9 NASA also established an Office of Safety, Reliability, and Quality Assurance at its Headquarters, though that office was not given the “direct authority” over all of NASA? s safety operations as the Rogers Commission had recommended. Rather, NASA human space flight centers each retained their own safety organization reporting to the Center Director. In the almost 15 years between the return to flight and the loss of Columbia, the Shuttle was again being used on a regular basis to conduct space-based research, and, in line with NASA? original 1969 vision, to build and service a space station. The Shuttle flew 87 missions during this period, compared to 24 before Challenger. Highlights from these missions include the 1990 launch, 1993 repair, and 1999 and 2002 servicing of the Hubble Space Telescope; the launch of several major planetary probes; a number of Shuttle-Spacelab missions devoted to scientific research; nine missions to rendezvous with the Russian space station Mir; the return of former Mercury astronaut Senator John Glenn to orbit in October 1998; and the launch of the first U.S. elements of the International Space Station.

After the Challenger accident, the Shuttle was no longer described as “operational” in the same sense as commercial aircraft. Nevertheless, NASA continued planning as if the Shuttle could be readied for launch at or near whatever date was set. Tying the Shuttle closely to International Space Station needs, such as crew rotation, added to the urgency of maintaining a predictable launch schedule. The Shuttle is currently the only means to launch the already-built European, Japanese, and remaining U. S.

odules needed to complete Station assembly and to carry and return most experiments and on-orbit supplies. 10 Even after three occasions when technical problems grounded the Shuttle fleet for a month or more, NASA continued to assume that the Shuttle could regularly and predictably service the Station. In recent years, this coupling between the Station and Shuttle has become the primary driver of the Shuttle launch schedule.

Whenever a Shuttle launch is delayed, it impacts Station assembly and operations. In September 2001, testimony on the Shuttle? achievements during the preceding decade by NASA? s then-Deputy Associate Administrator for Space Flight William Readdy indicated the assumptions under which NASA was operating during that period: Report Volume I The Space Shuttle has made dramatic improvements in the capabilities, operations and safety of the system. The payload-to-orbit performance of the Space Shuttle has been significantly improved – by over 70 percent to the Space Station. The safety of the Space Shuttle has also been dramatically improved by reducing risk by more than a factor of five.In addition, the operability of the system has been significantly improved, with five minute launch windows – which would not have been attempted a decade ago – now becoming routine.

This record of success is a testament to the quality and dedication of the Space Shuttle management team and workforce, both civil servants and contractors. 11 5. 2 THE NASA HUMAN SPACE FLIGHT CULTURE Though NASA underwent many management reforms in the wake of the Challenger accident and appointed new directors at the Johnson, Marshall, and Kennedy centers, the agency? powerful human space flight culture remained intact, as did many institutional practices, even if in a modified form. As a close observer of NASA? s organizational culture has observed, “Cultural norms tend to be fairly resilient … The norms bounce back into shape after being stretched or bent.

Beliefs held in common throughout the organization resist alteration. ”12 This culture, as will become clear across the chapters of Part Two of this report, acted over time to resist externally imposed change.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. ORGANIZATIONAL CULTURE Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of a particular institution. At the most basic level, organizational culture defines the assumptions that employees make as they carry out their work; it defines “the way we do things here. ” An organization? culture is a powerful force that persists through reorganizations and the departure of key personnel. The human space flight culture within NASA originated in the Cold War environment. The space agency itself was created in 1958 as a response to the Soviet launch of Sputnik, the first artificial Earth satellite.

In 1961, President John F. Kennedy charged the new space agency with the task of reaching the moon before the end of the decade, and asked Congress and the American people to commit the immense resources for doing so, even though at the time NASA had only accumulated 15 minutes of human space flight experience.With its efforts linked to U. S.

-Soviet competition for global leadership, there was a sense in the NASA workforce that the agency was engaged in a historic struggle central to the nation? s agenda. The Apollo era created at NASA an exceptional “can-do” culture marked by tenacity in the face of seemingly impossible challenges. This culture valued the interaction among August 2003 101 ACCIDENT INVESTIGATION BOARD COLUMBIA research and testing, hands-on engineering experience, and a dependence on the exceptional quality of the its workforce and leadership that provided in-house technical capability to oversee the work of contractors.

The culture also accepted risk and failure as inevitable aspects of operating in space, even as it held as its highest value attention to detail in order to lower the chances of failure. The dramatic Apollo 11 lunar landing in July 1969 fixed NASA? s achievements in the national consciousness, and in history. However, the numerous accolades in the wake of the moon landing also helped reinforce the NASA staff? s faith in their organizational culture.Apollo successes created the powerful image of the space agency as a “perfect place,” as “the best organization that human beings could create to accomplish selected goals. ”13 During Apollo, NASA was in many respects a highly successful organization capable of achieving seemingly impossible feats. The continuing image of NASA as a “perfect place” in the years after Apollo left NASA employees unable to recognize that NASA never had been, and still was not, perfect, nor was it as symbolically important in the continuing Cold War struggle as it had been for its first decade of existence.NASA personnel maintained a vision of their agency that was rooted in the glories of an earlier time, even as the world, and thus the context within which the space agency operated, changed around them. As a result, NASA? s human space flight culture never fully adapted to the Space Shuttle Program, with its goal of routine access to space rather than further exploration beyond low-Earth orbit.

The Apollo-era organizational culture came to be in tension with the more bureaucratic space agency of the 1970s, whose focus turned from designing new spacecraft at any expense to repetitively flying a reusable vehicle on an ever-tightening budget.This trend toward bureaucracy and the associated increased reliance on contracting necessitated more effective communications and more extensive safety oversight processes than had been in place during the Apollo era, but the Rogers Commission found that such features were lacking. In the aftermath of the Challenger accident, these contradictory forces prompted a resistance to externally imposed changes and an attempt to maintain the internal belief that NASA was still a “perfect place,” alone in its ability to execute a program of human space flight.Within NASA centers, as Human Space Flight Program managers strove to maintain their view of the organization, they lost their ability to accept criticism, leading them to reject the recommendations of many boards and blue-ribbon panels, the Rogers Commission among them. External criticism and doubt, rather than spurring NASA to change for the better, instead reinforced the will to “impose the party line vision on the environment, not to reconsider it,” according to one authority on organizational behavior.This in turn led to “flawed decision making, self deception, introversion and a diminished curiosity about the world outside the perfect place. ”14 The NASA human space flight culture the Board found during its investigation manifested many of these characteristics, in particular a self-confidence about NASA possessing unique knowledge about how to 102 Report Volume I safely launch people into space.

15 As will be discussed later in this chapter, as well as in Chapters 6, 7, and 8, the Board views this cultural resistance as a fundamental impediment to NASA? s effective organizational performance. 5. AN AGENCY TRYING TO DO TOO MUCH WITH TOO LITTLE A strong indicator of the priority the national political leadership assigns to a federally funded activity is its budget.

By that criterion, NASA? s space activities have not been high on the list of national priorities over the past three decades (see Figure 5. 3-1). After a peak during the Apollo program, when NASA? s budget was almost four percent of the federal budget, NASA? s budget since the early 1970s has hovered at one percent of federal spending or less. 4.

0 3. 5 Percent of Federal Budget 3. 0 2. 5 2. 0 1. 5 1. 0 0. 5 0.

0 1959 1962 1965 1968 1971 1974 1977 1980 983 1986 1989 1992 1995 1998 Figure 5. 3-1. NASA budget as a percentage of the Federal budget. (Source: NASA History Office) Particularly in recent years, as the national leadership has confronted the challenging task of allocating scarce public resources across many competing demands, NASA has had difficulty obtaining a budget allocation adequate to its continuing ambitions. In 1990, the White House chartered a blue-ribbon committee chaired by aerospace executive Norman Augustine to conduct a sweeping review of NASA and its programs in response to Shuttle problems and the flawed mirror on the Hubble Space Telescope. 6 The review found that NASA? s budget was inadequate for all the programs the agency was executing, saying that “NASA is currently over committed in terms of program obligations relative to resources available–in short, it is trying to do too much, and allowing too little margin for the unexpected.

”17 “A reinvigorated space program,” the Augustine committee went on to say, “will require real growth in the NASA budget of approximately 10 percent per year (through the year 2000) reaching a peak spending level of about $30 billion per year (in constant 1990 dollars) by about the year 2000. Translated into the actual dollars of Fiscal Year 2000, that recommendation would have meant a NASA budget of over $40 billion; the actual NASA budget for that year was $13. 6 billion.

18 During the past decade, neither the White House nor Congress has been interested in “a reinvigorated space program. ” Instead, the goal has been a program that would continue to August 2003 2001 ACCIDENT INVESTIGATION BOARD COLUMBIA produce valuable scientific and symbolic payoffs for the nation without a need for increased budgets.Recent budget allocations reflect this continuing policy reality. Between 1993 and 2002, the government? s discretionary spending grew in purchasing power by more than 25 percent, defense spending by 15 percent, and non-defense spending by 40 percent (see Figure 5. 3-2). NASA? s budget, in comparison, showed little change, going from $14. 31 billion in Fiscal Year 1993 to a low of $13. 6 billion in Fiscal Year 2000, and increasing to $14.

87 billion in Fiscal Year 2002. This represented a loss of 13 percent in purchasing power over the decade (see Figure 5. -3). 19 1. 50 The lack of top-level interest in the space program led a 2002 review of the U. S.

aerospace sector to observe that “a sense of lethargy has affected the space industry and community. Instead of the excitement and exuberance that dominated our early ventures into space, we at times seem almost apologetic about our continued investments in the space program. ”20 WHAT THE EXPERTS HAVE SAID Warnings of a Shuttle Accident “Shuttle reliability is uncertain, but has been estimated to range between 97 and 99 percent.If the Shuttle reliability is 98 percent, there would be a 50-50 chance of losing an Orbiter within 34 flights … The probability of maintaining at least three Orbiters in the Shuttle fleet declines to less than 50 percent after flight 113. ”21 -The Office of Technology Assessment, 1989 Change from Base Year 1993 1. 40 1. 30 Non-Defense 1. 20 1.

10 Total Discretionary Defense 1. 00 0. 90 FY 1993 NASA FY 1994 FY 1995 FY 1996 FY 1997 FY 1998 FY 1999 FY 2000 FY 2001 FY 2002 Figure 5. 3-2. Changes in Federal spending from 1993 through 2002. (Source: NASA Office of Legislative Affairs) And although it is a subject that meets with reluctance to open discussion, and has therefore too often been relegated to silence, the statistical evidence indicates that we are likely to lose another Space Shuttle in the next several years … probably before the planned Space Station is completely established on orbit. This would seem to be the weak link of the civil space program – unpleasant to recognize, involving all the uncertainties of statistics, and difficult to resolve.

” -The Augustine Committee, 1990 Fiscal Year 1965 1975 1985 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004Real Dollars (in millions) 5,250 3,229 7,573 14,310 14,570 13,854 13,884 13,709 13,648 13,653 13,601 14,230 14,868 15,335 (requested) 15,255 Constant Dollars (in FY 2002 millions) 24,696 10,079 11,643 17,060 16,965 15,790 15,489 14,994 14,641 14,443 14,202 14,559 14,868 NA NA Shuttle as Developmental Vehicle “Shuttle is also a complex system that has yet to demonstrate an ability to adhere to a fixed schedule” NASA Human Space Flight Culture “NASA has not been sufficiently responsive to valid criticism and the need for change. ”22 -The Augustine Committee, 1990 The Augustine Committee, 1990 Faced with this budget situation, NASA had the choice of either eliminating major programs or achieving greater efficiencies while maintaining its existing agenda. Agency leaders chose to attempt the latter. They continued to develop the space station, continued robotic planetary and scientific missions, and continued Shuttle-based missions for both scientific and symbolic purposes. In 1994 they took on the responsibility for developing an advanced technology launch vehicle in partnership with the private sector.They tried to do this by becoming more efficient. “Faster, better, cheaper” became the NASA slogan of the 1990s.

23 The flat budget at NASA particularly affected the human space flight enterprise. During the decade before the Columbia accident, NASA rebalanced the share of its budget allocated to human space flight from 48 percent of agency funding in Fiscal Year 1991 to 38 percent in Fiscal Year 1999, with the remainder going mainly to other science and technology efforts. On NASA? s fixed budget, that meant August 2003 Figure 5. 3-3. NASA Budget. Source: NASA and Office of Management and Budget) Report Volume I 103 ACCIDENT INVESTIGATION BOARD COLUMBIA EARMARKS Pressure on NASA? s budget has come not only from the White House, but also from the Congress. In recent years there has been an increasing tendency for the Congress to add “earmarks” – congressional additions to the NASA budget request that reflect targeted Members? interests.

These earmarks come out of already-appropriated funds, reducing the amounts available for the original tasks. For example, as Congress considered NASA? Fiscal Year 2002 appropriation, the NASA Administrator told the House Appropriations subcommittee with jurisdiction over the NASA budget that the agency was “extremely concerned regarding the magnitude and number of congressional earmarks” in the House and Senate versions of the NASA appropriations bill. 24 He noted “the total number of House and Senate earmarks … is approximately 140 separate items, an increase of nearly 50 percent over FY 2001.

” These earmarks reflected “an increasing fraction of items that circumvent the peer review process, or involve construction or other objectives that have no relation to NASA mission objectives. The potential Fiscal Year 2002 earmarks represented “a net total of $540 million in reductions to ongoing NASA programs to fund this extremely large number of earmarks. ”25 tion of Boris Yeltsin and halting the proliferation of nuclear weapons and the means to deliver them. Space Shuttle Program Budget Patterns For the past 30 years, the Space Shuttle Program has been NASA? s single most expensive activity, and of all NASA? s efforts, that program has been hardest hit by the budget constraints of the past decade.Given the high priority assigned after 1993 to completing the costly International Space Station, NASA managers have had little choice but to attempt to reduce the costs of operating the Space Shuttle. This left little funding for Shuttle improvements. The squeeze on the Shuttle budget was even more severe after the Office of Management and Budget in 1994 insisted that any cost overruns in the International Space Station budget be made up from within the budget allocation for human space flight, rather than from the agency? s budget as a whole. The Shuttle was the only other large program within that budget category.

Figures 5. 3-4 and 5. 3-5 show the trajectory of the Shuttle budget over the past decade. In Fiscal Year 1993, the outgoing Bush administration requested $4. 128 billion for the Space Shuttle Program; five years later, the Clinton Administration request was for $2. 977 billion, a 27 percent reduction.

By Fiscal Year 2003, the budget request had increased to $3. 208 billion, still a 22 percent reduction from a decade earlier. With inflation taken into account, over the past decade, there has been a reduction of approximately 40 percent in the purchasing power of the program? budget, compared to a reduction of 13 percent in the NASA budget overall. Change –50. 0 –417. 4** –168. 9 –53.

0 0. 0 –50. 0 –31. 0 +25.

0 –40. 0 –5. 0 +44. 8 NASA Operating Plan* 4,052. 9 3,772.

3 3,155. 1 3,143. 8 2,960. 9 2,912. 8 2,998. 3 2,984.

4 3,118. 8 3,270. 0 Change –25.

1 –6. 4 0. 0 –35. 0 –190. 0 –15.

0 –29. 7 –26. 8 –6. 9 –8. 9 the Space Shuttle and the International Space Station were competing for decreasing resources. In addition, at least $650 million of NASA? s human space flight budget was used to purchase Russian hardware and services related to U.S.

-Russian space cooperation. This initiative was largely driven by the Clinton Administration? s foreign policy and national security objectives of supporting the administraFiscal Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 President? s Request to Congress 4,128. 0 4,196.

1 3,324. 0 3,231. 8 3,150. 9 2,977. 8 3,059. 0 2,986. 2 3,165.

7 3,283. 8 3,208. 0 Congressional Appropriation 4,078.

0 3,778. 7 3,155. 1 3,178. 8 3,150.

9 2,927. 8 3,028. 0 3,011. 2 3,125.

7 3,278. 8 3,252. 8 Figure 5. 3-4. Space Shuttle Program Budget (in millions of dollars). Source: NASA Office of Space Flight) * NASA? s operating plan is the means for adjusting congressional appropriations among various activities during the fiscal year as changing circumstances dictate. These changes must be approved by NASA? s appropriation subcommittees before they can be put into effect. **This reduction primarily reflects the congressional cancellation of the Advanced Solid Rocket Motor Program 104 Report Volume I August 2003 ACCIDENT INVESTIGATION BOARD COLUMBIA 6000 5500 40% Purchasing Power 45% Purchasing Power CONGRESSIONAL BUDGET REDUCTIONSIn most years, Congress appropriates slightly less for the Space Shuttle Program than the President requested; in some cases, these reductions have been requested by NASA during the final stages of budget deliberations.

After its budget was passed by Congress, NASA further reduced the Shuttle budget in the agency? s operating plan–the plan by which NASA actually allocates its appropriated budget during the fiscal year to react to changing program needs. These released funds were allocated to other activities, both within the human space flight program and in other parts of the agency.Changes in recent years include: Fiscal Year 1997 • NASA transferred $190 million to International Space Station (ISS). Fiscal Year 1998 • At NASA? s request, Congress transferred $50 million to ISS. • NASA transferred $15 million to ISS. Fiscal Year 1999 • At NASA? s request, Congress reduced Shuttle $31 million so NASA could fund other requirements. • NASA reduced Shuttle $32 million by deferring two flights; funds transferred to ISS. • NASA added $2.

3 million from ISS to previous NASA request. Fiscal Year 2000 • Congress added $25 million to Shuttle budget for upgrades and transferred $25 million from operations to upgrades. NASA reduced Shuttle $11. 5 million per governmentwide rescission requirement and transferred $15. 3 million to ISS. Fiscal Year 2001 • At NASA? s request, Congress reduced Shuttle budget by $40 million to fund Mars initiative.

• NASA reduced Shuttle $6. 9 million per rescission requirement. Fiscal Year 2002 • Congress reduced Shuttle budget $50 million to reflect cancellation of electric Auxiliary Power Unit and added $20 million for Shuttle upgrades and $25 million for Vehicle Assembly Building repairs. • NASA transferred $7. 6 million to fund Headquarters requirements and cut $1. million per rescission requirement.

[Source: Marcia Smith, Congressional Research Service, Presentation at CAIB Public Hearing, June 12, 2003] Constant FY 2002 Dollars in Millions 5000 4500 4000 3500 3000 2500 2000 1500 Flight Rate “Freeze Design” Policy (Kraft Report) Space Flight Operations Contract Initial Funding for High Priority Safety Upgrades Initiated Space Shuttle Upgrades Prgrm Operating Plan Actuals 7 8 6 8 8 4 1st Flight to ISS FY 2004 President’s Budget 7 4 6 5 5 5 5 5 4 4 91 92 Y93 Y94 Y95 Y96 Y97 Y98 Y99 Y00 Y01 Y02 Y03 Y04 Y05 Y06 Y07 Y08 F F F F F F F F F F F F F F FY FY F FFigure 5. 3-5. NASA budget as a percentage of the Federal budget from 1991 to 2008. (Source: NASA Office of Space Flight) This budget squeeze also came at a time when the Space Shuttle Program exhibited a trait common to most aging systems: increased costs due to greater maintenance requirements, a declining second- and third-tier contractor support base, and deteriorating infrastructure.

Maintaining the Shuttle was becoming more expensive at a time when Shuttle budgets were decreasing or being held constant. Only in the last few years have those budgets begun a gradual increase.As Figure 5. 3-5 indicates, most of the steep reductions in the Shuttle budget date back to the first half of the 1990s.

In the second half of the decade, the White House Office of Management and Budget and NASA Headquarters held the Shuttle budget relatively level by deferring substantial funding for Shuttle upgrades and infrastructure improvements, while keeping pressure on NASA to limit increases in operating costs. 5. 4 TURBULENCE IN NASA HITS THE SPACE SHUTTLE PROGRAM In 1992 the White House replaced NASA Administrator Richard Truly with aerospace executive Daniel S.Goldin, a self-proclaimed “agent of change” who held office from April 1, 1992, to November 17, 2001 (in the process becoming the longest-serving NASA Administrator). Seeing “space exploration (manned and unmanned) as NASA? s principal purpose with Mars as a destiny,” as one management scholar observed, and favoring “administrative transformation” of NASA, Goldin engineered “not one or two policy changes, but a torrent of changes. This was not evolutionary change, but radical or discontinuous change. ”26 His tenure at NASA was one of continuous turmoil, to which the Space Shuttle Program was not immune.

Of course, turbulence does not necessarily degrade organizational performance. In some cases, it accompanies productive change, and that is what Goldin hoped to achieve. He believed in the management approach advocated by W. Edwards Deming, who had developed a series of widely acclaimed management principles based on his work in Japan during the “economic miracle” of the 1980s. Goldin attempted to apply some of those principles to NASA, including the notion that a corporate headquarters should Report Volume I ot attempt to exert bureaucratic control over a complex organization, but rather set strategic directions and provide operating units with the authority and resources needed to pursue those directions. Another Deming principle was that checks and balances in an organization were unnecessary August 2003 105 ACCIDENT INVESTIGATION BOARD COLUMBIA 5. 6 A CHANGE IN NASA LEADERSHIP Read Here Figure 5. 5-4.

Age of the Space Shuttle infrastructure. (Source: Connie Milton to Space Flight Advisory Council, 2000. Daniel Goldin left NASA in November 2001 after more than nine years as Administrator. The White House chose Sean O?Keefe, the Deputy Director of the White House Office of Management and Budget, as his replacement. O? Keefe stated as he took office that he was not a “rocket scientist,” but rather that his expertise was in the management of large government programs. His appointment was an explicit acknowledgement by the new Bush administration that NASA? s primary problems were managerial and financial. By the time O? Keefe arrived, NASA managers had come to recognize that 1990s funding reductions for the Space Shuttle Program had resulted in an excessively fragile program, and also realized that a Space Shuttle replacement was not on the horizon.In 2002, with these issues in mind, O? Keefe made a number of changes to the Space Shuttle Program.

He transferred management of both the Space Shuttle Program and the International Space Station from Johnson Space Center to NASA Headquarters. O? Keefe also began considering whether to expand the Space Flight Operations Contract to cover additional Space Shuttle elements, or to pursue “competitive sourcing,” a Bush administration initiative that encouraged government agencies to compete with the private sector for management responsibilities of publicly funded activities.To research whether competitive sourcing would be a viable approach for the Space Shuttle Program, NASA chartered the Space Shuttle Competitive Sourcing Task Force through the RAND Corporation, a federally funded think tank. In its report, the Task Force recognized the many obstacles to transferring the Space Shuttle to non-NASA management, primarily NASA? s reticence to relinquish control, but concluded that “NASA must pursue competitive sourcing in one form or another.

”68 NASA began a “Strategic Management of Human Capital” initiative to ensure the quality of the future NASA workforce.The goal is to address the various external and internal challenges that NASA faces as it tries to ensure an appropriate mix and depth of skills for future program requirements. A number of aspects to its Strategic Human Capital Plan require legislative approval and are currently before the Congress. on certain launch pad areas being exposed to the elements. When rain falls on these areas, it carries away zinc, runs onto the leading edge of the Orbiter? s wings, and causes pinholes in the Reinforced Carbon-Carbon panels (see Chapter 3). In 2000, NASA identified 100 infrastructure items that demanded immediate attention.NASA briefed the Space Flight Advisory Committee on this “Infrastructure Revitalization” initiative in November of that year.

The Committee concluded that “deteriorating infrastructure is a serious, major problem,” and, upon touring several Kennedy Space Center facilities, declared them “in deplorable condition. ”67 NASA subsequently submitted a request to the White House Office of Management and Budget during Fiscal Year 2002 budget deliberations for $600 million to fund the infrastructure initiative. No funding was approved. In Fiscal Year 2002, Congress added $25 million to NASA? budget for Vehicle Assembly Building repairs.

NASA has reallocated limited funds from the Shuttle budget to pressing infrastructure repairs, and intends to take an integrated look at infrastructure as part of its new Shuttle Service Life Extension Program. Nonetheless, like Space Shuttle upgrades, infrastructure revitalization has been mired by the uncertainty surrounding the Shuttle Program? s lifetime. Considering that the Shuttle will likely be flying for many years to come, NASA, the White House, and Congress alike now face the specter of having to deal with years of infrastructure neglect.

Roof • Siding • Doors Boxcar Offices Figure 5. 5-5 and 5. 5-6. Examples of the seriously deteriorating infrastructure used to support the Space Shuttle Program. At left is Launch Complex 39A, and at right is the Vehicle Assembly building, both at the Kennedy Space Center. Report Volume I August 2003 115 ACCIDENT INVESTIGATION BOARD COLUMBIA The new NASA leadership also began to compare Space Shuttle program practices with the practices of similar high-technology, high-risk enterprises.

The Navy nuclear submarine program was the first enterprise selected for comparative analysis.An interim report on this “benchmarking” effort was presented to NASA in December 2002. 69 In November 2002, NASA made a fundamental change in strategy. In what was called the Integrated Space Transportation Plan (see Figure 5. 6-1), NASA shifted money from the Space Launch Initiative to the Space Shuttle and International Space Station programs. The plan also introduced the Orbital Space Plane as a complement to the Shuttle for the immediate future. Under this strategy, the Shuttle is to fly through at least 2010, when a decision will be made on how long to extend Shuttle operations – possibly through 2020 or even beyond.As a step in implementing the plan, NASA included $281.

4 million in its Fiscal Year 2004 budget submission to begin a Shuttle Service Life Extension Program,70 which NASA describes as a “strategic and proactive program designed to keep the Space Shuttle flying safely and efficiently. ” The program includes “high priority projects for safety, supportability, and infrastructure” in order to “combat obsolescence of vehicle, ground systems, and facilities. ”71 When the Bush Administration came to the White House in January 2001, the International Space Station program was $4 billion over its projected budget.The Administration? s Fiscal Year 2002 budget, released in February 2001, declared that the International Space Station would be limited to a “U.

S Core Complete” configuration, a reduced design that could accommodate only three crew members. The last step in completing the U. S. portion of this configuration would be the addition of the Italian-supplied but U. S. owned “Node 2,” which would allow Europe and Japan to connect their laboratory modules to the Station.

Launching Node 2 and thereby finishing “core complete” configuration became an important political and programmatic milestone (see Figure 5. -1). Node 2 Figure 5. 7-1. The “Core Complete” configuration of the International Space Station. Figure 5. 6-1. The Integrated Space Transportation Plan.

During congressional testimony in May of 2001, Sean O? Keefe, who was then Deputy Director of the White House Office of Management and Budget, presented the Administration? s plan to bring International Space Station costs under control. The plan outlined a reduction in assembly and logistics flights to reach “core complete” configuration from 36 to 30. It also recommended redirecting about $1 billion in funding by canceling U. S. lements not yet completed, such as the habitation module and the X-38 Crew Return Vehicle. The X-38 would have allowed emergency evacuation and landing capability for a seven-member station crew. Without it, the crew was limited to three, the number that could fit into a Russian Soyuz crew rescue vehicle. In his remarks, O? Keefe stated: NASA? s degree of success in gaining control of cost growth on Space Station will not only dictate the capabilities that the Station will provide, but will send a strong signal about the ability of NASA? s Human Space Flight program to effectively manage large development programs.

NASA? s credibility with the Administration and the Congress for delivering on what is promised and the longer-term implications that such credibility may have on the future of Human Space Flight hang in the balance. 72 At the request of the White House Office of Management and Budget, in July 2001 NASA Administrator Dan Goldin August 2003 5. 7 THE RETURN OF SCHEDULE PRESSURE The International Space Station has been the centerpiece of NASA? s human space flight program in the 1990s. In several instances, funds for the Shuttle Program have paid for various International Space Station items.The Space Station has also affected the Space Shuttle Program schedule.

By the time the functional cargo block Zarya, the Space Station? s first element, was launched from the Baikonur Cosmodrome in Kazakhstan in November 1998, the Space Station was two years behind schedule. The launch of STS-88, the first of many Shuttle missions assigned to station assembly, followed a month later. Another four assembly missions in 1999 and 2000 readied the station for its first permanent crew, Expedition 1, which arrived in late 2000. 116 Report Volume I ACCIDENT INVESTIGATION BOARD COLUMBIA ormed an International Space Station Management and Cost Evaluation Task Force.

The International Space Station Management and Cost Evaluation Task Force was to assist NASA in identifying the reforms needed to restore the Station Program? s fiscal and management credibility. While the primary focus of the Task Force was on the Space Station Program management, its November 2001 report issued a general condemnation of how NASA, and particularly Johnson Space Center, had managed the International Space Station, and by implication, NASA? s overall human space flight effort. 3 The report noted “existing deficiencies in management structure, institutional culture, cost estimating, and program control,” and that “the institutional needs of the [human space flight] Centers are driving the Program, rather than Program requirements being served by the Centers.

” The Task Force suggested that as a cost control measure, the Space Shuttle be limited to four flights per year and that NASA revise the station crew rotation period to six months. The cost savings that would result from eliminating flights could be used to offset cost overruns.NASA accepted a reduced flight rate. The Space Shuttle Program office concluded that, based on a rate of four flights a year, Node 2 could be launched by February 19, 2004. In testimony before the House Committee on Science on November 7, 2001, Task Force Chairman Thomas Young identified what became known as a “performance gate.

” He suggested that over the next two years, NASA should plan and implement a credible “core complete” program. In Fall 2003, “an assessment would be made concerning the ISS program performance and NASA? credibility. If satisfactory, resource needs would be assessed and an [ISS] ? end state? that realized the science potential would become the baseline.

If unsatisfactory, the core complete program would become the ? end state.? ”74 Testifying the same day, Office of Management and Budget Deputy Director Sean O? Keefe indicated the Administration? s agreement with the planned performance gate: The concept presented by the task force of a decision gate in two years that could lead to an end state other than the U. S. ore complete Station is an innovative approach, and one the Administration will adopt. It calls for NASA to make the necessary management reforms to successfully build the core complete Station and operate it within the $8.

3 billion available through FY 2006 plus other human space flight resources … If NASA fails to meet the standards, then an end-state beyond core complete is not an option. The strategy places the burden of proof on NASA performance to ensure that NASA fully implements the needed reforms. 75 Mr. O?Keefe added in closing: A most important next step – one on which the success of all these reforms hinges – is to provide new leadership for NASA and its Human Space Flight activities. NASA has been well-served by Dan Goldin. New leadership is now necessary to continue moving the ball down the Report Volume I field with the goal line in sight. The Administration recognizes the importance of getting the right leaders in place as soon as possible, and I am personally engaged in making sure that this happens. A week later, Sean O? Keefe was nominated by President Bush as the new NASA Administrator.

To meet the new flight schedule, in 2002 NASA revised its Shuttle manifest, calling for a docking adaptor to be installed in Columbia after the STS-107 mission so that it could make an October 2003 flight to the International Space Station. Columbia was not optimal for Station flights – the Orbiter could not carry enough payload – but it was assigned to this flight because Discovery was scheduled for 18 months of major maintenance. To ensure adequate Shuttle availability for the February 2004 Node 2 launch date, Columbia would fly an International Space Station resupply mission.The White House and Congress had put the International Space Station Program, the Space Shuttle Program, and indeed NASA on probation. NASA had to prove it could meet schedules within cost, or risk halting Space Station construction at core complete – a configuration far short of what NASA anticipated. The new NASA management viewed the achievement of an on-schedule Node 2 launch as an endorsement of its successful approach to Shuttle and Station Programs.

Any suggestions that it would be difficult to meet that launch date were brushed aside.This insistence on a fixed launch schedule was worrisome. The International Space Station Management and Cost Evaluation Task Force, in particular, was concerned with the emphasis on a specific launch date. It noted in its 2002 review of progress toward meeting its recommendations that “significant progress has been made in nearly all aspects of the ISS Program,” but that there was “significant risk with the Node 2 (February ? 04) schedule. ”76 By November 2002, NASA had flown 16 Space Shuttle missions dedicated to Station assembly and crew rotation.Five crews had lived onboard the Station, the last four of them delivered via Space Shuttles. As the Station had grown, so had the complexity of the missions required to complete it.

With the International Space Station assembly more than half complete, the Station and Shuttle programs had become irreversibly linked. Any problems with or perturbations to the planned schedule of one program reverberated through both programs. For the Shuttle program, this meant that the conduct of all missions, even non-Station missions like STS-107, would have an impact on the Node 2 launch date.In 2002, this reality, and the events of the months that would follow, began to place additional schedule pressures on the Space Shuttle Program. Those pressures are discussed in Section 6. 2.

5. 8 CONCLUSION Over the last decade, the Space Shuttle Program has operated in a challenging and often turbulent environment. As August 2003 117 ACCIDENT INVESTIGATION BOARD COLUMBIA discussed in this chapter, there were at least three major contributing factors to that environment: • Throughout the decade, the Shuttle Program has had to function within an increasingly constrained budget.Both the Shuttle budget and workforce have been reduced by over 40 percent during the past decade. The White House, Congress, and NASA leadership exerted constant pressure to reduce or at least freeze operating costs.

As a result, there was little margin in the budget to deal with unexpected technical problems or make Shuttle improvements. • The Shuttle was mischaracterized by the 1995 Kraft Report as “a mature and reliable system … about as safe as today? s technology will provide. Based on this mischaracterization, NASA believed that it could turn increased responsibilities for Shuttle operations over to a single prime contractor and reduce its direct involvement in ensuring safe Shuttle operations, instead monitoring contractor performance from a more detached position.

NASA also believed that it could use the “mature” Shuttle to carry out operational missions without continually focusing engineering attention on understanding the mission-by-mission anomalies inherent in a developmental vehicle. • In the 1990s, the planned date for replacing the Shuttle shifted from 2006 to 2012 and then to 2015 or later.Given the uncertainty regarding the Shuttle? s service life, there has been policy and budgetary ambivalence on investing in the vehicle. Only in the past year has NASA begun to provide the resources needed to sustain extended Shuttle operations. Previously, safety and support upgrades were delayed or deferred, and Shuttle infrastructure was allowed to deteriorate. The Board observes that this is hardly an environment in which those responsible for safe operation of the Shuttle can function without being influenced by external pressures.It is to the credit of Space Shuttle managers and the Shuttle workforce that the vehicle was able to achieve its program objectives for as long as it did. An examination of the Shuttle Program? s history from Challenger to Columbia raises the question: Did the Space Shuttle Program budgets constrained by the White House and Congress threaten safe Shuttle operations? There is no straightforward answer.

In 1994, an analysis of the Shuttle budget concluded that reductions made in the early 1990s represented a “healthy tightening up” of the program. 77 Certainly those in the Office of Management and Budget and in NASA? congressional authorization and appropriations subcommittees thought they were providing enough resources to operate the Shuttle safely, while also taking into account the expected Shuttle lifetime and the many other demands on the Federal budget. NASA Headquarters agreed, at least until Administrator Goldin declared a “space launch crisis” in June 1999 and asked that additional resources for safety upgrades be added to the NASA budget. By 2001, however, one experienced observer of the space program described the Shuttle workforce as “The Few, the Tired,” 118Report Volume I and suggested that “a decade of downsizing and budget tightening has left NASA exploring the universe with a less experienced staff and older equipment. ”78 It is the Board? s view that this latter statement is an accurate depiction of the Space Shuttle Program at the time of STS107.

The Program was operating too close to too many margins. The Board also finds that recent modest increases in the Shuttle Program? s budget are necessary and overdue steps toward providing the resources to sustain the program for its now-extended lifetime.Similarly, NASA has recently recognized that providing an adequately sized and appropriately trained workforce is critical to the agency? s future success.

An examination of the Program? s management changes also leads to the question: Did turmoil in the management structure contribute to the accident? The Board found no evidence that the transition from many Space Shuttle contractors to a partial consolidation of contracts under a single firm has by itself introduced additional technical risk into the Space Shuttle Program.The transfer of responsibilities that has accompanied the Space Flight Operations Contract has, however, complicated an already complex Program structure and created barriers to effective communication. Designating the Johnson Space Center as the “lead center” for the Space Shuttle Program did resurrect some of the Center rivalries and communication difficulties that existed before the Challenger accident. The specific ways in which this complexity and lack of an integrated approach to Shuttle management impinged on NASA? s performance during and before the flight of STS-107 are discussed in Chapters 6 and 7.

As the 21st century began, NASA? s deeply ingrained human space flight culture – one that has evolved over 30 years as the basis for a more conservative, less technically and organizationally capable organization than the Apollo-era NASA – remained strong enough to resist external pressures for adaptation and change. At the time of the launch of STS-107, NASA retained too many negative (and also many positive) aspects of its traditional culture: “flawed decision making, self deception, introversion and a diminished curiosity about the world outside the perfect place. 79 These characteristics were reflected in NASA? s less than stellar performance before and during the STS-107 mission, which is described in the following chapters. August 2003 ACCIDENT INVESTIGATION BOARD COLUMBIA ENDNOTES FOR CHAPTER 5 The citations that contain a reference to “CAIB document” with CAB or CTF followed by seven to eleven digits, such as CAB001-0010, refer to a document in the Columbia Accident Investigation Board database maintained by the Department of Justice and archived at the National Archives. 1 16 Bush administration space policy is discussed in Dan Quayle, Standing Firm: AVice-Presidential Memoir (New York: Harper Collins, 1994), pp. 185-190. Report of the Advisory Committee on the Future of the U. S. Space Program, December 1990. The quotes are from p. 2 of the report? s executive summary. Report of the Advisory Committee on the Future of the U. S. Space Program. Measured in terms of total national spending, the report? s recommendations would have returned NASA spending to 0. 38 percent of U. S. Gross Domestic Product – a level of investment not seen since 1969. For Fiscal Years 1965-2002 in Real and Constant Dollars, see NASA, “Space Activities of the U.S. Government – in Millions of Real Year Dollars,” and “Space Activities of the U. S. Government – Adjusted for Inflation,” in Aeronautics and Space Report of the President – Fiscal Year 2002 Activity, forthcoming. For Fiscal Years 2003-2004 in Real Dollars, see Office of Management and Budget, “Outlays By Agency: 19622008,” in Historical Budget of the United States Government, Fiscal Year 2004, (Washington: Government Printing Office, 2003), pp. 70-75. Commission on the Future of the U. S. Aerospace Industry, Final Report, November 18, 2002, p. 3-1. U. S.Congress, Office of Technology Assessment, “Shuttle Fleet Attrition if Orbiter Recovery Reliability is 98 Percent,” August 1989, p. 6. From: Round Trip to Orbit: Human Space Flight Alternatives: Special Report, OTS-ISC-419. Report of the Advisory Committee on the Future of the U. S. Space Program. Howard E. McCurdy, Faster, Better, Cheaper: Low-Cost Innovation in the U. S. Space Program (Baltimore: The Johns Hopkins University Press, 2001). Letter from Daniel Goldin to Representative James T. Walsh, October 4, 2001. CAIB document CAB065-01630169. Ibid. W.Henry Lambright, Transforming Government: Dan Goldin and the Remaking of NASA (Washington: Price Waterhouse Coopers Endowment for the Business of Government, March 2001), pp. 12; 27-29. Deming? s management philosophy was not the only new notion that Goldin attempted to apply to NASA. He was also an advocate of the “Total Quality Management” approach and other modern management schemes. Trying to adapt to these various management theories was a source of some stress. For a discussion of Goldin? s approach, see Howard McCurdy, Faster, Better, Cheaper: Low-Cost Innovation in the U.S. Space Program (Baltimore: The Johns Hopkins University Press, 2001). It is worth noting that while the “faster, better, cheaper” approach led to many more NASA robotic missions being launched after 1992, not all of those missions were successful. In particular, there were two embarrassing failures of Mars missions in 1999. Lambright, Transforming Government, provides an early but comprehensive evaluation of the Goldin record. The quote is from p. 28. Goldin is quoted in Bill Harwood, “Pace of Cuts Fuels Concerns About Shuttle,” Space News, December 19-25, 1994, p. . McCurdy, Faster, Better, Cheaper. 17 Report of the Presidential Commission on the Space Shuttle Challenger Accident, June 6, 1986, (Washington: Government Printing Office, 1986), Vol. I, p. 82, 118. Report of the Presidential Commission, Vol. I, p. 48. Report of the Presidential Commission, Vol. I, p. 52. Report of the Presidential Commission, Vol. I, pp. 164-165. Report of the Presidential Commission, Vol. I, pp. 198-201. Report of The National Commission for the Review of the National Reconnaissance Office: The NRO at the Crossroads, November 2000, p. 66.Roger Guillemette, “Vandenberg: Space Shuttle Launch and Landing Site, Part 1,” Spaceflight, October 1994, pp. 354-357, and Roger Guillemette, “Vandenberg: Space Shuttle Launch and Landing Site, Part 2,” Spaceflight, November 1994, pp. 378-381; Dennis R. Jenkins, Space Shuttle: The History of the National Space Transportation System – The First 100 Missions (Cape Canaveral, FL, Specialty Press, 2001), pp. 467476. Vice President? s Space Policy Advisory Board, A Post Cold War Assessment of U. S. Space Policy, December 1992, p. 6. Quoted in John M. Logsdon, “Return to Flight: Richard H.Truly and the Recovery from the Challenger Accident,” in Pamela E. Mack, editor, From Engineering to Big Science: The NACA and NASA Collier Trophy Research Project Winners, NASA SP-4219 (Washington: Government Printing Office, 1998), p. 363. Aviation Week ; Space Technology, November 10, 1986, p. 30. There are proposals for using other U. S. systems, in development but not yet ready for flight, to provide an alternate U. S. means of station access. These “Alternate Access to Space” proposals have not been evaluated by the Board. Testimony of William F. Readdy to the Subcommittee on Science, Technology and Space, U. S.Senate, September 6, 2001. Howard E. McCurdy, Inside NASA: High Technology and Organizational Change in the U. S. Space Program (Baltimore: The Johns Hopkins University Press, 1993), p. 24. Garry D. Brewer, “Perfect Places: NASA as an Idealized Institution,” in Radford Byerly, Jr. , ed. , Space Policy Reconsidered (Boulder, CO: Westview Press, 1989), p. 158. Brewer, when he wrote these words, was a professor of organizational behavior at Yale University with no prior exposure to NASA. For first-hand discussions of NASA? s Apollo-era organizational culture, see Christopher Kraft, Flight: My Life in Mission Control (New York: E.P. Dutton, 2001); Gene Kranz, Failure is Not an Option: Mission Control from Mercury to Apollo 13 (New York: Simon ; Schuster, 2000); and Thomas J. Kelly, Moon Lander: How We Developed the Apollo Lunar Module (Washington: Smithsonian Institution Press, 2001). Brewer, “Perfect Places,” pp. 159-165. As NASA human space flight personnel began to become closely involved with their counterparts in the Russian space program after 1992, there was grudging acceptance that Russian human space flight personnel were also skilled in their work, although they carried it out rather differently than did NASA.Report Volume I 18 2 3 4 5 6 19 20 21 7 8 22 23 9 10 24 25 26 11 12 27 13 28 29 14 15 30 31 August 2003 119 ACCIDENT INVESTIGATION BOARD COLUMBIA 57 32 For two recent works that apply the “Iron Triangle” concept to other policy areas, see Randall B. Ripley and Grace A. Franklin, Congress, the Bureaucracy and Public Policy, 5th Edition, (Pacific Grove, CA: Brooks/ Cole Publishing Company, 1991); and Paul C. Light, Forging Legislation: The Politics of Veterans Reform, (New York: W. W. Norton, 1992). Information obtained from Anna Henderson, NASA Office of Space Flight, to e-mail to John Logsdon, June 13, 2003.National Academy of Public Administration, A Review of the Space Shuttle Costs, Reduction Goals, and Procedures, December 1994, pp. 3-5. CAIB document CAB026-0313. Presentation to NASA Advisory Council by Stephen Oswald, Acting Director, Space Shuttle Requirements, “Space Flight Operations Contract (SFOC) Acquisition Status,” April 23, 1996. CAIB document CTF0641369. Bryan D. O? Connor, Status Briefing to NASA Administrator, “Space Shuttle Functional Workforce Review,” February 14, 1995. CAIB document CAB015-0400. Ralph Vartabedian, “Ex-NASA Chief Hits Flight Safety,” Houston Chronicle, March 7, 1996.Kathy Sawyer, “NASA Space Shuttle Director Resigns,” Washington Post, February 3, 1996, p. A3. See also “Take this Job and Shuttle It: Why NASA? s Space Shuttle Chief Quit,” Final Frontier, July/August 1996, pp. 16-17; “NASA Alters Its Management, Philosophy,” Space News, February 12-18, 1996, p. 3. Report of the Space Shuttle Management Independent Review Team, February 1995. Ibid, pp. 3-18. NASA News Release 95-27, “Shuttle Management Team Issues Final Report,” March 15, 1995. Aerospace Safety Advisory Panel, “Review of the Space Shuttle Management Independent Review Program,” May 1995.CAIB document CAB015-04120413. Jose Garcia to President William Jefferson Clinton, August 25, 1995. See, for instance: “Determinations and Findings for the Space Shuttle Program,” United States House of Representatives, Subcommittee on Space, of the Committee on Science, 104 Cong. , 1 Sess. , November 30, 1995. See remarks by Daniel S. Goldin, Opening Remarks at the September 30, 1996, ceremony commemorating the signing of the Space Flight Operations Contract, Houston, Texas. (Videotape recording. ) Congressional Budget Office, “NASA? Space Flight Operations Contract and Other Technologically Complex Government Activities Conducted by Contractors,” July 29, 2003. Russell Turner, testimony at public hearing before the Columbia Accident Investigation Board, June 12, 2003. See Section 204 of Public Law 105-303, October 28, 1999. Joe Rothenberg to Dan Goldin, August 17, 2001, CAIB document CAB015-1134; “Space Shuttle Privatization,” CAIB document CAB0151135; “Space Shuttle Privatization: Options and Issues,” Rev: 8/14/01, CAIB document CAB015-1147. Ron Dittemore, “Concept of Privatization of the Space Shuttle Program,” September 2001.CAIB document CTF005-0283. Ibid. Roy Bridges, Testimony before the Columbia Accident Investigation Board, March 25, 2003. The quotes are taken from NASA-submitted material appended to the statement of NASA Administrator Daniel Goldin to the Senate Subcommittee on Science, Technology and Space, March 22, 2000, p. 7. National Commission on Space, Pioneering the Space Frontier: An Exciting Vision of Our Next Fifty Years in Space, Report of the National Commission on Space (Bantam Books, 1986). President Ronald Reagan, “Message to the Congress on America? Agenda for the Future,” February 6, 1986, Public Papers of the Presidents of the United States: Ronald Reagan: Book I-January 1 to June 27, 1986 (Washington, DC: U. S. Government Printing Office, 19821991), p. 159. Office of Space Systems Development, NASA Headquarters, “Access to Space Study—Summary Report,” January 1994, reproduced in John M. Logsdon, et al. eds. , Exploring the Unknown, Volume IV: Accessing Space NASA SP-4407 (Government Printing Office, 1999), pp. 584-604. Report Volume I The White House, Office of Science and Technology Policy, “Fact Sheet–National Space Transportation Policy,” August 5, 1994, pp. -2, reprinted in Logsdon et al. , Exploring the Unknown, Volume IV, pp. 626631. Report of the Space Shuttle Management Independent Review Team, pp. 3-18. “Statement of William F. Readdy, Deputy Associate Administrator, Office of Space Flight, National Aeronautics and Space Administration before the Subcommittee on Space and Aeronautics Committee on Science, House of Representatives,” October 21, 1999. CAIB document CAB0260146. Letter from Daniel Goldin to Jacob Lew, Director, Office of Management and Budget, July 6, 1999.NASA, Space Shuttle Independent Assessment Team, “Report to the Associate Administrator, Office of Space Flight, October-December 1999,” March 7, 2000. CAIB document CTF017-0169. Ibid. Ibid. Dr. Richard Beck, Director, Resources Analysis Division, NASA, “Agency Budget Overview, FY 2003 Budget,” February 6, 2002, p. 20. CAIB document CAB070-0001. Space Flight Advisory Committee, NASA Office of Space Flight, Meeting Report, May 1-2, 2001, p. 7. CAIB document CTF017-0034. Senators Bill Nelson, Bob Graham, Mary Landrieu, John Breaux, and Orrin Hatch to Senator Barbara Mikulski, September 18, 2001.Space Flight Advisory Committee, NASA Office of Space Flight, Meeting Report, May 1-2, 2001, p. 7. CAIB document CTF017-0034. Task Force on Space Shuttle Competitive Sourcing, Alternate Trajectories: Options for Competitive Sourcing of the Space Shuttle Program, Executive Summary, The RAND Corporation, 2002. CAIB document CAB003-1614. NNBE Benchmarking Team, NASA Office of Safety ; Mission Assurance and NAVSEA 92Q Submarine Safety ; Quality Assurance Division, “NASA/Navy Benchmarking Exchange (NNBE),” Interim Report, December 20, 2002. CAIB document CAB030-0392. The team? final report was issued in July 2003. NASA FY 2004 Congressional Budget, “Theme: Space Shuttle. ” [Excerpt from NASA FY 2004 budget briefing book also known as the “IBPD Narrative”]. CAIB document CAB065-04190440. NASA, “Theme: Space Shuttle. ” CAIB document CAB065-04190440. Testimony of Sean O? Keefe, Deputy Director, Office of Management and Budget, to the Subcommittee of the Committee on Appropriations, “Part 1, National Aeronautics and Space Administration,” Hearings Before a Subcommittee of the Committee on Appropriations, United States House of Representatives, 107th Congress, 1st Sess. May 2001, p. 32. “Report by the International Space Station (ISS) Management and Cost Evaluation (IMCE) Task Force to the NASA Advisory Council,” November 1, 2001, pp. 1-5. CAIB document CTF044-6016. Testimony of Tom Young, Chairman, ISS Management and Cost Evaluation (IMCE) Task Force, to the Committee on Science, U. S. House of Representatives, “The Space Station Task Force Report,” Hearing Before the Committee on Science, United States House of Representatives, 107th Congress, 1st Sess. , November, 2001, p. 23.Testimony of Sean O? Keefe, Deputy Director, Office of Management and Budget, to the Committee on Science, U. S. House of Representatives, “The Space Station Task Force Report,” Hearing Before the Committee on Science, United States House of Representatives, 107th Congress, 1st Sess. , November, 2001, p. 28. Thomas Young, IMCE Chair, “International Space Station (ISS) Management and Cost Evaluation (IMCE) Task Force Status Report to the NASA Advisory Council,” (Viewgraphs) December 11, 2002, p. 11. CAIB document CAB065-0189.General Research Corporation, Space Shuttle Budget Allocation Review, Volume 1, July 1994, p. 7. CAIB document CAIB015-0161. Beth Dickey, “The Few, the Tired,” Government Executive, April 2001, p. 71. Brewer, “Perfect Places,” pp. 159. 58 59 33 34 35 60 61 36 62 63 64 37 38 65 66 67 68 39 40 41 42 43 44 69 70 45 71 72 46 47 48 49 73 74 50 51 52 53 75 76 54 77 78 79 55 56 120 August 2003 ACCIDENT INVESTIGATION BOARD COLUMBIA CHAPTER 6 Decision Making at NASA The dwindling post-Cold War Shuttle budget that launched NASA leadership on a crusade for efficiency in the decade before Columbia? final flight powerfully shaped the environment in which Shuttle managers worked. The increased organizational complexity, transitioning authority structures, and ambiguous working relationships that defined the restructured Space Shuttle Program in the 1990s created turbulence that repeatedly influenced decisions made before and during STS-107. This chapter connects Chapter 5? s analysis of NASA? s broader policy environment to a focused scrutiny of Space Shuttle Program decisions that led to the STS-107 accident. Section 6. illustrates how foam debris losses that violated design requirements came to be defined by NASA management as an acceptable aspect of Shuttle missions, one that posed merely a maintenance “turnaround” problem rather than a safety-of-flight concern. Section 6. 2 shows how, at a pivotal juncture just months before the Columbia accident, the management goal of completing Node 2 of the International Space Station on time encouraged Shuttle managers to continue flying, even after a significant bipod-foam debris strike on STS-112. Section 6. notes the decisions made during STS-107 in response to the bipod foam strike, and reveals how engineers? concerns about risk and safety were competing with – and were defeated by – management? s belief that foam could not hurt the Orbiter, as well as the need to keep on schedule. In relating a rescue and repair scenario that might have enabled the crew? s safe return, Section 6. 4 grapples with yet another latent assumption held by Shuttle managers during and after STS-107: that even if the foam strike had been discovered, nothing could have been done. flying the Shuttle with a known problem that violated design requirements?It would seem that the longer the Shuttle Program allowed debris to continue striking the Orbiters, the more opportunity existed to detect the serious threat it posed. But this is not what happened. Although engineers have made numerous changes in foam design and application in the 25 years that the External Tank has been in production, the problem of foam-shedding has not been solved, nor has the Orbiter? s ability to tolerate impacts from foam or other debris been significantly improved. The Need for Foam Insulation The External Tank contains liquid oxygen and hydrogen propellants stored at minus 297 and minus 423 degrees Fahrenheit.Were the super-cold External Tank not sufficiently insulated from the warm air, its liquid propellants would boil, and atmospheric nitrogen and water vapor would condense and form thick layers of ice on its surface. Upon launch, the ice could break off and damage the Orbiter. (See Chapter 3. ) To prevent this from happening, large areas of the External Tank are machine-sprayed with one or two inches of foam, while specific fixtures, such as the bipod ramps, are hand-sculpted with thicker coats. Most of these insulating materials fall into a general category of “foam,” and are outwardly similar to hardware store-sprayable foam insulation.The problem is that foam does not always stay where the External Tank manufacturer Lockheed Martin installs it. During flight, popcorn- to briefcase-size chunks detach from the External Tank. Original Design Requirements Early in the Space Shuttle Program, foam loss was considered a dangerous problem. Design engineers were extremely concerned about potential damage to the Orbiter and its fragile Thermal Protection System, parts of which are so vulnerable to impacts that lightly pressing a thumbnail into them leaves a mark. Because of these concerns, the baseline August 2003 6. 1 A HISTORY OF FOAM ANOMALIESThe shedding of External Tank foam – the physical cause of the Columbia accident – had a long history. Damage caused by debris has occurred on every Space Shuttle flight, and most missions have had insulating foam shed during ascent. This raises an obvious question: Why did NASA continue Report Volume I 121 ACCIDENT INVESTIGATION BOARD COLUMBIA F6. 1? 4 F6. 1? 5 F6. 1? 6 F6. 1? 7 F6. 1? 8 F6. 1? 9 F6. 1? 10 F6. 1? 11 Columbia having been equipped with umbilical cameras earlier than other Orbiters. There is lack of effective processes for feedback or integration among project elements in the resolution of In-Flight Anomalies.Foam bipod debris-shedding incidents on STS-52 and STS-62 were undetected at the time they occurred, and were not discovered until the Board directed NASA to examine External Tank separation images more closely. Foam bipod debris-shedding events were classified as In-Flight Anomalies up until STS-112, which was the first known bipod foam-shedding event not classified as an In-Flight Anomaly. The STS-112 assignment for the External Tank Project to “identify the cause and corrective action of the bipod ramp foam loss event” was not due until after the planned launch of STS-113, and then slipped to after the launch of STS-107.No External Tank configuration changes were made after the bipod foam loss on STS-112. Although it is sometimes possible to obtain imagery of night launches because of light provided by the Solid Rocket Motor plume, no imagery was obtained for STS-113. NASA failed to adequately perform trend analysis on foam losses. This greatly hampered the agency? s ability to make informed decisions about foam losses. Despite the constant shedding of foam, the Shuttle Program did little to harden the Orbiter against foam impacts through upgrades to the Thermal Protection System.Without impact resistance and strength requirements that are calibrated to the energy of debris likely to impact the Orbiter, certification of new Thermal Protection System tile will not adequately address the threat posed by debris. that the complexity and political mandates surrounding the International Space Station Program, as well as Shuttle Program management? s responses to them, resulted in pressure to meet an increasingly ambitious launch schedule. In mid-2001, NASA adopted plans to make the over-budget and behind-schedule International Space Station credible to the White House and Congress.The Space Station Program and NASA were on probation, and had to prove they could meet schedules and budgets. The plan to regain credibility focused on the February 19, 2004, date for the launch of Node 2 and the resultant Core Complete status. If this goal was not met, NASA would risk losing support from the White House and Congress for subsequent Space Station growth. By the late summer of 2002, a variety of problems caused Space Station assembly work and Shuttle flights to slip beyond their target dates. With the Node 2 launch endpoint fixed, these delays caused the schedule to become ever more compressed. Meeting U.S. Core Complete by February 19, 2004, would require preparing and launching 10 flights in less than 16 months. With the focus on retaining support for the Space Station program, little attention was paid to the effects the aggressive Node 2 launch date would have on the Shuttle Program. After years of downsizing and budget cuts (Chapter 5), this mandate and events in the months leading up to STS107 introduced elements of risk to the Program. Columbia and the STS-107 crew, who had seen numerous launch slips due to missions that were deemed higher priorities, were further affected by the mandatory Core Complete date.The high-pressure environments created by NASA Headquarters unquestionably affected Columbia, even though it was not flying to the International Space Station. February 19, 2004 – “A Line in the Sand” Schedules are essential tools that help large organizations effectively manage their resources. Aggressive schedules by themselves are often a sign of a healthy institution. However, other institutional goals, such as safety, sometimes compete with schedules, so the effects of schedule pressure in an organization must be carefully monitored.The Board posed the question: Was there undue pressure to nail the Node 2 launch date to the February 19, 2004, signpost? The management and workforce of the Shuttle and Space Station programs each answered the question differently. Various members of NASA upper management gave a definite “no. ” In contrast, the workforce within both programs thought there was considerable management focus on Node 2 and resulting pressure to hold firm to that launch date, and individuals were becoming concerned that safety might be compromised. The weight of evidence supports the workforce view.Employees attributed the Node 2 launch date to the new Administrator, Sean O? Keefe, who was appointed to execute a Space Station management plan he had proposed as Deputy Director of the White House Office of Management and Budget. They understood the scrutiny that NASA, the new Administrator, and the Space Station Program were under, August 2003 Recommendations: • None d Here 6. 2 SCHEDULE PRESSURE Countdown to Space Station “Core Complete:” A Workforce Under Pressure During the course of this investigation, the Board received several unsolicited comments from NASA personnel regarding pressure to meet a schedule.These comments all concerned a date, more than a year after the launch of Columbia, that seemed etched in stone: February 19, 2004, the scheduled launch date of STS-120. This flight was a milestone in the minds of NASA management since it would carry a section of the International Space Station called “Node 2. ” This would configure the International Space Station to its “U. S. Core Complete” status. At first glance, the Core Complete configuration date seemed noteworthy but unrelated to the Columbia accident. However, as the investigation continued, it became apparent Report Volume I 31 ACCIDENT INVESTIGATION BOARD COLUMBIA but now it seemed to some that budget and schedule were of paramount concern. As one employee reflected: I guess my frustration was … I know the importance of showing that you … manage your budget and that? s an important impression to make to Congress so you can continue the future of the agency, but to a lot of people, February 19th just seemed like an arbitrary date … It doesn? t make sense to me why at all costs we were marching to this date. The importance of this date was stressed from the very top.The Space Shuttle and Space Station Program Managers briefed the new NASA Administrator monthly on the status of their programs, and a significant part of those briefings was the days of margin remaining in the schedule to the launch of Node 2 – still well over a year away. The Node 2 schedule margin typically accounted for more than half of the briefing slides. Figure 6. 2-1 is one of the charts presented by the Shuttle Program Manager to the NASA Administrator in December 2002. The chart shows how the days of margin in the existing schedule were being managed to meet the requirement of a Node 2 launch on the prescribed date.The triangles are events that affected the schedule (such as the slip of a Russian Soyuz flight). The squares indicate action taken by management to regain the lost time (such as authorizing work over the 2002 winter holidays). Figure 6. 2-2 shows a slide from the International Space Station Program Manager? s portion of the briefing. It indicates that International Space Station Program management was also taking actions to regain margin. Over the months, the extent of some testing at Kennedy was reduced, the number of tasks done in parallel was increased, and a third shift of workers would be added in 2003 to accomplish the processing.These charts illustrate that both the Space Shuttle and Space Station Programs were being managed to a particular launch date – February 19, 2004. Days of margin in that schedule were one of the principle metrics by which both programs came to be judged. NASA Headquarters stressed the importance of this date in other ways. A screen saver (see Figure 6. 2-3) was mailed to managers in NASA? s human spaceflight program that depicted a clock counting down to February 19, 2004 – U. S. Core Complete. SSP Schedule Reserve SSP Core Complete 1 35 3 28 Schedule Margin – Past 4 14 6 8 18 1 OV-103) 2 Moved Node2 to OV-105 Late OMM start (Node 2 was onMargin (in months) 3 Accommodate 4S slip 1 week 5 -14 -1 re 7 -9 9 -21 10 4 ISS adding wrist joint on UF2 5 Moved OV-104 Str. Ins. to 9th flt 6 Engine Flowliner cracks 7 Reduced Structural Inspection Requirements -2 1 2 8 Accommodate 4S slip 9 O2 flexline leak/ SRMS damage 10 Defer reqmts; apply reserve 12. 01 03. 02 06. 02 09. 02 12. 02 Management action Schedule impact event SSP Core Complete Schedule Threats STS-120/Node 2 launch subject to 45 days of schedule risk • HQ mitigate Range Cutout • HQ and ISS mitigate Soyuz • HQ mitigate Range Cutout • HQ and ISS mitigate Soyuz • HQ and ISS mitigate Soyuz Management Options


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