[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]
THE COLUMBIA ACCIDENT
INVESTIGATION BOARD REPORT
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON SCIENCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 4, 2003
__________
Serial No. 108-27
__________
Printed for the use of the Committee on Science
Available via the World Wide Web: http://www.house.gov/science
______
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COMMITTEE ON SCIENCE
HON. SHERWOOD L. BOEHLERT, New York, Chairman
LAMAR S. SMITH, Texas RALPH M. HALL, Texas
CURT WELDON, Pennsylvania BART GORDON, Tennessee
DANA ROHRABACHER, California JERRY F. COSTELLO, Illinois
JOE BARTON, Texas EDDIE BERNICE JOHNSON, Texas
KEN CALVERT, California LYNN C. WOOLSEY, California
NICK SMITH, Michigan NICK LAMPSON, Texas
ROSCOE G. BARTLETT, Maryland JOHN B. LARSON, Connecticut
VERNON J. EHLERS, Michigan MARK UDALL, Colorado
GIL GUTKNECHT, Minnesota DAVID WU, Oregon
GEORGE R. NETHERCUTT, JR., MICHAEL M. HONDA, California
Washington CHRIS BELL, Texas
FRANK D. LUCAS, Oklahoma BRAD MILLER, North Carolina
JUDY BIGGERT, Illinois LINCOLN DAVIS, Tennessee
WAYNE T. GILCHREST, Maryland SHEILA JACKSON LEE, Texas
W. TODD AKIN, Missouri ZOE LOFGREN, California
TIMOTHY V. JOHNSON, Illinois BRAD SHERMAN, California
MELISSA A. HART, Pennsylvania BRIAN BAIRD, Washington
JOHN SULLIVAN, Oklahoma DENNIS MOORE, Kansas
J. RANDY FORBES, Virginia ANTHONY D. WEINER, New York
PHIL GINGREY, Georgia JIM MATHESON, Utah
ROB BISHOP, Utah DENNIS A. CARDOZA, California
MICHAEL C. BURGESS, Texas VACANCY
JO BONNER, Alabama
TOM FEENEY, Florida
RANDY NEUGEBAUER, Texas
C O N T E N T S
September 4, 2003
Page
Witness List..................................................... 2
Hearing Charter.................................................. 3
Opening Statements
Statement by Representative Sherwood L. Boehlert, Chairman,
Committee on Science, U.S. House of Representatives............ 23
Written Statement............................................ 24
Statement by Representative Ralph M. Hall, Minority Ranking
Member, Committee on Science, U.S. House of Representatives.... 25
Written Statement............................................ 27
Statement by Representative Dana Rohrabacher, Chairman,
Subcommittee on Space and Aeronautics, Committee on Science,
U.S. House of Representatives.................................. 28
Written Statement............................................ 29
Statement by Representative Bart Gordon, Member, Committee on
Science, U.S. House of Representatives......................... 29
Written Statement............................................ 30
Prepared Statement by Representative Joe Barton, Member,
Committee on Science, U.S. House of Representatives............ 31
Prepared Statement by Representative Nick Smith, Chairman,
Subcommittee on Research, Committee on Science, U.S. House of
Representatives................................................ 31
Prepared Statement by Representative Vernon J. Ehlers, Chairman,
Subcommittee on Environment, Technology, and Standards,
Committee on Science, U.S. House of Representatives............ 33
Prepared Statement by Representative John Sullivan, Member,
Committee on Science, U.S. House of Representatives............ 33
Prepared Statement by Representative J. Randy Forbes, Member,
Committee on Science, U.S. House of Representatives............ 34
Prepared Statement by Representative Jerry F. Costello, Member,
Committee on Science, U.S. House of Representatives............ 34
Prepared Statement by Representative Eddie Bernice Johnson,
Member, Committee on Science, U.S. House of Representatives.... 35
Prepared Statement by Representative Michael M. Honda, Member,
Committee on Science, U.S. House of Representatives............ 35
Prepared Statement by Representative Sheila Jackson Lee, Member,
Committee on Science, U.S. House of Representatives............ 35
Panel
Admiral Harold W. Gehman, Jr., U.S. Navy retired, Chairman of the
Columbia Accident Investigation Board, accompanied by Board
members Major General Kenneth W. Hess, Dr. James N. Hallock,
and Dr. Sheila E. Widnall
Oral Statement............................................... 37
Written Statement............................................ 39
Discussion
Risk........................................................... 43
Crew Escape.................................................... 45
Shuttle Replacement............................................ 47
Continuing Shuttle Operations.................................. 48
NASA's Culture and Management.................................. 48
Vision......................................................... 49
International Space Station and Space Shuttle Mishap
Interagency Investigation Board Charter...................... 50
Defining Benchmarks for Progress and Past Reports.............. 50
Schedule Pressure.............................................. 51
Inaction to Previous Foam Loss................................. 52
Reduction in Safety Procedures................................. 52
Shuttle Servicing of Hubble.................................... 52
Schedule Pressure.............................................. 53
Independent Technical Authority................................ 55
Vision......................................................... 56
Budget......................................................... 58
Benchmarks of Implementation................................... 59
Shuttle Design Compromises..................................... 60
One-year Review................................................ 61
Following Through on the Report's Recommendations.............. 62
Workforce...................................................... 62
Characteristics of a Follow-on Vehicle......................... 64
Manned vs. Unmanned Science.................................... 66
Defining Cultural and Organizational Problems.................. 67
The Culture of Safety.......................................... 70
Accountability................................................. 73
NASA Recruiting and Retention.................................. 74
Prioritizing Space Research Within the Federal Budget.......... 74
The Value of Research in Space................................. 75
The Process of Defining a Vision............................... 76
The Difference Between ``Observations'' and ``Recommendations''
in the Report................................................ 77
NASA Engineering and Safety Center............................. 78
SFOC Board of Investigation.................................... 79
Cost Estimates and Mission Parameters of a Follow-on Vehicle... 79
ISS Supply..................................................... 80
Shuttle Support of ISS Construction............................ 80
Funding as a Factor in the Accident............................ 81
Accountability................................................. 82
Appendix 1: Answers to Post-Hearing Questions
Admiral Harold W. Gehman, Jr., U.S. Navy retired, Chairman of the
Columbia Accident Investigation Board.......................... 86
THE COLUMBIA ACCIDENT INVESTIGATION BOARD REPORT
----------
THURSDAY, SEPTEMBER 4, 2003
House of Representatives,
Committee on Science,
Washington, DC.
The Committee met, pursuant to call, at 10 a.m., in Room
2318 of the Rayburn House Office Building, Hon. Sherwood L.
Boehlert [Chairman of the Committee] presiding.
hearing charter
COMMITTEE ON SCIENCE
U.S. HOUSE OF REPRESENTATIVES
The Columbia Accident
Investigation Board Report
thursday, september 4, 2003
10:00 a.m.-12:00 p.m.
2318 rayburn house office building
1. Purpose
On Thursday, September 4th at 10:00 a.m., the Science Committee
will hold a Full Committee hearing on the findings and recommendations
of the Columbia Accident Investigation Board (CAIB). The Committee will
receive testimony from retired Navy Admiral Harold Gehman, Chairman of
the 13-member Board, along with three members of the Board.
2. Background
This is the first in a series of hearings the Science Committee
will hold this fall on the Space Shuttle accident and related problems
highlighted in the CAIB report. This hearing provides an opportunity
for Admiral Gehman to present the report to the Committee and will set
the stage for the follow-up hearings. The overall goal this fall is to
fully understand the risks, costs, and benefits of the human space
flight program, including the Space Shuttle, and to determine what
actions need to be taken to reform NASA.
While the CAIB has said it intends the report to help NASA in
safely getting back to human space flight, the report is hard hitting.
It describes in detail the specific physical causes of the Shuttle
Columbia's demise and documents the failures of NASA's organization in
recognizing and dealing with the dangers the Shuttle faced. The CAIB
makes a number of recommendations to remedy both problems, some that
NASA must meet before the Shuttle returns to flight, and others that
the report suggests will take longer to implement. It is likely that
Congress will ultimately be responsible for ensuring those
recommendations are met.
The CAIB report also cites as contributions to the Shuttle accident
NASA's reluctance to realistically assess its ability to conduct human
space flight missions on a constrained budget and the lack of a
national commitment to an ambitious and probably expensive vision for
human space flight. The report sets the stage for a thorough public
policy debate regarding the future of human space flight, the prospects
for a Shuttle replacement, the appropriate balance of human and robotic
missions, future priorities in space exploration, and the level of
resources that should be allocated for such activities. The Committee's
findings will, among other things, form the basis of a NASA
reauthorization bill next year.
3. Witnesses
Admiral Harold Gehman (retired), Chairman, Columbia Accident
Investigation Board. Formerly Co-Chairman of the Department of Defense
review of the attack on the U.S.S. Cole. Before retiring, Gehman served
as the NATO Supreme Allied Commander, Atlantic, Commander in Chief of
the U.S. Joint Forces Command, and Vice Chief of Naval Operations for
the U.S. Navy. Gehman earned a B.S. in Industrial Engineering from Penn
State University and is a retired four star Admiral.
James Hallock, Ph.D., Manager, Aviation Safety Division, Volpe National
Transportation Systems Center, Massachusetts. Dr. Hallock contributed
to Group III of the CAIB, which focused on engineering and technical
analysis of the accident and resulting debris. He has worked in the
Apollo Optics Group of the MIT Instrumentation Lab and was a physicist
at the NASA Electronics Research Center, where he developed a
spacecraft attitude determining system. He joined the DOT
Transportation Systems Center (now the Volpe Center) in 1970. Hallock
received B.S., M.S. and Ph.D. degrees in Physics from the Massachusetts
Institute of Technology (MIT). He is an expert in aircraft wake vortex
behavior and has conducted safety analyses on air traffic control
procedures, aircraft certification, and separation standards, as well
as developed aviation-information and decision-support.
Major General Kenneth W. Hess, Commander, Air Force Safety Center,
Kirtland Air Force Base, New Mexico, and Chief of Safety, United States
Air Force, Headquarters U.S. Air Force, Washington, D.C. Major General
Hess contributed to Group II of the CAIB, which scrutinized NASA
training, operations, and the in-flight performance of ground crews and
the Shuttle crew. Hess entered the Air Force in 1969 and has flown
operationally in seven aircraft types. He has commanded three Air Force
wings--the 47th Flying Training Wing, 374th Airlift Wing, and 319th Air
Refueling Wing--and commanded the U.S. 3rd Air Force, RAF Mildenhall,
England. Hess also has extensive staff experience at the Joint Staff
and U.S. Pacific Command. He holds a B.B.A. from Texas A&M University
and a M.S. in Human Relations and Management from Webster College.
Sheila E. Widnall, Ph.D., Institute Professor and Professor of
Aeronautics and Astronautics and Engineering Systems, Massachusetts
Institute of Technology (MIT), Massachusetts. Dr. Widnall also
contributed to Group III of the CAIB, which focused on engineering and
technical analysis of the accident and resulting debris. Widnall has
served as Associate Provost, MIT, and as Secretary of the Air Force.
She is currently Co-Chairman of the Lean Aero-space Initiative. A
leading expert in fluid dynamics, Widnall received her B.S., M.S., and
Ph.D. in Aeronautics and Astronautics from MIT.
4. Attachments:
Executive Summary, Columbia Accident Investigation
Report.
Chapter 11, Recommendations, Columbia Accident
Investigation Report.
CRS Report, NASA's Space Shuttle Columbia, Synopsis
of the CAIB Report (RS21606).
CRS Report, NASA's Space Shuttle Columbia: Quick
Facts and Issues for Congress (RS21408).
Attachment 1
COLUMBIA ACCIDENT INVESTIGATION BOARD REPORT
Volume I
August 2003
EXECUTIVE SUMMARY
The 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 81.7 seconds after
launch, and struck the wing in the vicinity of the lower half of
Reinforced Carbon-Carbon 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 break-up 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 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's
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 space flight, is a developmental activity
with high inherent.
Chairman Boehlert. The hearing will come to order. I want
to welcome everyone here for the first of what will be an
extensive series of hearings on the future of the Shuttle
program, and of the manned space flight programs, in general.
This is a pivotal moment in NASA's history, and this committee
intends to lead the way in examining the issues that will
enable Congress and the White House to chart NASA's future.
Perhaps I should say in ``confronting the issues'' because
moving forward will require asking tough questions and facing
up to tough choices.
We will be better able to do that because of the
extraordinary work that has been done by Admiral Gehman and the
entire membership and staff of the Columbia Accident
Investigation Board. The Board members have been inspiring
models: independent, focused, inquiring, tough, candid, and
accessible. The Board report has to be the starting point for
setting NASA's future course.
If the Shuttle is to return to flight, then, at a minimum,
every single one of the CAIB's return-to-flight recommendations
must be implemented. That includes the recommendation that NASA
have a detailed plan for addressing the organizational and
cultural deficiencies the CAIB has so convincingly described.
Indeed, Mr. Hall and I wrote to Admiral Gehman back in the
early summer suggesting just that sort of recommendation to
help ensure that NASA would act on the central recommendations
concerning organization and culture.
I think all of us need to face up to the rather
disheartening picture of NASA that has been so painstakingly
drawn by the CAIB. If we fail to do so, it is readily apparent
that we will just have to go through this same and sad exercise
again. NASA's experience may be the ultimate proof of
Santayana's famous observation about those who fail to learn
from the past being doomed to repeat it.
The sad fact is that the loss of the Columbia and her crew
was preventable. This is not even close to being a case in
which the problems could only be seen in hindsight. We need to
clearly identify and root out each of the systemic and
individual failures that led to this accident. The CAIB report
is a blueprint for doing so. The memory of the Columbia crew
compels us to do no less.
I have to say that I am concerned about some of the ways
NASA has been approaching the return-to-flight thus far. I
admire Administrator O'Keefe and I am pleased he has embraced
the CAIB report with his words. But deeds are what count. And I
am concerned that NASA may already be rushing to meet
unrealistic launch dates instead of examining this report
closely and moving deliberately.
I am also concerned that NASA has been trumpeting changes
in its safety organization that do not appear to address any of
the problems that have been persuasively identified in the
Board's report. Delay is not the goal, but if safety is to
improve, NASA must not be judging itself by how quickly it can
send the Shuttle back into orbit.
And undue haste is ill advised for another reason, too. We,
as a Committee, and as a nation, need some time to consider our
overall space policy.
We need to make fundamental decisions about the future of
the Shuttle program and of the manned space flight program. We
need to get, perhaps for the first time, accurate cost
estimates of what it will cost to run the Space Shuttle and
other manned programs safely and accurate descriptions of what
they will be able to accomplish. I, for one, am not willing to
write NASA a blank check for the Shuttle program.
We also need to have a better appraisal of what the risks
are of operating the Space Shuttle, because even after
implementing the CAIB recommendations, the Shuttle will
continue to be a risky vehicle, and I am not willing to see the
Shuttle fly without regard to the level of risk.
Finally, we need to better define NASA's overarching human
space flight vision: something that has been lacking for more
than a generation. That won't be easy, and it can only be done
after hearings that will enable us to make a clear-eyed
appraisal of the costs, benefits, and risks of different
options.
So I approach today's hearing soberly because of the
tragedy that has brought us here and the daunting tasks that
lie ahead. But I also approach today with eagerness, because we
have a rare chance to reshape our nation's space program, and
we will be able to benefit from the outstanding work of Admiral
Gehman and his team. I look forward to hearing from them.
Mr. Hall.
[The prepared statement of Mr. Boehlert follows:]
Prepared Statement of Chairman Sherwood Boehlert
I want to welcome everyone here for the first of what will be an
extensive series of hearings on the future of the Shuttle program, and
of the manned space flight programs, in general. This is a pivotal
moment in NASA's history, and this committee intends to lead the way in
examining the issues that will enable Congress and the White House to
chart NASA's future. Perhaps I should say in ``confronting the issues''
because moving forward will require asking tough questions and facing
up to tough choices.
We will be better able to do that because of the extraordinary work
that has been done by Admiral Gehman and the entire membership and
staff of the Columbia Accident Investigation Board (CAIB). The Board
members have been inspiring models--independent, focused, inquiring,
tough, candid and accessible. The CAIB report has to be the starting
point for setting NASA's future.
If the Shuttle is to return to flight, then, at a minimum, every
one of the CAIB's return-to-flight recommendations must be implemented.
That includes the recommendation that NASA have a detailed plan for
addressing the organizational and cultural deficiencies the CAIB has so
convincingly described. Indeed, Mr. Hall and I wrote to Admiral Gehman
back in July suggesting just that sort of recommendation to help ensure
that NASA would act on the central recommendations concerning
organization and culture.
I think all of us need to face up to the rather disheartening
picture of NASA that has been so painstakingly drawn by the CAIB. If we
fail to do so, it's readily apparent that we will just have to go
through this same sad exercise again. NASA's experience may be the
ultimate proof of Santayana's famous observation about those who fail
to learn from the past being doomed to repeat it.
The sad fact is that the loss of the Columbia and her crew was
preventable. This is not even close to being a case in which the
problems could only be seen in hindsight. We need to clearly identify
and root out each of the systemic and individual failures that led to
this accident. The CAIB report is a blueprint for doing so. The memory
of the Columbia crew compels us to do no less.
I have to say that I am concerned about some of the ways NASA has
been approaching the return-to-flight thus far. I admire Administrator
O'Keefe and I'm pleased he has embraced the CAIB report with his words.
But deeds are what will count. And I'm concerned that NASA may already
be rushing to meet unrealistic launch dates instead of examining this
report closely and moving deliberately.
I'm also concerned that NASA has been trumpeting changes in its
safety organization that do not appear to address any of the problems
that have been persuasively identified in the CAIB report. Delay is not
the goal, but if safety is to improve, NASA must not be judging itself
by how quickly it can send the Shuttle back into orbit.
And undue haste is ill-advised for another reason, too. We, as a
committee, and as a nation, need some time to consider our overall
space policy.
We need to make fundamental decisions about the future of the
Shuttle program and of the manned space flight program. We need to get,
perhaps for the first time, accurate cost estimates of what it will
cost to run the Space Shuttle and other manned programs safely and
accurate descriptions of what they will be able to accomplish. I, for
one, am not willing to write NASA a blank check for the Shuttle
program.
We also need to have a better appraisal of what the risks are of
operating the Space Shuttle--because even after implementing the CAIB
recommendations, the Shuttle will continue to be a risky vehicle--and I
am not willing to see the Shuttle fly without regard to the level of
risk.
Finally, we need to better define NASA's overarching human space
flight vision--something that has been lacking for more than a
generation. That won't be easy, and it can only be done after hearings
that will enable us to make a clear-eyed appraisal of the costs,
benefits and risks of different options.
So I approach today's hearing soberly because of the tragedy that
has brought us here and the daunting tasks that lie ahead. But I also
approach today with eagerness because we have a rare chance to reshape
our nation's space program, and we will be able to benefit from the
outstanding work of Admiral Gehman and his team. I look forward to
hearing from them.
Mr. Hall.
Mr. Hall. Chairman, thank you for a good opening statement,
and I think it is a statement that we all need to keep and to
refer back to as we proceed and as we adhere to and recognize
the findings of the Admiral and his colleagues. So I say to
you, Admiral, again, good morning. And thanks for your
openness. Thanks for your being available to anyone who wanted
to talk to you about anything. And thanks for the work you have
done, you and all of your colleagues. And thanks for the work
we will be expecting you to do and the oversight we will expect
of you in the days that are--lie ahead. The Nation owes a great
debt of gratitude to all of you and to your staff for your very
dedicated service. I am grateful to you, and I think every
Member up here is.
When you began your work seven months ago, it was not at
all clear that we would ever unravel the physical cause of the
accident. And there will be some who are not totally satisfied
with the findings, but I think you have a lot of backup
material there and--that they can refer to, and I just--indeed,
your report, I think, makes it very clear that a series of
reviews over the years, since the Challenger, had uncovered
some of the same sorts of problems that you found during your
investigation. This committee needs to get your best assessment
of why these problems have continued to occur and what will be
required to keep them from causing another accident. Your
answers will help me shape legislation that I am developing. It
will help others of us shape legislation that we are developing
to provide for continued oversight. And the end of the two-year
period, the first really important two-year period, we don't
want this thing just to dwindle away like it did after the
Challenger. We want to keep it before people and keep the goal
in sight, and that goal in sight should be safety, safety,
safety. If real estate people say location, location, location,
I think the American people today are calling for safety.
I know that there are a lot that want to know who is at
fault for the Columbia accident. Maybe they wanted names and
things like that, but--and that is understandable, but your
report makes it clear that the conditions that ultimately led
to the accident were not just a result of a few individual
actions. I personally am not as interested in assigning the
blame as I am to working to fix the problems identified by your
investigation. We are going to need your help in determining
the best way to proceed from here on out.
In that regard, I am very interested in your
recommendations for returning the Shuttle fleet to flight. This
committee needs to know why you included the items you did, and
equally important, why some potential tasks were not included
in your recommendations.
Mr. Chairman, the Columbia Accident Investigation Board has
performed a very important service. Now it is up to Congress, I
think, in cooperation with the White House and in cooperation
with the NASA Administrator to make this report work to seek
and find and figure out every area of safety that we can to
consider issues that are beyond the Board's charter. And
namely, we need to decide on some concrete goals for the human
space flight program and be willing to commit the resources
necessary to meet those goals.
There will be those who will say that we should walk away
from human space flight as a result of this accident. It has
been said. I disagree. The question is not whether we should
have a human space flight program. The real question is how to
make that program as safe and productive as possible. My view
is that we should complete the International Space Station as
originally planned so that it can be a productive research
facility. We need to fix the Shuttle, and as part of that
effort, take a serious look at how best to protect the crews
that are going to be flying the Shuttle for the next 10 to 20
years.
Finally, we need to get some concrete goals for human
exploration beyond the Space Station. Establishment of human
exploration goals would ensure that we make the appropriate
investments in our space program, would revitalize the NASA
workforce and would serve as a source of inspiration for both
the NASA workforce and the American people.
With respect to crew safety, I would note that just a month
ago, the House of Representatives unanimously approved an
amendment that I offered up that many of us on this committee
had offered up at the Committee level here. We all agreed on
safety, we just couldn't agree exactly on how it was to be
done, so my amendment simply said to launch out onto a program
for safety, a study as to how to get that safety and who ought
to do it, not to assess blame, but to be grateful to those that
made the program great that put these people, magnificent men
and women, into the air and brought them back safely so many,
many, many times. I think we are going to continue to rely on
the Shuttle for a lot of years to service the Space Station. We
need to do everything we can to ensure that if this Shuttle
comes under threat in the future the crew is given every
possible opportunity to survive.
I didn't send up that amendment to cause any problems or to
nudge anybody, but I sent it up simply to say to the world that
we are interested in safety, we care about safety, and we are
going to launch a program designating and designing how we can
make it safe. And if we don't do that, we may not have the
Shuttle as safe as it should be, if we should have another
tragedy in the next five years or eight years or six years or
six months or 10 months, but we better be on our way. And we
better have a program to show the American people that we are
trying to make it safe for the men and women who will man the
Shuttle. We have to do that. That is our goal. That is my goal.
And if we don't have that well underway or completed when we
have another tragedy, we can forget about the space program. I
don't want to do that.
I yield back my time, Mr. Chairman.
[The prepared statement of Mr. Hall follows:]
Prepared Statement of Representative Ralph M. Hall
Good morning. I'd like to welcome Admiral Gehman and his colleagues
from the Columbia Accident Investigation Board to today's hearing. The
Nation owes a debt of gratitude to all of the Board members and staff
for your dedicated service.
When you began your work seven months ago, it was not at all clear
that we would ever unravel the physical cause of the accident. It is a
tribute to your efforts that we can now be highly confident that a foam
strike did in fact lead to the loss of the Space Shuttle Columbia and
its crew.
At the same time, your report makes a persuasive case that other
factors made an equal contribution to the Shuttle accident. It is
painful reading, because the Board essentially has concluded that NASA
never really learned the lessons of the Space Shuttle Challenger
accident more than 17 years ago. Indeed the CAIB report makes it clear
that a series of reviews over the years since Challenger had uncovered
the same sorts of problems that you found during your investigation.
This committee needs to get your best assessment of why those problems
have continued to occur, and what will be required to keep them from
causing another accident. Your answers will help me shape legislation
that I am developing to provide for continued oversight of the
implementation of the Gehman recommendations.
I know that there are some who want to know who was at fault for
the Columbia accident. That is understandable. However, your report
makes it clear that the conditions that ultimately led to the accident
were not just the result of a few individuals' actions. I personally am
not as interested in assigning blame as I am in working to fix the
problems identified by your investigation. We are going to need your
help in determining the best way to proceed from here on out.
In that regard, I am very interested in your recommendations for
returning the Shuttle fleet to flight. This committee needs to know why
you included the items you did, and equally importantly, why some
potential tasks were not included in your recommendations.
Mr. Chairman, the Columbia Accident Investigation Board has
performed an important service. However, it is now up to Congress--in
coordination with the White House--to consider issues that are beyond
the Board's charter. Namely, we need to decide on some concrete goals
for the human space flight program and be willing to commit the
resources necessary to meet those goals.
There will be those who say that we should walk away from human
space flight as a result of this accident. I disagree. The question is
not whether we should have a human space flight program--the real
question is how to make that program as safe and productive as
possible. My view is that we should complete the International Space
Station as originally planned so that it can be a productive research
facility. We need to fix the Shuttle, and as part of that effort take a
serious look at how best to protect the crews that will be flying the
Shuttle for the next 10 to 20 years. Finally, we need to set some
concrete goals for human exploration beyond the Space Station.
Establishment of human exploration goals would ensure that we make the
appropriate investments in our space program, would revitalize the NASA
workforce, and would serve as a source of inspiration for both the NASA
workforce and the American public.
With respect to crew safety, I would note that just a month ago,
the House of Representatives unanimously approved my amendment
providing adequate funds for NASA to at least begin assessing Space
Shuttle crew rescues options seriously. If we lose another Shuttle and
its crew, the impact on the space flight program will be disastrous. We
are going to continue to rely on the Shuttle for many years to service
the Space Station, and we need to do everything possible to ensure that
if the Shuttle comes under threat in the future, the crew is given
every possible opportunity to survive.
Mr. Chairman, I will close by again expressing my appreciation for
the Board's efforts.
Chairman Boehlert. Thank you very much, Mr. Hall.
Mr. Rohrabacher.
Mr. Rohrabacher. First of all, I would like to thank Ralph
Hall and our Democratic colleagues for the bipartisan spirit
that we have had in this committee since this tragedy. This
could be a very tumultuous time for us all, but we have worked
together and we have kept politics out of it, and we have all
been trying our best, as just demonstrated by Ralph Hall's
wonderful statement, and so we appreciate that and all the work
you have done.
I would also like to thank Chairman Boehlert for his
leadership and Chairman Boehlert for his good judgment during
this very vexing time. It is--now it is our time to pick up
this job. And Admiral Gehman and his crew have done a terrific
job, a wonderful job. Now it is time for us to do our job. It
is our work--actually, you might say our work actually begins
today.
Today's hearing is the first step in understanding, on this
end of the hearing anyway, what went wrong with the Space
Shuttle Columbia, what went wrong with NASA, and what choices
we have in the future, what type of vision we must have in
order to achieve the goals that we set as part of that vision.
We are greatly indebted to Admiral Gehman and the whole
Columbia Accident Investigation Board for what they have done
and for a terrific and an outstanding job. Their work will be
an invaluable resource for us as we now move forward to solve
the problems at NASA and to set a course for NASA in the
future.
A key element of NASA's success in the past was a clear
national objective and purpose when it came to our space
program. Mercury, Gemini, Apollo, all were involved, of course,
with beating the Russians to the moon and all of that was
something that Americans understood, all of us in--as American
citizens, of people in the government, people in the
Legislative Branch, people in NASA, we all knew what that goal
was and the vision. We were behind it, and we were part of the
team. Our civil space program today suffers from a lack of
strategic vision and a lack of broader national goals.
Putting America's space program back on track means more
than fixing a flawed piece of Shuttle technology. In fact, the
Shuttle itself remains a major question mark as we go through
the findings of the Gehman report. For the last 30 years, NASA
may well have been on the wrong path when it comes to the
Shuttle. The Shuttle has failed miserably to meet its original
goals, and our reliance on such a complex, high-risk technology
has drained billions of dollars from our Treasury and billions
of dollars from other space programs. And it has regrettably
cost us too much money and cost too many lives.
Now there have been successes in the Shuttle program as
well. I was part of the Reagan Administration when the first
Shuttle landed, and I know how important the Shuttle was to
inspiring the American people at a time when we had our--when
our national spirits needed inspiring. And who can say what
type of a contribution that made, seeing that Shuttle land and
knowing it was probably one of the most magnificent engineering
feats in all of human history. That did inspire us. And how
many billions of dollars were added to our economy? Hundreds of
billions by that inspiration. And that has to be put into the
equation as well.
Yet when focusing on the loss of our bravest astronauts and
our brave astronauts, we must want to make sure that we look at
human space travel in the future that we do, as Ralph has just
stated, our utmost to ensure that we are protecting those
astronauts and those people's lives in the line as well. But
with that in mind, we should not close the door on human space
travel. The astronauts who have given their lives would not
want us to turn around, would not want us to be earthbound
because lives were lost. They knew the risks they were taking,
and that is why they are unique among American heroes today,
and we honor them in this hearing and we honor them by moving
forward. It is a risky venture to move forward into space with
human beings, but I would submit today that it is worth the
risk.
We have the rare opportunity to help NASA today. And with
Admiral Gehman's help and with his team's help to break the
bureaucratic malaise that has gripped the NASA bureaucracy for
too long. Our space program should be about expanding American
freedom into a new frontier and to carry all of humankind to
new heights into the heavens above and to a better life here on
this planet. It is not the time to turn around; it is the time
to move forward and do what is right to finish the Space
Station and to move forward with new technologies that will
carry us to greater heights.
Mr. Chairman, thank you for your leadership, and I look
forward to working with you in the weeks ahead.
[The prepared statement of Mr. Rohrabacher follows:]
Prepared Statement of Representative Dana Rohrabacher
I'd like to thank Chairman Boehlert for his leadership in calling
this important hearing. Today's hearing is the first step in
understanding what went wrong with the Space Shuttle, what went wrong
with NASA, and what choices we have as we strive to set a new vision
for our space program. We are greatly indebted to Admiral Gehman and
the Columbia Accident Investigation Board for their dedicated service
and their outstanding report. Their work will be an invaluable source
to us as we grapple with the problems at NASA.
A key element of NASA's success in the past was a clear national
objective and purpose. Mercury, Gemini, and Apollo were about beating
the Russians to the Moon and beating the Russians in the Cold War.
Unfortunately today, our civil space program suffers from a lack of
strategic vision and a lack of any connection to such broader national
goals.
For the last 30 years, I believe, NASA has been on the wrong path
with the Space Shuttle. The Shuttle has failed miserably to meet any of
its original goals. Our reliance on such a complex and high-risk
technology has drained billions of dollars from our treasury and has
regrettably cost too many lives.
We should not close the door on human space travel, however. It is
a risky venture, but worth the risks. We have the rare opportunity to
help NASA break the bureaucratic malaise that has gripped it for so
long. Our space program should be about expanding American freedom into
a new frontier.
Mr. Chairman, I believe your leadership and this committee will
help frame this critical debate.
Chairman Boehlert. Thank you very much, Mr. Rohrabacher.
Mr. Gordon.
Mr. Gordon. Thank you, Mr. Chairman. I will be brief,
because I think that you did an excellent job in laying out our
charge before this committee. And I think that if we will
follow your outline, we will all be well served. And let me
also say that I think we all should be grateful to Mr. Hall's
tenacious efforts before, and I am sure they are going to be
continuing to bring us back to flight, but also in a safe
manner. And I look forward to working with my friend from
California as our Committee works to oversee the progress of
this report.
So Admiral Gehman, let me join everyone in welcoming you
and certainly your Board here--or the members of the Board that
came today, and more importantly, I want to thank you for seven
long, I am sure, months. You--they were longer for you than for
a lot of folks. You have done a good job. Excuse me.
Admiral Gehman, you--your report warrants a thorough public
hearing, and this hearing will be an important initial step in
that regard. And as I reviewed the report, I found that there
were a number of things that were troubling to me. And let me
mention just a few. I am troubled that NASA failed to heed
early reviews that identified many of the same problems that
you described in your Board's report. I am troubled by your
finding that NASA's safety system has repeatedly fallen short
of the mark. I am troubled by your conclusion that, in your
words, ``years of workforce reduction and outsourcing have
cowed from NASA's workforce the layers of experience and hands-
on systems knowledge that once provided a capacity for safety
oversight.'' I am troubled by your report's finding that the
pressure by NASA's headquarters to meet an artificial Space
Station Core Complete milestone may have unduly influenced
Shuttle Manager's decisions. And I am worried that we have seen
echoes of that pressure in some of the headquarters'
pronouncements on the timetable for Shuttle return-to-flight.
So Admiral Gehman, fixing the problems identified by your
report will take time and money. We should not kid ourselves in
that regard. And I would like to get your views on how
expensive and how time-consuming that effort is likely to be.
When NASA submits its proposed budgets for fixing the problems,
we need to know whether they are going to be realistic. And I
would also like to get your views on what benchmarks this
committee should be seeking for NASA to determine whether or
not they are complying with your report's finding.
We have got a lot to cover today. I am anxious to hear what
you have to say. And once again, thank you, and all of you, for
being here with us.
[The prepared statement of Mr. Gordon follows:]
Prepared Statement of Representative Bart Gordon
Good morning. I want to join my colleagues in welcoming Admiral
Gehman to this hearing. I also want to add my thanks for the hard work
all of the Board members did over the last seven months in
investigating the causes of the Columbia accident. Your report warrants
a thorough public airing, and this hearing will be an important initial
step in that regard.
Admiral Gehman, your report ranges over a number of important
issues. As I reviewed your report, I found much that was troubling to
me. Let me mention just a few items:
I am troubled that NASA failed to heed earlier
reviews that had identified many of the same problems you
describe in your Board's report.
I am troubled by your finding that NASA's safety
system has repeatedly fallen short of the mark.
I am troubled by your conclusion that ``yeas of
workforce reductions and outsourcing have culled from NASA's
workforce the layers of experience and hands-on systems
knowledge that once provided a capacity fog safety oversight.''
I am very troubled by your Board's finding that
pressure by NASA Headquarters to meet an artificial Space
Station ``Core Complete'' milestone may have unduly influenced
Shuttle managers' decisions.
And I worry that we've seen echoes of that pressure
in some of the Headquarters pronouncements on the timetable for
Shuttle return-to-flight.
Admiral Gehman, fixing the problems identified in your report will
take time and money--we should not kid ourselves in that regard. I'd
like to get your views on how expensive and how time-consuming that
effort is likely to be. When NASA submits its proposed budgets for
fixing the problems, we need to know whether they are realistic. I'd
also like to get your views on what ``benchmarks'' this committee
should be seeking from NASA to determine whether or not they are
complying with your report's findings.
Well, we have a great deal to cover today. I again want to welcome
you to today's hearing, and I look forward to your testimony.
Chairman Boehlert. I want to thank all of my colleagues for
their opening statements and all of the Members will have leave
to insert their opening statements in the record at this
juncture.
[The prepared statement of Mr. Barton follows:]
Prepared Statement of Representative Joe Barton
Thank you, Mr. Chairman, for holding this important hearing. I also
want to thank Admiral Gehman and his colleagues of the Columbia
Accident Investigation Board (CAIB) for accomplishing the daunting task
of investing the accident. We are here today to learn more about the
causes of the accident, both physical, and intangible, such as the
organizational culture at NASA.
The crew of the Columbia risked their lives in pursuit of knowledge
that might improve the quality of life for all mankind. I am very
supportive of NASA and realize that if we are to learn about the
mysteries of this universe, space exploration must continue. However,
in exploring space, we should not unnecessarily risk lives. The CAIB
report mentioned the need to create a new vehicle for manned spaced
flights. It also cautioned against falling into the trap of trying to
do too many things with one vehicle. I fully echo this view. I am
hesitant to send seven more astronauts on a vehicle that is unsafe. To
that end, we need to move toward building a newer and safer space
vehicle--whether that is a new Space Shuttle, or an Orbital Space
Plane. The current fleet of Space Shuttles can be improved, but they
cannot be made 100 percent safe. We cannot allow manned space flights
on a continuing basis until safer vehicles are developed.
I also hope that we, as a Congress and also the Nation as a whole,
take this time to develop the goals of our space program. In the 1960s,
President Kennedy laid down a broad agenda for our nation to become the
first to walk on the moon. The Columbia accident has given us the
opportunity to regain that national enthusiasm and spirit toward the
space program. I will continue to work with my Science Committee
colleagues to investigate the best possible steps through which to move
the program forward.
[The prepared statement of Mr. Smith of Michigan follows:]
Prepared Statement of Representative Nick Smith
I want to thank Chairman Boehlert for holding this hearing to
review the findings and recommendations of the Columbia Accident
Investigation Board (CAIB). I'd also like to thank the witnesses for
appearing here today, and for the tremendous work that they provided in
preparing this report. Admiral Gehman and his team should be commended
for delivering a thorough report that will be important to this
committee as we move forward.
I understand that the CAIB was charged with assessing what caused
the accident and give recommendations for changes that need to be made
at NASA to better assure safety. The Board determined that the accident
was caused by a piece of insulating foam that damaged the left wing of
the Columbia, eventually leading to a thermal breakdown of the wing and
breakup of the orbiter. The Board also concluded that bureaucratic
pressures and cultural problems within NASA likely contributed to the
circumstances that led to the accident. This morning we begin the
process of learning more about NASA's internal workings and what went
wrong in the days, months and years leading up to February 1, with the
aim to guide Congress and the Administration through important
crossroads.
Since the successful Soviet launch of Sputnik in 1957, our
country's space program has been an integral part of our national sense
of identity. Space exploration has captured the imagination of the
American public while generating a wealth of scientific discovery. I
remember the pride and awe that I felt when Neil Armstrong took his
first steps on the moon. Other missions, like in 1998 when the
Sojourner Rover landed on Mars and sent back color pictures of the
landscape, have continued to fuel our fascination with space
exploration.
Unfortunately, the space program has also been associated with a
number of national tragedies, such as in 1967, when Apollo 1 exploded
on the launch pad, in 1986, when the Space Shuttle Challenger was lost
shortly after takeoff, and again last February, when the Space Shuttle
Columbia broke up during the final stages of re-entry into the Earth's
atmosphere. It has taken this latest disaster to focus needed scrutiny
on the state of our country's space program.
Americans want to know how the Columbia accident happened, but they
also want to know the cost-benefit of manned space flight. The CAIB
report is very thorough in assessing what caused the Columbia breakup
and how NASA's management structure and safety procedures contributed
to this. It goes on to recommend certain changes that should be made in
order to continue human space flight. The report does not address the
basic question of whether the cost and priority now given to manned
space flight is justified.
One of the important decisions that needs to be made is what
balance should be struck between funding for manned and unmanned space
flight. As Chairman of the Research Subcommittee, I am interested in a
more quantitative evaluation of the value of science research performed
on both types of space flight, as well as on the International Space
Station (ISS). Advancements in nanotechnology, miniaturization, and
robotics will eventually accommodate most outer space research and
exploration. Sending humans into space may be necessary in order to
continue important life-science research. However, most functions of
space flight can be accomplished without the cost and danger of
involving astronauts.
I have often questioned witnesses on the justification for manned
space flight because I am concerned that the costs are high and the
benefits too few compared to unmanned flight or for that matter
spending those dollars on research through the National Science
Foundation or National Institutes of Health. With limited dollars for
research in tight budgetary times, it is imperative that Congress
direct funding toward investments that give us the greatest scientific
return that hopefully can result in economic returns!
The Washington Post has reported that the International Space
Station, if completed, is expected to cost $17 billion over budget. In
addition, the three-person crew spends a majority of their time simply
doing maintenance as opposed to doing actual research--an effort the
Wall Street Journal appropriately referred to as ``the modern
equivalent of a New Deal program to keep spacemen busy digging holes
and filling them in again until we can find some more productive
goal.'' While manned Shuttles do provide us with some useful scientific
information, the major objective of many missions is simply to re-
supply the Space Station. At this time of tight budgets in the U.S. and
with a growing reluctance in other contributing countries, these costs
may have been given a higher priority than is justified. With NASA
already spending nearly half of its $15 billion budget on human space
flight, serious consideration should be given to the continuing
viability of the Shuttle program and ISS.
In contrast, unmanned space missions have provided us with
extremely useful and interesting information, and at a much lower cost.
For instance, according to the ``Bulletin of the Atomic Scientists,''
the Galileo project discovered and analyzed oceans and volcanoes on
Jupiter's moons, and sent back information on the planet's weather
patterns at a cost of $1.35 billion over 14 years. The Mars Pathfinder
mission, which operated three times longer than its original planned
lifetime, cost $270 million, provided our scientists with more than
16,000 images from Mars, 15 chemical analyses of rocks, and large
amounts of useful information on Martian winds and weather. The Kepler
space telescope, which will cost an estimated $286 million and is
expected to be operational by 2006, will be able to observe nearly
100,000 stars and any planets in orbit around them. This will allow us
to estimate how many Earth-like planets capable of sustaining life
exist in the universe.
I fear the exercise of debating all potential changes to NASA will
be futile if we first do not closely scrutinize the costs and benefits
of our space science efforts, particularly with regard to manned versus
unmanned exploration.
[The prepared statement of Mr. Ehlers follows:]
Prepared Statement of Representative Vernon J. Ehlers
I want to express my thanks to Admiral Gehman and the entire
Columbia Accident Investigation Board for producing an excellent and
thorough report. The Admiral and the Board have taken the lead in
rigorously determining not only the technical cause of the accident,
but also in outlining underlying cultural and organizational factors
which contributed to the loss of the orbiter. The Board has identified
the need for changes at NASA; it is now Congress' task to make sure
those changes take place.
Most importantly, Congress must lead the Nation in determining
whether, and to what extent, we should continue human space
exploration. If we continue with human exploration of space, we must
have a clear vision and mission, and be willing to pay the price of
human space exploration--which will not be cheap.
We could decide to simply maintain the status quo in human space
exploration, with missions to the International Space Station and low
earth orbit exploration as has been done by the Space Shuttle. The
Shuttle could be recertified and refurbished for this purpose in the
near-term for relatively limited costs.
However, to continue human space exploration over the long haul, we
must admit that, though the Space Shuttle has served us well, it is
aging and has outlived its usefulness. A new vehicle will be needed.
The replacement vehicle should be safer, more efficient, cost less to
operate, and have shorter turn-around times than the Shuttle if the
vehicle is reusable. These are achievable goals with modern
technologies; however, we must bear in mind that development and
initial deployment of the vehicle will be expensive. However, if the
vehicle is designed well enough, we may actually save money in the
long-term compared to the expensive maintenance cost of the Shuttle.
If we consider going even further into space, for example, a manned
flight to Mars and back, the cost and the risk to personnel greatly
increases. While landing a robot on Mars costs about $150 million, a
manned mission would cost 1,000 times that amount, approximately $150
billion. Crew safety is also a significant issue. Personally, I do not
believe we should attempt a human expedition to Mars until our
technological capabilities have improved. In particular, we need better
propulsion systems and light life support systems for a mission to be
viable.
Furthermore, we need to remember that, although the American people
are enamored by the glamour of space travel, the basic mission of NASA
is scientific. Dollar for dollar, far more scientific knowledge is
gained from unmanned missions than missions involving human space
flight. The current unmanned exploration of Mars has yielded
significant results at relatively low cost and the Hubble Space
Telescope has provided scientists with a better understanding of our
universe than we will ever get from the International Space Station--at
a small fraction of the cost.
I look forward to a vigorous debate on these issues and a stronger,
revitalized NASA.
[The prepared statement of Mr. Sullivan follows:]
Prepared Statement of Representative John Sullivan
Thank you Mr. Chairman, I appreciate your calling this hearing
today on the findings and recommendations of the Columbia Accident
Investigation Board. As a Member of the Space and Aeronautics
Subcommittee on the House Science Committee, I consider it an honor to
be a part of this investigation and I appreciate Admiral Gehman and his
board for their tireless work on behalf of our nation and for coming to
testify here today.
The Columbia Accident Investigation Board has provided this
committee with an excellent blueprint to start the long-term
investigation into the organizational and technical factors that led to
the loss of the Columbia. Today we will learn exactly what went wrong
with the Columbia when she disappeared into the heavens on February 1,
2003, and review remedies to thwart future safety risk with human space
flight.
Our hearing today is one of many that will undoubtedly raise
difficult questions with regard to the costs and benefits of human
space flight and what actions need to be taken to reform NASA to return
our Space Shuttle fleet to operational status. Ultimately, this
committee will be charged with making decisions on the level of
financial resources that will be allocated to human space flight in
NASA's reauthorization next year.
The loss of the Space Shuttle Columbia affected our entire nation.
This hearing is undoubtedly one of many that will determine the
structure of NASA and the future of human space flight. As a nation of
explorers, I view this hearing as an opportunity to plot the course for
NASA's future and revitalize our priorities for manned space
exploration.
[The prepared statement of Mr. Forbes follows:]
Prepared Statement of Representative J. Randy Forbes
Thank you, Mr. Chairman. Admiral Gehman, Dr. Hallock, Major General
Hess, and Dr. Windall, I would like to thank you and all members of the
Columbia Accident Investigation Board for their hard work in completing
this comprehensive report, and for appearing before the Committee
today.
America's space program is a symbol of our success as a
scientifically and technologically advanced nation. However, tragedies
like the Space Shuttle Challenger and Columbia make some think twice
about whether it is worth continuing to send humans into space. The
crew of the Columbia took this important scientific assignment knowing
the risks involved, but recognized that this mission was not only a
service to the Nation, but to all of humanity. With that said, it is
chilling to read the Columbia Accident Investigation Board (CAIB)
report and learn that this accident could have been prevented. There is
no excuse for poor management to lead to the untimely deaths of these
brave explorers.
NASA needs to take these recommendations to heart and fix the
problems that could lead to another Shuttle tragedy. We must now look
at this disaster as an opportunity to rebuild our space program to the
finest in the world. As the Committee proceeds with its hearings on the
Space Shuttle accident and related problems highlighted in the CAIB
report, it is my hope that we can redefine the objectives of the space
program to find solutions to the failed organizational structure at
NASA.
We have a long road ahead of us in getting our space program back
on track.
[The prepared statement of Mr. Costello follows:]
Prepared Statement of Representative Jerry F. Costello
Good morning. I want to thank Admiral Harold Gehman for appearing
before our committee to present the Columbia Accident Investigation
Board report to the Committee.
In discussing the Columbia accident, we must remember to honor the
seven astronauts, their vision and their legacy. Space Shuttle flights
are what many people consider a routine event; however, each mission
has an extremely high risk. Both our nation and our world benefit
enormously from each mission.
These seven extraordinary men and women aboard the Space Shuttle
Columbia gave their lives for the pursuit of science and discovery. We
are fortunate to have an astronaut corps comprised of highly trained
men and women who regularly bear this risk. Their strong passion for
space exploration has immeasurably benefited our nation and the world.
We will never forget the dedication and sacrifice of the crew of the
Columbia.
Today's hearing serves as an opportunity to fully understand the
risks, costs, and benefits of the human space flight program, including
the Space Shuttle, and to determine what reforms need to be made at
NASA. The report describes that a foam strike during launch caused the
Shuttle to break apart during re-entry; however, NASA's inconsistent
safety culture was equally responsible for this disaster.
The report describes a Shuttle program that failed to learn the
lessons from the 1986 Challenger accident, the first Shuttle disaster.
In the case of the Challenger, and it seems now with Columbia, safety
requirements were ignored because of schedule pressures, budget
constraints, and workforce reductions.
NASA presented Space Shuttle safety upgrades to Congress in its FY
2001 budget. These upgrades were designed to keep the Shuttle flying
safely and efficiently to 2012 and beyond. However, the Space Flight
Leadership Council accepted the upgrades only ``as long as they were
financially feasible'' (CAIB, 188). The safety upgrade initiative had a
short lifespan because of conflicting dates and the assumption that
upgrades would be a waste of money if the Shuttle were to be retired in
the near future. In the FY 2003 budget request, NASA submitted a
request that reduced spending on safety upgrades by 34 percent.
Proposed safety upgrades continued to be either not approved or
deferred.
I am interested in the cost-cutting of the Shuttle safety upgrades
and the continued budget constraints of NASA. NASA's concept of mission
safety appears rather meaningless if it is funding a safety upgrade in
order to fly safely and then canceling it for budgetary concerns.
NASA continues to be our gateway to the universe. It is through
NASA's efforts that we will understand our planet, our solar system and
beyond. Our investigation and journey into space will continue;
however, the agency governing such exploration will be forever changed.
I welcome Admiral Gehman and look forward to his testimony.
[The prepared statement of Ms. Johnson follows:]
Prepared Statement of Representative Eddie Bernice Johnson
Thank you, Mr. Chairman. I would like to thank you for calling this
all important hearing today, and I would also like to thank Admiral
Gehman for agreeing to appear here today to answer our questions on
this most important investigation into the February 1 Space Shuttle
Columbia disaster.
Today we are here to discuss the Columbia Accident Investigation
Board (CAIB) report. It is imperative that we conduct this
investigation because the space exploration research program has been
one of the most successful research programs in the history of this
country. To protect the safety and integrity of the future of this
country's space program, we must learn from the mistakes of the past.
The report from this investigation will allow us to see what went wrong
and how to prevent it from happening again.
It was over 40 years ago that this nation's leaders in human space
travel were given the foresight to recognize the importance of space
research. We owe those leaders some homage for their foresight, and I
am hoping that we will then have the foresight to continue this type of
research.
Human space exploration is inherently risky. Distance, speed and an
environment that cannot support human life combine to make human space
flights particularly precarious.
That is why it is so essential that we put forth a concerted effort
to protect the safety of our astronauts.
Although we have lost a very precious group of national heroes,
many lives have also been saved because of the lessons we have learned.
This most unfortunate and tragic loss of five men and two women,
representing a mosaic of races and nationalities, will be mourned and
these great American heroes will not be forgotten.
[The prepared statement of Mr. Honda follows:]
Prepared Statement of Representative Michael M. Honda
I thank the Chairman and Ranking Member for holding this important
hearing, and I thank the members of the Columbia Accident Investigation
Board for their hard work on this difficult matter.
In preparing its report, the Columbia Accident Investigation Board
received unsolicited comments from individuals at NASA who were
becoming concerned that safety might be compromised as a result of
pressure to hold firm to the launch date of February 19, 2004 for Node
2. Those individuals attributed that date to Administrator O'Keefe.
The report concludes that ``the environment of the countdown to
Node 2 and the importance of maintaining the schedule may have begun to
influence managers' decisions, including those made about the STS-112
foam strike,'' and that during Columbia's last flight, ``Shuttle
Program managers were concerned with the foam strike's possible effect
on the launch schedule.''
The report is also somewhat vague on budgetary numbers, but it does
note that the Administration's FY 2003 budget request for Shuttle
upgrades was a 34 percent cut from the FY 2002 planned cut. This by
itself seems quite significant, but in fact the cut to Shuttle safety
upgrades was even greater because for the FY 2003 budget, OMB required
both Shuttle safety upgrades and Shuttle infrastructure revitalization
projects out of the same pot of money.
I look forward to hearing Admiral Gehman's thoughts on the impact
of schedule pressure and funding cuts in Shuttle safety upgrades on the
safety lapses that the Board found contributed to the Columbia
accident.
[The prepared statement of Ms. Jackson Lee follows:]
Prepared Statement of Representative Sheila Jackson Lee
Mr. Chairman,
Thank you for moving so swiftly and convening this important
hearing. I would also like to commend Ranking Member Hall, as well as
the Chair and Ranking Member Gordon of the Space Subcommittee for their
leadership, and tireless work since the tragedy of February 1st to
ensure that Congress and NASA and Admiral Gehman's team are all on the
same page--working together to find the best way to get NASA's vital
mission back on track. And, I would like to offer my sincere
appreciation and commendation to Admiral Gehman and his excellent team
at the Columbia Accident Investigation Board for their hard work,
tenacity, creativity, dedication, and openness in service to this
nation.
We are at a crossroads in the ongoing history of human space
exploration. February 1st was a dark moment for people around the world
who dream of pushing the envelope of human existence. We now have a
solid report before us that can serve as a roadmap for the future of
American space exploration, and we need to start looking to the future
because this mission is vital to our growth as an economy, and as a
society. But first I would like to look back one more time on what we
have lost--seven of humankind's greatest heroes, and for those of us
from Houston--friends and neighbors: Colonel Rick Husband, Lieutenant
Colonel Michael Anderson, Commander Laurel Clark, Captain David Brown,
Commander William McCool, Dr. Kapana Chawla, and Colonel Ilan Ramon.
Those seven courageous explorers paid the ultimate price to improve our
understanding of the universe, to advance our medical and engineering
sciences, to keep the United States economy on the cutting edge of
technology, and to inspire young and old alike.
Mr. Chairman, I, with my colleague from Houston Congressman Nick
Lampson, have introduced H.R. 525, which would posthumously award the
seven members of the Columbia crew with the Congressional Gold Medal.
It would also require the Secretary of the Treasury to make bronze
duplicates of that medal available for sale to the public, to serve as
an enduring reminder of the sacrifice of those brave pioneers and to
pay for the cost of producing the Gold Medals. The bill now has 135 co-
sponsors. I hope to see that bill go forward this year, and we continue
to focus on the Columbia, what it meant to us, and what it means to our
future.
Again, Admiral Gehman, I would like to commend you and your team
for putting out this outstanding piece of work. I admit that a couple
of days into February, with debris from the Columbia scattered across
the Southwest--I had doubts as to whether we would ever know what
caused this tragedy. But, with some great technical expertise and
modern day sleuthing, you have put together a very compelling story of
how the Columbia went down. That will be enormously valuable as we move
forward.
Obviously, the most frustrating thing for all of us is realizing
just how many opportunities there had been over the days, months, even
years before the crash, to prevent this loss. Knowing that there were
people at NASA--and not just some interns with naive notions--but
experienced engineers, who had recognized the dangers, and tried to
take prudent steps to get images that may have averted disaster; these
experts were ignored. That is truly painful to think about. Page 169 of
the report gives great insight into the broken culture of safety at
NASA that impeded the flow of critical information from engineers up to
program managers. I quote: ``Further, when asked by investigators why
they were not more vocal about their concerns, Debris Assessment Team
members opined that by raising contrary points of view about Shuttle
mission safety, they would be singled out for possible ridicule by
their peers.''
That reaffirms to me that strong whistleblower protections do not
just protect workers. They protect lines of communication and dialog
that prevent waste, fraud, and abuse, and, in this case, might have
saved lives. I will be working this year on legislation that will
enhance whistleblower protections for the NASA workforce, to make sure
that critical information is never lost due to intimidation or fear.
The report gives clear recommendations for NASA, concerning
technical and management changes, but there is still much work ahead to
decide how Congress, and this committee in particular, should respond
to this disaster. The report makes it clear that cuts in budget and
workforce at NASA over the past decade had detrimental effects on the
safety of the NASA mission. I believe that in this committee, on this
side of the aisle, we have been consistent in calling for increasing
resources for NASA programs. We have been calling for a clear mission
from the NASA Administrator, that would enable us to make appropriate
allocations for research, development, and upgrades when needed for the
Shuttle. And this has not just been about one Administrator, or one
Administration, this has been a consistent push for at least the four-
plus terms that I have been here. It is time that we all realize that
the NASA mission is valuable, and is worth the investment, and cannot
be done on the cheap. Admiral Gehman has stated in the report that
budget cuts hampered safety. Today I would like to push him a bit
harder to determine what kind of budget increases might be necessary to
get safety programs where they need to be.
Another important area that I feel needs further exploration by
this committee, and advisement from the Admiral, is the subject of
accountability. I respect and commend Administrator O'Keefe for taking
responsibility for what happened on his watch. However, this report
makes it clear that multiple middle-to-high level managers made
seriously flawed decisions that jeopardized the mission and ultimately
cost lives. I am from Houston, and the people I am talking about are
probably my neighbors. I am not interested in pointing fingers just for
the sake of it. However, if holding people accountable will set an
example and make future NASA managers more diligent, and make the
program safer, perhaps this committee should consider a specific
inquiry for that purpose. Also, I wonder if we owe it to the families
of the fallen crew of the Columbia, and those of the Challenger, who
were promised 15 years ago that the ``culture'' would change.
A final issue that I believe demands our attention is: What about
the International Space Station? Has it been immune to the management
problems that are described for the Shuttle mission? Of course, a space
mission is at most risk during take-off and re-entry--so I hope that
the Space Station is stable and safe right now--but we have two fine
astronauts manning the Station now. I would like to know if there is
any reason to think that they might be in danger or that the Space
Station have its own ``falling foam'' that has been disregarded and
might need attention? It seems that this could be an even more urgent
issue than the Shuttle, since we already have people at risk.
We have a lot of work ahead: management issues, budget issues,
technical issues, safety issues, and making sure that the NASA mission
and vision match their potential. This report is an excellent
foundation to work from. I look forward to the discussion.
Chairman Boehlert. And now it is important that we get to
our distinguished witness--witnesses. And before anything, I
want to say, once again to Admiral Gehman and to all of the
members of the Board, how sincere we are in expression--
expressing our appreciation for your thoroughness, for the
scope, and for the independence you have demonstrated. You have
done a great service, not just for the program or for the
Congress, but for the Nation, and we thank you for that.
With that, let me present Admiral Harold Gehman and the
members of the Columbia Accident Investigation Board. And
Admiral Gehman, you may wish to introduce your colleagues
individually.
STATEMENT OF ADMIRAL HAROLD W. GEHMAN, CHAIRMAN, COLUMBIA
ACCIDENT INVESTIGATION BOARD; ACCOMPANIED BY JAMES HALLOCK,
PH.D., MANAGER, AVIATION SAFETY DIVISION, VOLPE NATIONAL
TRANSPORTATION SYSTEMS CENTER; MAJOR GENERAL KENNETH W. HESS,
COMMANDER, AIR FORCE SAFETY CENTER; AND, SHEILA E. WIDNALL,
PH.D., INSTITUTE PROFESSOR AND PROFESSOR OF AERONAUTICS AND
ASTRONAUTICS AND ENGINEERING SYSTEMS, MASSACHUSETTS INSTITUTE
OF TECHNOLOGY (MIT)
Admiral Gehman. Thank you, Mr. Chairman, Mr. Hall, the
distinguished Members of this committee. Thank you very much
for the compliments. And on behalf of the Board, I accept those
kind words for the Board members who are not here. I will
introduce my colleagues here, and then I would ask the Chairman
to allow me to introduce my opening statement into the record.
And I will just say a few words, and we can get right to the
questions.
Chairman Boehlert. Without objection, so ordered.
Admiral Gehman. Thank you, sir. Beside me, to my left, is
Dr. Jim Hallock. Dr. Hallock is the manager of the Department
of Transportation's Volpe National Transportation Systems
Center from Massachusetts. Beside him is Major General Ken
Hess, the Commander of the Air Force Safety Center and the
Chief of Safety of the U.S. Air Force. And beside Ken Hess is
Dr. Sheila Widnall, the Institute Professor and Professor of
Aeronautics and Astronautics and Engineering Systems at the
Massachusetts Institute of Technology and previous Secretary of
the Air Force.
I know that all of the Members of this committee feel as
the Board does, that the tragic loss that this nation suffered
on 1 February 2003 is a price that we paid that is so dear that
it demands that we all do our part to ensure that an accident
like this never happens again. I want to thank this committee
and the leadership of this committee for helping this Board get
over a rough start the first couple of weeks, the first couple
of months to enable us to be at a position where we are right
now that we are discussing the merits of our report and not the
process by which this Board was founded. We can talk about
that, too. But we could not have gotten to this position had it
not been for the guidance, cooperation, and mentorship of both
Branches of the Congress, and we appreciate it very much.
Before I begin, Mr. Chairman, I would like to offer my
thanks to my 12 colleagues on the Board who gave up seven
months of their lives to produce this report. Approximately 120
full-time investigators and the thousands of NASA engineers and
employees who helped us with this, not to mention the nearly
30,000 volunteers who walked shoulder to shoulder across the
State of Texas picking up 84,000 pieces of debris, which turned
out to be instrumental in our reconstruction and forensic work.
And to all of those unnamed and unsung heroes, we owe a great
debt.
Let me just make a couple of points. I committed, a long
time ago, to this committee and to the public, that our report
would attempt to put this accident into context. And by
context, there--I mean any one of several contexts. There is
the context of the history of the human space flight program.
There is a context of the budget process. There is a context of
management and leadership. There is a context of all of the
previous reviews and investigations that NASA has gone through
and whether or not they learned. And then there is the context,
as has been mentioned this morning, of what is exactly our
nation's vision of what we want to do in space, and how does
the Shuttle program fit into it.
Obviously, the first thing we had to do was determine the
physical cause of this accident. We did. The foam did it. For
those of you on this committee who may not be intimately
familiar with the foam, I would like to introduce you to it.
This is an actual piece of foam. This is the left bipod
ramp. The little black line here indicates approximately where
it fractured. So this part of it here came off. And this is
about the right size. This is the right size. And this is about
what it weighs. And so this is the party of the first part
here. This is what it looks like, in case somebody is not
familiar with it. The Board was very deliberate in how we chose
our words about saying that the foam did it. We didn't say
``most likely.'' We didn't say ``all evidence supports.'' We
didn't say ``it was the conclusion of the Board.'' We said,
``The foam did it.'' And we are quite content with that, and we
are quite sure of it. And we would be delighted to discuss
that, if you want to talk about it some more.
If the foam did it, the Board was then interested in
answering the following question: if the foam caused this
accident, was this a legitimate surprise, an anomalous event
that had never happened before? Or if not, was this something
that happened before and why wasn't it fixed? What was the
process by which NASA went through attempts to understand and
fix why it happened? Of course, as has been reported in the
press, it was not a surprise anomalous event. This thing has
happened before. And when we got into a deep comprehensive
analysis of how the Shuttle program handles unknowns and risks
and surprises and how they conduct research and development to
understand what is happening and how they learn as an
institution, we were not very pleased with what we found. And
that statement takes about 150 pages in our report to document.
Being concerned, then, with what we found, we then took two
simultaneous paths to come to a set of recommendations. The
first path was a path of academic and theoretical review of how
to handle high-risk, high-technology institutions. How do you
handle risky activity safely? The second path was a review of
what we call ``best business practices'' or ``best safety
practices.'' And that is the review of institutions in the
United States that actually handle risky enterprises and do a
good job of it and what could we learn from those enterprises.
From these two reviews, we took what you might call a
sampling or a recipe or a cookbook of the characteristics that
we thought applied to NASA. We then took that template, applied
it to NASA, and we are not very pleased with what we found. We
then concluded our report with what we considered to be
concrete, specific, actual recommendations to fix these
management problems that we believe would go a long way toward
making the operation of the Shuttle more safe in the future.
Let me just close by saying one word about accountability.
The Board does not believe that accountable persons can hide
behind the excuse of bad management or culture or any other
subterfuge. There is a role for personal accountability. And in
our report, we think that the report is full of evidence of
personal performance. But it is up to either the Administrator
of NASA or this committee if you decide to hold people
accountable for their actions. The Board decided long ago,
announced publicly, and we have--and I will defend, very
strongly, the position that we took that it is not our job to
sit in judgment over other people. However, all of the
performance factors that you may be interested in are in the
report. They are all in there. And if you or the Administrator
of NASA feels that some accountability is required, we did our
job, we laid it out for you, and we don't think that that
constitutes dodging the issue of accountability.
Thank you very much, Mr. Chairman. And my panel and I of
colleagues here are delighted to be here and ready to answer
all of your questions.
[The prepared statement of Admiral Gehman follows:]
Prepared Statement of Admiral Harold W. Gehman, Jr.
Good Morning Mr. Chairman, Congressman Hall, distinguished Members
of the Committee.
I know Members of this committee feel as we on the Board do: that
the price this nation paid on February 1, 2003 was so dear, it demands
we do our part to ensure an accident like this never happens again.
It is an honor to appear today before the House Committee on
Science. I thank you for inviting me to pay tribute to the legacy of
Rick Husband, Willy McCool, Mike Anderson, Dave Brown, K.C. Chawla,
Laurel Clark, and Ilan Ramon in presenting the findings of the
investigation into the tragic loss of the Space Shuttle Columbia.
Before I begin, I would like to commend the efforts of my 12 fellow
Board members, 120 investigation staff members, 400 NASA engineers, and
more than 25,000 debris searchers who have contributed immensely to the
investigation.
Today I will provide the Committee with the final conclusions of
the Board with respect to the following three areas:
The physical cause of the accident
The organizational characteristics of NASA that
contributed to the accident
Recommendations the Board has made in regards to the
Space Shuttle Program
I. Physical Cause
The Board has determined that 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. The breach was initiated by a piece
of insulating foam that separated from the left bipod ramp of the
External Tank and struck the wing in the vicinity of the lower half of
Reinforced Carbon-Carbon (RCC) panel 8 at 81.9 seconds after launch.
During 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.
Entry data demonstrated that the flaw in the left wing was extant
prior to entry. The flight events are well documented, and establish
that progressive destruction occurred as the orbiter entered the
atmosphere. Superheated air damaged the structure of the wing first,
leading to the abnormal aerodynamic forces that caused the eventual
breakup. Once the orbiter began entry, there was no possibility of
recovery.
The Board reached this conclusion after extensive analysis of five
lines of evidence:
The aerodynamic scenario
The thermodynamic scenario
The detailed system timeline from telemetry and
recovered on-board recorder
The videographic and photographic scenario
Debris reconstruction and forensics.
Additionally, the Board conducted foam impact tests in order to
determine that this potential cause was indeed plausible. The tests
proved this, and much more. The tests demonstrated that External Tank
foam shed during launch could create considerable damage to the RCC
panels and the tests also added to the body of knowledge regarding RCC
strength. The foam impact testing ends for all time the common belief
within NASA that foam strikes are just a flight turnaround issue, and
also serves as a dramatic stimulus to change some people's attitudes
about what we really ``know.'' Furthermore, it demonstrates the Board's
finding that the characterization of the Space Shuttle as operational
rather than experimental was flawed. The direct result of this mindset
was the lack of testing on such matters as the cause of foam shedding,
the force of foam projectiles, and the strength of the RCC panels to
withstand such debris strikes.
II. Organizational Causes
Mr. Chairman, the Board believes very strongly that complex systems
almost always fail in complex ways. Most accident investigations fail
to dig deeply enough into the causes beyond identifying the actual
physical cause of the accident; for example, the part that failed and
the person in the chain of command responsible for that failure. While
this ensures that the failed part receives due attention and most
likely will not fail again, such a narrow definition of causation
usually does not lead to the fixes that prevent future accidents.
Our investigation into the loss of the Columbia was designed to get
to the heart of the accident, and reveal the characteristics of NASA
that allowed the accident to occur. As everyone knows, NASA is an
outstanding organization, with highly skilled and motivated people and
a long history of amazing accomplishments. However, there are long-
standing management issues that led to the Columbia disaster.
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
Program, subsequent years of resource constraints, fluctuating
priorities, schedule pressures, mischaracterization of the Shuttle as
operational rather than developmental, and lack of an agreed upon
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 stifled
professional differences of opinion
Lack of integrated management across program elements
The evolution of an informal chain of command and
decision-making processes that operated outside the
organization's rules
The Board believes that these factors are just as much to blame as
the foam. We began an analysis of how high reliability organizations
handle risky enterprises, creating a template for us to use to examine
management and culture at the Space Shuttle Program. The Board has
concluded that the Space Shuttle Program does not have the
characteristics of a high reliability organization. Furthermore,
history and previous studies demonstrate that NASA, as a whole, does
not ``learn'' well.
The results of our very intrusive investigation into the Space
Shuttle Program demonstrate clearly that gradually and over a period of
many years, the original system of checks and balances has atrophied.
Instead of using a system of checks and balances provided by
independent engineering and safety organizations, the Shuttle Program
placed all responsibility and authority for schedule, manifest, cost,
budgeting, personnel assignments, technical specifications and the
waivers to those specifications and safety in one office. That action
created an office that could make programmatic trades to achieve
whatever goals were set for it by a higher authority. For example, if
meeting the schedule were priority number one, the program could trade
safety upgrades against schedule. We find this to be an excellent
system if one's goal is to know whom to blame if something goes wrong,
but NOT an excellent system if one's goal is to maximize safety.
III. Recommendations
The Board does not believe that the Space Shuttle is inherently
unsafe, and we were under no pressure to say that it was safe. However,
there are things that must be done to make it more safe than it is and
many of these things must be accomplished before return-to-flight.
Furthermore, if the Shuttle is to continue flying past the next few
years, there are even more safety requirements necessary. Our
recommendations and observations also constitute an attempt to find
items that might be dangers in the future.
There are three types of recommendations in the report. The 15
Short-Term recommendations outline the fixes needed for return-to-
flight. The 14 Mid-Term recommendations refer to the needs for
continuing to fly for the next three to 12 years. The Long-Term
recommendations discuss the considerations that must be made for
continuing to fly the Space Shuttle beyond 12 years, including
recommendations for replacing the Shuttle.
In addition to the cultural and organizational considerations that
NASA must address, there are several recommendations that stand out.
One of these is the call for NASA to take an integrated approach to the
issue of the danger posed by debris by combining steps to reduce debris
creation in the first place, an overall toughening of the orbiter, both
in the RCC components and the other parts of the Thermal Protection
System, including the tiles, and developing a capability for on-orbit
inspection and repair. The Board studied scores of other findings of
significance with respect to how exactly to prevent the next accident.
Among the numerous recommendations is the need for better engineering
drawings, better safety and quality assurance programs, and improved
documentation. Additionally, there are specific ways to improve the
orbiter maintenance down period without sacrificing safety, as well as
recommendations on what to look for on bolt fractures, holdpost
anomalies, Solid Rocket Booster attach rings, test equipment and
training needs.
Conclusion
Mr. Chairman, at the beginning of this investigation, I promised a
final report that places this accident in context, rendering the
complete picture of how the loss of the Columbia fits into the
complicated mosaic of budget trends, the myriad previous external
reviews of NASA and the Shuttle Program, the implementation of Rogers
Commission recommendations, changing Administrations and changing
priorities, previous declarations of estimates of risk, work force
trends, management issues and several other factors. We have done this
to the best of our ability and I believe we have succeeded.
It is our intent that this report be the basis for an important
public policy debate that needs to follow. We must establish the
Nation's vision for human space flight, and determine how willing we
are to resource that vision. From these decisions will flow the debate
on how urgent it is to replace the Shuttle and what the balance should
be between robotic and human space flight, as well as many other
pressing questions on the future of human space flight. Let the debate
begin.
Thank you Mr. Chairman. This concludes my prepared remarks and I
look forward to your questions.
Columbia Accident Investigation Board Selected Biographies
Adm. Harold W. Gehman Jr., U.S. Navy retired, completed more than 35
years of active duty in October 2000. His last assignment was as NATO's
Supreme Allied Commander, Atlantic, and as the Commander in Chief of
the U.S. Joint Forces Command, one of the five U.S. Unified Commands.
Immediately after retiring, Gehman served as Co-Chairman of the
Department of Defense review of the terrorist attack on the USS Cole.
Gehman graduated from Pennsylvania State University with a Bachelor of
Science degree in Industrial Engineering and a commission in the Navy
from the Naval ROTC program. He served at all levels of leadership and
command and was promoted to four-star admiral in 1996. He became the
29th Vice Chief of Naval Operations in September 1996. As Vice Chief he
was a member of the Joint Chiefs of Staff, formulated the Navy's $70
billion budget, and developed and implemented policies governing the
Navy's 375,000 personnel.
Maj. Gen. Kenneth W. Hess is the Air Force Chief of Safety,
Headquarters U.S. Air Force, Washington, and Commander, Air Force
Safety Center, Kirtland Air Force Base, N.M. Hess entered the Air Force
in 1969 through Officer Training School at Lackland Air Force Base,
Texas, and has extensive staff experience at Headquarters U.S. Air
Force, the Joint Staff and U.S. Pacific Command. He has commanded three
Air Force wings: 47th Flying Training Wing, 374th Airlift Wing and
319th Air Refueling Wing. Prior to assuming his current position, Hess
was Commander of 3rd Air Force, Royal Air Force Base, Mildenhall,
England. He is a command pilot with more than 4,200 hours in various
aircraft.
Dr. James Hallock is Manager of the Aviation Safety Division at the
Department of Transportation's Volpe Center. He received BS, MS and
Ph.D. degrees in Physics from the Massachusetts Institute of Technology
and authored or co-authored two patents and more than 135 papers and
reports. He worked in the Apollo Optics Group of the MIT
Instrumentation Lab (now the Draper Lab) from 1963 to 1966, dealing
with the selection of Earth landmarks for updating guidance computers
on Apollo and the potential effects of solar flare radiation on
Apollo's optical systems. From 1966 to 1970, he was a physicist at the
NASA Electronics Research Center and did research in modern optics
(holography and spatial filtering) and developed a spacecraft attitude
determining system. In 1970 he joined the DOT Transportation Systems
Center (now the Volpe Center) and studied aircraft wake vortices,
developed aviation safety systems, and conducted many detailed safety
studies.
Dr. Sheila Widnall, Professor of Aeronautics and Astronautics and
Engineering Systems. Massachusetts Institute of Technology (MIT),
Cambridge. She has served as Associate Provost, MIT, and as Secretary
of the Air Force. As Secretary of the Air Force, Dr. Widnall was
responsible for all affairs of the Department of the Air Force. Dr.
Widnall was also responsible for research and development and other
activities prescribed by the President or the Secretary of Defense.
Since returning to MIT, she has been active in the Lean Aerospace
Initiative, with special emphasis on the space and policy focus teams.
Her research activities in fluid dynamics have included the following:
boundary layer stability, unsteady hydrodynamic loads on fully wetted
and supercavitating hydrofoils of finite span, unsteady lifting-surface
theory, unsteady air forces on oscillating cylinders in subsonic and
supersonic flow, unsteady leading-edge vortex separation from slender
delta wings, tip-vortex aerodynamics, helicopter noise, aerodynamics of
high-speed ground transportation vehicles, vortex stability, aircraft-
wake studies, turbulence, and transition.
Discussion
Risk
Chairman Boehlert. Thank you very much, Admiral Gehman.
The report states that the Board believes that the Shuttle
is not inherently unsafe, but it also says repeatedly that the
Shuttle is inherently risky and should be treated as
experimental. And parenthetically, let me say, I couldn't agree
more that it should be treated as experimental when, in the
view of most, it was treated as operational. How do you
reconcile those two statements? I assume that we'll likely lose
the Shuttle if the vehicle is flying another 10 to 20 years. At
what point does something become so risky that it becomes
inherently unsafe? Did the Board ever receive any convincing
risk analysis from NASA for the Shuttle program?
Admiral Gehman. Mr. Chairman, we chose those words very,
very carefully. We very carefully used the sentence with two
negatives in it. We--the statement that the Shuttle is not
inherently unsafe was chosen to allow us to send the signal
that we didn't think it's safe. It is not safe. It is risky.
And we didn't think it is unsafe. If we thought it was unsafe,
we would have recommended that we suspend flying operations. We
would have said that. The Board was under no pressure to allow
NASA to continue to fly this thing. The Board completely
divorced itself from cost and schedule and International Space
Station requirements. And we do believe that with proper
management and proper skill and a good, elegant management
scheme that the Shuttle can be operated reasonably safely. But
as you said, it can not--it is a risky enterprise and always
will be. It always will be risky.
Chairman Boehlert. What level of risk is that?
Admiral Gehman. We--I am going to let my colleagues in on
this one, because we have actually seen numbers. My own view is
that the numbers have little or no validity. And numbers along
the lines of the probability of a failure in a mission of one
in 200 are kind of the most commonly accepted numbers. I am
going to let--these people have also seen other numbers. And
then I will--I have a comment I would like to make. Does the
gentleman want to say something?
Chairman Boehlert. Dr. Hallock.
Dr. Hallock. Yes, there are a number--a lot of numbers that
float around that we have been looking at. NASA has done a job
in the sense of trying to look at the various things that could
affect the Shuttle. For example, the number that Admiral Gehman
just mentioned, the one in 200, is the chance of actually
having a problem due to a micrometeorite or an orbital debris
strike and actually cause loss of crew and vehicle. So the
numbers are large. But there are many other types of things
that they can run into that can be a problem, too, most of
which have been looked at. But once again, it is the
compounding of all of these numbers that become important.
Yes, it is a risky venture, but, you know, we have a lot of
other risky ventures that we are involved with. In fact,
sitting next to an Admiral, I think immediately of submarines
that go into an environment that is, you know, much like the
space environment. When you are well underwater, you are in a
place where it is not very easy to escape from to get back to
the Earth.
Major General Hess. Yes, I obviously agree with the Admiral
and Dr. Hallock on this issue. And in the course of our seven
months, I think we became fairly intimate with the fact that
truly quantifying the risks in numeric terms for the Shuttle
is, I think, a little bit like dreaming. I don't think you
could actually do it. You can't quantify the risk of the human
factor interfaces and all of the different layers that are
involved in making management and technical decisions as well
as the work that is ongoing everyday with the Shuttle. So you
can probably estimate, but the error band is fairly wide. And
so hanging our hat on a number is--after our study, nothing I
would do with the Shuttle. And I am always reminded that, yes,
the technology is risky and the uncertainty that is involved
always causes you to question whether or not it is safe or
unsafe to fly, but the difficulties in--that we have
encountered in both Challenger and Columbia were of the human
management decision style, not the technology itself. So I
think the risk, in the context, is manageable, but it takes
some elegant operations to do that.
Chairman Boehlert. Dr. Widnall, do you wish to add any?
Dr. Widnall. Sure, I will add a little bit. I think--I
would certainly agree with my colleagues. And the phrase that I
would use about trying to put numerical values on risk is that
it is perhaps necessary but not sufficient. If you look at the
risk of the Shuttle, you can divide it into two parts. There is
the physical characteristics or the hardware. You can sort of
analyze and dig deep into how the hardware was qualified, what
depth of engineering analysis was used, you know, how safe do
we feel the actual operation of the hardware is. But I think
obviously more important are the organizational issues. And for
me, the issue of how one decides to waive a requirement, how
one decides to treat an anomaly and continue flying, the depth
of engineering analysis that was applied to the various systems
to, in some sense, certify them. I think these are very
important issues, and they are not quantifiable.
Chairman Boehlert. Thank you. Thank you very much for
outstanding answers.
Admiral Gehman. Mr. Chairman, may--I wanted to add
something.
Chairman Boehlert. After they spoke.
Admiral Gehman. To get to your issue, though, it is a
lesser--at least it was a lesser to me, that when you ask to--
the answer to your question depends on who you ask. For
example, NASA has a number. They actually have a calculated
number for each mission. And if you go, for example, to the
U.S. Air Force, which operates the eastern range where they
launch it, and you ask them what their risk number is, you find
it to be much larger--much different than NASA's number. It is
very interesting. And in the case of the Challenger
investigation, the famous Dr. Feynman quote at the end, he
tried to address this question, too. And he kind of said that,
you know, kind of the best he could determine was 99 percent,
one out of 100, which is, of course, much higher than NASA's.
So the answer to your question depends on who you ask. And if
you ask an independent agency, you get a number which is more
risky than if you ask NASA.
Thank you, sir.
Chairman Boehlert. Thank you very much.
Mr. Hall?
Mr. Hall. Mr. Chairman, thank you.
Admiral, of course, I want to get back to safety. I want to
visit with you and the other three of you there. And the word
``risk'' and ``risky'' and ``risk assessment'' and ``risk
containment'' and all of that have been voiced, and of course,
proper words for this situation and for this report. And how
many times have I heard these brave men and women astronauts
referred to as the Columbuses and the Magellans of space. And I
often wonder how many ships were lost at seas and how many
crews were before Columbus or Magellan or Amerigo Vespucci or
whoever it was that hit this shore first, how many we lost and
how much risk they were assessing and a different risk.
But I think we need to think in terms of we do have a risk,
and we can--and we get the last guess at how to fix it, how to
fix that risk. I know that even prior to the Challenger and
prior to Columbia, I know that the President, after the
Challenger, thought we had assessed the risk and had attended
to it and had addressed it. I know the Congress thought we had.
I know the NASA Administrator, whoever it was at that time,
thought we had. But obviously they thought we had a safe
Shuttle. And now, complying with your recommendations, we are
going to think that we are making it safe, and we are going to
think we have addressed the risk. Now we were wrong twice. We
can't afford to be wrong again. And I think that now is the
time to start the journey toward doing something about it if we
are wrong again, that we haven't assessed the risk, that we
haven't pushed back any risk. I don't suppose it is possible to
say it is absolutely, without any question, risk-free. There is
no way to do that. I wish we could.
Crew Escape
But we can certainly--in case we are wrong, we can have a
way for those that are aboard that vehicle to survive. Now we
have asked for that before. I know that we have asked for it
for at least 10 years since the last loss. And each time, we
have been told that we can't have a vehicle aboard the vehicle.
I think the gentleman from California has addressed that a lot
of times. And the answer we always got was, ``Well, the weight.
It is a weight problem.'' And ``It is a money problem.'' And it
is both of those problems. But now, before we send anybody else
up, even though we think we have addressed the risks, we have
touched every base that we can humanly touch, we need to touch
one more base and have them have a way out in case we are wrong
again.
So with that, Admiral, let me say your report contains some
``observations'' about crew escape systems for the Shuttle. And
it mentions the fact that the Aerospace Safety Advisory Panel's
2002 report recommended that the NASA consider upgrading the
Shuttle to include crew escape systems in view of the Shuttle's
proposed life extension. And that makes sense. That should have
been done. Yet your report does not actually make a
recommendation one way or the other, that I can see, about
adding a crew escape system for the Space Shuttle. Now you know
that a lot of us feel very strongly that this is an area that
NASA needs to address if this decision is made to fly the
Shuttle for an extended period.
Without asking the question of why we sent this particular
Shuttle, why we sent the oldest one we had, why we sent the one
that couldn't dock at the Space Station, why we sent the one
that wouldn't have available the telescope. All of those things
are assuming blame to somebody. I am not interested in that. I
am interested in causation. I am interested in doing something
about it, if we are wrong, again, on our risk assessment. So we
owe it to them to give them a fighting chance. The loss of
another Shuttle would not--should not inevitably, absolutely
mean the loss of the crew.
So let me just ask you directly, if NASA plans to fly the
Shuttle past 2010, should NASA be required to develop escape
systems for the crews that will be flying those Shuttle
missions? That is a good yes answer, isn't it?
Admiral Gehman. As long as you say they should consider,
the answer is yes. In my opinion, the answer is yes. The Board
did not do an in-depth study of that issue, so I am not
speaking for the Board here, but we did. We looked at that
issue a little bit, and as long as it is couched in the terms
of should they consider it, the answer, in my opinion, is yes.
Mr. Hall. Dr. Hallock, do you have anything to add to that?
Dr. Hallock. Well, I agree with that in the sense that one
needs to always look at possible ways to be able to allow the
crew to survive.
Mr. Hall. We don't need to just look at them. We need to do
something about them. We need to get underway with it.
Dr. Hallock. I agree.
Mr. Hall. I can find people that are more intelligent than
those of us in Congress, so all we have to do is come up with
the money. But finding those of you out there who are givers
and are giving your time here today, have given your life to
what you are doing. We need you to come up with a way for those
people to get out of there if something happens. You can be
catapulted out of an F-16 or whatever. I can't understand why,
with all of the modern technology and all of the intelligence
and the genius we have here, a lady with MIT and the General
that has given his life to this country, Dr. Hallock that has
studied all of your life and been smarter than almost everybody
else that you knew or you were around. Surely to God you can
come up with some way to get people out of there if they say,
``Hey, the damn thing is knocking. There is a rod knocking in
it. Let us get out of here.'' Dr. Widnall.
Dr. Widnall. Sure, I guess maybe what I need to do is
define the word ``consider'', because I think if one were--if
one proceeds down that road, and I think it is a good idea, it
would take a really in-depth engineering analysis and a
consideration of, perhaps, design options and a calculation of
what this would actually be, what would its characteristics be,
and in fact, would it make the Shuttle, as a vehicle, more
risky or less risky. And that is the calculation that has to be
done.
Mr. Hall. Sure, weight and structure----
Dr. Widnall. Weight, strength----
Mr. Hall. Sure.
Dr. Widnall [continuing]. Materials. Let me just mention as
a----
Mr. Hall. Jack Kennedy had the start of all of those things
before----
Dr. Widnall. Sure.
Mr. Hall [continuing]. He ever launched the first one.
Dr. Widnall. Yeah. Let me just indicate the particularly
demanding environment that the Shuttle saw when it reentered.
Reentering at mach 25, at those altitudes, those kinds of
temperatures 10,000 to 3,000 degrees Fahrenheit, there are few
materials that will withstand those kinds of temperatures. And
so it is a very challenging engineering problem. But that would
be my definition of the word ``consider.''
Mr. Hall. Well, we knew the velocity of the foam that you
shot into that trial wing. We knew the speed at that time. We
knew all of those things before the Columbia loss. We knew that
could happen. Why can't we use that--why can't we use our
genius to come up with a vehicle that will save these people if
we are wrong about attending to the risk assessment? Why can't
we do that?
Dr. Widnall. It is perfectly reasonable to start down that
road.
Mr. Hall. And it--don't--wouldn't you be very uncomfortable
if you left here today and didn't believe that we were going to
start down that road, whether we get down that road or not,
that we are underway trying to get down to that road and that
we are lucky enough and have enough support from up above that
we don't have a tragedy before we get to the end of the road of
finding that answer?
Dr. Widnall. I think it is----
Mr. Hall. We better dang well be underway hadn't we--if we
have another tragedy.
Dr. Widnall. Yeah, it is a completely reasonable path to
take.
Mr. Hall. Because I am going to support the NASA
Administrator. I am going to work with him from this point
forward. I am going to try to comply with the Admiral's
recommendations. I am going to work with everybody on this
committee, but I want us to be underway to find a way in case
we are wrong and we are not successful at doing what we think
we are doing about risk that we can get them out, if it
happens.
I yield back my time.
Chairman Boehlert. Thank you very much.
The Chair of the Subcommittee on Space and Aeronautics, Mr.
Rohrabacher.
Shuttle Replacement
Mr. Rohrabacher. Thank you very much. And with due respect
to Mr. Hall, I would like to sort of take this from the other
side of the coin. Is--Admiral Gehman, isn't your finding that
we should be trying to minimize our reliance on the Shuttle
rather than trying to invest more into the Shuttle and--so it
could be used more in the future?
Admiral Gehman. Yes, sir. Our recommendations are a series
of recommendations to make the present operations of the
Shuttle more safe, but our recommendation is to replace the
vehicle as soon as possible. And in our editorializing in
chapter nine, we specified, to get back to Mr. Hall's point,
that whatever it is that we replace the Shuttle with that the
concept of the operations should be to separate the crew from
the cargo, because as long as you keep the crew and the cargo
together, you have to suboptimize human safety. And that--and
therein is the dilemma.
Continuing Shuttle Operations
Mr. Rohrabacher. So we should do our best to phase out the
Shuttle and go to a new system rather than trying to bolster
the capabilities of the Shuttle?
Admiral Gehman. The Board wrote that the Board was
surprised and disappointed to find ourselves here at 2003
without a replacement vehicle, even on the drawing board.
Mr. Rohrabacher. In terms of what we have to do and what
the Shuttle is necessary for in the future, Space Station is
certainly something that will not be completed without the
Shuttle. And even to make the type of safety upgrades that we
are talking about today will take a certain length of time that
would go well into Station's life span. Is it--do you have any
recommendation at all in terms of whether the Shuttle should be
used to complete the Space Station, given its current risks?
Admiral Gehman. The Board report, I believe, speaks very
clearly to the subject of operating the Shuttle at what we call
the midterm, that is like two to 15 years or two to 10 years.
And in there, we specify very clearly, I believe, that the
present management scheme is not adequate to operate the
Shuttle safely. Technically, hardware-wise, as long as you take
care of the Shuttle and as long as you aggressively investigate
every single waiver and every single anomaly, we believe the
Shuttle can be operated for another 10 years with a degree of
safety.
NASA's Culture and Management
Mr. Rohrabacher. So if we change the--one of the central
findings, if we come to grips with one of the central findings
of your Commission, which is the culture or attitude of what
was going on safety-wise at NASA, that that might, in itself,
enable us to reach a safety threshold in which the Shuttle
could be used to complete the work on Station?
Admiral Gehman. That is correct. Are there any other Board
members who want to--but that is the central core of our
recommendation. And that is that the present management scheme
tends to hide or overlook or not react to those little tiny
signals that something is going wrong. And it is those little
tiny signals, like foam coming off and things like that, that
you have to go after aggressively. And we can't predict what
the next thing to go wrong with the Shuttle is, but we do know
that the present management scheme is not good enough to catch
it.
Chairman Boehlert. Mr. Rohrabacher, just let me intervene,
if I may, and it won't be taken out of your time. But little
tiny signals, Shuttle after Shuttle, debris, foam comes off,
assumed that, since it came off, they assume too much that it
was going to be the size of the previous foam and no larger.
And isn't the basic thrust of your whole report that too much
was assumed and they weren't skeptical enough?
Admiral Gehman. Absolutely correct. And they didn't have
the resources to have a robust research and development
department. And they--and the engineers were all funded from
the Shuttle programs, so, you know, they are not going to tell
their boss that he is in trouble and et cetera, et cetera. But
yes. Yes, sir. You are exactly right.
Chairman Boehlert. Thank you.
Mr. Rohrabacher?
Mr. Rohrabacher. That, of course, is the difference between
being proactive and being reactive. And in fact, I think your
report suggests that the NASA attitude went beyond being
reactive. It was actually blase toward some of these signs that
Chairman Boehlert has just pointed out.
Let us go to that attitude now, as soon as we get done with
these beeps and buzzes. Did your Commission find that this lack
of energy or this blase attitude or bad culture, whatever we
want to call it, that this was part of the NASA culture in the
past during the Apollo programs and other programs, or was this
something that has just sort of evolved into place in these
last 10 to 15 years?
Admiral Gehman. We spent a lot of pages trying to answer
that question, Mr. Rohrabacher. And it is our conclusion that
it appears to us that, as you study history and you study the
previous reviews of NASA management, and you know, NASA is
never not being reviewed by somebody, so there are a lot of
data points out there, that it seems to ebb and flow. After a
big tragedy, like Apollo or Challenger, they take a whole lot
of management actions to make the program more safe and make it
more sensitive to engineering problems. And then, over the
years, forces begin to act on NASA. And some of these forces
are external forces, by the way. Some of these forces are
budget pressure or schedule pressure put on by both ends of
Pennsylvania Avenue. And NASA then starts to--it starts to
migrate or morph its management scheme to be more effective,
more efficient, more cost-effective. And we specifically found,
for example, that--in this particular case that we were looking
at so carefully, the Space Shuttle program, the Space Shuttle
program management actually had been squeezed to the point
where the Program Manager had so much authority, so much
responsibility, and so much authority that he could trade
schedule against safety upgrades. He could trade costs against
research and development. And we found this to be unhealthy.
Vision
Mr. Rohrabacher. One last thrust here, and that is this
attitude and this evolution in the wrong direction, that does
have something to do with a lack of vision and a lack of goals
of the whole space program, does it not? We have a saying on
top of us here that says, ``Where there is no vision, the
people perish.'' And let us note where there--when there is no
vision, astronauts perish. And is that not what we are talking
about here?
Admiral Gehman. We noted in our report that a lack of an
agreed national vision causes NASA to have an unclear set of
criteria on how to make decisions.
Mr. Rohrabacher. And leads to that attitude?
Admiral Gehman. It absolutely does.
Mr. Rohrabacher. Okay. Thank you very much.
Chairman Boehlert. Thank you very much.
Mr. Gordon?
Mr. Gordon. Thank you, Mr. Chairman. And Chairman
Rohrabacher, I hope that you will continue this effort to try
to find that vision. I think it is very important.
International Space Station and Space Shuttle Mishap
Interagency Investigation Board Charter
A couple quick questions, because, as you know, we are
caught in here with the bells. As you are well aware, Admiral
Gehman, you had to make a variety of changes to the original
charter that was set out in this Contingency Plan to develop a
Commission that you felt comfortable with. As I understand it,
we revert back to that original charter now if there is some
problem in the future. Would it be fair to say that this
committee ought to review--reviewing that original charter and
making some changes so that if there is another occasion that
we will be better prepared early on?
Admiral Gehman. To my knowledge, the NASA Contingency Plan,
which created this board, is still in existence and the words
haven't been changed. And if you feel that those--that
Contingency Plan is not right, yes, it should be reviewed.
Mr. Gordon. Well, you obviously did, because you asked for
it to be changed----
Admiral Gehman. That is correct.
Mr. Gordon [continuing]. A variety of times.
Admiral Gehman. That is correct. Um-hum.
Defining Benchmarks for Progress and Past Reports
Mr. Gordon. Okay. Now, as you have said on a variety of
occasions outside the specifics of the foam, a lot of what your
work was was rehashing the McDonald report. And if NASA had
done a better job of following the McDonald report, we may or
may not be here, but we would be in a better situation. I think
it is very important, as our Chairman pointed out earlier,
that, you know, when the crowds diminish and you are gone home,
that at least this committee doesn't lose its enthusiasm for
oversight and for setting up benchmarks.
And again, as the Chairman said, that is more than just
good will, it is the deeds. So I will--what I am going to--
because I think we can't get it all done today, but I am going
to write you and ask that you lay out your thoughts on how--
what kind of benchmarks, what type of processes that we need to
set up to see that these things are followed, as we had hoped
the McDonald would be. And you can do it more extensively later
in that letter, but I will let you go ahead now. And if you
would like to give this committee advice as to what kind of
benchmarks we need to set up. And if you would help us, also,
talk a little bit about what kind of rough dollar figures that
we need to be looking for.
Admiral Gehman. The Board agreed with me that we would not
be doing a thorough job if we did not study history. And we
studied history, the history of NASA and the history of the
investigations--previous investigations of NASA, including what
we found in retrospect to be a very, very good report done just
three years ago by Harry McDonald. But also, we went back to
the Rogers report and the Norm Augustine report and the Kraft
report. And all of these reports, which we carefully
documented, you might say we found nothing new. NASA has been
told over and over again that they are--that a number of the
things they are doing increase the risks to the Shuttle. They
are--I think your question, though, is really an excellent one
and that is two years from now or three years from now or four
years from now, how do we ensure ourselves that the follow-up--
that the progress is there and that the follow-up is there and
that this natural migration of these good traits back to bad
traits doesn't occur again, like it has happened in the past.
And the Board has discussed this a little bit, and we would be
delighted to dialogue with you on how you get at that, because
I think that is the central question.
Mr. Gordon. And you are going to be around a little longer.
You will have staff a little bit longer. And if you--I will
send a letter of request and would welcome your advice as to
how we can follow up on that.
There are lots more, Mr. Chairman, but I guess we better
go.
Chairman Boehlert. Well, I think we can get in one more
round. We have eight minutes to go, so we will go to Mr. Smith
of Texas, and then we will take a brief pause. We have two
votes. We will get right back. This is very important.
Mr. Smith of Texas. Thank you, Mr. Chairman.
Admiral Gehman, let me get directly to my questions. The
first is that the report raised a concern about greater
priority being given to scheduling demands than safety. Who or
what pushed these scheduling--put these scheduling pressures on
the individuals involved?
Schedule Pressure
Admiral Gehman. The--we believe that we got right to the
bottom of that in our report. And when you ask senior managers
at NASA to a person, 100 percent of them deny that there was
any schedule pressure. And then when you go down and talk to
the worker bees, the project people who are actually working on
the Shuttle program, to a person, they say that there was
enormous schedule pressure. So schedules, of course, are not
bad things. I mean, everybody uses schedules as a management
tool.
Mr. Smith of Texas. Do you think the pressures were more
internal than external?
Admiral Gehman. I think that there was a great difference
of opinion between the senior managers and the junior people.
And of course, any time you have got the senior managers
working on one set of script and the other people working on
another one, you have got a dangerous situation.
Mr. Smith of Texas. They are conflicting responses to----
Admiral Gehman. Complete miscommunications as to what the
truth was.
Inaction to Previous Foam Loss
Mr. Smith of Texas. Admiral Gehman, none of the external
advisory groups voiced concerns about the foam despite the
fact, as we know, that foam has been falling off consistently.
What significance do you attach to the fact that none of those
concerns were raised?
Admiral Gehman. Thank you, sir. And by the way, that, of
course, struck the Board right in the forehead like a two-by-
four that these wonderful previous panels, including Rogers,
missed the significance of the foam coming off. If we are so
brilliant that we can see that foam is a hazard to the Shuttle,
why didn't all of these other people see it?
Mr. Smith of Texas. Exactly.
Admiral Gehman. And the way we answered that was that
these--we have to set up a management scheme that can detect
this kind of stuff, not--knowing that it is very hard to
detect. And the management scheme that we put in place would be
one in which waivers or exceptions or violations to the
specifications would be reviewed by a group of people who have
no interest in cost and schedule. That is the only way we can
see to safely get things like foam and--oh, by the way, the
Board felt it very important that we come up with others, by
the way. We think it is kind of a cheap shot to take a--to
criticize NASA for missing the foam, so we said, ``Okay. If you
are so smart, tell me what the other ones are.'' And we came up
with half a dozen other ones that are very dangerous in which
they decided to waive. I know, and my panel members, I know,
for example, Dr. Widnall would like to--might want to comment
on the testing of bolt catchers and things like that. So you
know, there are others. So the answer to your question is this
independent technical review authority.
Reduction in Safety Procedures
Mr. Smith of Texas. And a couple more questions real
quickly, Admiral. You expressed concern in the report about the
drastic reductions in government inspectors and the mandatory
points of inspection, which actually started in the early
1990's. Was this intended to shift greater responsibility to
the contractor or was it to meet budgetary constraints?
Admiral Gehman. It was both. It was--they assumed--their
belief was----
Mr. Smith of Texas. Neither of which was good.
Admiral Gehman. Neither of which was good.
Mr. Smith of Texas. Okay.
Admiral Gehman. They assumed that the maintenance and
preparation for launch of the Shuttle, they had done it so many
times, they thought it was a routine operation and could be
contracted.
Shuttle Servicing of Hubble
Mr. Smith of Texas. Lastly, Admiral Gehman, if the Shuttle
flies again, and we hope that it does, is there any reason why
it would be limited only to servicing the Space Station? Is
there any reason why it couldn't continue to service other
science missions, including the Hubble?
Admiral Gehman. No, there is no reason except that the on-
orbit inspection repair capability, which we recommended, would
be different for the two missions.
Mr. Smith of Texas. All right. Thank you. Thank you, Mr.
Chairman.
Chairman Boehlert. Thank you. Just let me make an
observation. Waivers are something we are going to get into in
greater depth a little bit later on. There are over 3,200
waivers that have been granted. Over 1,000 of them hadn't been
reviewed in more than a decade, so that is something you
rightly emphasized and that is something we should focus on.
But before that focus, we have to take leave for a few minutes
to go respond to the call of the House. We should be back
within 15 minutes. If you have--if you would like coffee or--I
can't give you a break to go sailing, Admiral, but we can give
you a--we will try to--the staff will try to accommodate
anything you might want, if you want----
[Recess.]
Schedule Pressure
Chairman Boehlert. Let us resume. Mr. Costello?
Mr. Costello. Mr. Chairman, thank you. Admiral, you
answered a question earlier posed to you by my colleague, Lamar
Smith, and I would like to follow up on that. On pages 116
through 118 and later in your report, you refer to the schedule
pressure, the pressure that was put on NASA employees by the
schedule that was adopted by the Administrator. And I would
like to ask a few questions concerning the pressures that may
have been added because of the schedule. And one is you
apparently, according to your report, the Board's report, you
very carefully evaluated the impact that the schedule pressure
may have had on Shuttle safety. And specifically, the
Administrator seems to have laid out a management goal of
completing node two of the International Space Station by
February 19, 2004.
And my question is, from reading the report, is that most
of the NASA program people believed that that was an
unrealistic goal. They also believed that if they didn't meet
these arbitrary goals that something bad was going to happen to
them. And I wonder if you might comment what you found
regarding the schedule pressure and how that impacted safety.
Admiral Gehman. We did find that schedule pressure, undue
schedule pressure, excessive schedule pressure, was at work on
the workforce in NASA, even though as I indicated in my
previous answer, the senior management will deny that. But we
did find it present in the workforce. And as the illustrations
in our report indicate, we also were concerned that some of the
measures that NASA was taking to stay on schedule appear to be
cutting into the safety margin, such things as working on
weekends, conducting safety checks in parallel instead of
series. They are all listed in those charts in there. They all
appear to be a--they all appear to support our basic hypothesis
that bad traits and bad engineering habits had crept into the
NASA organization. We don't think--we don't say in our report,
and I don't think the Board feels that schedule pressure caused
this accident. That is not what we are suggesting.
Mr. Costello. The--you talk repeatedly in the report about
the communication failures at NASA concerning the Columbia
disaster. And you know, it is surprising to me that the
Administrator and top management never seem to hear from the
people in the program level that the schedule, the Core
Complete goal needed to be adjusted or changed. Did you find
any evidence at all of discussions that may have taken place
concerning the goal complete--Core Complete goal among the top
managers or any consideration of how it impacted safety of the
Shuttle? I know the top management said that they never heard,
but in your investigation, did----
Admiral Gehman. Yes. I will let General Hess answer that.
He is the expert on that area.
Major General Hess. Thanks. I think in our investigation of
it, and it is documented in some of the charts in the report,
we know that the International Space Station managers, as well
as the Shuttle managers, were briefing the number of days of
slack in the schedule. And the briefing charts were, in the
last venue, I think, in December of 2002 indicated to the
leadership that they were projecting as much as a 45-day late,
last line on the chart says, but we are going to hold to the
February date. And so I think that the discussion was there
that they were telling the NASA leadership that their best
estimates were that they were going to be behind, but they were
still sticking to the date.
Now how far the conversations went beyond the briefing
chart, I don't think we know, but when we get back and look at
the circumstantial evidence, how it unfolded with regards to
decisions made on STS-113 and then on-orbit decisions were made
with this particular mishap, it looks like it all came together
to influence decisions.
Mr. Costello. General, a follow-up question, if I can. Do
you have any concerns that the return-to-flight goal laid out
by the Administrator may produce some of the same pressures?
Major General Hess. Well, obviously I would have concerns
if NASA doesn't have a realistic timeline decided. I think
that, perhaps giving them some credit here, the initial
estimates about when they wanted to return to flight were done
before the full value of the report was laid out before them so
they could actually see the recommendations and how long it was
going to take them to get from where they are currently to
actually the return-to-flight decision. And certainly some of
the key return-to-flight recommendations will establish a
timeline that may not have been apparent when the schedule set.
So I think that they have every opportunity to fix the schedule
that will be realistic.
Chairman Boehlert. Thank you very much.
Let me ask you, Admiral, before I go to Mr. Calvert, NASA
has indicated the return-to-flight report will be out next
Monday, I think, the 8th, or Tuesday. Will you be in a position
to give a sort of an instant evaluation of that plan?
Admiral Gehman. I, obviously--I am going to retain a small
staff, because we have more work to do, and we are at your
disposal to do whatever you want to do. I would say that Mr.
O'Keefe indicated in testimony yesterday that the return-to-
flight schedule is events-driven, not calendar-driven. So he
said we return to flight when we are ready, not--and not on a
date.
Chairman Boehlert. And you are due to be testifying before
the Committee with Mr. O'Keefe on the 10th----
Admiral Gehman. That is correct.
Chairman Boehlert [continuing]. And so I am sure you will
have some choice words on that.
Mr. Calvert.
Independent Technical Authority
Mr. Calvert. Thank you, Mr. Chairman. And thank you for
having this hearing and the hearings we are going to have in
the future. And I want to thank Admiral Gehman and certainly
the Investigation Board for all of their hard work, and we
certainly appreciate that.
I would like to spend a little bit of time on the issue
that was brought up during your testimony, Admiral, and that is
the role of independence. I am interested in learning more
about the Board's suggestion that the responsibility and
authority for decisions involving technical requirements and
safety should rest with an Independent Technical Authority. And
I agree with you. I agree with the conclusion and the relating
recommendation. NASA needs to utilize independent assessment
capabilities that will serve them throughout the life cycle of
the space system and human space generally. And as you know,
Admiral, in your career in the United States Navy, some of the
oldest and best assessment--independent assessment work came
from the Navy's painful experience from World War II with
torpedo fuses, which was well-documented and the Navy learned
their lesson and it created something that was just in my
District, the NAVSEA Corona, which I represent, which trace
back to that original problem. Within your recommendation that
NASA stand up on an independent assessment capability, is there
room, encouragement, direction for NASA to use the experience--
that kind of experience and to follow agencies like DOD to
establish that authority?
Admiral Gehman. I thank you for the question. And the
answer is that--the answer to that question gets right to the
core of our recommendation. We tried to devise a practical,
workable recommendation that would fix as many of the problems
in one--at one time as we possibly could. And the traits and
the unhappy characteristics that we saw in the ignoring of
engineering advice, the e-mail story about the images, all--
many, many of these ills, we thought could be fixed with one
management fix. And that management fix is to take the
ownership of the level one specifications and requirements and
all waivers to them, and the Chairman had mentioned how many,
3,000 and some odd waivers we are flying with right now, invest
them in a technical engineering organization, which is
divorced, isolated from cost and schedule pressure. And this is
done other places. We have found other places where it is done.
You mentioned NAVSEA Corona, which does not only the--now it
does missile--it does all kinds of analysis of weapons'
effectiveness. And they are completely independent from the guy
who has to shell the money out. And so you get an independent
assessment. We find that to be a very attractive methodology
for fixing a number of problems.
Mr. Calvert. And when you say independent of NASA, would
they have a separate budget? Would NASA still control their
budget? Would you kind of expand on how that organization will
work and how its--and the relationship with the Shuttle Program
Manager?
Admiral Gehman. It is not our intent that they will be
independent from NASA. It is our intent that they be
independent from the Shuttle program. Now they would still be
within NASA, as we viewed it. We were very careful in our
report, and we discussed among ourselves, at great length, the
issue of not specifying in any great detail how this
organization should be set up. Since we are not going to be
around to micromanage it or be around to make the fine-tuning
that are necessary to any management change, we decided instead
to specific in great--with great detail and great directness
how this organization should work, what its function should be,
but not drawing the wiring diagram. So this organization would
be within NASA, but it would be independent of the Shuttle
program.
Mr. Calvert. I understand. Dr. Hallock, General Hess, Dr.
Widnall, any other comments on that, on the independent
technical board?
Dr. Widnall. Yes, I might make a comment. I think this, as
the Admiral has indicated, is an extremely important
recommendation. And from my way of thinking, what we have given
NASA is a template or, as a scientist, I might say we have
given them a set of boundary conditions. I believe very
strongly that it is in the working out that will take place
within the agency of how this will work, what processes will be
used, how the interaction and interfaces between the Shuttle
program and independent technical agency, how that will all
work I believe will go a long way toward challenging the basic
culture of NASA, because it will challenge some of their basic
assumptions about, you know, what is true, what is fact, what
is analysis, how do you make decisions. So I look to it to have
a really good effect on the agency, the working out of the
details within the template.
Mr. Calvert. Thank you. Thank you, Mr. Chairman.
Chairman Boehlert. Mr. Lampson.
Mr. Lampson. Thank you, Mr. Chairman.
Vision
Well, Admiral Gehman, I want to join with my colleagues who
have passed commendations on to you and the other Board members
and your staff are--the work that you have done on this report.
I, too, remember back when--I guess in February when
Administrator O'Keefe said, ``We may never know the answer.'' I
think that we can feel confident that you have, indeed,
determined the physical cause of this accident.
I read your report to say that NASA must see significant
reform, the agency must develop a vision for the future, and
that the Administration and Congress must provide NASA with
adequate funding levels. And I see that as a new mantra for us.
Let us do what my Senator said the other--yesterday when she
said, ``Let us throw out faster, better, cheaper in the garbage
can. Let us start looking at reform, vision, and funding and
perhaps we can have some different successes.'' It seems clear
from your report in the area of reform that NASA and the space
community are comprised of an enormously talented and dedicated
group of men and women who are capable of making the cultural
changes that your report indicates. How, specifically, do we
continue to support their important efforts as NASA continues
their return-to-flight process and institutionalizes the
changes that will support and sustain safe operations over the
long run?
Admiral Gehman. That is a tall question, Mr. Lampson, but I
will give you a couple of answers to that. First of all, it
isn't NASA that needs a vision. It is the country that needs a
vision. NASA has got lots of visions, but visions without
resources are just dreams. We need an agreed vision, and then
NASA can execute that. The reforms that we call for in our
report can not be instituted by the Administrator of NASA
alone. He is going to have to have your help. For example, this
independent technical review authority that we just discussed
will have a manpower bill associated with it. These are people
that are going to have to be hired, and they are going to have
to be paid. They are going to have to have career paths et
cetera, et cetera. So they are going to--the Administrator is
going to have to come up here and get your assistance on this.
Some of the other reforms are going to require your
assistance, too, because they are not solely within the purview
of the Administrator of NASA. The funding business--the Board,
in order that we weren't affected by cost and funding, we kind
of isolated ourselves from costs, and we don't know exactly
what it is going to cost to return to flight. I would say that
our experience of working this problem for better--just under
seven months, indicates that none of the things we have
recommended are terrifically expensive. I mean, they aren't
showstoppers. But some of the things that we recommended for
the midterm, for example, this completely independent new
technical review authority, an independent safety organization
with line authority over safety means more people, more
government people. And some of the other recommendations,
having to do with the oversight of the contract needs more
government employees. So he is going to have to come up here
and explain to you how he is going to go about it, and you are
going to have to help him.
Mr. Lampson. You made the comment about vision, and in the
report, you also said ``lack of agreed national vision for
human space flight.'' Would you expand on that finding for just
a few seconds, please?
Admiral Gehman. Well, we attempted to find everything that
we possibly could that contributed to bad habits and bad traits
and bad management at NASA. And there were a lot of things that
contributed a little tiny bit and some things that contributed
largely. This was a contributor. It--for lack of an agreed
national vision, you don't know how many years to amortize
investment in infrastructure. It is hard to argue budgets
before Congress if you don't have an agreed vision to where you
are going. You don't know when to replace equipment. We saw, in
some of their technical laboratories, 1960-era oscilloscopes
and things like that, analog meters when everybody is using
digital meters, you know. And there are basic infrastructure
decisions and basic investment decisions, which NASA has a hard
time arguing or justifying because we don't have a complete
agreement on how long is a Shuttle going to be around, what is
it going to be used for in the future. And so it is very
difficult for them to make investment kinds of choices.
Mr. Lampson. Thank you very much.
I would like to ask, and I am not going to, because my time
is about to run out. I would like to ask, at some point in
time, for your advice on--and the Board's advice on how to
recognize in the future when a lack of resources has pushed a
program into an unsafe condition. And there might be something
that you may want to think about and at a future opportunity
that we will have--but let me take my last couple of seconds
and close, if I may. I do believe that we should give NASA the
funding that it needs, but first, the agency must make
necessary reforms and establish a vision. Your report calls on
the White House and on Congress and NASA to honor the memory of
Columbia's crew by reflecting on the Nation's future in space.
And I couldn't agree more. And now that your report has been
released, this Administration must provide Congress and the
American people with a vision and a concrete set of goals for
the Nation's human space flight program after the International
Space Station. And I am hopeful that the agency will establish
a phased series of goals over the next 20 years, including
human visits to the Earth-Sun libation points, Earth-orbit
crossing asteroids, as we have been reading about, deployment
of a human-tended research and habitation facility on the moon,
and human expeditions to the surface of--and moons of Mars. And
I attempted to push such legislation, push NASA into the
direction of my Space Exploration Act legislation that I
introduced in the last Congress. I am going to do that again,
Mr. Chairman, next week, and I invite all of our colleagues on
this panel to please take a look, please make advice or
suggestions to me as to how to make it the kind of legislation
that would fit into our discussion today.
And again, I thank you, Admiral Gehman. I yield back my
time.
Budget
Chairman Boehlert. Thank you very much, Mr. Lampson.
I would note a particular passage in the report on page
209, ``NASA has usually failed to receive budgetary support
consistent with its ambitions.'' I would suggest that probably
that would apply to any agency of the Federal Government. And I
am glad we are focusing so much attention on vision, because we
have to have a shared vision. It has to be at the Executive
Branch and the Legislative Branch, and we--and the American
people signing on to that vision.
But further, and I would report on page 105 of the report,
we are talking about budget reductions. We are all part of this
process. But let me just read a couple of things here.
``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.'' And then it
goes on to enumerate all of the changes that were made.
Of course we haven't provided NASA, or any other agency,
with every dollar they have requested. And we have to be very
mindful of our special responsibilities. But when it is pointed
out that we don't provide the budget to--consistent with an
agency's ambitions, I would suggest that the agency better
adjust its ambitions, and we better sign on to what we agree on
is the vision for a program for the rest of the budget year and
beyond.
With that, I go to Mr. Gutknecht, the Vice Chair.
Mr. Gutknecht. Thank you, Mr. Chairman.
Benchmarks of Implementation
And again, I thank all of you for what you have done. And I
think your answers today have been very candid, and we
appreciate that more than you can imagine.
I--yesterday, the Administrator, Mr. O'Keefe, testified
before the Senate Commerce Committee. And he indicated
unequivocally that he understood the message and would
implement the recommendations of your report. But you know,
success leaves clues, and good management requires setting
benchmarks and finding, you know, as we go forward how are we
doing in terms of implementing that. And if you were sitting on
this side of these desks, what would you look for in terms of
benchmarks so that we could actually have a better confidence
that they really are implementing the plan, at least as you
outline in your report? Any particular things we should look
for in the next six months to----
Admiral Gehman. I will take a--I will mention a couple
things, and I think I am going to ask Dr. Widnall, who has some
comments about oversight and review and things like that. First
and foremost, of course, is the Stafford-Covey--well, the first
and foremost is the waiting for the NASA return-to-flight plan.
We have to get it, and we have to look at it. Second of all I
think very prudently, we have a very illustrious large panel,
the Stafford-Covey Return-To-Flight Review Group, which is
going to provide an opinion, an evaluation not of our report,
but they are going to provide an evaluation of the adequacy of
NASA's response to it. And I think that that is a very, very
good step. But the real core of our recommendations are
recommendations which are--need to be implemented a year from
now, two years from now, and three years from now. And I think
that the question remains open in my mind as to how to follow
up on that effectively. And setting benchmarks is a good way to
do it. There are other ways to do it. And I think that Dr.
Widnall wanted to make a comment about the efficacy of some
kind of a review panel, which might measure those things.
So if you will allow me, I will recognize Dr. Widnall.
Mr. Gutknecht. Please.
Dr. Widnall. Okay. Well, let me make a couple remarks.
First of all, I do believe that our recommendation that in the
return-to-flight, the--NASA should come forward with a plan on
reorganization was actually inspired. It is one of those things
that happens when a group of people get together and, you know,
talk deeply about an issue. And I think it really was an
inspired idea. From my point of view, the organization that we
have recommended, the Independent Technical Authority and the
safety organization, have specific attributes, and you could
almost check them off. We leave it to NASA to do the details to
figure out where in the organization it housed, who it reports
to, and all of that. And the--but the processes, the fact of
its independence is a specific attribute that can be measured.
And there is no fudging up of that. So I think that is
identifiable.
As to the issue of oversight, I think there has been a
tendency to simply recommend an oversight committee. I think
there is a big difference between oversight inside an
organization and oversight outside of an organization. I have
not been a fan of standing outside oversight committees,
because I think, with time, they tend to atrophy. They lose,
you know, the urgency. They have an initial charter. They have
an initial mission, and they set out on that mission, but then
over time, it kind of dwindles away. So I am concerned about
establishing yet another ``outside advisory committee.'' I am
much more in favor of what I would call the sense of urgency,
short-time committee, such as we, ourselves, were. We were a
short-time committee, seven months. We had a sense of urgency
about what we were doing. We were willing to work real hard for
a short period of time.
So those are some of the trade-offs that you might think
about as you look into the issue of how can you get adequate
oversight for some of the details that need to be followed up
on. I do believe that safety is a technical discipline. So you
will need comments from people who, basically, are safety
disciplinarians and people who have had experience at these
kind of very intense investigations, such as our Board. But the
question of follow and oversight is a challenging question. And
I know that you will be giving a great deal of thought to this
as you proceed.
Shuttle Design Compromises
Mr. Gutknecht. And speaking of urgency, and I know we all
have to run and vote, but I couldn't let you go without at
least mentioning, and perhaps you could respond briefly, Homer
Hickham wrote a fairly blunt piece in the Wall Street Journal
the other day. And he titled the piece, ``NASA's Vietnam.'' And
in it, he says, and if I could just read this into the record.
He says, ``Take a look at the Shuttle's stack and see what you
see: a fragile space plane sitting on the back of a huge
propellant tank between two massive solid rocket boosters. The
Shuttle has to sit right in the middle of all of this turmoil
of launch, because we once believed that it would be cheaper to
bring back those engines and rebuild them rather than to build
new ones. That has proved not to be the case, far from it. But
it has left the crew sitting in the most vulnerable position
possible in terms of design.'' Would any of you like to talk
about it, because essentially what he says is that the whole
design is a flawed strategy and that we have to get serious
about coming up with a whole new way of launching a returnable
vehicle? Would anybody like to comment? And I apologize,
because our time is short, and we don't have enough time to
discuss it in length, but----
Admiral Gehman. We have felt so strongly about this, and we
devoted the whole first chapter in our report to the issue of
the compromises that were made when they built this thing. And
because we felt that the compromises--the original design
compromises left us with what we have got. I mean, it is--what
we have got is what we have got. And it is a compromised
vehicle. Now it is an engineering marvel, but I know, as an
aerodynamisist and Dr. Hallock also is a physicist, we all
constantly scratch our heads as to why you have three 400,000
horsepower engines on a glider. And why do you put them into
orbit? And we know the answer. I mean, we know the answer, but
in retrospect, it is an interesting question. But in--to make a
long story short, we agree with you, and that is why we devoted
a whole chapter to the issue of the design compromises that
were originally made when the original--when this Shuttle was
originally built.
Mr. Gutknecht. And that is why you essentially recommend
that as soon as possible, this vehicle be replaced.
Chairman Boehlert. Thank you. The gentleman's time is
expired.
Now we have another vote, but we will dash over, and I
promise you faithfully we will dash right back. And Mr. Wu will
be first up. We will see who dashes the fastest.
[Recess.]
One-year Review
Chairman Boehlert. Let me bring up a subject that you might
not want me to bring up. But Admiral Gehman, you indicated that
you are not going to be micromanaging and fine-tuning
everything, but we do need, and we have got our special
oversight responsibilities. We have to be vigorous with them,
and I can assure you we will be. And I understand, Dr. Widnall,
you said about all of these external panels, appointing new
panels. You are not quite certain they always do the job that
they intend to do, but at the risk of offending you, this is a
compliment to you, we need some help in evaluating the plan and
would the panel be receptive to, sort of, a one-year review?
Now I don't know how practical that is, because you are
constituted under the authority of NASA. Maybe you could be
reconstituted under the authority of the Congress, but I think
you provide an invaluable service to the Nation. You have
expertise. You have brought an awful lot to the table for us to
consume and digest. And I would like some help in the process.
And I am wondering if you would be receptive to, sort of, a
one-year look back, an evaluation, not micromanaging, not fine-
tuning, evaluating how NASA has responded to what you have
proposed, what the Administrator says he embraces, which we are
applauding. Admiral, would you care to comment on that?
Admiral Gehman. Yes, sir. I consulted my colleagues about
that, and I am authorized to say, on their behalf, that if it
is requested by the Congress, we would do that.
Chairman Boehlert. Thank you very much. And I appreciate
that. And I can almost assure you that it will be requested by
the Congress.
Now if Mr. Wu isn't back but--Dr. Widnall, did you wish to
offer some supplementary comments for the record?
Dr. Widnall. Let me make two. Let me second what Admiral
Gehman said. And I see it--one of its virtues as providing some
continuity, and in some sense, that is a force multiplier for
the time that we all put in on this. And so I think it actually
gratifies us, because we will feel that our work is even more
effective if we do provide this kind of continuity, so it is
certainly something that I welcome.
Following Through on the Report's Recommendations
Chairman Boehlert. I have been in Congress 21 years. I
started out at the lowest level on the first tier as a junior
member. And over these years, I have seen a lot of reports.
They are issued. They are produced by dedicated Americans who
bring special expertise to the table, and more often than not,
they gather dust on the shelf. The Rogers report was--there was
immediacy in responding to some of the recommendations, then
the atrophy set in, as you have referred to. We are going to
follow through on this thing. We have got to be vigorous. And
we just can't look to NASA and say, ``All right. Now the
problem has been identified. You know how to fix it. Fix it.''
We have got to be part of the solution. And so we have to look
ourselves in the mirror and say, ``Are we as vigorous as we
should be in connection with our oversight responsibilities?''
And so Mr. Wu is not back yet. We will----
Dr. Widnall. Well, the second point I wanted to make, which
was really the point that you called on me for, was just, as we
finished the last round of questions, was really just to point
out the time scales involved in these sorts of endeavors in the
space field. I mean, when you talk about let us find a
replacement Shuttle, you know, you are talking ten years. You
are talking a very high level of technology. It also goes back
to the issue that I discussed with Mr. Hall. You know, what is
the word ``consider.'' The word ``consider'' means to do an in-
depth engineering analysis of what are the possibilities, what
are the trade-offs, what are the options. And that certainly is
a process that needs to go forward as we think about replacing
the Shuttle, new concepts for manned space vehicles, how do we
service the Space Station. All of these things require an in-
depth engineering analysis. And the time scale involved is
certainly measured in years, certainly up to ten years before
one would have a new generation of vehicles.
So that was really the only point I wanted to make.
Chairman Boehlert. Thank you very much.
And I see our distinguished colleague, Mr. Wu, is back. Mr.
Wu is recognized for five minutes.
Mr. Wu. Thank you very much, Mr. Chairman.
Admiral Gehman, always good to see you and members of your
Board, although one always wishes under other circumstances.
Like others, I want to commend you for finding the physical
cause of this tragedy at the RCC panel 8 and also for
identifying some of the organizational and, one might say,
cultural factors in NASA that have contributed to this set of
tragedies.
Workforce
I want to encourage the panel here to look forward a bit
and focus on something related to the cultural and
organizational issues that you identified, but not exactly
those. And that is the recruitment and retention of the best
and brightest, especially young people, but people of all ages.
In my experience, as I have gotten older, everybody else has
gotten younger in various organizations. My teachers have
gotten a lot younger, in my eyes. As I visited NASA sites, and
this is with great respect to NASA personnel, they seem older
than I remember them when I saw them on television when I was a
young person watching the Apollo program and the Gemini program
and so on. And I know older folks, whether it is at NASA or on
the Board or in Congress can make great contributions, but back
in the 1960's, there were, you know--NASA was--especially as
Chairman of various committees. There were few places to go.
And NASA was probably the place to go if you were really into
technology and really hot to go. It was not only
technologically and scientifically the most exciting place to
go, but it was also part of this competition with the Soviet
Union that made it a part of our national purpose.
You know, today, the Cold War is over. We were the first
the moon. And in addition to that, we have all of these private
companies and other places where folks in technology can be
drawn off to, whether it is by higher salaries or nimbleness of
movement--adeptness of movement in the organization, what are
some of the things that can be done to help NASA recruit and
retain people? And some of the negative factors that are there,
some of the positive things that can be built in for the
future. And I would just like to engage the panel to discuss
that.
Admiral Gehman. Absolutely. And the panel has discussed it.
And I know, as an educator, Dr. Widnall has an opinion about
that, as do my other colleagues. I, very briefly, will say--
list three things. First and foremost is a mission. And it is
not--a good mission, a good recognized mission, which excites
people, will overcome low government salaries and a whole bunch
of other things. The second place is you have to have a really
great place to work. And that--I am talking about the work
attitude, the climate at work, and all of that kind of stuff.
And I think NASA is a good place to work. It can be made better
because of some of the traits that we have talked about.
And the last one would be I would like to see NASA reduce
the number of times that they give the top really good jobs to
outsiders. NASA, too often in my mind, takes the top, really
best jobs, and gives them and recruits outsiders rather than
moving people up from within. They like to hire Admirals and
Generals for Center Directors and things like that instead of
taking the best NASA people and make them Center Directors and
things like that, even though I like Admirals and Generals. I
really think that if you are a career NASA employee and you
want to get a--and you want to rise to the top and then you see
the top jobs going to outsiders, you just have to scratch your
head. As part of that, in the Space Flight Operations Contract,
the SFOC, a lot of very high level positions, which I thought
ought to be government positions, are now contractor positions.
And once again, these are top level positions, which have been
contracted out to really competent people, but what it is
instills in the workforce is that you work for the government
for 15 or 18 years, and then if you really want to go into the
top jobs, you have to go over to the contractor side to get to
the top job. I found--I find all three of these things that
could make the place a much better place to work.
And as an educator and a close student of this, I know that
Dr. Widnall may want to comment on it.
Dr. Widnall. Yeah. I knew this was coming. No. And as an
educator, as an aerospace educator, I know that there is
something about aerospace that evokes the passion of young
people. There is no question about it. There is hardly any
other field to which people are drawn because of the real
excitement of the field. There is no question about that.
As an aerospace educator, I feel that it is my
responsibility to take that passion and turn it into an
appreciation for responsible engineering. And I think that that
is a challenge. I do think it is no longer the case that NASA
is the only place to go. I mean, this committee knows more than
any other Committee about the broad range of science and
technology that our nation is advancing: work in the biological
sciences, work in the computer sciences and miniaturization,
new materials. Science and technology are advancing across a
broad front. Space is exciting, but it is not the only exciting
thing that we, as a Nation, are doing.
So what I think is that we have to learn to operate in a
much more complex environment where young people, in fact, do
have a range of options, a range of exciting things to do. And
I think we have to ensure that across a broad range of
disciplines. And I think it will feed directly into our science
and technological strength as a Nation. Young people are
excited by the development of new capabilities. And to the
extent that NASA moves forward with a vision, a national vision
for space and the development of new capabilities, I think
young people will naturally be drawn to NASA as a place for
employment.
Mr. Wu. I have a burning follow-up question, but I know
better, Mr. Chairman, than to ask if I could ask it under these
circumstances. Thank you very much, Mr. Chairman.
Mr. Ehlers. [Presiding.] The gentleman's time is expired.
And we will see if there can be a second round for burning
follow-up questions.
I apologize if my question is not relevant or has been
answered, because I have been popping in and out of three
meetings this morning, all of which, unfortunately, happen to
be urgent. And I apologize for that.
Characteristics of a Follow-on Vehicle
But looking toward the future, it seems to me the very
first thing that we, in the Congress, and frankly, the American
people have to decide is whether we want to continue human
exploration of space. And I suspect the answer is yes just
because, as Dr. Widnall mentioned, there is some magic to
aerospace that this is something that we want to do. It is part
of our background or ethic that we should be out exploring in
every dimension. So assuming the answer is yes, it seems to me
that our highest priority has to be to design, develop, and
build a new type of space vehicle.
My first question is do you see that, and what do you
regard as the characteristics we need. It seems to me that,
given modern technology that has developed since the design of
the Space Shuttle, that we can build it safer and better, more
efficient, with less turnaround time and higher efficiency and
lower cost. And that, perhaps, in the long run, we will, in
fact, save money to have a new vehicle if we can design one
that satisfies those criteria. So that is the first question.
And secondly, I would appreciate just a comment from you on
the balance between what one might call scientific research and
what one might call human exploration. We all know that, dollar
for dollar, we get much more science done with unmanned
experiments, satellites, rovers, than we do with human
exploration of space. I--just--even though this was not your
task, I am asking for your opinion. What is the balance now and
what do you think it should be between those two? So two
questions.
And we will start at----
Admiral Gehman. Well, I am going to ask Dr. Hallock to take
a shot at the first one, sir, and then we will rearm----
Mr. Ehlers. Okay.
Admiral Gehman [continuing]. To take a shot at the second
one.
Mr. Ehlers. Dr. Hallock.
Dr. Hallock. When you look back at what we--this thing that
we were studying, the Shuttle, remember it came from the 1960's
technology. And it also, as we point out particularly in
chapter one, it--when it was being put together, a lot of the
requirements were actually given to people. To follow up on a
question that we discussed earlier this morning, you know, why
do you put the Shuttle where you do where it can get hit by all
of this material that is out there? Well, the reason is that
one of the key requirements that was levied upon these people
back then was that you wanted to put together a system that
would be reusable. Things like those big engines and everything
that you put on the Shuttle. In order for them to be reusable,
you had to put it on something that came back. Well, the--what
I am really saying is when you--if--I fully agree that one
needs to look at trying to come--look to the future and
redesign, come up with a design of a vehicle to get us safely
into space, but not burden it with so many things that actually
were compromises.
And these are the things that I think that have led to all
of these problems. For example, you know, if you look at the
Shuttle and look at some of the earlier designs, you know, you
put the Shuttle on the top. So what is going to fall on it?
Nothing. If anything, it is shedding material as opposed to
having things that could come off and hit it. So that is my
point is that you really can do it, but you need to have a
clean slate. And as part of that clean slate, you can also add
in those other issues, which were what can we do to allow ways
for the crew to get out in case there is a real problem? There
are a number of things you can add.
Mr. Ehlers. So in your opinion, do you think that we can
design something that meets the criteria I mentioned: safer,
less expensive, more efficient, less turnaround time?
Dr. Hallock. But once again, we have got 30 years of
technology now behind us at this point, and I firmly believe
that you can do that. Yes.
Mr. Ehlers. And can that be a good replacement for the tile
system which is one of the biggest factors in the slow
turnaround?
Dr. Hallock. Well, they even have an interim thing where
they have come up with a tile that is much stronger and can
withstand a lot of strikes more so than the existing. So there
is some intermediate technology types of things that can be
done, too. Yes.
Manned vs. Unmanned Science
Mr. Ehlers. Right. And the second question----
Admiral Gehman. First of all, I would--I agree with Dr.
Hallock, and I would ask you to factor into your equation of
the--not only the next vehicle, but also the robotics versus
the human--the value of the human space flight program, that as
long as the only way that we have to get outside of the Earth's
gravitational field, or to get into orbit or to escape the
Earth's gravitational field is to sit on top of an enormously
explosive chemical reaction, which is--right now, that is the
only way we know how to do it. You are flirting with a very
dangerous process. And there is no getting around it, and we
should not ever diminish how dangerous that is. And then when
you come home, you have to take all--every single kilojoule of
that same amount of energy and you have got to somehow
dissipate it in order to slow yourself down from orbital speed.
And that is also extraordinarily dangerous. You have got to
figure out a way that you can reenter the Earth's atmosphere
and dissipate all of that energy in the form of heat. You have
got to change the speed into heat, and then you have got to
dissipate all of that heat, which puts the humans in a very
dangerous situation. And we should not minimize that danger.
And now the reason I gave that little lecture, if you will
forgive me, is because when you start--that is job one is to
get the humans safely up there and back in.
Mr. Ehlers. Well, I will just interject. That assumes a
return vehicle. You are going to have a capsule come back and
dispose of the engines.
Admiral Gehman. But even if you bring the--even if you were
using a capsule, you still have a kinetic energy problem. You
have got to get up there, and you have got to get back down.
Mr. Ehlers. No, but you don't have as much to dissipate.
Admiral Gehman. That is correct.
Mr. Ehlers. Considerably less.
Admiral Gehman. Considerably less. That is right. But if
you consider job one to be safely--get into orbit and safely
get back, then everything else that you add on to--every other
requirement, you are going to--and if you say you want it to be
efficient and cost-effective and reusable, et cetera, et
cetera, et cetera, you are whittling into that safety
requirement. And so this Board, with this experience that we
have gained from this investigation, would say let us not, in
any way, diminish the danger and the physical challenges here
and start adding additional requirements into this. Let us just
get them safely into orbit and safely home.
Now the robotics or the human thing, I would offer that we
didn't really do much of a study in this, but we did educate
ourselves into this matter as well as the vision thing so that
we could put our report into context. And my personal view is
that every briefing I have listened to, every book I read on
the subject indicates that no matter what your vision, long-
range vision is for what we are going to do with interplanetary
travel or stations on the moon or whatever it is, all visions,
they all start in low-Earth orbit. None of them start on the
surface of the Earth. And therefore, we have to perfect getting
into and out of low-Earth orbit, no matter what the plan for
the future is. That is our view. And perfecting getting into
and out of low-Earth orbit is a worthy enough goal by itself.
Mr. Ehlers. Okay. I have to excuse myself to go vote, and
the Chairman has returned. Thank you very much.
Chairman Boehlert. The Chair recognizes, Mr. Bell.
Mr. Bell. Thank you, Mr. Chairman.
Defining Cultural and Organizational Problems
Admiral Gehman, good to see you again. I want to commend
you for the report and also the way you and the committee
conducted yourselves throughout the investigation. It was
impressive, and I certainly respect the openness that you
demonstrated both with Members of this committee but also with
the public throughout the process.
I want to follow-up on something that my colleague, Mr. Wu,
was talking about in terms of the cultural and organizational
problems that you point out in the report. The day the report
came out, I had the opportunity to speak to a group of NASA
employees that evening. And while there seemed to be a general
acceptance, certainly an expectation that the report would be
critical, the one area that they seemed to feel that there will
be some difficulty with has to do with changing the culture of
NASA. And in looking at the report, in chapter seven, I wanted
to go over some of the statements therein and see if maybe you
can expand on them so there is--there will be a clear
understanding of what we are talking about when you say
``changing the culture.''
Starting with avoiding oversimplification, and I will just
read this particular part, ``The Columbia accident is an
unfortunate illustration of how NASA's strong cultural bias and
its optimistic organizational thinking undermined effective
decision-making. Over the course of 22 years, foam strikes were
normalized to the point where they were simply a maintenance
issue, a concern that did not threaten a mission's success.''
And when you read something like that, I can--you point to a
cultural bias, but was it so much a cultural problem or was it
a--caused by not having a system in place that would help
identify that kind of problem and address it?
Major General Hess. I think the answer to your question is
basically yes in both counts. But what we are getting at is in
the definition of organizational and cultural that we adapted
is how does--even absent rules react to--in the instance of
oversimplification, what we saw was an almost immediate
assumption that there is not a problem. And this is a learned
behavior. It took 22 years for them to learn that, perhaps
there is not a problem with foam--but when you put down one of
the things that you need to avoid, if you are a highly reliable
organization that deals in high-risk technology is that you
don't just assume that there are no problems. You start by
assuming that there is a worse case and by----
Mr. Bell. Admiral, did you want to comment as well?
Admiral Gehman. No, I agree. And we thought long and hard
about that particular section. And the relationship to culture
is that, as we carefully defined in our little blue sidebar in
the front of that chapter seven, that culture is, as we used it
in here, in this report, culture is how the organization acts
kind of intrinsically. It is how they act outside of the rules.
It is how they act when their boss is not in the room. And it
is how they think.
And in this particular case, they have an oversimplified
view of a complex issue, and they stick to that oversimplified
view. They get rigid in it, and they do not realize that these
are complex things in which one flaw can affect another system.
Mr. Bell. And please, let me be clear. I am not, in any
way, critical of what is stated. I just think there needs to be
a clear direction going forward so that people understand
exactly what you mean when we talk about changing the culture,
because I would agree. There are obvious problems that need to
be addressed, but they can't be addressed unless there is a
clear understanding.
In the paragraph above, importance of communication. Every
manager knew the party line. We will wait for the analysis. No
safety of flight issue expected. In the course of the
investigation and the people that you talked to, what did--what
was your understanding of how such a ``party line'' is
developed?
Admiral Gehman. The--there are a number of factors, but the
one that I would point to is what I would call--I like to
characterize it as an informal chain of command. That is, once
the Space Shuttle program opined on something, then other
people, other divisions, other agencies, even though they are
technically independent, were hesitant to move against that
opinion. The Shuttle program----
Mr. Bell. For fear of reprisal or----
Admiral Gehman. For fear of reprisal, for fear of being
ridiculed, but mostly, the problem was that even though on
paper they had a set of checks and balances, independent
engineers and independent safety, the fact of the matter is the
Shuttle program over the years had become so powerful that all
funding flowed from the Shuttle program. All promotions go from
the Shuttle program. They had become so powerful that
independent voices and minority opinions were not welcome. And
it takes--in a complex matrix organization, like the Shuttle
program is, it takes a very elegant communication scheme
carefully managed and carefully nurtured to make a matrix
organization work. And they had allowed some of those
characteristics to atrophy over time.
And I don't know if General Hess, who is the expert on
this, wants to comment on it.
Mr. Bell. Well, so the goal would be to develop a system
where communication is encouraged rather than discouraged. And
from what you are saying, it sounds like perhaps it wasn't
discouraged, but people feared.
Admiral Gehman. They did. They did. And we think that our
fix about having this independent technical review authority,
which owns all of the specifications and requirements, which
would be full of engineers and safety people who have no
relationship to cost and schedule of the program, would be free
to discuss all of these things, because they wouldn't be
intimidated by the guy who is worried about cost and schedule.
Mr. Bell. Lastly----
Admiral Gehman. As a matter of fact, their reward system
would be based upon bringing problems up. That is how they get
rewarded.
Mr. Bell. Lastly, I want to go to the section commitment to
a safety culture and the last line in that. ``Organizations
that successfully deal with high-risk technologies create and
sustain a discipline safety system capable of identifying,
analyzing, and controlling hazards throughout a technology's
life cycle.'' Obviously that system was not in place. How do
you accomplish that, because that has to be the number one goal
that whatever is developed will last throughout a technology's
life cycle?
Major General Hess. I think that the answer to that
question also rests in--that is their job. That is going to be
their role in life is to bring that life cycle and systems
analysis look into the technology that is involved. The second
part of it, obviously, in this chapter we talk a great deal
about the information systems that are there that are supposed
to be tracking anomalies and giving trend information and the
fact that they really don't. So you know, there is a fix that
could happen just in information systems and how you manage the
information but having somebody whose job it is to run risks
and do trends and to control the level one requirements and the
waivers is going to give you that life cycle that we think is
so very important.
Mr. Bell. Thank you, Mr. Chairman.
Chairman Boehlert. Proceeding along those lines, because of
the many important recommendations that you have made, two of
the most important are one, establish an Independent Technical
Engineering Authority and have that funded directly from NASA
headquarters so it has no connection to or responsibility for
schedule or program costs. And the second one is the Office of
Safety and Mission Assurance should be independently resourced.
I think those are highlighted recommendations. And we are going
to follow through, and so is NASA.
Mr. Feeney?
Mr. Feeney. All right. Thank you, Mr. Chairman. And thank
you to Admiral Gehman and your entire Commission. I haven't
thoroughly read from cover to cover the report yet, but my
office staff has several times, and we are going to continue to
pay attention to it.
I am impressed by the entire approach you have taken. I
want to thank you, particularly for being accessible. I got a
briefing just before our break personally from Admiral Gehman.
I thank you for that, for the time we spent together at the
hangar where we were putting together the Shuttle. And several
other members of the Board were there. It was certainly a quite
moving experience. And I will tell you that, you know, part of
the appreciation for the way you have memorialized the
astronauts that have passed away in human flight is in the
emblem that you put on the back here. We are not just talking
about the most recent disaster. You include discussions about
Apollo 1, the Challenger, and the Columbia as well. And of
course, the Latin phrase there--my Latin is a little rusty. I
got a D in Latin and had to quit the basketball team because of
it. And actually, the Latin teacher's wife was the coach of the
basketball team. He understood why I had to quit, but to the
stars, despite adversity, always explore. I think that that is
the mission that I believe in and that basically was the
fundamental mission of your report.
The Culture of Safety
I want to pick up where Congressman Bell left off talking
about the culture of safety, because it is sort of in amorphous
concept to some of us. It is not a technical issue. It is not a
precise issue, and--but it is a cultural issue that is very
important. And as a lawyer by background, I am under--I
understand burdens of proof. And I would like you, at one
point, to describe for me the difference between a culture in
safety where you presume that everything is okay unless you
know otherwise as opposed to a culture that basically tells you
that nothing is right unless you can prove that it is
functioning. And I want to ask you as you go through that sort
of switch and, say, a burden of proof approach, which is
something that I can understand, to talk a little bit about
NASA's history. NASA originally approached the Board in its
initial briefings and espoused their confidence that they had
developed a culture of safety and were surrounded by the
culture, and yet, upon investigation, this Board found out that
that simply wasn't accurate.
In the aftermath of Challenger, there were some interesting
differences between the approach that NASA took and the lessons
it learned and the way it trained its inspectors and the way it
dealt with response to the disaster and say the Navy took. The
Navy, for example, developed the SUBSAFE program and the naval
reactor program. They trained some 5,000 Navy nuclear
propulsion program personnel on the lesson specifically learned
from Challenger. And yet it seems like all too quickly, NASA,
for a variety of reasons, fell right back into some of the same
habits. And so I guess I would like you to tell me number one,
whether NASA has--understands in how their going to implement
this shift in burden of proof, number two, how they reacted to
the lessons of the Challenger disaster, and number three, in a
more generic sense, this isn't the only near disaster we have
had.
We had the Apollo 12 issue. We had the fuel cell explosion
on Apollo 13. We have had launch pad aborts on Shuttles
involving non-personnel craft. We have got the commercial
problems we have from time to time, the military launches. How
are we, on a routine basis, going to learn from all of the, not
only disasters with people involved, but also the new disasters
or situations where people were not involved? And with that
sort of open-ended question, Admiral Gehman, if you will refer
the answer to the appropriate people or pick it up.
Admiral Gehman. Mr. Feeney, first of all, I will say
something about the culture of safety and something about
learning and then turn it over to my colleagues here who
studied this more closely than I did. I was quite confident and
quite firm in my deliberations with my colleagues about
hammering this subject fairly strongly, because of the way we
defined culture. We were very careful in our report to make
sure that, for our readers, that we didn't confuse management
and we didn't confuse leadership with culture. Culture is what
you do rather than what you say.
For example, if you say that safety is the most important
thing we do and nothing we do is going to compromise safety,
but I want you to come up here to Washington, DC every 30 days
and give me a brief on how you are doing on making the node two
complete schedule, that is doing one thing and saying another.
And that, of course, trickles down to the workforce. I mean,
that word gets out as to what is important.
We studied at great----
Mr. Feeney. By the way, if I can, Admiral, just to
interrupt briefly, but you have a wonderful definition of
culture. It is not like the--I mean, people that read the
report on page 101 it is very specific and then later
throughout the report but especially 177 you talk about the
organizational and cultural problems that exist in NASA today,
so you do a great job in the report.
Admiral Gehman. Yeah, we knew that there would be some
misconstruing and blurring of what the terms meant, so we were
careful to define them. We also found, if we go back to that
list that General Hess was referring to earlier, we tried to
put a recipe or--in there for what we considered to be the
characteristics of a high reliability organization, which we
would certainly hope that NASA would be a high reliability
organization. And one of the characteristics is that the
organization is a learning organization. And by that, they not
only learn from big disasters, but they learn from the little
things.
And just as you point out, in the organizations which we
consider to be high reliability organizations, they teach their
people from big disasters and little disasters. And they like
to keep bringing up Three Mile Island and they keep bringing up
the Challenger and they keep bringing up the loss of the
submarine Thresher, and they keep bringing these things up to
see what we can learn from them. NASA tends not to do that. And
they tend not to do that, at least our interviews, and our
experience was they tend not to do that, because for some
reason they have gotten the idea that by bringing up all of
these failures or near-misses that somehow they are tarnishing
the image of the employees or they are diminishing the
impression that they are all perfect. And that, of course, is
wrong-headed. And therefore, we determined, and we wrote in our
report, that NASA is essentially not a learning organization
and they do not learn from these mistakes. And of course, that
is a very serious problem.
General Hess, do you want to make any further comment on
that?
Major General Hess. That is right. And the part that I
would add in the overall construct of how they approach this
cultural dynamic that we are trying to get it is just exactly
the issue of, absent rules, they are going to react and respond
in a way that is dedicated to performing the mission reliably.
Okay. And in almost any check and balance that we talk about
inside the program, these attributes can be enhanced just by
some of the organizational changes that are there. But
organization alone is not going to fix the problem. You are
going to have to lead your way through it. You are going to
have to get managers to understand and buy into this at all
levels so that it becomes the way that the organization
responds in times of crisis and in times of planning as well.
Chairman Boehlert. The gentleman's time is expired.
Ms. Jackson Lee?
Ms. Jackson Lee. Thank you very much, Mr. Chairman, and
allow me to thank the Chairman and the Ranking Member of the
Full Committee and as well the Chairman and Ranking Member of
the Subcommittee for what will be, in think, a very effective
line of hearings that we will have and, as well, an ability to
be able to follow this line of reasoning that has been so ably
played out for us by this very strong report.
Might I say to the Board, thank you, also, for your good
work. And as I begin my remarks, allow me to put this in the
focus that I can recollect was the experience on that fateful
day, February 1, and that is that this whole debate is on the
question of lives as well as the mission and vision of this
Nation on behalf of the American people. So I would like to
note that what we do today is in tribute to and reflection of
the sacrifice that Rick D. Husband made, William C. McCool,
Michael P. Anderson, David N. Brown, Kalpana Chawla, Laurel
Blair Salton Clark, and Ilan Ramon. Clearly, I think, this is a
major tribute, if you will, or need for a major tribute to
their lives that we not allow what has occurred to be
repetitious.
I do want to also say to the Board that this is in no way a
cover-up. And we thank you for your forthrightness and your
instructiveness. I will say again, referring back to February
1, that since it was post-9/11, you can imagine the various
thoughts that occurred. So it was even larger than maybe
incidents of the past that we do not diminish any of the
incidents of the past.
You have spoken about the question of a culture of safety,
and I want to refer to some of the language that you used in
the report. The Board found that there is a broken safety
culture. You also mentioned that schedule pressure related to
the construction of the International Space Station, budget
constraints, and workforce reductions also were factors in the
question of what caused the Columbia accident. One of the
initiatives that I am going to propose would be enhanced
whistle blower legislation, specifically for NASA personnel,
because I think that the comment that the Ranking Member made
at the very beginning is so potent, and that is what happened
after Challenger and the emotions and the interests and the
commitment seemed to peter out.
I am holding in my hands a series of hearings over 1997,
'96, '99 where we discussed the question of safety over and
over again. And I would refer you to some words that I offered
in 1996: ``So that there is no mistake, I do have questions and
concerns regarding some of the issues involving NASA, the
personnel reductions which continue to take place, and the
safety of the Space Shuttle.'' That was in 1996, March 28. On
September 23, 1999: ``We want NASA to provide safe vehicles for
our brave astronauts, yet it would be an aim of us to demand a
strong Space Shuttle safety policy when we are cutting the very
resources that would fund this policy.''
Now you have already shied away somewhat from numbers, but
allow me to ask these questions on the safety element, and I
applaud this freestanding organizational structure that deals
with safety and oversight from NASA headquarters. I want you to
comment on the responsibility of NASA headquarters aside from
directly the Administrator as it relates to your report. I
would like you also to explore the idea of holding managers
accountable for errors, because when we talk about the safety
culture, how do we break that line of reasoning? And you might
add your thoughts about whistle blower protection overall. You
haven't seen the legislation, so I would imagine you couldn't
comment on that.
And finally, Admiral, would you put yourself--and others
that might want to comment, would you put yourself, Admiral, in
the position of being an Admiral and finding or having an
incident such as this occurring under the military structure?
What would be your reaction or your actions as it relates to
personnel who were directly associated with the responsibility
of ignoring information that came directly to them that
questioned whether or not there was a sense of safety? My last
point is for Dr. Widnall, because I was fascinated by your
comments with respect to education. How do we retain the bright
and the best as we have moved toward outsourcing over the last
decade? I remember growing up looking to those bright folks at
NASA. And you admired them and wanted to be like them. How do
you restrain--have that--solve that problem?
And I thank you very much for your presence here today.
Mr. Smith of Michigan. [Presiding.] The gentlelady from
Texas' time has expired in asking the question, but we will now
turn it over to Admiral Gehman.
Accountability
Admiral Gehman. Thank you very much, Ms. Jackson Lee, and
thank you for your support during this--during the time of this
investigation. We enjoyed talking to you several times about
it.
The Board, while, indeed, it decided not to make judgments
about the responsibility of individuals, the Board, in no way
suggests that our position--suggests that individuals should
not be held accountable for their actions. They should be held
accountable, and they should be held accountable by their
appropriate supervisory chain of command. On page 203 of our
report, we have a little editorial in there about the role of
leaders and the role of managers and their responsibility for
setting the conditions for either success or failure. And they
are, indeed--we do believe that the top level managers are
responsible for setting the conditions up, and if they set
conditions in which free and open communications were stifled
or engineers were intimidated or safety was shortchanged, and
they are responsible for that, and they have to hold
responsibility for that. I believe that we document in our
report, and we are pretty careful to do this. I mean, we wanted
to be very careful about this. These bad traits and these ill
characteristics that we are all numbering here came about
gradually and slowly over a long period of time due to budget
constraints, manpower constraints, and lots of other reasons.
But these things didn't happen all in one year or one month
or--they happened over a long period of time, and they happened
in response to forces, both internal and external. I think that
we have kind of--it is all there in the report, I think. And I
think I kind of agree with your comment that there probably is
some account taking that probably needs to be done by the
proper authorities. We just didn't feel we were----
Mr. Smith of Michigan. Admiral Gehman, I--excuse me for
interrupting. I would ask everybody to be brief in reacting to
Congresswoman Jackson Lee, and we will try to get one more
five-minute series in before we----
Admiral Gehman. Maybe I will let Dr. Widnall respond to the
last point.
NASA Recruiting and Retention
Dr. Widnall. I would like to respond to that question a
little more broadly with respect to this question of how do we
retain the best and the brightest, because this is the very
Committee that is charged with that responsibility. I believe
the Nation has been richly rewarded by the investments that we
have made in science and technology education and research
across a broad range of scientific and engineering disciplines.
So it isn't just the question of how we retain these
individuals in NASA. I think the question goes much deeper. How
do we strengthen our science and education system? How do we
encourage young people to pursue professional careers in
science and engineering? And how do we utilize their talents
once they graduate? I think in order to do that, it really
requires a vigorous program of research and technical
development across a broad front. And I would certainly include
NASA within that.
I do think, as an aerospace educator, that NASA has a
built-in advantage with, what I view, as the innate passion
that goes along with the exploration of space. But we really
need to pursue these issues across a much wider front.
Mr. Smith of Michigan. The gentlelady's time has expired.
Prioritizing Space Research Within the Federal Budget
I will proceed with my five minutes. And let me start out
by suggesting that since the successful Soviet launch of
Sputnik in 1957, certainly our country's space program has been
an intricate part of our excitement as Americans and certainly
a stimulus to more students getting into science and math. I
think we have lost some of that.
Congress is charged with setting priorities. As some of you
may know, I Chair the Research Subcommittee, and we have had
testimony in terms suggesting that much of the scientific
research could be better accommodated as effectively on
unmanned space flight, and some of the research could be
accomplished in ground labs. And so not only manned versus
unmanned flight, but also should some of these research dollars
go into NIH to cure cancer rather than man's exploration of
outer space?
It would seem to me that we need to analyze the costs and
the benefits of this program. And really, as I understand the
Board, and congratulations for the time that you have
sacrificed and the efforts you made to do this, such a good and
thorough job, but your charge really was what went wrong and
how do we keep it from going wrong again. But in terms of the
costs and benefits, how do these compare with that of unmanned
space flight or other science research that we might conduct,
and did the Board look at these issues?
Admiral Gehman. We did not, Mr. Smith. What we attempted to
do to help you with that question was to properly characterize
the risks and properly characterize the costs of the Shuttle
program. And we did not look into those other issues. And I am
going to have to defer on that. I don't have any knowledge of
the value--the cost value of----
The Value of Research in Space
Mr. Smith of Michigan. Well, as I talk to other scientific
groups, including JPL, we don't have a good quantitative
evaluation of the science research. Some have suggested, well,
once we get the Space Station up and running and get it fully
manned, maybe we can do some really constructive research. But
it would be my opinion, and for any Board member that--for any
of the witnesses that would like to comment, that manned space
flight can contribute a great deal to the additional
information of how humans acclimate themselves in outer space.
And maybe part of that is do we intend to put people of this
country into outer space for longer periods of time. We have
been in this endeavor for quite a while. And with the new
technology of, not only robotics, but of nanotechnology and
miniaturization, a tremendous potential for unmanned space
flight, it seems to me. Does--would there be any comment from
the witnesses?
Admiral Gehman. We did not evaluate that, but if anybody
wants to comment, help themselves. We did not look into that.
Mr. Smith of Michigan. What--how might we best--you know,
and I think it is exciting to have high school students put in
research projects, but in terms of real valuable scientific
research, it is probably not substantial in contributing to our
research efforts. We are now reducing funding for NIH for--to
develop better research on health. We are now reducing research
dollars for the National Science Foundation, which I oversee in
our Research Subcommittee, in terms of basic or fundamental
research. So a tremendous challenge, I think, for this
committee and this Congress as we evaluate how quickly do we
want to push the program and maybe a comment that you might
react to is NASA projected the March launch before you came out
with your final report. It seems like this is pushing more
rapidly than NASA's ability to totally react to some of the
recommendations in your report. Admiral Gehman?
Admiral Gehman. I--yes, sir. I would--I believe Mr. O'Keefe
and I are going to have an opportunity to appear beside each
other next week before your Committee. But yesterday, before
the Senate, he reiterated to that question--reiterated an
answer to that question several times in which he said that
NASA's return-to-flight plans are events-driven, not calendar-
driven. And that date out there is just a hypothetical mark on
the wall. It is not the--it is not a firm date. I will let him
answer that question.
Mr. Smith of Michigan. And I just say to Dr. Hallock and
General Hess and Dr. Widnall that part of my bias, which I have
expressed in my statement, which, without objection, will be
entered into the record, is my son and daughter were--both
worked at JPL, and so they led me down the road of the kind of
information of how valuable unmanned space flight was and--in
the reductions of budget that limits a tremendous potential in
that arena.
Any other comments from the witnesses? If not, the
Committee stands in recess. Oh, here he is. The Committee does
not stand in recess. I thought you were one of the upper
ranking staff people that said I have only got three minutes
left.
Chairman Boehlert. And he promptly ignored it. I never
ignore it.
We are going to have a series of votes all day,
unfortunately. But let me, while we are waiting for--Mr.
Nethercutt, you are here. Thank you.
The Process of Defining a Vision
Mr. Nethercutt. Thank you, Mr. Chairman. Ladies and
gentlemen, thank you for being here.
Admiral, I appreciate all the work you and the Board have
done. I think you have done a great job of being frank, both
personally and privately, in giving a clear indication of your
independence. I noted that the Board noted: ``It is in the
Nation's interest to replace Shuttle as soon as possible as the
primary means to transporting humans to and from Earth orbit.''
And it strikes me, as I listen to the questioners and the
Chairman and others have an exchange with you witnesses, that
it seems to me the question of vision has come up a number of
times. What do we really want the space program to do? Where do
we want to go? How do we invigorate our young scientists to be
excited about working at NASA, and so forth?
And I have thoughts about a vision, and that is not
necessarily--certainly not the point of this hearing. But I
know that you all have become very familiar with the culture at
NASA, the process that NASA goes through, the experts that are
employed there. And I am wondering whether you feel that NASA
can organizationally be capable of defining its vision, a
vision, an adequate, thoughtful vision, or the future of the
agency. Is the organization, perhaps, too risk-averse at this
point, given the seriousness of your report, to define some
sort of a grand national vision for human space flight? It is a
little theoretical, but I think it is a valuable theoretical
question to have answered, because it sort of defines where we
are headed with respect to the agency and human space flight. I
mean, my sense is maybe we ought to be looking at the moon and
have, sort of, a lunar expedition policy that guides us. There
is great science, I think, that can come from there. But there
is Mars and there are other places. So I am wondering if you
could answer those questions for the record and for me.
Admiral Gehman. I think we ought to ask all four Board
members, but I will answer very briefly and say I have
confidence in NASA. I think it is a great organization. I think
they are capable of proposing and staffing a national vision.
But of course, NASA's vision doesn't count. It is the--we were
very careful to say it has to be an agreed vision. So it has to
be your vision and the White House's vision. I don't believe
NASA is too risk-adverse or that they are in any kind of a
defensive crouch as a result of this accident. I think they are
fully capable of leading us and proposing us, but they can only
propose. The--my view is that NASA is fully capable of that
challenge.
I will ask my colleagues to help.
Dr. Hallock. I agree, too. The issue, though, is that one
can have quite a few visions. There are so many, many things,
as some of you have already talked about today, whether--from
the robotics issues to the manned space flight issues as well
as is it--should we be going to the moon at this point or
should we be thinking about putting Space Stations further out?
Someone mentioned libation points, too, as being places. So the
hard part is--I think we can all come up with visions of them.
The problem is how do we constrain them, because there are
only so many things we can do. I think it is important for the
country to have one, because it really does have a lot of
secondary issues, secondary things. And one of the main ones
that pops to mind is one that we have been talking about here,
and that is the education thing. We need to stimulate people to
start thinking about these very technical issues and want to go
into those fields and work on them. But picking what the vision
should be? Oh, boy. I would like to be a part of picking it,
but I--it would be very hard to say this is the one and only
thing we should be doing.
Mr. Nethercutt. General Hess, do you care to--Dr. Widnall?
Dr. Widnall. Sure. Yeah. You know, when you raised the
issue of vision and NASA constructing a vision, I wrote down
the word ``partner.'' And then I wrote down the word ``tough.''
I think NASA needs a tough partner. If I had to make a comment
about NASA, it is not that they are risk-averse. It is that
they have often overreached technologically. They have been
overoptimistic in looking for the leapfrog in accomplishing
certain goals. Another--and my Board members basically said it
before I said it. An unconstrained vision is not a vision. NASA
needs a tough partner to rub right up against and get a common
agreement about what the vision is that is--matches the
resources that the Nation is willing to provide to accomplish
this vision. So tough partner. And that--it would be you guys.
The Difference Between ``Observations'' and ``Recommendations''
in the Report
Mr. Nethercutt. Yeah, I understand. And I think we are
willing to be partners. I just--culturally, I am willing to be
sure--I think we look to the experts there to make these
judgments. Let me ask a question for--on behalf of the
Committee that--for the record, that I hope will be helpful to
all of us, if I may. The report provides 29 recommendations and
27 observations. ``Please explain the substantive differences
between an observation and a recommendation.'' And I am
wondering whether NASA can ignore the observations and still be
in compliance with your report.
Admiral Gehman. Well, we started off with this--the first
draft of this report back in June was 1,000 pages. And after
some hard negotiating, I got it down to 400 pages. What you see
now are 248 pages after some more arm-twisting. And we had to
do some prioritizing. The observations are--they are all true.
They are all serious. They all are potential danger points for
maybe some future accident, but they didn't affect--they aren't
talking about this accident, and that is kind of how we made
the differentiation. We think that they are offered as serious
matters. They are offered as things that we observed and as we
saw as we traveled around and talked to people. They are
potential problems for NASA. One of them could be the cause of
a future accident. So they do need to be addressed by NASA, but
they aren't related to this accident. So----
Mr. Nethercutt. So you want the recommendations followed up
on and responded to, but you want the observations to be
noticed and acted upon, I assume, as well?
Admiral Gehman. That is correct. That is correct. As a
matter of fact, we say in there that NASA must take action on
these things.
Mr. Nethercutt. Thank you, Mr. Chairman, for the extra
time.
Chairman Boehlert. Thank you very much.
And vision has been thrown around very loosely today. We
all want vision, you know. Proverbs. But the vision, you have
got--tough partnership is very important, Dr. Widnall. And part
of that vision has to include what you hope to accomplish, at
what cost, and at what risk. So we can talk about vision all
day, you know. I still remember Martin Luther King's speech of
his vision, a nation where the people are judged not by the
color of their skin but the content of their character. And we
are still not there yet. So the vision we need is a vision
where the Executive Branch and the Legislative Branch are the
senior partners. NASA is part of the Executive Branch, so--
well, enough sermonizing.
NASA Engineering and Safety Center
Let me get to a couple of very pertinent questions on my
mind. You have made some specific recommendations, the Board
has. And NASA has established a new safety center at Langley.
Incidentally, it was established before the report was out. I
know you have had interaction with NASA, but can you tell us,
Admiral and members of the Board, whether you believe that the
new center reflects any of the changes you have recommended in
the report?
Admiral.
Admiral Gehman. The way I would answer that is that I would
suggest that if you--if one were to write down the specifics of
our recommendation for this independent technical review
authority and make out a checklist or a template that the
emerging and still changing engineering and safety center at
Langley does not match up, not exactly. That doesn't mean that
it is not good and they shouldn't do it, but it does not match
up exactly.
Am I--Board members, am I--have we got it right? Yeah. I
don't want to speak for them, but I think we are in agreement
on that.
Chairman Boehlert. Have you had any conversations with
Administrator O'Keefe? Is this--should this be considered, as I
feel it should be, a work in progress?
Admiral Gehman. Yes. That is my understanding that they
haven't even agreed on their charter. They haven't agreed on--
--
Chairman Boehlert. Okay. Fine. So this is not the be-all-
and-end-all. This is----
Admiral Gehman. That is correct.
Chairman Boehlert. Okay. All right. Next question I want to
ask is----
Admiral Gehman. Mr. Chairman. Mr. Chairman, can Dr. Widnall
stick her----
Chairman Boehlert. Oh, by all means. I would never silence
Dr. Widnall.
Dr. Widnall. No. Just let me add that I consider safety to
be a professional or technical discipline. And it would not be
a bad idea to have an organization--the one that is described
at Langley, as--I would view as almost like a research
organization to look at the fundamentals of safety as a
technical discipline. That is independent from the line
organization that we have suggested that would have a function
in the actual conduct of operations. So both organizations
could exist and be mutually supportive.
Chairman Boehlert. Thank you. And I just want to make sure
we have the record clear so we don't have presentation from
NASA that says, ``Well, look at what we are doing at Langley.
Boy, we have addressed the problem.'' That is only a very small
part of the problem.
SFOC Board of Investigation
This is a quickie, Admiral Gehman. I want to get it on the
record. In the section of Space Flight Operations Contract
between NASA and USA, there is a section of the contract
dealing with the fee reduction for catastrophic loss. That
provision requires the NASA Contracting Officer, in conjunction
with the Board of Investigation, to make a determination as to
the cause of the loss. There has been some confusion about
whether the Columbia Accident Investigation Board is the Board
of Investigation referenced in the SFOC. Is the Columbia
Accident Investigation Board the Board of Investigation
referenced?
Admiral Gehman. No, sir.
Chairman Boehlert. All right. Thank you.
Cost Estimates and Mission Parameters of a Follow-on Vehicle
Next--that was an easy one. In chapter nine, the Board
talks about designing the Shuttle replacement without regard to
cost. But isn't that just a recipe for getting into the same
problem we did with the Shuttle? Does it make sense to design
something without cost parameters and then reassess it once we
know real budget projections? Doesn't that just encourage the
disconnect between ambition and resources that you cite in the
report?
Admiral Gehman. I am sorry we didn't make ourselves more
clear. What we are suggesting, we are actually--we were--what
we were doing there is criticizing the current process of our
Democratic--wonderful Democratic institutions of trying to
design the next vehicle with a start and stop kind of a process
before there was complete agreement on what the vehicle is
supposed to do. And what we suggested is that the right process
would be we have a good healthy debate on what we want to do in
space, we agree on what it is we want this vehicle to do, then
you go into the design process and the cost process. And what
we suggest is that it is a--it would be a wonderful leap
forward if you agreed that the only--that we--that what it is
we want to do is to get into and out of orbit safely. And that
would--even that would be a giant leap forward.
And then once you decide what it is you want to do, then
the design and the cost of the vehicle follows that. We--I am
sorry we weren't clear on that, but we recommend that you and
the Senate and the White House, first of all, agree on what it
is that you want this vehicle to do then go into the design
process. We are hearing things about people have even got
pictures of this vehicle and we haven't even decided what it is
going to do yet. And then the process is reversed.
Chairman Boehlert. Thank you very much for that
clarification.
Now here is the deal. We have promised our very
distinguished panelists that we would have them out by 2. Mr.
Rohrabacher, you are next, followed by Ms. Jackson Lee. Mr.
Nethercutt, do you have any more?
Mr. Nethercutt. No.
Chairman Boehlert. All right. Mr. Rohrabacher is
recognized.
ISS Supply
Mr. Rohrabacher. As we move forward with certain decisions
that need to be made and our discussions with NASA, it will be
helpful to us to have certain issues totally clarified. And I
think this is pretty clear, but I want to ask you very
specifically. Is it the recommendation of the Commission that
if the Space Station can be supplied by an alternate system
rather than the Space Shuttle, that it should be supplied by
the alternate system?
Admiral Gehman. It is our recommendation that we separate
the people from the cargo as soon as possible.
Shuttle Support of ISS Construction
Mr. Rohrabacher. As soon as possible? Mr. Chairman, I would
like you to note that answer. That is----
Chairman Boehlert. Duly noted.
Mr. Rohrabacher [continuing]. Something that we have been
receiving some--a lot of resistance from NASA, for safety
reasons and every other reason, it sounds like. It is unclear
to us. In terms of using the Shuttle, when necessary, would the
Commission agree that the Shuttle would be necessary to finish
the construction of Space Station?
Admiral Gehman. Oh, we believe that the Shuttle can be
safe--could be operated in a more safe manner than it is now,
easily, for another decade.
Mr. Rohrabacher. Thus, Mr. Chairman, in making a decision
as to whether to move forward and finish the Space Station and
the Shuttle, the Commission is deciding that it would be safe--
well, at least we can change and develop the situation so that
the Shuttle is safe in completing the mission of building the
Space Station.
Chairman Boehlert. That opinion is duly noted.
Funding as a Factor in the Accident
Mr. Rohrabacher. Right. Finally, is it the finding of the
Commission that funding is not--was not a major cause of the
Columbia tragedy? That--is it your finding that even if we
would have funded the Shuttle at a higher level, that the
complacency that you have spoken about in your testimony may
well have continued and that that was an issue at least as big,
if not bigger, than the--any funding issue at hand?
Admiral Gehman. The Board did not evaluate the relative
contribution of the factors that we listed, but constrained and
squeezed budgets was a factor as a--it was a contributing
factor to this Shuttle----
Mr. Rohrabacher. Okay. So funding was a contributing factor
as was, of course, what you have been saying----
Admiral Gehman. A lot of other things.
Mr. Rohrabacher [continuing]. Along with complacency
within----
Admiral Gehman. That is correct.
Chairman Boehlert. If the gentleman will yield?
Mr. Rohrabacher. Certainly.
Chairman Boehlert. There is always--we are all partners to
this venture. We all have to share our part of the
responsibility, but let me tell you, if we had written a blank
check to NASA, that wouldn't have changed the decision or the
manner in which the request for imagery was treated. If we had
written a blank check to NASA, that wouldn't have changed the
manner in which they responded to the repeated instances of
foam debris falling. So while we are not going to just wipe our
slate clean in the Legislative Branch, as I enumerated earlier,
and your report put out very specifically. It was within NASA
that decisions were made to transfer funding----
Admiral Gehman. Right.
Chairman Boehlert [continuing]. Out of the program. It is
within NASA that the decision was made to sort of not give the
proper responsibility authority and independence to the safety
function. So I don't want this to be misinterpreted by anybody
as this is an apology for the Congress. We will share part of
the responsibility. We have got to stand up to that, but the
fact of the matter is changes are needed, they are needed, and
they are clearly articulated in your report. I will have some
closing comments in a moment.
Mr. Rohrabacher. Just finish?
Chairman Boehlert. Just one more, and then we will go to
Ms. Jackson Lee.
Mr. Rohrabacher. And finishing up on that area, the
funding--the institutional process of funding may well be what
you were looking at in terms of the way we fund NASA, not
necessarily the specific funding decisions made by the
Congress. I just--for the record, as well, there are numerous
occasions which we--which I heard Members of this committee, on
both sides of the aisle, talk to people who are sitting right
in the spot that you are in right now and say anything that in
any way affects safety should be taken care of without regard
to budget and that we will back you up if that is what--if you
tell us that this is the reason you need that money. However,
Mr. Chairman--our internal--sometimes there are internal
deadlines that are made based on funding that is already agreed
to and those internal deadlines of NASA sometimes are reflected
in the decisions we have made at--funding certain projects.
Chairman Boehlert. Thank you very much, Mr. Rohrabacher.
Ms. Jackson Lee.
Accountability
Ms. Jackson Lee. Thank you very much, Mr. Chairman. The
importance of this warranted me in staying with you, Admiral.
And I do not--and the Board, I do not want to keep you away
from tasty cuisine. And I thank you very much for your
patience.
I want to just reinforce my earlier remarks with respect to
reciting the names of those who lost their lives on Columbia 7,
because this is about them and their families. And
particularly, it is about them because there are how many in
line following them, meaning astronauts in training, who would
do it at a drop of a hat, meaning go into space ready,
courageous. And I hope that my colleagues will join me in
sponsoring the Congressional Gold Medal that we have now filed
to be able to honor them. But I believe it is important to
restate their names and to note their families, because I don't
think one family member publicly did anything to suggest that
we should not continue whatever our vision and our mission is.
And I think this question of probing responsibility is not
simply finger pointing, and I think the Chairman has just said
we all can stand in line right now. And I want to put on the
record that when I made the comment about safety, it was in
1999 where there was a billion dollar cut through the
appropriations process out of this Congress for the NASA
budget. I might suggest that the belt tightening was their way
of saying, ``We can handle it.''
And I want to get back to you were in the middle of saying
the word ``accounting.'' And I would like to be able to have
you answer that along the lines of your role militarily on how
you would deal with that. And I would like Major Hess to
comment that if a tragedy of this moment occurred, I am
recalling the submarine issue with the Japanese fishing boat
and the sort of scenario that occurred. I would appreciate your
comment on that. I also would appreciate a comment as to
whether or not we should be concerned about the International
Space Station. Is that susceptible to the same management
problems that tragically helped, if you will, result in the
Columbia 7 tragedy? And I would also like to find out--as I
look at this report globally, you are not condemning human
space flight. There is vitality to humans going in space. I
didn't see it in the report. I don't want to miss it. And I
would appreciate you commenting on the value of that through
your work and interviews with individuals.
Admiral, you were in the middle of the accountability
question and who we should hold, how we should hold those
responsible.
Admiral Gehman. Right. I will let General Hess, who has
conducted many, many safety--accident investigations in the
aircraft accidents and comment on that. But generally speaking,
in our military experience, we conduct two separate
investigations. And one investigation is--does have an
accountability, responsibility kind of a goal. And the other
one is an investigation to really find out, no kidding, what
happened and every single contributing cause that may have
contributed to that accident in which we assure people that no
accountability will be--there will be no punishment, no
intimidation of any witnesses or anything like that. And what
we tried to do in this investigation is to roll those two kinds
of investigations into one in which we brought out the
performance of people. We documented it in our report. And if
the proper authorities want to hold those people accountable, I
think they should. We are not escaping the issue of
accountability. We just decided that we aren't the judges. But
we did--we were the investigators, so we put it all in the
report.
Ms. Jackson Lee, we did not examine the International Space
Station program, but I suspect that many of the things that we
unearthed in this investigation probably might be good to look
at in that program, also, not that it is not well run and not
well managed. I have no evidence whatsoever to indicate that it
isn't well run and well managed, but if we have cultural
problems with communications and openness and the role of
engineers and things like that, it probably is in more than one
program.
General Hess, do you want to comment on the military--how
military would handle a loss of life like this?
Major General Hess. I think that there is--a good way to
approach the answer to your question is that when we
investigate accidents, it is very likely that outcomes can kind
of fall in three general areas. One, if you find culpability on
the part of leadership, a removal from position is not an
unheard of event. Two, if you find that in the case of, let us
say, a pilot flying an airplane and he flew it outside of the
rules, that pilot going to a flight evaluation board to
determine whether or not he retains his wings as a result of
that event is not unheard of. In the cases where, for example,
there is a mechanical failure, for example, F-16s, being a
single-engine airplane, we were dropping them out of the sky
left and right in the late '90's because of mechanical
failures, those are problems that you go back and you fix
logistically. Well, there is not any personal culpability in
the operation. So accountability is part of what we do. And we
think it is very, very important, because it helps us continue
to follow the rules.
Chairman Boehlert. General, you have had the last word. We
are going to--your--the gentlelady's time has expired.
Ms. Jackson Lee. Thank you, Mr. Chairman.
Chairman Boehlert. And we are going to be faithful to our
promise to our distinguished panelists to have them permitted
to exit. And incidentally, the fine cuisine, they each grabbed
half a sandwich----
Ms. Jackson Lee. Oh, did--that you provided, Mr. Chairman?
Chairman Boehlert [continuing]. Provided to them here.
Yeah.
Ms. Jackson Lee. Mr. Chairman, would you yield for a moment
so that you can--so that he could have the last word? I just
want to--I will pose it to you.
Chairman Boehlert. Who is ``he'' going to have the last
word?
Ms. Jackson Lee. You indicated this witness, but I will
pose it to you. I assume I heard Admiral Gehman say that we
would be able to speak with him directly one on one and have
the opportunity to visit with at least Admiral Gehman and maybe
some of the Board members.
Chairman Boehlert. Not right now. I mean, let me tell you,
it has been my experience, and we are finished now, because we
are going to be faithful to our promise to the panelists. It
has been my experience that this Board, Admiral Gehman, every
single member of the Board, has been accessible----
Ms. Jackson Lee. Right. That is all I needed.
Chairman Boehlert [continuing]. And very receptive to any
requests we have made of them. Let me tell you, I just want to
stand and applaud you for what you have done for us and for
America.
[Applause.]
Chairman Boehlert. We are now adjourned.
[Whereupon, at 2 p.m., the Subcommittee was adjourned.]
Appendix 1:
----------
Answers to Post-Hearing Questions
Responses by Admiral Harold W. Gehman, Jr., U.S. Navy retired, Chairman
of the Columbia Accident Investigation Board
Questions submitted by Representative Ralph M. Hall
Q1. You made 15 return-to-flight recommendations and 14
recommendations that do not have to be completed before return-to-
flight. How did you go about deciding what is a return-to-flight
requirement and what isn't? Four example, your report just says
``initiate an aggressive program to eliminate all External Tank Thermal
Protection System debris-shedding at the source. . .''
Q1a. If you are concerned enough to call for an aggressive program to
eliminate all ET Thermal Protection System debris-shedding, why
shouldn't NASA keep the fleet grounded until they have completed the
task?
A1a. The exposure of the Orbiter to some amount of debris is a feature
of the Shuttle's original design and cannot be eliminated at this time.
The Board concluded that it would be impossible to eliminate all
debris-shedding but NASA needed to take a three-pronged approach which
will improve the safety of the Shuttle: reduce the level of debris to
the minimal level possible, work to strengthen the orbiter to take any
debris hits and establish the capability for inspection and repair on
orbit. If NASA follows all the RTF recommendations, redesigns the Bipod
area, improves the photographic capability on launch, develops a
capability to do an on-orbit inspection, develops a repair capability
for the tile and RCC in orbit and has the Space Station as a possible
sanctuary, the safety level increases for RTF.
Q1b. How much time should NASA have to complete the program?
A1b. We did not specify a specific time for the non-RTF
recommendations, but it is considered a mid-term recommendation, which
means one-three years.
Q1c. The bipod problem is being fixed by getting rid of the ramp
entirely. There is another area of ET foam where shedding has been
noted--the so-called flange areas at the edges of the inter-tank zone.
Shouldn't this area be fixed before return-to-flight?
A1c. The Board believed that NASA could make some significant
improvements in the flange areas with proper testing and understanding
why foam debris has originated from this area.
Q1d. In another critical area, do you think the Shuttle flight should
remain grounded until NASA has fully developed a means to repair
reinforced-carbon-carbon leading edge panels while in orbit?
A1d. The Board was very clear on this issue--``. . .develop a
practicable capability to inspect and effect emergency repairs to the
widest possible range of damage to the TPS, including tile and RCC. .
.''
Q1e. In another critical area, in view of the early warning signals
that NASA is getting of a potential problem, as well as the potential
catastrophic consequences of a failure, why shouldn't redesign of the
``hold down'' bolt system be a return-to-flight requirement?
A1e. The ``hold down'' bolt system is already a redundant system, but
the Board felt it had the potential to be a catastrophic failure.
Specific observations were made and this significant issue should be
addressed by NASA because it fell into the category of ``weak signals''
that could be indications of fixture problems.
Q2. The CAIB calls on NASA to ``initiate a program designed to
increase the Orbiter's ability to sustain minor debris damage by
measures such as improved impact-resistant Reinforced Carbon-Carbon and
acreage tiles.. . .''
Q2a. Again, the Board does not require installing an improved thermal
protection system on the Orbiter before the next flight. Why not?
A2a. The Board feels it is NASA's responsibility to develop and
implement the technical solution.
Q2b. The specification for the TPS tiles and panels requires that the
maximum impact they are designed to sustain is 0.006 foot-pounds. This
is quite small. We now know that foam can inflict massive damage on the
leading-edge panels. Why should anyone have confidence that the Orbiter
can return to flight until the plans for replacing the Orbiter thermal
protection system are completed?
A2b. Risk will always be inherent in space flight but the Board felt
that if NASA followed through on the RTF recommendations, the Space
Shuttle would be safe to fly in the short-term. If NASA redesigns the
Bipod area, improves the photographic capability on launch, develops a
capability to do an on-orbit,inspection, develops a repair capability
for the tile and RCC in orbit and has the Space Station as a possible
sanctuary, the safety level increases for RTF. Furthermore, the RCC is
actually much more impact resistant than this specification, but no one
knows for sure how much tougher. This recommendation is aimed at
requiring NASA to test its flight hardware rather than rely on
analysis.
Q3. The Board dissects at some length the weaknesses of the ``Crater''
model as used to analyze the foam damage during the Columbia's flight.
As a result of the investigation, do you have any indication of the
extent to which NASA is relying on equally weak analytical models in
the Shuttle or Station programs?
A3. There is clear guidance that NASA must update its model regarding
the evaluation of TPS damage: ``Develop, validate, and maintain
physics-based computer models to evaluate TPS damage from debris
impacts.'' One area NASA needs to look into is the use of hydrodynamic
structural codes. The Board found other areas where systems were
certified for flight by analysis rather than actual testing, such as
the Bolt Catchers, and the Board found that this was not proper for a
flight development vehicle.
Q4. Your report was critical of the 1995 Kraft report's assumption
that the Shuttle could be viewed as a mature fleet of ``operational''
vehicles. You argue quite forcefully that the Shuttle is still an R&D
vehicle--not an operational vehicle. Then in your discussion of a
proposed approach to improving NASA's Shuttle safety system, you
highlight the safety programs of the nuclear Navy as being a good model
to emulate. However, the nuclear Navy consists only of operational
vehicles--no one would argue that our nuclear missile submarines are
R&D vehicles. As a result, the differences between the Shuttle fleet
and the Nation's submarine fleet would seem to be far greater than any
perceived similarities--and the safety model would not seem to be
relevant. Would you care to comment?
A4. There will never be a perfect match on benchmarking. The Board was
impressed with the fact that the nuclear Navy manages a complex system
and it can be argued they continually learn about nuclear power as it
ages and matures and it has comparable responsibilities in research,
design, construction, testing, training, operation, and maintenance--
there are some valid lessons learned that can be applied to NASA
regarding: communication and action; recurring training and learning
from mistakes; encouraging minority opinions; retaining knowledge;
worst-case event failures. The Board's Report takes the best safety
practices from several case studies, not just Naval Reactors.
Q5. While rejecting the premiers underlying the Kraft Report, the
Board was silent on the future structure of a Shuttle contract.
Q5a. Why didn't you provide some guidance to the agency, the
Administration and Congress on the wisdom of continuing with the Space
Flight Operations Contract as it stands?
A5a. In the Board's investigation, we did not find any direct
relationship between the SFOC and the cause of the mishap. However,
there was clear mention that outsourcing has an unintended consequence
of reducing the in-house engineering and technical capabilities in the
civil servant side of NASA and complicating the issues of safety
independence. The Board clearly said, ``. . .In the aggregate, these
mid-1990s transformations rendered NASA's already problematic safety
system simultaneously weaker and more complex.''
Q5b. Are the incentives in the SFOC contract, which includes an
incentive for cost savings for both NASA and the contractor, a part of
the problem here?
A5b.
The Board found no evidence that the extensive use of incentives
contributed to this accident. However, the Board did find what are
apparently unintended consequences on the NASA work force that it felt
were worth noting. Among those unintended consequences were: migration
of technical expertise, increased communications challenges, systems of
informal hierarchies, loss of truly effective checks and balances.
Q6. After the Challenger tragedy, part of NASA's return-to-flight
action required the cancellation of all existing waivers and the review
of all existing documentation relating to critical items, failure
modes, and the hazards of flying the vehicle. Much of the time needed
to return to flight was consumed by this effort. The Board does not
recommend a similar effort as a requirement for returning to flight
this time, although you do recommend a re-certification program if the
Shuttle is to be flown past 2010. Why shouldn't we re-certify the
vehicle now? Do you think the Shuttle would pass a re-certification in
2010?
A6. The Board shares this concern, and based its fundamental
recommendation to create an independent technical authority with the
ownership of all technical specifications and all waivers to those
specifications on the premise that certification to ``continue to fly''
should be very carefully monitored. Included in the duties of this
independent authority will be the requirement to understand and
safeguard the systems specifications over time. The Mid-Life
Certification program will bump up against this authority, just as we
intended.
The Mid-Life Certification (MLC) is a necessary process that will
require NASA and Shuttle program managers to review all the basic
vehicle design and certification criteria and revalidate them. This re-
certification will uncover design and manufacturing assumptions that
were made using the limited 10-year/100-launch life span of the system.
Shuttle program management has delegated the development of MLC to the
individual elements and subsystem managers. Approximately 80 percent of
the effort will reside in the orbiter itself. The orbiter element is
beginning its MLC program development using a three-step process, an
expanded Certification of Flight Readiness (called CoFR plus),
certification verification, and certification extension.
CoFR plus is the first step for orbiter return to fly as well as
MLC. This more rigorous certification will begin this summer in
preparation for the anticipated first flight after Columbia. In
addition to the normal subsystem-by-subsystem review of flight
certification, reported upchannel to the program management, the
orbiter MLC office wants to add a horizontal check to verify
certification between subsystems. Essentially, they want to look at
known problem areas in one system and determine if there's a risk to
other systems. An example of this horizontal review is the integrated
approach used to alert other systems of the problem with the flex
hoses. This will facilitate an integrated approach to certification of
all the subsystems as part of the overall system as well as their
interaction. The intent is to integrate this process improvement into
all future certifications.
The SSP's extended life raises several questions about the vehicle
and component's original certification. The verification of
certification step is envisioned to be a review of the CoFR process
with intent to verify that the program is reviewing the right areas,
prior to flight approval, with regard to the current operating
environment (as compared to the anticipated operating environment in
the late '70s). The long-term exposure to salt air and the high wear
induced by maintenance are two examples of environments that the
original certification did not anticipate. The flex hoses, mentioned
previously, failed under low frequency vibration induced stress that
was not anticipated in the original certification. This MLC process is
expected to be a one-time review. The orbiter office is planning to
complete this verification for all CRIT 1.1 systems in time for the
next CoFR. The remaining CRIT systems will be accomplished thereafter.
The extension of the SSP certification beyond 2020 is the final
step. This data intensive process will include a review of the NASA and
contractors' databases with intent to mine all the original
certification criteria and assumptions that may not be valid today.
Their intent is to do this archival review as well as current trend
analysis using UA, PRACA, CARS data et al. This information will then
be used to build new certification criteria and maintenance or
modification programs to sustain the SSP. Additionally, this review
will build a database to be used in future certifications and provide
training for younger engineers in the program invaluable experience
relating to system certification processes. The extension program will
be designed as a one-time review as well.
The MLC is currently ranked in the third tier of SLEP projects, at
the top of a list of undefined projects. This list of undefinitized
projects, including Mid-Life Certification, Fleet Leader and Corrosion
Control, are the core of a service life extension for this system.
Funds to start MLC are programmed to begin in '04 and include adding 50
to 100 additional personnel to get this program started. MLC is
expected to increase certification confidence and build a sustainment
program complete with maintenance, inspection and modifications that
will extend the life of the Shuttle program. The key to success will be
in its funding and rigor as the program office integrates the various
systems toward one goal.
The Shuttles next certification and the SLEP program should be
founded on the basis of a thorough Mid-Life Certification. The SLEP
management recognized this problem at the 7 May 2003 program review;
``We need a focused effort to move these activities from the
undefinitized to the definitized portion of the budget. Progress should
be targeted to support the 2004 Summit.'' The orbiter program is
starting out with some outstanding ideas on how to organize this
tremendous MLC task. The program office should standardize the approach
between the systems to ensure rigor and accuracy of the final product.
NASA has most of the necessary ingredients for a successful sustainment
program for the Shuttle Program. The only impediment to building it is
a centrally organized sustainment office with authority to integrate
the various SSP systems and sites.
Q7. Your report did not address the issue of the role played by the
astronaut corps in agency management. Do you have any opinions on the
subject? Is it on balance healthy or unhealthy?
A7. The Board was disappointed in the Astronaut office participation in
the MMT. The representation at these meetings was random and there was
little consistency in tracking valuable information. In fact, the
Astronaut office did not know there was even a foam debris issue until
after the Columbia mishap. The Board also believes simply assigning
mal-prepared Astronauts to management positions is not a course of
action with high probability of success. If Astronauts are to be
encouraged to enter the management field, they require proper education
and training.
Q8. Admiral Gehman, your report devoted a great deal of space to a
discussion of the pressure exerted by NASA Administrator O'Keefe to
meet the artificial milestone of Space Station ``Core Complete'' by
February 19, 2004. Do you think that the explanation that ``all of the
Shuttle launches were delayed anyway, so it wasn't real pressure'' is
plausible, or was the reality that each Shuttle launch delay simply
added to the pressure perceived by the NASA workforce?
A8. If a Shuttle launch is delayed, it may not mean that all subsequent
launches slip. Many times the next mission moves ahead of the delayed
mission. During this investigation the Board found that people who work
at NASA have the legendary can-do attitude, which contributes to the
agency's successes. But it can also cause problems. When workers are
asked to find days of margin, they work furiously to do so and are
praised for each extra day they find. But those same people (and this
same culture) have difficulty admitting that something ``can't'' or
``shouldn't'' be done, that the margin has been cut too much, or that
resources are being stretched too thin. No one at NASA wants to be the
one to stand up and say, ``We can't make that date.'' It should also be
noted that the number of days delayed is not a one-to-one match on the
amount of margin lost. The Board found sufficient evidence that
schedule pressure was felt at the working level.
Q9. Your report is critical of the ``NASA culture'' and you say that
it needs to be changed, that it is a question of ``leadership.'' What
specifically needs to be done and how we will in the Congress be able
to confirm that the culture has successfully changed?
A9. Changing culture is a very difficult thing to do in any
organization. The Board feels that it will require management changes
that include the CAIB recommendations for an: independent technical
engineering, a truly independent safety authority and a fully
integrated Shuttle program. Secondly, the Board feels it will require
leadership from the top that must come from the senior levels of NASA.
The Report clearly defines what we mean by ``culture.'' Good cultural
habits can only be established by consistent and steady demands by
management over a prolonged period of time.
Q10. At several points in your report, you seem to be critical of the
fact that the number of mandatory inspection points for Shuttle launch
processing has been cut back dramatically over the years, but you don't
produce a clear recommendation on this point.
Q10a. Did the Board think that there were too few mandatory inspection
points? If so, what was the specific basis of your concern?
A10a. The Board observed that the GMIPs changed from over 40,000 in the
early 1990s to approximately 8500 in 2003. There was a general movement
in the Government to outsource to contractors. While the Board could
not tie this reduction in GMIPs to a causal relationship to the
accident, there is a concern that NASA went too far in reducing the
GMIPs that resulted in a decreased engineering expertise in NASA civil
servants for proper oversight.
Q10b. If you think significantly more mandatory inspection points are
needed, why wasn't that one of the report's recommendations?
A10b. The Board did not have the expertise to recommend specific
additions to the GMIPs but clearly was concerned that this needed to be
reviewed by NASA in the observation: . . .Perform an independently led,
bottom-up review of the KSC Quality Planning Requirements Document to
address the entire quality assurance program and its administration.
This review should include development of a responsive system to add or
delete government mandatory inspections.''
Q11. The report's discussion of the budgetary history at NASA,
especially in the Shuttle upgrade and safety programs, is incomplete.
Q11a. What documents did you receive from NASA and OMB that detailed
upgrade requests from the Shuttle or Safety programs to the NASA
Headquarters budget office, from NASA to OMB, and pass-backs from OMB
to NASA?
A11a. We received no documents from OMB, and no documents containing
pre-decisional budget data from NASA.
Q11b. Technically, your Board was a NASA panel, so why couldn't the
Board at a minimum have gotten all the material in the possession of
the agency?
A11b. Executive privilege protects pre-decisional, NASA-executive
office communications. We could have requested such information from
NASA, but we were advised by NASA general counsel's office that the
request would have been denied on the basis of executive privilege.
Q11c. Did anyone advise you not to pursue the budget document
requests? If so, who?
A11c. Executive privilege protects pre-decisional NASA-Executive office
communications. We could have requested such information from NASA, but
we were advised by NASA general counsel's office that the request would
have been denied on the basis of executive privilege.
Q11d. Do you have any strong opinion about the current mix of Shuttle
upgrades and the appropriateness/robustness of the Shuttle upgrades
program? On what is that opinion based?
A11d. The Board does not have a strong opinion regarding this question.
Q12. The report notes on page 78 that the tests conducted to validate
the hypothesis that the foam had damaged the thermal protection system
did not meet with wholehearted approval from NASA. Please describe the
circumstances surrounding the conduct of the test program? Is this
episode related to the Board's comment that, ``The changes we recommend
will be difficult to accomplish--and will be internally resisted?''
A12. The foam impact testing became so important to the investigation
that the Board felt we must have control over the entire process. There
initially was resistance from some NASA personnel as to the type of
testing that was required and the importance of testing to the final
outcome of the investigation. The Board concluded that the most
effective method for conducting the test was for the Board to have
final authority over the entire foam-testing program. This issue was
not specifically related to the Board's concern that changes would be
internally resisted, but did contribute to the overall sense that NASA
is resistant to outside criticisms.
Q13. One thread running through the Board's review of NASA's budget
history is the continuing quest to find efficiencies in the Shuttle
program, to reduce the annual request for appropriations. Congress has
heard testimony on many occasions that budget cuts have safety impacts,
but there is no metric by which a particular reduction in budget can be
tied directly to a specific reduction in safety. Group IV John Logsdon
has been contacted and is responding.
Q13a. Is it fair to say that your report concludes that because of
budget pressures the Shuttle program was operating at thin margins, but
that you couldn't tie this accident directly to budget cuts? If so, why
couldn't you make a stronger statement about the effect on safety of
the declining Shuttle budget?
A13a. Precisely because there was no way of establishing a direct
causal link, we felt that what is said in the report was as strong as
we could substantiate.
Q13b. Does the Board have any advice for us on how to recognize in the
future when a lack of resources has pushed the program into an unsafe
condition? How will we know? Who will be competent to make this
assessment?
A13b. Both the independent technical authority and the independent
safety authority we recommend in the report will be able to make these
judges, as would a reconstituted and effective ASAP.
Questions submitted by Representative Bart Gordon
Q1. Please provide some specific ``benchmarks'' that will allow
Congress to assess the extent to which NASA is complying with the
recommendations of the Columbia Accident Investigation Board (CAIB)
over the next several years.
A1. The HSC has asked that the CAIB be reconvened in one year to track
the progress of the recommendations. The CAIB is prepared to do this.
Q2. Many of the findings and recommendations in your report were in
fact clearly stated in the 2000 report of the Space Shuttle Independent
Assessment Team (SIA), chaired by Dr. Henry McDonald. One could
conclude that if SIAT report had been embraced by the agency, the
Columbia accident might never have happened.
Q2a. Can you explain why NASA failed to heed Dr. McDonald's report in
the three years after its release?
A2a. It is unfair to say that NASA failed to heed the SIAT report since
there was follow-up on some of the report's recommendations by NASA;
however, NASA did not agree with all the recommendations of the SIAT
report. The reasons NASA resists implementing recommendations from
outside reviews are complex. Among the chief reasons are: NASA thinks
it knows better; budget constraints have caused shrinkage of R&D
activities and independent, in-house engineering work; schedule
pressure; and, leadership shifts toward managers and away from
engineers.
Q2b. What will have to occur for your report to receive a more
favorable reception, and how likely do you think that is?
A2b. The Stafford-Covey RTF group will be one means to track the short-
term recommendations. A newly chartered ASAP, periodic reconvening of
the CAIB and Congressional oversight may be a means to ensure mid-term
and long-term recommendations are followed. The Board Report predicts
resistance to change, which are the primary reasons we recommended an
independent technical/engineering authority with the authority to
safeguard and/or grant all waivers to basic system requirements and
specifications.
Questions submitted by Representative Sheila Jackson Lee
Q1. What actions would you recommend be taken by NASA and the Congress
to ensure that the International Space Station program is not facing
safety concerns similar to those uncovered by the CAlB investigation?
A1. The investigation of the ISS was not part of the Charter of the
CAIB so we do not feel qualified to answer this question. However, the
lessons learned from the Columbia Accident should be studied by the ISS
program management for benchmarking purposes. The NASA IG is capable of
using the Columbia Accident Investigation Board's report as a roadmap
to use in the case of the ISS.
Q2. Your report seems to be quite critical of the amount of downsizing
of the government employees and the amount of contracting out that has
occurred at the agency.
Q2a. Is that true? If so, what is the basis of your concern?
Q2b. How many government employees do you think will need to be added
to address the concerns raised in your report?
A2a,b. Since NASA was established in 1958, its civil service workforce
has fluctuated widely. In 1967, at the height of the Apollo program,
the workforce reached approximately 35,900 personnel. In the mid-70s an
involuntary separation program decreased the workforce by several
thousand employees. By 1980, the workforce had stabilized near 21,000.
It remained close to that level until 1986, when the Space Shuttle
Challenger accident forced a re-examination of NASA, adding significant
man-hours to Safety and Quality Assurance processes.
NASA began some ambitious new programs in the late '80s and its
workforce began to grow again peaking in 1992 at more than 25,000. When
the Clinton Administration took office in 1993, it initiated steps to
reduce the size of the overall federal workforce. Total NASA headcount
went from approximately 25,000 civil servants in FY 1993 to slightly
more than 18,000 (full-time permanents) by the end of 2002. As the NASA
workforce declined, the continuing strategy was to lose junior
personnel first, resulting in an experienced but aging workforce. In
November 1995, NASA selected United Space Alliance--a Rockwell
International and Lockheed Martin partnership--as the prime contractor
for space flight operations. Thus, fewer civil servants were required
to manage the program, NASA estimated that it would be able to make
personnel reductions in the range of 700 to 1,100 full-time equivalent
personnel (FTEs) at the Kennedy Space Center alone. The challenge to
Space Shuttle contractors, including United Space Alliance, was to
address the aging workforce concerns through a continual influx of
inexperienced personnel who could stay with the industry for many
years. Contractors have much more flexibility in their personnel
decisions than does the Federal Government. Compensation packages,
including both wages and benefits, are tailor made to address the
shortages that face the industry while correcting oversupply in some
skills.
All SSP contractors, including United Space Alliance, have been
given financial incentives to reduce the cost of performing the
contract. Personnel costs can be reduced by eliminating personnel in
overhead support or management functions, or by encouraging
efficiencies in the direct labor elements. United Space Alliance,
through the Space Flight Operations Contract, is accountable for
professional, managerial and technical workforce support to the Space
Shuttle Program. Jobs range from maintenance personnel at Kennedy Space
Center to subsystem managers within the Mission Control structure. USA
recognized its obligation to maintain a balanced workforce in the
professional skills, and that there must be a flow of personnel through
the ``pipeline'' to guard against future shortfalls in critical skills.
United Space Alliance stated that while they accepted the challenge
to reduce the headcount on the Space Shuttle program, they intended to
do so without reducing the direct headcount. They would do this
primarily through efficiencies achieved by consolidations. USA did not
place the same emphasis on the retention of the nonprofessional,
technician workforce. USA has stated that they do not suffer from the
same concerns as with engineers and has never faced a shortage of
applicants for these jobs.
United Space Alliance closely tracks personnel trends, especially
with respect to engineering manpower. USA has a nearly bi-modal
distribution with respect to age or experience. There are a significant
number of personnel over 40 years of age as well as a significant
number in the under 30 age group. This illustrates a pipeline from
which the workforce of the future will be drawn. Other Space Shuttle
contractors may not have had the flexibility to make these kinds of
``overhead only'' process gains, as elimination of direct as well as
indirect personnel was necessary. While reducing the cost of labor
through lay-offs, the contractor must continually guard against
creating an impression of the company as an unattractive workplace.
Contrast the United Space Alliance distribution with ATK Thiokol
Propulsion in Utah, the supplier of the Reusable Solid Rocket Motor
(RSRM) since the 1970's.
During the peak production of the RSRM in the 1980's, Thiokol
employed over 4,000 personnel. Today, with production of the RSRM at
less than 30 units annually, their personnel count is stable at 1350.
Demographics at the Utah plant show a spike in the 45-49 age group,
with the majority of the workforce being over 45 years old. This trend
is true for engineering as well as plant personnel. ATK Thiokol has
identified their aging workforce as a significant issue in relation to
the Shuttle program Service Life Extension Program (SLEP). ATK Thiokol
recognizes that they must ``pump significant new energy into recruiting
new talent and retaining/training the younger ones currently in our
workforce now.'' The contracting community at Marshall Space Flight
Center recognized the risk associated with downsizing and has
eliminated incentives associated with cost cutting in the latest RSRM
contract.
The Michoud Assembly Facility workforce has been declining over the
past five years. In 1998, there was some increase in hiring as a result
of the RLV and X-33 programs. However, after that, hiring was limited
to budget driven replacements only. Budget challenges have led to the
involuntary separations which approached ten percent in 2002. One of
the risks of multiple periods of downsizing is that it may lead to a
perception among the workforce of limited potential for both growth and
reliable employment. This has been highlighted as one of the most
significant reasons for the voluntary attrition over the past three
years. The average age of the employee at Michoud is now 47.8 years,
but the skilled labor (represented) employees average 48.2 years. In
conclusion, the issues associated with aging workforce present
formidable challenges to the future of the Shuttle Program, especially
if the vehicle is expected to serve until 2020 and beyond. Of the major
contractors only USA has a recruiting effort with significant numbers.
Additionally, while USA's benefit packages have been considered by
some to be below the industry standard, we have reviewed DCAA
documentation that reflects that the packages are among the better in
the industry and may actually be considered excessive. It is essential
that NASA take actions to ensure a stable experienced base of support
for the Shuttle programs. This may require modifications to way
contract incentives are used or other contractual changes. It may
benefit NASA to continue the bundling of Space Shuttle element
contracts, ETR, SSME, and RSRM under the SFOC and USA in order to
maximize the return on leverage of personnel recruitment efforts.