NASA's Next Step

nce proud, cocky, even arrogant, NASA has been humbled. Not only by the Columbia and Challenger catastrophes, but by its inability to find, let alone fix, the core problem that led to those tragedies. NASA might have the right stuff, but increasingly it appears to have the wrong culture. And until the agency reaches deep inside to find and cure what's ailing, its critics and many of its own managers fear that another disaster-one that could halt human space flight, possibly forever-is inevitable. The Columbia Accident Investigation Board report warned in its August 2003 report that "only significant structural changes to NASA's organizational culture will enable it to succeed," even if all the shuttle's technical flaws were corrected. With Columbia, as with Challenger, the board found, decision-makers were overly influenced by pressures to launch on time. In blind adherence to safety rules, they ignored hunches and intuition about faulty equipment. They valued organizational charts over good communication. The report chastised the agency for habitually turning a deaf ear to outside critics, and for clinging to the belief that NASA alone knew best how to safely send people into space.

"Signals were overlooked, people were silenced," the report charged. Communication did not flow effectively up and down the formal chain of command, it concluded, in part because NASA was not following its own rules. "Cultural traits and organizational practices detrimental to safety were allowed to develop, including . . . lack of integrated management across program elements . . . and the evolution of an informal chain of command."

This culture-based critique hasn't gone down easily inside an agency famous for its steely-eyed engineering prowess. Wayne Hale, the NASA executive who will give the final go for the next shuttle launch, says he was "blissfully ignorant of the whole sociology thing" until April 23, 2003. That day, sociologist Diane Vaughan, author of The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA (University of Chicago Press, 1996), told Columbia investigators that the space agency-and, by association, the mission management team that Hale leads-was guilty of "an incremental descent into poor judgment." Vaughan testified that before Columbia's fatal disintegration, NASA's human space flight managers repeated many of the mistakes that led to the Challenger launch debacle 17 years earlier.

When a Columbia panelist pointed out that Vaughan's book is required reading for safety operators on Navy nuclear submarines, Hale decided the thick treatise was worth a read. Several airplane trips and one long day of jury duty later, the seasoned flight director was a believer: "You've got to go through 400 or 500 pages to find them, but she's got some real gems in that book."

Long regarded as one of the agency's most levelheaded managers, Hale personifies NASA's recent awakening to the truth. In a soul-searching memo to the space shuttle team in January, the deputy shuttle program chief wrote, "We dropped the torch through our complacency, our arrogance, self-assurance, sheer stupidity, and through continuing attempt[s] to please everyone. It is time to adjust our thinking."

During Columbia's final flight, Hale asked for U.S. spy satellite photographs that could have confirmed engineers' early suspicions about wing damage and an impending re-entry disaster. When his predecessor, mission management team leader Linda Ham, deemed the images unnecessary, Hale let the request slide. That decision will haunt him for the rest of his days. He got Ham's job in a management shake-up last summer.

Now, his colleagues chuckle when Hale obsesses over things such as the shape of his conference tables and the behaviors they elicit. His mission management team meeting rooms at the Florida launch site and in Texas Mission Control will be furnished with perfect squares because he read a Navy study about people deferring to whoever sits at the end of a long, narrow rectangle. He wants everyone to speak up. Before the tragedy, Hale never gave a thought to the role behavior plays in risk management. "Now," he says, "I don't know whether I spend enough time thinking about it."

THE COLUMBIA MIND-SET

"We get it," Administrator Sean O'Keefe says, over and over again, of the Columbia board's findings. "There's not one aspect of this we're not going to follow through on." Why was the Columbia report such an eye-opener for NASA when none of the dozens of earlier warnings about management culture hit home? A likely answer is timing. The Columbia accident interrupted planning for the new national space exploration strategy that President Bush announced in January. Senior administration officials began crafting the strategy in secret in late 2002, but had to put it on hold for several months after the accident.

The plan is to retire the space shuttle in 2010 or as soon as possible thereafter, replace it with a safer mode of transportation, and then use the moon as a training ground and possible launching base for a future human expedition to Mars. But before heading to Mars, NASA must finish the space station, the laboratory for all the medical research necessary to protect humans from the effects of a lengthy space journey to Mars. To finish the space station, NASA needs the shuttles flying again. That means satisfying the Columbia board's requirements, and then some.

So rather than shelve the 248-page Columbia document beside dozens of mishap reports, O'Keefe established five committees to help the agency implement it. One is a federal advisory panel chaired by two veteran astronauts to monitor progress on 15 mostly technical fixes that must be completed before the next shuttle is launched. Another is an executive team O'Keefe assigned to scour every page of the report for wisdom that can be applied across the $15-billion-a-year agency.

The leader of that team had a conversion experience resembling Wayne Hale's. At the time of the accident, Goddard Space Flight Center Director Alphonso Diaz believed NASA's problems were isolated in the shuttle program. Then the Maryland executive received his special-delivery copy of the Columbia report and started reading. After he got past several chapters addressing the accident's physical cause, he says, "I started seeing the organizational causes everywhere in my history here." In his five years as director, Goddard has lost only one spacecraft, the Wide Field Infrared Explorer (WIRE) in 1999.

Diaz says he now can trace its disappearance to the Columbia mind-set. His team tagged 85 of the report's 193 recommendations, observations and findings for broad adoption, and put a copy of the list in the hands of 65,000 civil servants and contractor employees. Ombudsman offices have begun appearing at NASA installations nationwide as a direct result of Diaz's team's work.

When Diane Vaughan shared her Challenger research with the investigators, what had destroyed Columbia already was obvious. It was a hole in the fragile leading edge of the orbiter's left wing, made by a chunk of foam insulation that broke off from the shuttle's external fuel tank during launch on Jan. 16, 2003. Sixteen days later and just 16 minutes from touchdown, as Columbia descended, superheated air got inside the hole and melted the orbiter's aluminum skeleton. Aerodynamic forces prevailed. Seven astronauts died.

NASA had launched 113 shuttle flights, and foam loss resulting in orbiter damage was a problem from the very first flight in April 1981. But after 22 years without grave consequences, the phenomenon once considered a serious flaw was dismissed as a safety concern. "They continued to have anomalies and accepted [them] more and more," Vaughan told investigators. "It means that something systematic is going on in the organizations where these people work."

For many NASA insiders, identifying what is broken has proved as confounding as fixing it promises to be. "It would be hard for me to define to you what NASA culture is," O'Keefe's deputy, former astronaut Fred Gregory, said at a news conference last summer. By March, senior officials still had not defined a safety culture for the agency, although they had hired accident board consultant Behavioral Science Technology of Ojai, Calif., and charged it with changing the culture noticeably within six months. Behavioral scientist Laurie Broedling is amused, but not surprised. "That's the human space flight culture, which is predominantly an engineering culture: We set a goal, we pick a number," says Broedling, who oversaw NASA's continual improvement program as an associate administrator for a few years in the mid-1990s. "You've got to fix the root causes, not just the symptoms."

HORSEPOWER DISPARITY

Aside from instructing NASA not to allow budget and schedule managers any influence in safety or technical matters, the Columbia report offers little specific guidance on fixing those causes. But the panelists have plenty to say. The lack of a top-level forum for dissenting opinions disturbs Steve Wallace, chief accident investigator at the Federal Aviation Administration. He says the Office of Safety and Mission Assurance that NASA established after the Challenger disaster did not get the funding or authority it needed to stand up to program demands. "You had a bunch of SESers at one end of the table and a GS-13 or -14 safety guy at the other end. They'd listen to him politely, but there was this great horsepower disparity," says Wallace. "I don't think it was malicious or intentional; it was more subtle and insidious than that."

The report places the burden for change squarely on the shoulders of NASA's leaders, but sidesteps the question of whether a housecleaning is in order. More than three-fourths of shuttle managers at NASA's human space flight centers in Texas, Alabama and Florida quit, retired or got shoved aside after the accident, but the Washington headquarters echelon remains intact. One investigator points out that many of NASA's leaders grew up inside the 45-year-old bureaucracy. "The organization, in effect, trained them to manage and lead the way they did," says Air Force Chief of Safety Maj. Gen. Kenneth Hess. He says NASA leadership needs "special attention . . . just because of how committed [they] were to the idea that the foam was not a problem."

Scott Hubbard, the only NASA official on the Columbia panel, holds up the agency's Mars Exploration Rover program as a model for change. After the back-to-back failures of two Mars probes, an orbiter and a lander, Hubbard was called to Washington in 1999 to turn things around.

Then associate director for astrobiology and space programs at the Ames Research Center in California, Hubbard became the agency's first Mars program director in 2000. "In the Columbia experience, I noticed a lot of parallels to the fundamental cause of the Mars failures-things like not enough resources for testing or attention to other issues such as communication. The term inside the agency is 'being success-oriented,'" says Hubbard, now director of Ames.

"The Mars program went through its own failure assessment, introspection and painful recovery. It addressed a lot of the same issues, and it has come back to tremendous success," he says. March 2 marked the program's pinnacle, when scientists announced they have compelling evidence that life-sustaining water once puddled in a crater on the surface. The find came from Opportunity. The Mars rover and its twin, Spirit, have been scooting around opposite sides of the Red Planet to wide acclaim since January.

STRESS REHEARSAL

Even as it struggles to understand, define and alter its culture, NASA also is straining to get shuttles off the ground again. "It isn't getting easier. It's just getting harder," Sean O'Keefe told reporters in March. Complaints about unnecessarily tight schedules continue to emerge from some shuttle operating divisions. NASA's public message is that it won't launch another shuttle until it meets all the board's safety requirements. The target date for the first post-Columbia shuttle mission has slipped by a year-most recently from September 2004 to March 2005. Engineers needed more time to develop space-based repair procedures for the orbiter's heat-resistant skin and to fix problems with the shuttle's rudder and speed brakes. NASA has assigned the first mission to Discovery, but plans to have a second shuttle ready on short notice. In case of problems, Discovery's crew would take shelter in the International Space Station and wait to be rescued.

As they await a launch date, the mission management team-15 agency and contractor executives who supervise launches, landings and crucial day-to-day activities of every shuttle-rehearses making risky decisions in life-or-death situations. Hale takes the team to emergency training every six weeks. Ever mindful of his failure to insist on in-flight photos of Columbia, Hale makes certain that everyone has an opportunity to speak. He's criticized because opening the floor stretches out the decision-making process. "My response to that is, 'If you come up with the wrong decision, then you haven't taken the right amount of time.' "

The disputes test his mettle, but organizational psychologists being paid to observe the sessions view arguments as a sign of progress. After witnessing two simulations, the federally chartered Return to Flight Task Group declined to give the mission management team a passing grade. Group leader and veteran astronaut Richard Covey prescribed additional rehearsals until the team could show it is able to conduct a rigorous problem review in a specified amount of time while incorporating all safety inputs-including classified imagery and rulings from a Columbia board-ordered independent technical engineering authority that NASA has yet to create.

"My overall sense is solid progress, but still a great deal of work to be done," says Covey, a four-time shuttle flyer. Accident investigators did not make cultural transformation a requirement for the shuttle's return to flight, but NASA is eager to accomplish this so it can focus resources on the new national strategy for space exploration. "It's the behaviors we want to recognize and modify as quickly as possible," says Goddard's Diaz, acknowledging "changing the culture of the organization will take some time."

Even as NASA seems intent on that change, some wonder whether the agency's culture is broken at all. Longtime shuttle launch director Robert Sieck, now retired, questions the Columbia board's assessment that NASA's culture is at fault for the space shuttle's demise. Decision-makers were "not as smart as they needed to be" simply because the agency could not afford the proper resources, says Sieck, a task force member. Sieck's previous consulting activities included almost five years on the congressionally appointed Aerospace Safety Advisory Panel before it resigned en masse last year. "They needed better tools, or better information, but that's not the same as saying there's complacency and overconfidence," he says.

Former associate administrator Broed- ling, on the other hand, says the complexity of the space shuttle alone means reform is an uphill battle. "To accomplish a true transformation in six months has less than a 50 percent chance of success," she says. "And then you add NASA, and the larger system within which it works-the Congress, the executive branch, the budget, the expectations of the American people-and it is inherently, incredibly complex."

Success, says Columbia panelist Hess, means leaders must be sustained in their positions and remain committed to the task. "They will go through on pure adrenaline on the next couple of shuttle launches as they begin to perfect new ways of doing business," he says.

NASA leaders seem to understand their margin for error has dwindled to zero. "If we blow it this time," observes the agency's comptroller, Steven Isakowitz, "it will be many, many years, if not decades, before we get another shot."