[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
NASA'S ASTRONAUT HEALTH CARE
SYSTEM--RESULTS OF AN
INDEPENDENT REVIEW
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON SPACE AND AERONAUTICS
COMMITTEE ON SCIENCE AND TECHNOLOGY
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 6, 2007
__________
Serial No. 110-52
__________
Printed for the use of the Committee on Science and Technology
Available via the World Wide Web: http://www.house.gov/science
______
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COMMITTEE ON SCIENCE AND TECHNOLOGY
HON. BART GORDON, Tennessee, Chairman
JERRY F. COSTELLO, Illinois RALPH M. HALL, Texas
EDDIE BERNICE JOHNSON, Texas F. JAMES SENSENBRENNER JR.,
LYNN C. WOOLSEY, California Wisconsin
MARK UDALL, Colorado LAMAR S. SMITH, Texas
DAVID WU, Oregon DANA ROHRABACHER, California
BRIAN BAIRD, Washington ROSCOE G. BARTLETT, Maryland
BRAD MILLER, North Carolina VERNON J. EHLERS, Michigan
DANIEL LIPINSKI, Illinois FRANK D. LUCAS, Oklahoma
NICK LAMPSON, Texas JUDY BIGGERT, Illinois
GABRIELLE GIFFORDS, Arizona W. TODD AKIN, Missouri
JERRY MCNERNEY, California JO BONNER, Alabama
PAUL KANJORSKI, Pennsylvania TOM FEENEY, Florida
DARLENE HOOLEY, Oregon RANDY NEUGEBAUER, Texas
STEVEN R. ROTHMAN, New Jersey BOB INGLIS, South Carolina
MICHAEL M. HONDA, California DAVID G. REICHERT, Washington
JIM MATHESON, Utah MICHAEL T. MCCAUL, Texas
MIKE ROSS, Arkansas MARIO DIAZ-BALART, Florida
BEN CHANDLER, Kentucky PHIL GINGREY, Georgia
RUSS CARNAHAN, Missouri BRIAN P. BILBRAY, California
CHARLIE MELANCON, Louisiana ADRIAN SMITH, Nebraska
BARON P. HILL, Indiana PAUL C. BROUN, Georgia
HARRY E. MITCHELL, Arizona
CHARLES A. WILSON, Ohio
------
Subcommittee on Space and Aeronautics
HON. MARK UDALL, Colorado, Chairman
DAVID WU, Oregon TOM FEENEY, Florida
NICK LAMPSON, Texas DANA ROHRABACHER, California
STEVEN R. ROTHMAN, New Jersey FRANK D. LUCAS, Oklahoma
MIKE ROSS, Arizona JO BONNER, Alabama
BEN CHANDLER, Kentucky MICHAEL MCCAUL, Texas
CHARLIE MELANCON, Louisiana
BART GORDON, Tennessee RALPH M. HALL, Texas
RICHARD OBERMANN Subcommittee Staff Director
PAM WHITNEY Democratic Professional Staff Member
KEN MONROE Republican Professional Staff Member
ED FEDDEMAN Republican Professional Staff Member
DEVIN BRYANT Research Assistant
C O N T E N T S
September 6, 2007
Page
Witness List..................................................... 2
Hearing Charter.................................................. 3
Opening Statements
Statement by Representative Bart Gordon, Chairman, Committee on
Science and Technology, U.S. House of Representatives.......... 19
Written Statement............................................ 19
Statement by Representative Ralph M. Hall, Ranking Minority
Member, Committee on Science and Technology, U.S. House of
Representatives................................................ 20
Statement by Representative Mark Udall, Chairman, Subcommittee on
Space and Aeronautics, Committee on Science and Technology,
U.S. House of Representatives.................................. 14
Written Statement............................................ 15
Statement by Representative Tom Feeney, Ranking Minority Member,
Subcommittee on Space and Aeronautics, Committee on Science and
Technology, U.S. House of Representatives...................... 16
Written Statement............................................ 18
Panel 1:
Colonel Richard E. Bachmann, Jr., Chair, NASA Astronaut Health
Care System Review Committee; Commander and Dean of the U.S.
Air Force School of Aerospace Medicine
Oral Statement............................................... 21
Written Statement............................................ 23
Biography.................................................... 26
Dr. Richard S. Williams, Chief Health and Medical Officer,
National Aeronautics and Space Administration
Oral Statement............................................... 28
Written Statement............................................ 30
Dr. Ellen Ochoa, Director, Flight Crew Operations, NASA Johnson
Space Center
Oral Statement............................................... 32
Written Statement............................................ 34
Mr. Bryan D. O'Connor, Chief, Safety and Mission Assurance,
National Aeronautics and Space Administration
Oral Statement............................................... 38
Written Statement............................................ 39
Discussion
Contrasting Views and Findings From the Astronaut Health Care
System Review Committee...................................... 43
Risks of Pre-flight Alcohol Consumption........................ 45
Differences and Methods of the Reviews......................... 46
Scope of Investigation......................................... 49
Anonymity of Survey............................................ 49
Alleged Instances of Alcohol Abuse............................. 50
Policies to Insure Employee Openness........................... 51
Extent of Alleged Alcohol Abuse................................ 52
Openness of Safety Reporting/Recommendations and Future
Programs..................................................... 53
Panel 2:
Dr. Michael D. Griffin, Administrator, National Aeronautics and
Space Administration
Oral Statement............................................... 57
Written Statement............................................ 59
Discussion
Implementation of Recommendations.............................. 61
NASA Safety Culture............................................ 64
Anonymity and Authenticity of Reported Incidents............... 67
Charter of the NASA Astronaut Health Care System Review
Committee.................................................... 68
Appendix: Answers to Post-Hearing Questions
Colonel Richard E. Bachmann, Jr., Chair, NASA Astronaut Health
Care System Review Committee; Commander and Dean of the U.S.
Air Force School of Aerospace Medicine......................... 72
Dr. Richard S. Williams, Chief Health and Medical Officer,
National Aeronautics and Space Administration.................. 80
Dr. Ellen Ochoa, Director, Flight Crew Operations, NASA Johnson
Space Center................................................... 85
Mr. Bryan D. O'Connor, Chief, Safety and Mission Assurance,
National Aeronautics and Space Administration.................. 87
Dr. Michael D. Griffin, Administrator, National Aeronautics and
Space Administration........................................... 90
NASA'S ASTRONAUT HEALTH CARE SYSTEM--RESULTS OF AN INDEPENDENT REVIEW
----------
THURSDAY, SEPTEMBER 6, 2007
House of Representatives,
Subcommittee on Space and Aeronautics,
Committee on Science and Technology,
Washington, DC.
The Subcommittee met, pursuant to call, at 10:05 a.m., in
Room 2318 of the Rayburn House Office Building, Hon. Mark Udall
[Chairman of the Subcommittee] presiding.
hearing charter
SUBCOMMITTEE ON SPACE AND AERONAUTICS
COMMITTEE ON SCIENCE AND TECHNOLOGY
U.S. HOUSE OF REPRESENTATIVES
NASA's Astronaut Health Care
System--Results of an
Independent Review
thursday, september 6, 2007
10:00 a.m.-12:00 p.m.
2318 rayburn house office building
Purpose
On Thursday, September 6, 2007 at 10:00 a.m., the House Committee
on Science and Technology's Subcommittee on Space and Aeronautics will
hold a hearing to examine the results of two reports on the National
Aeronautics and Space Administration's (NASA) astronaut medical and
behavioral health care system. The first, the report of the NASA
Astronaut Health Care System Review Committee, provided an independent
assessment of NASA's medical and behavioral health care system. The
second, a Johnson Space Center internal review considered opportunities
for lessons learned in light of the incident involving NASA astronaut
Lisa Nowak. The hearing will explore the findings and recommendations
of these reports and any actions NASA plans to take in response to
them.
Witnesses
Witnesses scheduled to testify at the hearing include the
following:
Panel 1
Col. Richard E. Bachmann, Jr., Chair, NASA Astronaut Health Care System
Review Committee; Commander and Dean of the U.S. Air Force School of
Aerospace Medicine
Dr. Richard S. Williams, Chief Health and Medical Officer, NASA
Dr. Ellen Ochoa, Director, Flight Crew Operations, NASA Johnson Space
Center
Mr. Bryan O'Connor, Chief, Safety and Mission Assurance, NASA
Panel 2
Dr. Michael Griffin, Administrator, NASA
Potential Issues
The following are some of the potential issues that might be raised
at the hearing:
The external review of the astronaut health care
system identified a number of significant concerns--what was
the basis of the committee's findings and recommendations?
The external review of the astronaut health care
system identified a number of ``problematic'' cultural and
structural issues. Is there any evidence that the NASA culture,
particularly as it relates to the astronaut program,
unwittingly encourages the downplaying of human factors
problems (substandard task performance, risky behaviors, other
behavioral issues) that if unaddressed may pose risks to flight
safety or have mission impacts?
How pervasive are the problematic conditions
highlighted by the external review committee, and how should
NASA go about getting an answer to that question?
Are NASA's decision appeal processes, anonymous
reporting systems, and other safety and mission assurance
efforts adequately capturing human factors risks, and if not,
what should be done?
To what extent, if at all, should NASA get involved
in the off-duty lives of its astronauts in the interest of
ensuring that astronauts get the proper support and services
for dealing with behavioral issues or problems, especially
those that may not violate a medical or behavioral health
standard but which could potentially pose a flight safety risk
or have a mission impact if left unaddressed?
How can NASA ensure that an open and objective
environment exists within the agency for addressing medical or
behavioral concerns?
What explains the disconnect between the information
provided by interviewees to the external review committee and
the information provided to Mr. O'Connor during his
investigation?
Is NASA's timeline for resolving questions and
implementing recommended improvements to NASA policies,
procedures, and practices appropriate, and what will Congress
need to do, if anything, to ensure that the recommendations are
actually implemented?
Background Information
In the wake of the arrest of astronaut Lisa Nowak, the NASA
Administrator ordered an independent external review of NASA's
astronaut health care system, focused on space medicine operations at
the Johnson Space Center (JSC). It did not focus on the specifics of
the Lisa Nowak incident. In addition, an internal review was undertaken
by JSC management to determine ``whether there were any indicators
which could have prompted NASA to take actions that could have averted
the sequence of events.'' As part of the JSC review, ``astronaut
selection and retention procedures were reviewed to see if there were
any lessons learned that could be incorporated into the improved
practice of behavioral medicine.''
A. Report of the NASA Astronaut Health Care System Review Committee
In carrying out the NASA Administrator's directive, Dr. Richard
Williams, the NASA Chief Health and Medical Officer (CHMO), prepared
the task statement for the external review committee; selected the
Chairman of the committee; selected the members of the committee, based
on nominations from various federal agencies of ``appropriately
credentialed physicians and mental health professionals, employed by
the Federal Government or on active duty in the military services, and
experienced in medical and behavioral health support to organizations
and personnel engaged in critical or hazardous operations;'' and
appointed two NASA employees as ex-officio members of the committee,
one astronaut as a consultant, and one NASA employee as executive
secretary. The chairman of the committee was Col. Richard Bachmann,
Commander of the USAF School of Aerospace Medicine and specialist in
aerospace medicine. A list of the committee members is included as
Attachment 1 to this hearing charter.
Purpose of the Assessment
As stated in the report of the external review committee, the
purpose of the assessment was as follows:
``To provide rapid objective assessment, problem identification,
and recommendations for action or further study of the following
specific areas to the Chief Health and Medical Officer and NASA
Administrator:
1. Medical evaluation for acceptance to the Astronaut Corps,
to include psychological testing
2. Annual medical examination and certification of astronauts
for flight duty
3. Periodic medical and psychological evaluation and testing
of astronauts
4. Astronaut certification for space flight, from a medical
and behavioral health perspective
5. Professional qualifications of health care providers
6. Quality/adequacy of medical practice relative to expected
standards of care and
7. Administrative considerations of health services,
including:
a. Provider credentials and privileging
b. Record-keeping
c. Communication and reporting
d. Disposition of aeromedical concerns; and
e. Privacy considerations
8. Behavioral health considerations within the context of the
NASA Personnel Reliability Program (PRP)
These criteria were provided to the committee to help focus the
review, but did not constrain or limit the review. During the first
committee meeting, the CHMO asked the committee to provide opinions on
the following additional questions:
9. To what extent are disorders of conduct indicative of
underlying mental health pathology?
10. To what extent can regular psychological testing or
psychiatric evaluation predict a disorder of conduct or `act of
passion'?
11. What systemic procedures could be put in place to predict
disordered conduct?''
Approach and Schedule
The review committee was selected and appointed in late February
2007. The committee held three sets of meetings: in Washington, DC on
March 28th, at JSC on April 23-26th, and in San Antonio on May 30-31st.
During the JSC meeting, the committee members received briefings from
and had meetings with NASA personnel. Following that, the committee
members split up and held private interviews with astronauts, flight
surgeons, and astronaut family members. Members interviewed eight of 21
space medicine flight surgeons [who support flight crews], all of the
clinic-assigned flight surgeons [who provide clinic services for
astronauts and family members] and all of the behavioral health staff.
The groups also reviewed the facilities, offices, and relevant
documents for those functional areas.
The NASA astronaut office informed the Astronaut Corps of the
opportunity to speak with the committee on a voluntary basis. Fourteen
currently active astronauts (all but one had flown in space) chose to
speak to the members. Five astronaut family members also volunteered to
speak to committee members. After the JSC visit, the committee had
follow-up conversations/e-mail exchanges with a number of the
interviewees. The interviews were intended to be anonymous and
confidential, and Col. Bachmann cites that as the reason the
committee's report does not ``name names'' or provide information that
could identify specific individuals. There were no prepared sets of
questions. Instead, the members conducted open-ended interviews to
allow interviewees to offer whatever information they chose to share
with the committee members.
The committee held its third and final meeting on May 30-31, 2007
at the USAF School of Aerospace Medicine to consider draft findings
that had been developed by the members and to write the report. As
stated in the report: ``The findings and recommendations expressed in
this report represent the unanimous opinion of the committee.'' The
option of doing minority reports was made available to the committee
members but none saw the need to do so. The committee submitted its
draft report on June 21, 2007 to the NASA Chief Health and Medical
Officer ``to allow NASA functional areas an opportunity to provide
comments and correct factual errors or misstatements.'' Col. Bachmann
and the members of the committee briefed the senior NASA management
(including the NASA Administrator via teleconference) on July 16, 2007.
NASA Headquarters released the report to the public and held a press
conference on July 27, 2007.
Major Findings of the External Review
The external review committee's report identified a number of
significant issues related to NASA culture, communication, and
behavioral concerns. In conversations with staff, Col. Bachmann
emphasized that the issues and concerns cited in the report, which are
reflected in the report's findings, were raised by the interviewees in
the course of the confidential interviews. For example, the committee
members did not ask the interviewees about alcohol use by astronauts--
the incidents cited in the report were volunteered by interviewees
during the course of the interviews as specific examples of safety
concerns. According to Col. Bachmann, various concerns referenced in
the report were based on information provided by interviewees who were
eyewitnesses, and did not represent second- or third-hand hearsay.
Moreover, the types of concerns raised by interviewees were consistent
across a large proportion of the interviewees. As noted in the
committee's report: ``Although they do not represent a random or
exhaustive sample of the larger population of astronauts and family
members, the issues raised were remarkably consistent and compelling
and deserve focused attention.''
The following represent some of the most notable findings in the
external review report [a complete set of findings and recommendations
can be found in the external review committee's report, which has been
provided to Subcommittee Members]:
``Many anecdotes were related that involved risky
behaviors by astronauts that were well known to the other
astronauts and no apparent action was taken. Peers and staff
fear ostracism if they identify their own or others'
problems.''
``As the review progressed, it became apparent that
major vulnerabilities, underlying root causes, and contributing
factors extend well beyond the specific medical aspects of NASA
operations. . .These issues are so ingrained and longstanding
that it will take senior leadership action to remediate them.''
``Problems of communication were evident among the
four areas addressed: flight medicine, behavioral health,
flight medicine clinic, and the Astronaut Office. This theme
recurred in a variety of venues during the committee's visit to
JSC, and also extended to communication between these areas at
JSC and Headquarters.''
``Several senior flight surgeons expressed their
belief that their medical opinions regarding astronaut fitness
for duty, flight safety and mission accomplishment were not
valued by leadership other than to validate that all (medical)
systems were ``go'' for on-time mission completion. Instances
were described where major crew medical or behavioral problems
were identified to astronaut leadership and the medical advice
was disregarded. This disregard was described as
``demoralizing'' to the point where they said they are less
likely to report concerns of performance decrement. Crew
members raised concerns, regarding substandard astronaut task
performance which were similarly disregarded.''
``Interviews with both flight surgeons and astronauts
identified some episodes of heavy use of alcohol in the
immediate pre-flight period, which has led to flight safety
concerns. Alcohol is freely used in crew quarters. Two specific
instances were described where astronauts had been so
intoxicated prior to flight that flight surgeons and/or fellow
astronauts raised concerns to local on-scene leadership
regarding flight safety. However, the individuals were still
permitted to fly. The medical certification of astronauts for
flight duty is not structured to detect such episodes, nor is
any medical surveillance program by itself likely to detect
them or change the pattern of alcohol use.''
``Astronaut medical and behavioral health care is
highly fragmented. . .''
``Psychological testing evaluation is conducted, and
is intended to identify applicants who can adapt most readily
and perform effectively in the extreme environment of space
flight. However, this information is rarely and inconsistently
used.''
``There is no periodic psychological evaluation or
testing conducted on astronauts. Once selected as an astronaut
candidate, astronauts have no psychological evaluation for the
remainder of their careers unless selected for long duration
missions.''
Risky Behaviors--``Many anecdotes were related that involved risky
behaviors by astronauts that were well known to the other astronauts
and no apparent action was taken. Peers and staff fear ostracism if
they identify their own or others' problems.'' JSC officials described
to staff several mechanisms that are in place for peers or staff to
bring forward concerns about astronaut behavior, performance, or
concerns about flight safety. Those mechanisms include anonymous safety
reporting systems, approaching flight surgeons, the chief of the
astronaut office, the crew commander, or other management. In addition,
astronauts have access to the behavioral health clinic, the Employee
Assistance Program, and to flight surgeons. However, Col. Bachmann
indicated to staff that the external review heard instances of concerns
about personal behavior that could be embarrassing and substandard
performance during training and on-orbit, that could potentially impact
a mission but for which no actions were taken. He noted that human
factors issues were a consistent theme of the interviews, but that his
committee was not equipped to determine how widespread those issues
were across NASA and that determining the extent of the problem should
be an important task for agency management.
Barriers to Communication--``Problems of communication were evident
among the four areas addressed: flight medicine, behavioral health,
flight medicine clinic, and the Astronaut Office. This theme recurred
in a variety of venues during the committee's visit to JSC, and also
extended to communication between these areas at JSC and
Headquarters.'' JSC officials told staff that JSC is preparing an
anonymous survey to explore the relationship between astronauts and
flight surgeons and managers; to identify whether astronauts or flight
surgeons have concerns in raising flight safety or crew suitability
issues or whether barriers exist to doing so; and whether there are
suggestions for changes to policies and procedures. A group from JSC
Human Resources, including individuals with experience in survey
design, is developing the survey and will analyze the results. The
Flight Crew Operations Directorate and the Space Life Sciences
Directorate, among others, are providing input on the questions to be
included in the anonymous survey. (Staff has assembled a non-
comprehensive list of the key NASA and JSC offices, and associated
office responsibilities, involved in Astronaut Health Care and Safety
that is provided as Attachment 2.) The Flight Crew Operations
Directorate told staff that it will hold a Town Hall meeting with
astronauts to discuss the results of the survey. JSC plans to issue the
survey in mid-September. The results will be summarized in a report
that will be delivered to the JSC Director. While supporting the idea
of an anonymous survey, Col. Bachmann told staff that he thinks that it
is very important that the questions be structured to avoid being
overly narrow in focus; rather, the questions need to be open-ended to
encourage anonymous comment, and the questions should be comprehensive
enough to cover all of the issues raised in the report. In that regard,
NASA might benefit from having its proposed survey reviewed by external
survey experts.
Disregard of Flight Surgeon and Crew Opinions--Several senior flight
surgeons expressed their belief that their medical opinions regarding
astronaut fitness for duty, flight safety and mission accomplishment
were not valued by leadership other than to validate that all (medical)
systems were ``go'' for on-time mission completion. Instances were
described where major crew medical or behavioral problems were
identified to astronaut leadership and the medical advice was
disregarded. This disregard was described as ``demoralizing'' to the
point where they said they are less likely to report concerns of
performance decrement. Crew members raised concerns regarding
substandard astronaut task performance which were similarly
disregarded. JSC medical officials indicated that professional
disagreements among flight surgeons and between flight surgeons and
program officials could occur and were not suppressed. They described
to staff several appeals mechanisms that flight surgeons can take
should they choose to seek further consideration of a final medical
decision that differs from the one they put forth. One official noted
that he was unaware of cases where flight surgeons felt disregarded and
was not aware of any cases in which a flight surgeon had made a medical
decision that had been overruled by Shuttle or ISS program management.
Col. Bachmann indicated that the interviewees themselves were the ones
using the word ``disregarded,'' and that it was a theme that recurred
in the interviews. Mention of ``flight safety'' and ``mission impact
concerns came directly from the interviewees. He also noted that the
committee heard from individuals who chose not to take concerns to the
next level of management due to the ``demoralizing'' effects of being
disregarded.
Use of Alcohol in Pre-flight Period--``Interviews with both flight
surgeons and astronauts identified some episodes of heavy use of
alcohol by astronauts in the immediate pre-flight period, which has led
to flight safety concerns. Alcohol is freely used in crew quarters. Two
specific instances were described where astronauts had been so
intoxicated prior to flight that flight surgeons and/or fellow
astronauts raised concerns to local on-scene leadership regarding
flight safety. However, the individuals were still permitted to fly.
The medical certification of astronauts for flight duty is not
structured to detect such episodes, nor is any medical surveillance
program by itself likely to detect them or change the pattern of
alcohol use.'' As noted above, Col. Bachmann stressed that in its
anonymous interviews the committee members did not use a prepared set
of questions and did not ask about alcohol use. Instead the instances
of alcohol use were offered up by the interviewees as examples of
safety concerns they had witnessed. He later elaborated in the NASA
press conference that one instance cited involved a T-38 aircraft and
the other involved an ISS/Soyuz launch opportunity. Further, during the
NASA press conference that accompanied the public release of the
external review report, Col. Bachmann stated that ``the two specific
incidents of alcohol use that we put into the report were specifically
chosen to illustrate a larger problem, to call attention to the larger
issue which is the role of the flight surgeon in protecting both the
individual's health, flight safety, and mission completion, and the
fact that the flight surgeons and other astronauts who described their
role in these incidences and other which we did not obtain further
details on were to say that they felt concerned that their professional
input seemed to be disregarded, at least at the local level, and that
they were demoralized by that disregard to the point that they felt
like they would be less likely to report concerns or performance
decrement in the future.'' Col. Bachmann indicated to staff that based
on the information provided to the committee in the interviews, he
considered the reports of alcohol use to be more credible than NASA's
characterization of them as simply ``allegations.'' NASA Safety and
Mission Assurance chief Bryan O'Connor conducted an investigation of
the reported instances of alcohol use and concluded that ``within the
scope and limitations of this review, I was unable to verify any case
where a space flight crew member was impaired on launch day, or where
there was a disregard by managers of a flight surgeon or co-crew member
recommendation that a crew member not fly Shuttle or Soyuz.''
B. NASA Response to Recommendations of External Review
According to a NASA ``Fact Sheet on the Findings of the Astronaut
Health Care System Review Committee,'' that accompanied public release
of the review committee report on July 27, 2007, NASA reported the
following steps to respond to the committee's recommendations:
``Look for ways to enhance use of behavioral health
data in the astronaut selection process
Take steps to ensure that flight surgeons, trainers,
and astronauts are free to communicate concerns of flight
safety to senior leadership and encourage such communication
Adopt a formal code of conduct for the Astronaut
Corps
Provide regular training to flight surgeons regarding
behavioral health assessments
Promote better communication from flight surgeons to
all astronauts on their personal status with regard to medical
qualification for space flight assignments
Work to enhance a program of external peer review of
NASA's medical and behavioral health staff
Establish one credentialing and privileging authority
for both the flight medicine and behavioral health providers,
with documented processes for accountability
Institute behavioral health assessments in
conjunction with annual astronaut flight physicals''
During the press conference held on July 27, 2007, Ms. Shana Dale,
NASA Deputy Administrator, stated that:
``NASA's existing T-38 Aircraft Alcohol Use policy that has
historically been applied to space flight has been explicitly
extended as an interim policy to flight on any space craft.
This interim policy prohibits alcohol use for 12 hours prior to
flight and further states that astronauts will neither be under
the influence nor the effects of alcohol at the time of launch.
A comprehensive review of alcohol use policy prior to aircraft
use or space flight is already underway.''
In addition, on July 26, 2007, the Deputy Administrator of NASA,
requested an internal review of ``reported allegations of heavy use of
alcohol by astronauts in the immediate pre-(space) flight period.''
These incidences were identified in the report of the Astronaut Health
Care System Review Committee. A summary of the selected issues,
findings, and recommendations of the Space Flight Safety Review is
provided below. NASA has indicated to staff that additional responses
to the report and a recommendations implementation plan will be
forthcoming later in the year.
Space Flight Safety Review
The safety review was conducted by the Chief of the Safety and
Mission Assurance, Mr. Bryan O'Connor. According to the final report,
which was released to the public on August 29, 2007, the scope of the
review ``focuses on the space flight safety implications of alcohol use
or abuse. . .those things that could cause impairment during launch day
flight preparation.'' The after effects of alcohol use, such as
hangover, were included in the scope of the review. ``The relevant
question. . .was, `Did we have a situation where a crew member
presented on launch morning in an impaired state, was observed as such
by flight surgeon or another crew member, and was then cleared to fly
by operational management over the objections of the flight surgeon (or
other crew member)?' Aircraft flying operations in general were out of
scope.''
According to the written report, the safety review involved
inspection of crew quarters facilities at JSC and the Kennedy Space
Center and a review of policies and procedures before launch. Records
of JSC and Space Shuttle program hotlines, the NASA Safety Reporting
System (NSRS), and NASA's close call and mishap reporting systems for
``astronaut alcohol abuse and space or aircraft flight'' were also
examined. The review examined this data over the past 20 years. In
addition, the review encompassed voluntary interviews, held on a non-
confidential basis, with astronauts, flight surgeons, research and
operations support nurses, Shuttle-suit technicians, close-out-crew
technicians, and the mangers and staff of flight crew quarters.
Selected Findings and Recommendations
Finding: ``Alcohol is available for crew use, and
although it is possible to abuse it during limited private
times, the culture of professionalism in today's Astronaut
Corps, along with the highly visible, structured and supervised
schedule during the last several days prior to launch provide
reasonable controls to avoid flying an alcohol-impaired crew
member.''
Finding: ``In light of all the other controls in
place on launch day, the L-0 flight surgeon check provides a
reasonable likelihood of identifying signs of illness or
impairment of the level that would threaten flight safety, but
it could be supplemented by closer first hand observation prior
to crew departure for the pad.''
Recommendation: ``A flight surgeon should be located
in the suit room during suit up to allow more direct
contact with the crew members on launch day and reduce
the reliance on a suit tech (non-clinician) picking up
any last minute medical issue.''
The report includes reference to the T-38 policy on alcohol use per
Aircraft Operations and Training Procedures: T-38 Operating Procedures,
Volume 1. JSC Aircraft Operations Division, 2005:
``5.4.3 Alcohol A crew member is not qualified for flight
(takeoff) within 12 hours of consuming alcoholic beverages.
NASA air crews are expected to conduct themselves in a common
sense manner. Excessive drinking even prior to 12 hours, enough
to cause a hangover, is outside the spirit of the regulations.
The policy is that air crews will neither be under the
influence nor the effects of alcohol at the time of takeoff.''
As noted above, the NASA Deputy Administrator has stated that this
policy has been expanded to include space flight. According to NASA
medical personnel, the medical basis for applying the 12-hour rule to
space flight operations has not yet been determined.
C. Johnson Space Center (JSC) Internal Review Findings
As noted earlier in this hearing charter, ``In response to the
actions of astronaut Lisa Nowak. . .NASA JSC conducted an internal
review of records and of the workplace. There were two purposes for the
internal review. First, NASA JSC looked to determine whether there were
any indicators which could have prompted NASA to take actions that
could have averted the sequence of events. In addition, astronaut
selection and retention procedures were reviewed to see if there were
any lessons learned that could be incorporated into the improved
practice of behavioral medicine.''
The assessment considered 1) existing psychological screening for
admittance into the Astronaut Corps and the nature of any ongoing
psychological evaluations during an astronaut's career, 2) any
indicators, including interactions with Lisa Nowak and other astronauts
or NASA employees that may have raised concerns, and 3) recommended
changes to practices or procedures and lessons learned for the future.
The review included the following recommendations:
``Conduct a 30-minute Behavioral Medicine assessment
in conjunction with annual medical flight physicals.
Perform Behavioral Medicine flight assessments for
Shuttle crew members.
Enhance aeronautical adaptability ratings (an
assessment of fitness for flying duties) in astronaut medical
selections.''
D. Activities of Other Oversight and Advisory Bodies
The Aerospace Safety Advisory Panel (ASAP) has not issued a
position on either the internal or external report.
According a letter dated August 24, 2007 sent from the NASA
Inspector General to the NASA Administrator, ``In September 2007, we
plan to initiate a review of NASA's actions taken in response to
reports of astronauts' pre-flight use of alcohol. . . Our review will
evaluate the report of the Astronaut Health Care System Review
Committee and the SMA [Safety and Mission Assurance] review, including
their respective objectives and methodologies and determine whether
additional work by our office is warranted.''
ATTACHMENT 1
External Review Committee Members
Chair--Richard E. Bachmann, Jr., Colonel, USAF, MC, CFS, Commander,
USAF School of Aerospace Medicine, specialist in aerospace
medicine
Timothy W. Sowin, Colonel, USAF, MC, SFS, Chief, Aviation
Neuropsychiatry Branch, USAF School of Aerospace Medicine,
specialist in psychiatry and aerospace medicine
James P. Bagian, Colonel, USAFR. MC, SFS, Chief Patient Safety Officer,
Department of Veterans Affairs, specialist in aerospace
medicine and former NASA astronaut-physician
Mark S. Bauer, Professor of Psychiatry, Brown University & Providence
Veterans Affairs Medical Center
James R. Fraser, Captain, MC, USN (ret), Deputy Federal Air Surgeon,
specialist in aerospace medicine
Sandra A. Yerkes, Captain, MC, USN (ret), Director, NAVMED Medical
Accessions, psychiatrist
Elizabeth K. Holmes, Captain, MSC, USN (ret), Stockdale Center for
Ethical Leadership, clinical psychologist
Paul M. DeLaney, Captain, JAGC, USN, Chief of Staff, Office of the
Judge Advocate General, Dept. of the Navy, medico-legal advisor
Ex officio members:
James M. Duncan, NASA Chief of Space Medicine Operations at JSC
Wayne R. Frazier, NASA Office of Safety and Mission Assurance
Consultant:
Ellen S. Baker, current NASA astronaut physician
Executive Secretary:
John R. Allen, NASA Program Executive, Crew Health and Safety
Chairman Udall. I want to first welcome all of our
witnesses to today's hearing. We appreciate your service to the
Nation and your assistance to this subcommittee as we carry out
our oversight responsibilities.
In particular, I would like to thank Colonel Bachmann and
his review committee for their efforts to provide NASA and the
Congress with an independent assessment of NASA's astronaut
health care system.
I would also like to thank Administrator Griffin for his
willingness to ask for such a review. I think it was a good
decision that reflects well on the agency.
It is clear to me, and I think all Americans, that NASA's
astronauts represent the Nation's best and brightest. We all
respect their skill and bravery. In carrying out their
challenging missions they often make it look so easy that we
sometimes forget that they are human beings who face the same
medical and behavioral issues that the rest of us have to deal
with, along with the added rigors of high-stress jobs, long
hours of training, extended absences from families and friends,
and high-risk space flights.
It is thus critically important that NASA ensure that the
astronauts be provided with the best possible medical and
behavioral care throughout their careers.
In addition, NASA astronauts, flight surgeons, and support
personnel need to be confident that the lines of communication
with the agency are open and responsive so that concerns can be
quickly identified and addressed in a manner that maintains the
level of trust so vital to safety and optimal performance. I
don't think anyone inside NASA would disagree with those goals.
That is why after reviewing Colonel Bachmann's committee's
report I decided that this subcommittee needed to hold a
hearing to examine the report's findings and recommendations.
However, my decision was not made for the reasons that you
might think.
While there has been a great deal of attention given to the
finding related to alcohol use, and I have little doubt that
there will be discussion of that finding at today's hearing,
too, I think we do a real disservice to the independent review
committee if we ignore the warning flags they are raising about
the state of communications within the agency on both medical
and behavioral matters affecting the astronauts.
Let me read just a few of the findings from the report that
I think should concern us all. ``Many anecdotes,'' and I am now
quoting from the report, ``were related that involved risky
behaviors by astronauts that were well known to the other
astronauts and no apparent action was taken. Peers and staff
fear ostracism if they identify their own or others'
problems.''
To continue quoting from the report, ``Several senior
flight surgeons expressed their belief that their medical
opinions regarding astronaut fitness for duty, flight safety,
and mission accomplishment were not valued by leadership other
than to validate that all medical systems were go for an on-
time mission completion. Instances were described where major
crew medical or behavior problems were identified to astronaut
leadership, and the medical advice was disregarded. This
disregard was described as demoralizing to the point where they
said they are less likely to report concerns of performance
decrement. Crew members raised concerns regarding substandard
astronaut task performance which were similarly disregarded.''
``As the review progressed,'' again, I am quoting from the
report, ``it became apparent that major vulnerabilities,
underlying root causes, and contributing factors extend well
beyond the specific medical aspects of NASA operations. These
issues are so ingrained and longstanding that it will take
senior leadership action to remediate them.
``There is no periodic psychological evaluation or testing
conducted on astronauts. Once selected as an astronaut
candidate, astronauts have no psychological evaluation for the
remainder of their careers unless selected for long duration
missions. Astronaut medical and behavioral health care is
highly fragmented.'' That ends the quoting directly from the
report itself.
And I don't think anyone can listen to those findings and
think all is well within NASA's astronaut health care system.
This subcommittee needs to hear from Colonel Bachmann the basis
for his review panel's findings.
Equally important, this subcommittee needs to hear from
NASA management their plans for addressing the concerns raised
by the independent review, not just the alcohol-related ones.
Whatever the merits of focusing the agency's attention on
trying to get employees to publicly verify or refute reports of
alcohol use that those employees had provided in confidence to
the independent review committee, I think it runs the risk of
unintentionally worsening a communications environment at NASA
in which, to quote the independent review committee, ``Peers
and staff fear ostracism if they identify their own or others'
problems.''
Instead, it may be more appropriate to the disconnect, what
is being said in private and what is being said in public by
NASA personnel and another indicator that the broader issues
raised by the independent review committee warrant close and
sustained attention. And I certainly hope that that will be the
approach taken in the days and weeks ahead.
Well, we have a great deal to examine today. I again want
to welcome our witnesses, and I look forward to your testimony.
[The prepared statement of Chairman Udall follows:]
Prepared Statement of Chairman Mark Udall
Good morning. I first want to welcome all of our witnesses to
today's hearing.
We appreciate your service to the Nation and your assistance to
this subcommittee as we carry out our oversight responsibilities.
In particular, I would like to thank Col. Bachmann and his review
committee for their efforts to provide NASA and the Congress with an
independent assessment of NASA's astronaut health care system.
I'd also like to thank Administrator Griffin for his willingness to
ask for such a review--I think it was a good decision that reflects
well on the agency.
It is clear to me that NASA's astronauts represent the Nation's
best and brightest. We all respect their skill and bravery.
In carrying out their challenging missions, they often make it look
so easy that we can sometimes forget that they are human beings who
face the same medical and behavioral issues that the rest of us have to
deal with, along with the added rigors of high-stress jobs, long hours
of training, extended absences from families and friends, and high-risk
space flights.
It thus is critically important that NASA ensure that the
astronauts be provided the best possible medical and behavioral care
throughout their careers.
In addition, NASA astronauts, flight surgeons, and support
personnel need to be confident that the lines of communication within
the agency are open and responsive so that concerns can be quickly
identified and addressed in a manner that maintains the level of trust
so vital to safety and optimal performance.
I don't think anyone inside NASA would disagree with those goals.
That is why after reviewing Col. Bachmann's committee's report, I
decided that this subcommittee needed to hold a hearing to examine the
report's findings and recommendations. However, my decision was not
made for the reason you might think.
While there has been a great deal of attention given to the finding
related to alcohol use--and I have little doubt that there will be
discussion of that finding at today's hearing too--I think we do a real
disservice to the independent review committee if we ignore the warning
flags they are raising about the state of communications within the
agency on both medical and behavioral matters affecting the astronauts.
Let me read just a few of the findings from the report that I think
should concern us all:
``Many anecdotes were related that involved risky
behaviors by astronauts that were well known to the other
astronauts and no apparent action was taken. Peers and staff
fear ostracism if they identify their own or others'
problems.''
``Several senior flight surgeons expressed their
belief that their medical opinions regarding astronaut fitness
for duty, flight safety and mission accomplishment were not
valued by leadership other than to validate that all (medical)
systems were ``go'' for on-time mission completion. Instances
were described where major crew medical or behavioral problems
were identified to astronaut leadership and the medical advice
was disregarded. This disregard was described as
``demoralizing'' to the point where they said they are less
likely to report concerns of performance decrement. Crew
members raised concerns regarding substandard astronaut task
performance which were similarly disregarded.''
``As the review progressed, it became apparent that
major vulnerabilities, underlying root causes, and contributing
factors extend well beyond the specific medical aspects of NASA
operations. . .These issues are so ingrained and longstanding
that it will take senior leadership action to remediate them.''
``There is no periodic psychological evaluation or
testing conducted on astronauts. Once selected as an astronaut
candidate, astronauts have no psychological evaluation for the
remainder of their careers unless selected for long duration
missions.''
``Astronaut medical and behavioral health care is
highly fragmented. . .''
I don't think anyone can listen to those findings and think all is
well with NASA's astronaut health care system.
This subcommittee needs to hear from Col. Bachmann the basis for
his review panel's findings.
Equally importantly, this subcommittee needs to hear from NASA
management their plans for addressing the concerns raised by the
independent review--not just the alcohol-related ones.
Whatever the merits of focusing the agency's attention on trying to
get employees to publicly verify or refute reports of alcohol use that
those employees had provided in confidence to the independent review
committee, I think it runs the risk of unintentionally worsening a
communications environment at NASA in which, to quote the independent
review committee: ``Peers and staff fear ostracism if they identify
their own or other's problems.''
Instead, it may be more appropriate to take the ``disconnect''
between what is being said in private and what is being said in public
by NASA personnel as another indicator that the broader issues raised
by the independent review committee warrant close and sustained
attention.
I hope that will be the approach taken in the days and weeks ahead.
Well, we have a great deal to examine today. I again want to
welcome our witnesses, and I look forward to your testimony.
Chairman Udall. The Chair now is pleased to recognize the
gentleman from Florida, the Ranking Member, Mr. Feeney, for an
opening statement.
Mr. Feeney. Well, thank you, Mr. Chairman, and thank you
for having this important hearing. I want to tell you that it
is important enough that the Ranking Member of the Full
Committee, the esteemed Mr. Hall, is here. I offered to defer
to let him give the first opening speech, but he thought our
weakest link ought to go first.
But we take the challenges that NASA has in the behavioral
and the physical and the psychological well being as very, very
important, and this is an opportunity, both for oversight
committees of Congress and NASA and other outside experts to
find ways to dramatically improve as we go forward the well
being of astronauts in a wide variety of areas.
After the Lisa Nowak incident earlier this year, NASA
Administrator Mike Griffin, to his credit, convened the NASA
Astronaut Health Care System Review Committee. I want to thank
this distinguished panel of aerospace medical experts for their
service. I also want to commend Administrator Griffin for
inviting independent review of the health care system.
We can put the report's sensationalistic element aside for
a moment. The committee provided several thoughtful
recommendations to heighten the importance of human factors to
improve the monitoring of each astronaut's physical and mental
well being. After the Shuttle is retired, NASA's Constellation
program will return Americans to the Moon for extended stays.
An astronaut's physical and psychological well being will be
more important in the future of America's space program and not
less important.
So it is imperative to thoroughly examine this issue and
establish an astronaut health care system that properly
addresses future and not just current medical concerns. I note
that one of the challenges in going beyond low-Earth orbit with
human beings, even bigger perhaps than the mechanical and
technical and scientific challenges, are the physiological
challenges on astronauts that will spend extended periods in
space.
Unfortunately, the report's sensationalistic element,
specifically allegations of astronaut intoxication shortly
before space flight, drowned out the remainder of the report.
Since the report's issuance in late July, these allegations
remain uncorroborated. No eye witness has come forward to
specifically state who, what, when, and where.
So far the search for corroboration reveals the
shortcomings of relying on anonymous allegations, and I know
that the Colonel Bachmann's committee had its mission, and it
did it well, and there are advantages to having anonymous and
voluntary people come forward, but there are disadvantages,
too. While anonymity can certainly promote candor, but without
corroboration such allegations often unfairly force good men
and good women to prove a negative.
My office has heard from astronauts and NASA officials all
deeply devoted to human space flight and highly credible who
adamantly deny this misbehavior represents current or recent
conduct. These people have longstanding, firsthand knowledge of
the astronaut program and simply state that alcohol influence
during the immediate pre-flight period does not exist. Because
an astronaut interacts with so many people during this period,
I find it difficult to believe that such behavior could go
undetected.
But I don't want the alcohol issue to detract from a more
troublesome finding that flight surgeons and astronauts in
general may be hesitant to report major crew medical or
behavioral problems because their concerns would be disregarded
or ignored.
And James Oberg, a distinguished and respected space
commentator, followed up last month with a very thoughtful
story detailing inconsistent approaches to significant
astronaut health concerns.
I want to applaud NASA for being open to the committee's
recommendations, and I join the distinguished Chairman of this
subcommittee in suggesting that we focus on the future and how
we can improve astronaut safety and well being, and I think
that is the approach NASA should and will take.
This type of culture, normally called a normalization of
deviance after the first Shuttle disaster, has contributed now
to two Shuttle accidents. It cannot be allowed to flourish in
the most demanding of human endeavors, that is human space
flight. We have to be ever vigilant against such behavior, and
I am very much appreciative for Chairman Udall for calling this
hearing.
[The prepared statement of Mr. Feeney follows:]
Prepared Statement of Representative Tom Feeney
After the Astronaut Lisa Nowak incident earlier this year, NASA
Administrator Mike Griffin convened the NASA Astronaut Health Care
System Review Committee. I want to thank this distinguished panel of
aerospace medical experts for their service. I also want to commend
Administrator Griffin for inviting independent review of this health
care system.
If we can put the report's sensationalistic element aside for a
moment, the committee provided several thoughtful recommendations to
heighten the importance of human factors and to improve the monitoring
of each astronaut's physical and mental well-being.
After the Shuttle is retired, NASA's Constellation program will
return Americans to the Moon for extended stays. An astronaut's
physical and psychological well-being will be more and not less
important. So it is imperative to thoroughly examine this issue and
establish an astronaut health care system that properly addresses
future and not just current medical concerns.
Unfortunately, the report's sensationalistic element--allegations
of astronaut intoxication shortly before space flight--drowned out the
remainder of the report.
Since the report's issuance in late July, these allegations remain
uncorroborated. No eyewitness has come forward to specifically state
who, what, when, and where.
So far, this search for corroboration reveals the shortcomings of
relying on anonymous allegations. Anonymity can certainly promote
candor. But absent corroboration, such allegations unfairly force good
men and women to prove a negative.
My office has heard from astronauts and NASA officials--all deeply
devoted to human space flight and highly credible--who adamantly deny
this misbehavior represents current or recent conduct. These people
have longstanding first-hand knowledge of the astronaut program and
simply state that alcohol influence during the immediate pre-flight
period doesn't exist. Because an astronaut interacts with so many
people during this period, I find it difficult to believe that such
behavior could go undetected.
But I don't want the alcohol issue to detract from a more
troublesome finding that flight surgeons and astronauts are hesitant to
report ``major crew medical or behavioral problems'' because their
concerns would be disregarded or ignored. And James Oberg--a
distinguished and respected space commentator--followed up with last
month's thoughtful story detailing inconsistent approaches to
significant astronaut health concerns.
This type of culture--called a normalization of deviance--
contributed to the Challenger and Columbia accidents. It cannot be
allowed to flourish in the most demanding of human endeavors--human
space flight. We must be ever vigilant against such behavior.
Today's hearing is part of that vigilance.
Chairman Udall. Thank you, Mr. Feeney. At this point I am
pleased to acknowledge the presence of the Chairman of the Full
Committee, Chairman Bart Gordon, at the hearing, and I would
like to ask unanimous consent to recognize him for any remarks
he would like to make.
Without objection so ordered. Mr. Gordon.
Chairman Gordon. Thank you, Chairman Udall. Let me say that
you and Ranking Member Feeney have made my job a lot easier.
You have summed it up very well. I think there is a bipartisan
interest obviously in this issue, and although the alcohol
issues got a lot of the early publicity and certainly is
something to be concerned about, in all reports I think it
indicates that that was a very, a situation that was an
anomaly.
The bigger concern is, is there an openness, is there a
comfortableness within the NASA organization to other issues of
flight safety? And we have different, I mean, we just have
different testimony here, and I think that what I know is that
there is certainly smoke. Whether there is fire, we won't be
able to determine that today. I have no question that both
panels are individuals of integrity, trying to do the right
thing, and I think this will be a healthy exercise for NASA.
But the real question is, you know, is there that
comfortableness within the NASA flight safety operation that
allows everyone to step forward without feeling somehow they
are ostracized, without feeling somehow they have been
demoralized, quoting the report, about prior overlooks?
So, again, I welcome, and I think Mr. Feeney and Mr. Udall
have summed up our charge today, and I look forward to hearing
this testimony and some interaction between the members of the
panels.
[The prepared statement of Chairman Gordon follows:]
Prepared Statement of Chairman Bart Gordon
Thank you, Chairman Udall, for yielding to me. I will be brief.
When NASA released the report of the independent review panel that
examined NASA's astronaut health care system, it provoked a bit of a
firestorm due to the report's references to astronauts and alcohol use.
Unfortunately, that firestorm has all but eclipsed what to me are
some of the most important findings in the report--namely, the findings
that indicate that flight surgeons and astronauts have faced
difficulties in getting adequate attention paid to medical and
behavioral problems.
When I read statements in the report such as:
``Many anecdotes were related that involved risky behaviors by
astronauts that were well known to the other astronauts and no
apparent action was taken. Peers and staff fear ostracism if
they identify their own or other's problems.''
And ``Instances were described where major crew medical or
behavioral problems were identified to astronaut leadership and
the medical advice was disregarded. This disregard was
described as `demoralizing' to the point where they are less
likely to report concerns of performance decrement. . .''
. . .those statements trouble me.
Getting to the bottom of the concerns raised by the panel is what I
think NASA leadership needs to focus its attention on. And in getting
to the bottom of those concerns, I hope NASA will heed the advice
contained in Col. Bachmann's written testimony:
``NASA must ensure that people can identify such safety and
human performance concerns within NASA without fear of reprisal
or career injury. Public statements that such things are simply
impossible, challenging the veracity of these findings rather
than acknowledging how difficult raising such concerns can be,
do not encourage openness and safety.''
To my way of thinking--and with all due respect to Administrator
Griffin--disparaging a finding in the independent review panel's report
as an ``urban legend'' doesn't do much to encourage that needed
openness. . .especially when the Chair of that same independent panel
is prepared to testify that the finding is based on voluntary
interviews with eyewitnesses to the incidents.
I hope NASA can move beyond such statements and instead turn its
attention to giving the findings and recommendations of Col. Bachmann's
panel the attention that they deserve.
He and his committee have done NASA and the Nation a service in
identifying a number of issues that need attention and in offering
recommendations to improve NASA's astronaut health care system.
NASA certainly doesn't have to agree with all of those findings and
recommendations. But I hope that the agency will take them seriously.
We all recognize the bravery and dedication of the Nation's
astronauts. We need to do our part to ensure that we give them the best
astronaut medical and behavioral health care system possible.
Thank you, and I yield back my time.
Chairman Udall. Thank you, Chairman Gordon. As Mr. Feeney
noted, the Ranking Member, Mr. Hall, is also present. I would
like to ask unanimous consent that he also be recognized for
any opening remarks he would care to make.
Without objection, so ordered.
Mr. Hall. Mr. Chairman, thank you, and I thank you for
doing what you are doing. I realize that you had to do it, and
Bart Gordon is a fine Chairman and great native Tennessean, and
I admire him very much, enjoy working with him.
But, you know, I am so pro-NASA and pro-space and pro-Mike
Griffin that it is just really something that, accusations
sound more to me like someone that is wanting to be quoted
rather than something that might have happened by our most red,
white, and blue members of public service at any stage here.
Our very finest educated men and women that put their life in
the hands of those of us who light the stick of dynamite that
sends them off. Above and beyond public servants and I hate to
even see a hearing on something like this, but I understand the
Chairman, that it is something when you have these allegations
you have to hear it, and you have to, it is best to clear the
air, and I hope we can do that here.
I do want to thank you, Mr. Chairman, for--and I thank the
panelists for being here today to speak on this health reports,
what I would like to look at it as is most of you know I have
been a long-time supporter of astronaut safety, and indeed, it
has been my primary goal in relation to the U.S. space program.
And I have argued for years that we need to do everything we
can to insure that the men and women who are launched into
outer space are prepared and equipped with everything they need
to do the job and return to Earth safely. I believe this is
also the goal of each and every person working on the Shuttle
program at NASA.
In the wake of the Columbia disaster, Congress held a
series of investigations aimed at addressing the problems that
led to the accident, and these investigations culminated with
the CAIB report that outlined suggestions for NASA. So I know
that Administrator Griffin and his team have taken these
suggestions seriously and have implemented a series of changes
at NASA to address the concerns.
I don't look forward to the hearing, but I do look forward
to staying here and listening to the testimony, particularly
from the Administrator on the progress of these changes and
what NASA can do to continue to improve as we move forward. And
as my good friend, Representative Feeney, points out, we need
to continue to be vigilant, and as this Chairman is going to
do, I know from knowing him and his family before him that they
will address problems and they meet problems head on at NASA
and everywhere else so that there is a culture of safety that
prevails.
I look forward to the hearing, and I yield back my time,
and I thank the Chair.
Chairman Udall. I thank the Ranking Member for his always
insightful remarks and look forward to his participation
further in the hearing.
If there are other Members who wish to submit additional
opening statements, your statements will be added to the
record.
Without objection, so ordered.
At this time I would like to turn to the panel and
recognize our first panel witnesses. I would like to introduce
everybody in the panel, and then we will come back and start
with Colonel Bachmann. And I did want to initially introduce
Colonel Richard E. Bachmann, who is appearing before the
Subcommittee today in his capacity as the Chair of the NASA
Astronaut Health Care System Review Committee.
To Colonel Bachmann's left is Dr. Richard S. Williams, who
is the Chief Health and Medical Officer at NASA. Further to the
left on the table is Dr. Ellen Ochoa, who is the Director of
Flight Crew Operations at NASA, and our last witness on the
first panel we have Mr. Bryan O'Connor, the Chief of Safety and
Mission Assurance at NASA, a very esteemed and highly-qualified
panel. Welcome to all of you.
As our witnesses should know, spoken testimony is limited
to five minutes each, after which Members of the Subcommittee
and in this case the Full Committee will have five minutes each
to ask questions.
So we will begin with Colonel Bachmann. Thank you for being
here, and the floor is yours, Colonel.
Panel 1
STATEMENT OF COLONEL RICHARD E. BACHMANN, JR., CHAIR, NASA
ASTRONAUT HEALTH CARE SYSTEM REVIEW COMMITTEE; COMMANDER AND
DEAN OF THE U.S. AIR FORCE SCHOOL OF AEROSPACE MEDICINE
Colonel Bachmann. Mr. Chairman and distinguished Members of
the Committee, good morning. It is truly an honor for me to
speak to you today about the findings of the NASA Astronaut
Health Care System Review Committee.
NASA chartered this committee and selected the members to
review the medical and behavioral health care that is provided
to astronauts, provide opinions as to what, if any, procedures
or testing could be put in place to predict disordered conduct
or acts of passion. The entire report, each finding and
recommendation, was approved and is supported unanimously by
the entire committee.
The work of further evaluation and action on the
information contained within the report falls to NASA. The
committee reviewed documents and conducted interviews of
behavioral health medical professionals, astronauts, and family
members. Because we were focused on systems issues rather than
the behavior of specific individuals, we encouraged NASA
personnel to speak freely and assured them that the report
would not include any personally-identifiable information.
As the review progressed it became apparent that major
vulnerabilities, underlying root causes, and contributing
factors extend well beyond the specific medical aspects of NASA
operations.
The report's most important issues and risks can be
summarized in the following three areas: First, NASA personnel
feels strongly that human factors concerns are disregarded to
the point where they are reluctant to identify such concerns in
the future.
Second, the supervisors, peers, and other NASA personnel
must be empowered and expected to enforce standards of conduct.
And third, that medical and behavioral health services
should be integrated and focused on astronaut performance
enhancement. The perceived disregard of human factors concerns
has the greatest safety implications and demands immediate
attention.
Unfortunately, a disproportioned amount of attention has
been focused on astronaut alcohol use. Separately, NASA
astronauts and medical personnel describe two specific
instances of alcohol use to the committee as examples of a much
larger issue. The NASA personnel felt that human factors
concerns with significant safety implications had been
disregarded when raised to local on-scene leadership.
The interviewees were eyewitnesses to the events and
provided the information voluntarily and unprompted to the
committee. We wish to emphasize again that the specifics of the
incidents should not be the focus of the attention. The general
sense of disregard for human factors described as demoralizing
to the point where NASA personnel are less likely to report
concerns of performance decrement is the fundamental concern
NASA must investigate and remedy.
We understand the outrage that some members of NASA have
expressed at this particular finding. However, public
statements that such things are simply impossible, challenging
the veracity of the findings, referring to them as unproven
allegations or urban legends rather than acknowledging how
difficult raising such concerns can be, do not encourage
openness and safety, make future reporting even less likely,
and increase the risk of future mishaps or incidents.
The recently-released NASA space flight safety review did
not prove that the evidence described to us did not happen,
only that NASA personnel who shared their concerns with the
committee during the interviews did not bring these same
concerns forward during the safety review. We believe this may
represent continued fear and barriers to communication and may
be a cause for greater, not less, concern.
The committee identified a number of structural and
cultural issues that currently exist in NASA that make it even
more difficult to predict an episode of disordered conduct and
made recommendations to ameliorate them. These recommendations
include instituting a formal written code of conduct, creating
enduring supervisory mentoring relationships with effective
feedback and evaluation, and empowering supervisors, peers, and
support staff to bring forward concerns.
Solutions will require a systems-based approach. NASA has
acknowledged the intent to act upon most, if not all, of these
recommendations. Each finding and recommendation should be
explicitly addressed and tracked to resolution with both
internal and external oversight.
We believe the first and most important step that needs to
be taken by NASA is to conduct a thorough, appropriately-
constructed, anonymous survey of the relevant populations
covered by this report. This survey must be carefully worded in
order to obtain valid, actionable information. NASA senior
leadership must provide vocal support for the survey and
encourage NASA personnel to be open, honest, and thorough in
their replies. They must be assured of anonymity, freedom from
reprisal, and that the information will be used appropriately.
Otherwise the concerns will be driven further underground.
Only with such a comprehensive, anonymous, valid, and
visibly-supported survey can NASA truly determine the scope of
the problems and drive toward system solutions.
Thank you.
[The prepared statement of Colonel Bachmann follows:]
Prepared Statement of Colonel Richard E. Bachmann, Jr.
Mr. Chairman, Honorable Members of the Science and Technology
Committee, good afternoon.
My name is Colonel Richard Bachmann. I am the Chairman of the NASA
Astronaut Health Care System Review Committee. This committee was
chartered by NASA in February 2007 to conduct a review of the medical
and behavioral health care provided to astronauts and to provide
opinions as to what, if any, procedures or testing could be put in
place to predict disordered conduct or acts of passion.
In order to accomplish this review, the NASA Chief Health and
Medical Officer contacted the senior medical officers of various
federal agencies, such as the Department of Veterans Affairs, the
Department of Defense, and the Federal Aviation Administration, and
solicited nominations of ``appropriately credentialed physicians and
mental health professionals, employed by the Federal Government or on
active duty in the military services, and experienced in medical and
behavioral health support to organizations and personnel engaged in
critical or hazardous operations.'' The NASA Chief Health and Medical
Officer selected the committee members from the pool of nominees based
on professional credentials, operational experience and availability.
Assignment and notification to the committee members occurred in late
February 2007.
I was asked by the NASA Chief Health and Medical Officer to serve
as Chairman. I am an Air Force flight surgeon, specialist in Aerospace
and Occupational Medicine, and until last week, I was the Commander and
Dean of the US Air Force School of Aerospace Medicine. I am now the
Special Assistant to the Air Force Research Laboratory Commander, and
the new Commander of the US Air Force School of Aerospace Medicine
works for me.
The committee members are as follows:
Colonel Timothy Sowin, Air Force flight surgeon, specialist in
both psychiatry and aerospace medicine, and currently the Chief
of the Aviation Neuropsychiatry branch at the U.S. Air Force
School of Aerospace Medicine.
Colonel James Bagian, Air Force Reserve flight surgeon,
specialist in aerospace medicine, former NASA astronaut-
physician, and currently Chief Patient Safety Officer,
Department of Veterans Affairs.
Mark Bauer, specialist in psychiatry, Professor of Psychiatry,
Brown University and Providence Veterans Affairs Medical
Center.
James Fraser, Captain U.S. Navy retired, specialist in
aerospace medicine, currently Deputy Federal Air Surgeon,
Federal Aviation Administration.
Sandra Yerkes, Captain U.S. Navy retired, specialist in
psychiatry, currently Director, NAVMED Medical Accessions.
Elizabeth Holmes, Captain U.S. Navy retired, clinical
psychologist, currently on faculty at the Stockdale Center for
Ethical Leadership.
Paul DeLaney, Captain U.S. Navy Judge Advocate General Corps,
currently assigned to the U.S. Navy Chief of Staff, Office of
the Judge Advocate General.
Ex officio members of the committee are:
James Duncan, NASA Chief of Space Medicine Operations at
Johnson Space Center
Wayne Frazier, NASA Office of Safety and Mission Assurance
Consultant--Ellen Baker, current NASA astronaut physician
Executive Secretary--John Allen, NASA Program Executive, Crew
Health and Safety.
The committee members were nominated by their respective federal
agencies and selected by NASA because of their diverse backgrounds,
extensive experience, and professional credentials. The committee's
overarching goal is to enhance the ability of NASA to perform its
mission safely and effectively. All the members of the committee feel
greatly honored to have been selected for this task, and look upon it
as a civic duty to the Nation.
It is important to reiterate that the committee's findings,
recommendations and opinions provided to NASA in this report do not
reflect the official positions of the Air Force, Navy, Department of
Defense, FAA, or VA. The committee was called into being by NASA to
provide this report, and with the delivery of the report, the
committee's mission is complete. The committee members will continue to
be available to NASA to provide clarification or explanation on the
report itself, but the work of further evaluation, deliberation and
action on the information contained in the report falls to NASA. The
committee was not intended to provide ongoing oversight or assess
NASA's response to any issues raised in the report.
Our task was to identify potential vulnerabilities in NASA's
medical and behavioral health system and to recommend to NASA potential
corrective actions or areas requiring further study.
The committee convened for its first meeting at NASA Headquarters
in Washington, DC, on March 28, 2007 and received informational
briefings from a wide variety of NASA functional experts. NASA provided
the committee with an extensive set of policy documents and reports for
review and future reference.
After several weeks of document review, research and meetings via
teleconference, the committee met at Johnson Space Center from 23 to 26
April, 2007. During this period, Johnson Space Center personnel
presented informational briefings and were interviewed by the
committee. Then the committee divided into small teams and conducted
on-site reviews throughout the medical and behavioral health areas.
These reviews consisted of document reviews and interviews with
individuals and groups. NASA astronaut, medical and family support
office personnel assisted in soliciting astronauts and family member
volunteers to be interviewed by the committee. During the interviews,
NASA personnel were encouraged to speak freely, and were assured that
no personally identifiable information would be included in the report.
Although the astronauts and family members interviewed do not represent
a random or exhaustive sample of the larger population, the issues they
raised during these unstructured interviews were remarkably consistent
and compelling and deserve focused action.
The committee members met at the end of each day and reviewed their
findings and observations with the entire committee. After the
committee's departure from Johnson Space Center, astronauts and family
members continued to contact and were interviewed by individual
committee members.
Following the visit to JSC and subsequent interviews, each
committee member wrote up his or her findings and recommendations and
shared them with the entire committee via e-mail and telephonic
discussions. The NASA astronaut advisor and ex-officio members of the
committee were not included in the development of findings and
recommendations, but were available to the committee to answer
questions regarding NASA policies and procedures. The committee
gathered at the U.S. Air Force School of Aerospace Medicine from 30-31
May to draft the report. The committee decided to organize the report's
findings and recommendations according to the specific questions given
to the committee by the NASA CHMO at our initial formative meeting.
Each member was free to determine the level of significance
required for any particular piece of information to be considered a
finding. Each member's proposed findings and recommendations were
grouped under the appropriate subject area and combined whenever
possible. Each finding and recommendation was considered, discussed and
carefully written to ensure significance, validity and clarity. The
committee's criteria for a finding to be included in the report were
based on whether the finding addressed a specific question NASA asked
the committee to evaluate, and/or whether the issue identified
significant concerns regarding astronaut health, flight safety or
mission completion. During the initial phase of deliberations, we
recognized that dissenting opinions might arise and allowed for a
minority report to be included, but this proved to be unnecessary. The
entire report, all findings and recommendations, were approved
unanimously by the entire committee.
Work continued on the final wording for the next few weeks, with
each proposed refinement reviewed and approved by the entire committee.
A draft of the report was provided to NASA on June 21st for correction
of any factual errors and we received their response on July 3rd. The
committee formally presented the findings and recommendations to the
NASA Administrator and senior NASA staff on July 16th. After some very
minor revisions to provide additional clarity, the report was finalized
and delivered to NASA on July 25th. NASA released the report to the
public in concert with a news conference on July 27th.
The committee received outstanding support from NASA at every level
of the organization. It was clear from every interview that NASA
personnel are dedicated to accomplishing their mission--the interviews
were characterized by openness, honesty, cooperation and a palpable
desire to make things better. As the review progressed, it became
apparent that major vulnerabilities, underlying root causes and
contributing factors extend well beyond the specific medical aspects of
NASA operations. Many of the cultural and structural issues identified
in the report have existed for many years, pre-dating the current
leadership team, are deeply ingrained and will take senior leadership
action to remediate them.
The committee concluded that NASA's astronaut health care system
provides easily accessible services to astronauts and their families,
which were consistent with accepted standards of care. There is room
for improvement in the provision of behavioral health services,
particularly in selection, training, evaluation and support of
astronauts preparing for and participating in space missions. The
medical and behavioral health systems could be better integrated and
focused on astronaut performance enhancement.
During the interviews, members of the NASA medical and astronaut
communities raised significant concerns regarding barriers to
communication. As examples of these barriers to communication, they
described instances where medical personnel or fellow astronauts raised
concerns about an astronaut's fitness for flight due to alcohol use in
the immediate pre-flight period, and these concerns appeared to them to
be disregarded or overridden. The committee is very concerned about
this perception of disregard for human factors inputs, and strongly
recommends that NASA conduct further evaluation using tools such as
anonymous surveys, to determine the extent of such perceptions, and
ensure that human factors concerns are appropriately identified and
dealt with.
Unfortunately, since the release of the committee's report, a
disproportionate amount of media attention has been focused on the
section of the report discussing specific incidents of astronauts and
alcohol use. In separate interviews, NASA astronaut and medical
personnel described two specific instances of alcohol use to the
committee as examples of a much larger issue: that NASA personnel felt
that human factors concerns with significant safety implications had
been disregarded when raised to local on-scene leadership. These
incidents were described by eyewitnesses to the events, and were
provided voluntarily and unprompted by NASA personnel to the committee.
In order to encourage them to speak freely, the committee assured the
interviewees that we would make every effort to keep names, dates and
other specifics out of our notes and out of the report. The general
sense of disregard for human factors, described as ``demoralizing'' to
the point where NASA personnel are less likely to report concerns of
performance decrement, is the fundamental concern NASA must investigate
and address.
We understand the outrage that some members of NASA have expressed
at this particular finding. The fact remains that the incidents
described in the report that have generated so much concern and anger
were told to the committee voluntarily by NASA personnel who were
eyewitnesses to the incidents. NASA must ensure that people can
identify such safety and human performance concerns within NASA without
fear of reprisal or career injury. Public statements that such things
are simply impossible, challenging the veracity of these findings
rather than acknowledging how difficult raising such concerns can be,
do not encourage openness and safety.
Human behavior is complex. Prediction of future behavior, even by
behavioral health experts, is extremely difficult to perform
accurately. Systemic procedures alone cannot predict disordered
conduct, but human factors concerns or issues that arise or are
identified in one realm could be more effectively shared with others
and potentially result in earlier intervention. The committee
identified a number of structural and cultural issues that currently
exist in NASA that make it even more difficult to predict an episode of
disordered conduct, and made recommendations to ameliorate them. These
recommendations include instituting a formal, written code of conduct,
creating enduring supervisory/mentoring relationships with effective
feedback and evaluation, and empowering supervisors, peers and support
staff to bring forward concerns. Using similar processes, organizations
as diverse as the military, the FAA and the VA have made great
progress, with active supervisory and peer involvement, in changing
cultural attitudes towards safety, accountability, empowerment and
alcohol.
This report contains a wide range of findings and recommendations.
Some of these recommendations will be relatively simple to implement,
such as writing standard operating procedures to document processes,
which are already in place. Some will take substantially more time and
effort to implement, such as restructuring astronaut supervisory
relationships or focusing the attention of psychologists on astronaut
performance enhancement. Some recommendations entail changing deep
seated, long standing aspects of astronaut, flight surgeon and safety
cultures regarding alcohol use, code of conduct, acknowledgement of
human performance issues, selection, training, evaluation and
professional development, communication and privacy. None of these
issues lend themselves to easy analysis or correction of a single
factor. All of them require further study and evaluation by NASA.
Solutions will require a systems-based approach and will take time to
achieve.
We believe the three most important issues and risks in this report
can be summarized in the following areas: First, NASA personnel's sense
that human factors concerns are disregarded and that this has made them
reluctant to identify such concerns in the future: second, that
supervisors, peers and other NASA personnel must be empowered and
expected to enforce standards of conduct; and third, that medical and
behavioral health services should be integrated and focused on
astronaut performance enhancement. The issue of perceived disregard of
human factors concerns is by far the most worrisome and demanding of
immediate attention.
To restate, the committee believes the first and most important
step that needs to be taken by the NASA senior leadership is to conduct
a thorough, anonymous survey of the relevant NASA populations covered
by this report--medical personnel, astronauts, and training personnel.
This survey should be carefully worded in order to obtain valid,
actionable information. NASA senior leadership should provide vocal
support for the survey and encourage NASA personnel to be open, honest
and thorough in their replies. They must be assured of anonymity,
freedom from reprisal and that the information will be used
appropriately, otherwise the concerns will be driven further
underground. The committee's report identified many areas of concern to
NASA--only with such a comprehensive, anonymous, valid and visibly-
supported survey can NASA determine the scope of the problems and drive
toward systems solutions.
The committee appreciates the openness of and the assistance
provided by NASA leadership, astronauts, medical personnel and family
members. They clearly share the overarching goal of the committee--to
enhance the ability of NASA to perform its mission safely and
effectively.
Thank you.
Biography for Colonel Richard E. Bachmann, Jr.
Colonel Richard E. Bachmann, Jr. is Commander and Dean of the U.S.
Air Force School of Aerospace Medicine (USAFSAM), 311th Human Systems
Wing, Brooks City-Base, Texas. This organization is the center for
aeromedical education, training, and consultation in direct support of
Air Force, Department of Defense and allied nations, providing
peacetime and contingency support in hyperbaric medicine, human
performance enhancement, dental investigations, aeromedical evacuation
and environmental quality. It trains more than 5,000 students annually,
maximizing more than $171 million in educational assets.
Colonel Bachmann was born in Grand Forks, ND and was commissioned
through the Health Professions Scholarship Program. He served twice as
a squadron flight surgeon and has previously commanded at the squadron
and group level. He served as the USAFE Chief of Aerospace Medicine
during Operation ENDURING FREEDOM and was the Joint Task Force Surgeon
for Operation ATLAS RESPONSE (Africa flood relief).
Colonel Bachmann is a chief physician and chief flight surgeon,
board certified in both Aerospace Medicine and Occupational Medicine by
the American Board of Preventive Medicine. He has flown over 1,400
hours in 28 aircraft types and was the first flight surgeon to fly the
B-2.
EDUCATION
1982--Bachelor of Science in Biomedical Science (with High Honors),
University of Michigan College of Literature, Science and the
Arts, Ann Arbor, MI
1985--Aerospace Medicine Primary Course (Distinguished Graduate), USAF
School of Aerospace Medicine, Brooks AFB, TX
1985--Doctorate of Medicine, University of Michigan Medical School, Ann
Arbor, MI
1995--Master's degree in Public Health (Occupational Medicine),
University of Michigan School of Public Health, Ann Arbor, MI
1996--Air Command and Staff College (correspondence)
1997--Residency in Aerospace and Occupational Medicine, USAF School of
Aerospace Medicine, Brooks AFB, TX
1997--Air War College (correspondence), Outstanding Graduate
2001--Interagency Institute for Federal Health Care Executives, George
Washington University, Washington, D.C.
2003--Master's degree in Strategic Studies (with distinction), Air War
College, Air University, Maxwell AFB, AL
ASSIGNMENTS
1. June 1985-June 1986, Transitional Intern, David Grant Medical
Center, Travis AFB, CA
2. July 1986-July 1989, Squadron Flight Surgeon, 48th Fighter
Squadron, Langley AFB, VA
3. July 1989-July 1994, Chief of Flight Medicine, USAF Regional
Hospital; later Squadron Flight Surgeon, 90th Fighter Squadron,
Elmendorf AFB, AK
4. August 1994-June 1995, Resident in Aerospace and Occupational
Medicine, Phase I, University of Michigan School of Public Health, Ann
Arbor, MI
5. July 1995-June 1997, Resident in Aerospace and Occupational
Medicine, Phases II and III, USAF School of Aerospace Medicine, Brooks
AFB, TX
6. July 1997-July 1999, Commander, 48th Aerospace Medicine Squadron,
RAF Lakenheath, UK
7. July 1999-July 2002, Chief, Aerospace Medicine Division, Office of
the Command Surgeon, HQ USAFE, Ramstein AB, Germany
8. July 2002-June 2003, graduate student, Air War College, Air
University, Maxwell AFB, AL
9. July 2003-July 2005, Commander, 509th Medical Group, Whiteman AFB,
MO
10. July 2005-present, Commander and Dean, USAF School of Aerospace
Medicine, Brooks City-Base, TX
FLIGHT INFORMATION
Rating: Chief Flight Surgeon, FAA private pilot
Flight Hours: More than 1,400
Aircraft flown: B-2, F-15B/D/E, C-9, E-3, E/K/RC-135, T-38 and 22 other
major aircraft types
MAJOR AWARDS AND DECORATIONS
Legion of Merit
Meritorious Service Medal with three oak leaf clusters
Joint Service Commendation Medal
Air Force Achievement Medal
Global War on Terrorism Service Medal
Humanitarian Service Medal
Air and Space Campaign Medal
OTHER ACHIEVEMENTS/REGISTRY
Phi Beta Kappa Honor Society (1982)
Alpha Omega Alpha Medical Honor Society (1984)
Tactical Air Command Flight Surgeon of the Year (1988)
Diplomate of American Board of Preventive Medicine in Aerospace
Medicine (1997)
Diplomate of American Board of Preventive Medicine in Occupational
Medicine (1998)
Medical Licenses--Virginia, Michigan
PROFESSIONAL AFFILIATIONS
Aerospace Medical Association (Fellow and Life Member)
American College of Occupational and Environmental Medicine
EFFECTIVE DATES OF PROMOTION
Captain--10 Jun 85
Major--30 May 91
Lieutenant Colonel--30 May 97
Colonel--30 May 03
Chairman Udall. Thank you, Colonel Bachmann.
Dr. Williams is recognized.
STATEMENT OF DR. RICHARD S. WILLIAMS, CHIEF HEALTH AND MEDICAL
OFFICER, NATIONAL AERONAUTICS AND SPACE ADMINISTRATION
Dr. Williams. Mr. Chairman and Members of the Subcommittee,
thank you for the opportunity to appear today to discuss the
NASA Astronaut Medical and Behavioral Health Care Program. I am
pleased to provide you with insight into this comprehensive
program and discuss our plans regarding the findings of the
NASA Astronaut Health Care System Review Committee and the
internal review conducted at Johnson Space Center.
The NASA Astronaut Medical Behavioral Health Care Program
has succeeded in keeping our astronauts healthy and ready to
perform the challenging tasks that NASA asks of them. Over the
course of our nation's 40-year human space flight endeavor, the
health care system has contributed to the success of all NASA
human space flight missions. No mission has thus far been
abbreviated or terminated because of a health care issue.
Longer duration exploration missions will provide new
challenges, and we are committed to ensuring our program
continues to provide the best medical and behavioral health
care.
The health related recommendations of the Astronaut Health
Care System Review Committee are thoughtful and will contribute
to meeting the behavioral health challenges that lie ahead. I
take the recommendations of the review committee seriously, and
we thank the committee for all the time and effort involved in
their study. Our overarching goal is to improve behavioral
health and medical care for the astronauts.
Several of the committee recommendations were accepted
immediately, and many more will be accepted in the coming
months. Specifically, NASA accepts the recommendations
concerning analysis and use of behavioral health data and will
convene experts to address psychological testing as
recommended.
Briefings by the flight surgeons to crew members concerning
medical monitoring activities and briefings by principle
investigators concerning research data collection and the
context of obtaining informed consent will be re-emphasized.
Effective communication between astronauts and flight surgeons
will be addressed. We will ensure both groups are aware of the
multiple pathways to communicate safety and health concerns,
and we will be working together in support of NASA senior
leadership to reinforce these concepts.
Flight surgeon scheduling and task assignment and flight
medicine clinic operations will be closely examined with the
goal of enhancing continuity of care to the greatest extent
feasible. Options for providing effective behavioral health
services to all flight assignable astronauts for the purposes
of performing enhancement, performance enhancement will be
reviewed, and a behavioral health assessment will be conducted
as part of the annual astronaut physical examination. Options
for flight surgeon behavioral health assessment training will
also be identified.
A common credentialing and privileging process will be
applied to behavioral health and aeromedical services, and a
peer review of practice will be enhanced for both. NASA's
electronic medical records system will be reexamined to provide
maximum privacy consistent with safe medical practice in
compliance with all applicable statutes and regulation
governing privacy of medical information will be assured.
Process linkages between the behavioral health records
system and the electronic medical record will be reviewed and
established, and all appropriately-credentialed and privileged
practitioners will be granted records access as appropriate.
NASA will examine options for assuring quality of care
delivered by community consultants and practitioners. Written
operational instructions and procedures for the behavioral
health clinic will be examined and enhanced as appropriate.
The Aerospace Medicine Board charter will be reviewed and
updated to reflect appropriate membership, authority, and
accountability. Regular meetings will be scheduled between
behavioral health staff and flight surgeons to enhance clinical
communication.
Our initial responses to the committee's recommendation
were reviewed and endorsed by the NASA Medical Policy Board on
August 21, 2007. The Medical Policy Board consisting of medical
experts both external and internal to NASA is available to me
for consultation on all NASA and medical policy.
The Medical Policy Board will provide ongoing
implementation oversight, and I will provide progress reports
to the NASA Administrator.
Commitment to flight safety remains the foundation of our
effort, and we look forward to system improvements that will be
realized as a result of this report.
I look forward to answering any questions you may have this
morning.
[The prepared statement of Dr. Williams follows:]
Prepared Statement of Richard S. Williams
Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to appear today to discuss the NASA Astronaut Medical and
Behavioral Health Care Program. I am privileged to serve as the NASA
Chief Health and Medical Officer. The Office of the Chief Health and
Medical Officer was established as a new office in 2000 based on the
recommendations of external advisory groups. The purpose was to provide
an expanded oversight and policy role for the NASA's health care
system. I am pleased to provide you with insight into NASA's
comprehensive health care system and discuss our plans regarding the
findings of the NASA Astronaut Health Care System Review Committee and
the internal review conducted at Johnson Space Center (JSC).
Over the last two decades, the Johnson Space Center Space Medicine
Division has developed an excellent relationship with the astronauts
through astronaut and flight surgeon cooperation. The NASA Astronaut
Medical and Behavioral Health Care program has succeeded in keeping our
astronauts healthy and ready to perform the challenging tasks that NASA
asks of them. Over the course of our nation's 40-year human space
flight endeavor, the health care system has contributed to the success
of all NASA human space flight missions. No NASA mission has thus far
been shortened or terminated because of a health care issue. Longer-
duration exploration missions will provide new challenges and we are
committed to ensuring our program continues to provide the best medical
and behavioral health care to the Astronaut Corps. The health-related
recommendations of the Astronaut Health Care System Review Committee
are thoughtful and will contribute to meeting the behavioral health
challenges that lie ahead.
NASA Astronaut Medical and Behavioral Health Care Program
The NASA Astronaut Medical, Dental, and Behavioral Health Care
program was established almost 50 years ago by NASA to ensure the
health and well being of astronauts and their dependents. The program
provides a comprehensive health care system for astronauts. Health care
services are provided to ensure that astronauts meet established human
health standards in support of mission needs.
Policy governing astronaut medical and behavioral health is set by
NASA Headquarters. My office, the Office of the Chief Health and
Medical Officer (OCHMO), is responsible for establishing policy and
providing oversight of all NASA health and medical operations. The
Johnson Space Center is responsible for management of all NASA space
medical activities in support of human space flight. Astronauts and
dependents have traditionally received health care services at the NASA
Johnson Space Center Flight Medicine Clinic that included medical and
dental care, as well as psychiatric and psychological services. As the
focus of space flight changed to longer-duration missions, a separate
behavioral clinic was established and behavioral health support was
added to the pre-, in and post-flight support of astronauts flying on
the International Space Station (ISS) and their families.
The Astronaut Medical, Dental and Behavioral Health Care program
has evolved over time to meet changing mission needs and has
incorporated enhancements that were a direct result of internal and
external review. Notably, the Institute of Medicine (IOM) released a
report in 2001 entitled ``Safe Passage, Astronaut Care for Exploration
Mission.'' This report led NASA to adopt an occupational health model
for the health care of astronauts.
The findings of the Columbia Accident Investigation Board (CAIB)
had an important impact on the NASA culture and this certainly touched
the health care system. A governance structure including independent
technical authorities was established to set technical standards and
assure programmatic adherence to technical requirements. The Health and
Medical Technical Authority was established in 2006 to take
responsibility for health and medical program requirements and
standards, and ensure NASA program compliance with them. The Health and
Medical Technical Authority also provides a path for issues and
concerns to be raised relating to crew health issues, and works very
well with our occupational health model for astronaut health care
delivery.
Roles, Responsibilities and Decision-making
Flight surgeons in the Space Medicine Division provide medical care
to the astronauts utilizing the Flight Medicine Clinic at the Johnson
Space Center. Primary medical care and annual physical examinations for
aeromedical certification for space flight are performed by the flight
surgeons. Medical conditions may arise that necessitate referral or
consultation with external expert practitioners. Conditions that
violate an established medical standard may require that an astronaut
be relegated to duties not involving flying (DNIF) until the condition
resolves. This is referred to as ``grounding'' an astronaut. Flight
surgeons have the authority to ground astronauts who have developed
health conditions that prevent them from meeting medical standards. Any
grounding decision is reviewed by the Chief of the Flight Medicine
Clinic (FMC), and the Chair of the Aerospace Medicine Board (AMB), who
must provide concurrence.
Waivers may be granted for many medical conditions if they are
deemed stable and of no significance to the mission. Medical waivers
must be based on best medical evidence and professional opinion and
supported by sound aeromedical rationale. All cases for medical waiver
consideration are reviewed by the Aerospace Medicine Board. In the case
of permanent waivers, a recommendation is forwarded to me for review
and disposition. The NASA Medical Policy Board (MPB), consisting of
internal and external medical experts, is available to me for
consultation on waiver decisions as well as all NASA medical policy
matters.
Behavioral health specialists have been primarily responsible for
evaluation of astronaut candidates for selection and for support of
long-duration space flight astronauts and their family members.
Astronauts are evaluated by psychiatrists or psychologists and are
provided education and training on the rigors of long-duration space
flight and confinement. This training enables the astronaut to
recognize personal reactions to the isolated environment and aids the
astronaut in maximizing performance and mission success. Counseling and
therapy services are provided upon request to all astronauts and to all
dependents. Behavioral health providers have the same authority to
ground an astronaut (issue a DNIF status) and to bring a case to the
AMB for evaluation and recommendation for waiver or disqualification.
Any astronaut wishing to contest a flight surgeon grounding
decision can appeal to the Chief, Flight Medicine Clinic, or the Chief,
Space Medicine Division. The appeal is reviewed by the Aerospace
Medicine Board with a recommendation forwarded to me as indicated.
Appeals can be raised directly to my attention by the astronaut for
review and final decision.
Medical issues that arise immediately pre-flight or in-flight are
discussed between operational, medical, and astronaut management
authorities on a need-to-know basis giving due consideration to
privacy, crew member health and safety, and mission impact. The Agency
governance structure provides a path for dissenting opinions to be
raised through the Health and Medical Technical Authority chain of
command.
I made earlier reference to medical standards. They are defined to
establish fitness for flight and fitness for duty. Under the leadership
of the Space Medicine Division of the Space Life Sciences Directorate
at the NASA Johnson Space Center, standards are developed by teams of
experts in various fields of clinical medicine and aerospace medicine.
The standards are reviewed and approved by the Aerospace Medicine Board
at the NASA Johnson Space Center. The standards are then submitted to
the OCHMO at NASA Headquarters, which authorizes a review by the
Medical Policy Board (MPB) and final approval is granted for
implementation. These standards were first developed in 1978 and have
undergone several revisions since that time. The most recent revision
was completed in July 2007.
Internal and External Review of Medical Practice
Biennial internal audits of the Flight Medicine Clinic are
performed by my office. The objective of these audits is to review
clinical practice, record-keeping, and compliance with applicable
regulations. The most recent audit was conducted February 5-9, 2007.
The findings of this review cited a number of Flight Medicine Clinic
(FMC) practices as Agency Best Practices.
In addition, quarterly self-evaluations are performed to review
standards of care, medical record documentation, and adherence to
clinic policies and procedures. Documentation deficiencies that are
identified are reviewed and corrected. In addition, the Chief of the
Flight Medicine Clinic reviews all physical examinations for accuracy,
consistency, and adherence to established policies.
External review of our behavioral medicine services was performed
in February 2007. This review determined that NASA provided a competent
group of behavioral health providers (BHP) rendering excellent clinical
and occupational care. Recommendations were also made for improvement,
and actions were in place to address many of these areas at the time of
Dr. Bachmann's review. These actions specifically included
credentialing of NASA BHP providers, privileging of BHP providers by
the FMC, plans for external consultant peer review biannually by an
aerospace psychiatry consultant, and implementation of a formalized,
quarterly, internal peer review process.
Summary
NASA takes the recommendations of the Committee seriously, and we
thank the Committee for all the time and effort involved in their
study. We are evaluating each recommendation and are in the early
planning stages of responding to them. This task is made more difficult
by the anecdotal nature of some of the findings of the report. Our
overarching goal is to improve behavioral health and medical care for
the astronauts. Several of the Committee recommendations were accepted
immediately, and many more will be accepted in the coming months.
Specifically, NASA accepts the recommendations concerning analysis
and use of behavioral health data, and will convene experts to address
psychological testing as recommended. Briefings by the flight surgeons
to crew members concerning medical monitoring activities and briefings
by principal investigators concerning research data collection, in the
context of obtaining informed consent, will be reemphasized. Effective
communication between astronauts and flight surgeons will be addressed;
we will ensure both groups are aware of the multiple pathways to
communicate safety and health concerns; and we will be working together
in support of NASA senior leadership to reinforce these concepts.
Flight surgeon scheduling and task assignment and flight medicine
clinic operations will be closely examined, with the goal of enhancing
continuity of care to the greatest extent feasible. Options for
providing effective behavioral health services to all flight assignable
astronauts for the purposes of performance enhancement will be
reviewed, and a behavioral health assessment will be conducted as part
of the annual astronaut physical examination. Options for flight
surgeon behavioral health assessment training will also be defined.
A common credentialing and privileging process will be applied to
behavioral health and aeromedical services, and peer review of practice
will be enhanced for both. NASA's electronic medical records system
will be re-examined to provide maximum privacy consistent with safe
medical practice, and compliance with all applicable statutes and
regulations governing privacy of medical information will be assured.
Process linkages between the behavioral health records system and the
electronic medical record will be reviewed and established, and all
appropriately credentialed and privileged practitioners will be granted
records access as appropriate. NASA will examine options for assuring
quality of care delivered by community consultants and practitioners.
Written operational instructions and procedures for the behavioral
health clinic will be examined and enhanced as appropriate. The
Aerospace Medicine Board charter will be reviewed and updated to
reflect appropriate membership, authority and accountability, and
regular meetings will be scheduled between behavioral health staff and
flight surgeons to enhance clinical communication.
These initial responses were reviewed and endorsed by the Medical
Policy Board on August 21, 2007. The Medical Policy Board will provide
ongoing implementation oversight. I will continue to coordinate and
provide feedback to the Office of Safety and Mission Assurance and the
Flight Crew Operations Directorate at the Johnson Space Center.
Together we will provide regular progress reports to the NASA
Administrator.
Commitment to the health and welfare of the astronauts and all NASA
employees and to flight safety remains the foundation of our effort,
and we look forward to system improvements that will be realized as a
result of this report.
Chairman Udall. Thank you, Dr. Williams.
Dr. Ochoa, the floor is yours for five minutes.
STATEMENT OF DR. ELLEN OCHOA, DIRECTOR, FLIGHT CREW OPERATIONS,
NASA JOHNSON SPACE CENTER
Dr. Ochoa. Thank you. Good morning, Mr. Chairman, and
Members of the Subcommittee. Thank you for the opportunity to
appear before you today.
I have the privilege of managing the organization that
includes the Astronaut Office and the Aircraft Operations
Division at NASA Johnson Space Center. Prior to becoming
Director of Flight Crew Operations a year ago and Deputy
Director four years before that I was a member of the astronaut
office for 12 years and was fortunate enough to fly on four
Space Shuttle missions.
In my experience, astronauts prepare thoroughly and
uncompromisingly for their missions. One of my crew mates
compared it to preparing for the Olympics. Every act, every day
is designed to make sure that you are at your peak, both
mentally and physically, when you launch into space.
About 10 years ago as we began assembly of the
International Space Station, it became clear that astronaut
preparation needed to be raised to a new level to accomplish
the increased complexity of establishing and maintaining a
permanent human presence in space. Along with the Missions
Operations Directorate, whose job is to plan, train, and fly
missions, and the Space Life Sciences Directorate, who insures
the crew health, the Flight Crew Operations Directorate
developed new processes, training, evaluation methods, and
fitness standards to meet the challenge of assembling and
operating the Space Station.
Standards for fitness for duty are determined, measured,
and documented using a number of processes and tools. Comments
and quantitative evaluations by instructors are documented in
every phase of training and included in each astronaut's
personnel file. In addition to training in many areas ranging
from spacecraft systems to robotics and space walking to
expedition preparation, NASA uses other processes to prepare
and evaluate astronauts, including the Instructor Astronaut
Program, the Commander Upgrade Program, and the Astronaut
Evaluation Board. All of these are used by the Chief of the
Astronaut Office in the Flight Assignment Recommendation
Process.
Medical standards for flight are used by the Aerospace
Medicine Board to make certification decisions. Certification
results are addressed during bi-weekly meetings between
astronaut and flight surgeon management. The communication and
relationship between flight crew operations and the space
medicine community is strong, allowing NASA to effectively
address concerns regarding crew health and fitness. Flight
surgeons are aware of their responsibility to assure that an
astronaut's health or behavior does not present a risk to
themselves or the mission, and the flight crew management, as
well as NASA's leadership, support their efforts to do so.
Flight crews are very fortunate to have a group of flight
surgeons who are not only excellent physicians but who
understand the training and the operational environment of an
astronaut and the implications of that astronaut, of that
environment to astronaut health. The flight surgeons are
dedicated to maintaining or returning astronauts to flight
status when at all possible, keeping within the medical
standards that protect health and mission success.
Following the events of last February, Johnson Space Center
conducted an internal assessment, and NASA headquarters charted
the Astronaut Health Care System Review Committee. While
behavioral health recommendations were the focus of the health
care committee report, the report also included a number of
comments related to Astronaut Office behavior and processes. As
the committee itself noted, they did not attempt to determine
the veracity of those comments, nor was there any request for
information on Astronaut Office processes, policies, or
anything that could be characterized as Astronaut Office
culture.
In response to the committee report NASA has taken decisive
steps. Bryan O'Connor's thorough investigation confirmed my own
personal experiences both as a crew member and a manager of
flight crew. We have found no instance where astronauts have
used alcohol in immediate pre-flight period or were under the
effects or influence of alcohol at launch. And no case where a
flight surgeon or astronaut raised a concern about this to
management.
NASA has also responded to the committee's report by
developing an anonymous survey to determine what issues
actually exist and their scope. This survey will be provided to
the Astronaut Corps and flight surgeons this month. Both groups
will be asked to respond to questions regarding communication,
trust, and responsibilities and regarding potential concerns or
barriers to raising issues with flight safety or crew
suitability for flight.
Additionally, astronauts will be asked about policies and
procedures dealing with astronaut performance and feedback,
crew assignment, and space flight alcohol use. NASA will then
develop a plan to address any issues identified by the survey
report, a course of action that the committee indicated they
intended as NASA's response.
In conclusion, I am extremely proud to represent the
Astronaut Office, both within NASA and externally to Members of
this committee, to the media, and to the public. Our astronauts
are well prepared to carry out the Nation's Human Space Flight
Program. They take their responsibility very seriously.
The same can be said of the entire NASA team that prepares
and executes human space flight missions. The real proof of
that lies in the tremendous accomplishments of our Human Space
Flight Programs, accomplishments made possible by the dedicated
people at NASA; our engineers, flight controllers, scientists,
doctors, and astronauts.
I would be happy to respond to any questions.
[The prepared statement of Dr. Ochoa follows:]
Prepared Statement of Ellen Ochoa
Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to appear before you today to discuss the Astronaut Health
Care System Review Committee report. I have the privilege of managing
the organization that includes the Astronaut Office and the Aircraft
Operations Division at the NASA Johnson Space Center in Houston, Texas.
Prior to becoming Director of Flight Crew Operations one year ago, and
serving as Deputy Director for four years before that, I was a member
of the astronaut office for 12 years, and was fortunate enough to fly
on four Space Shuttle missions.
The NASA Astronaut Office is made up of very talented and motivated
people, who--after years of hard work, exceptional achievement in
science and engineering education, and dedication to excellence in
their careers--joined the corps through a rigorous and highly
competitive selection process. Selection as an astronaut candidate is
followed by years of intense preparation, including many types of
training as well as work in support of all phases of the development
and operations of NASA's human space flight programs. In my experience,
astronauts prepare thoroughly and uncompromisingly for their missions.
One of my crew mates compared it to preparing for the Olympics: every
act that you do every day is designed to make sure that you are at your
peak both mentally and physically when you launch into space. But at
NASA, we hold our equivalent of the Olympics every few months, every
time we launch a crew into space.
About 10 years ago, as we began assembly of the International Space
Station (ISS), it became clear that astronaut preparation needed to be
raised to a new level in order to accommodate the increased complexity
and difficulty of our new mission: establishing and maintaining a
permanent human presence in space. Both Shuttle missions to the
Station, which can be thought of as ``sprints,'' and the ``marathon''
long-duration stays on-board ISS, brought new challenges. Along with
the Mission Operations Directorate--whose job is to ``plan, train, and
fly'' missions--and the Space Life Sciences Directorate--who ensures
the crew's health before, during, and after flight--the Flight Crew
Operations Directorate developed new procedures, processes, training,
evaluation methods, and fitness standards to meet the challenge of
successfully assembling and operating the ISS. These processes and
tools have evolved over the past decade, and have served us well in
preparing the corps for the rigors of space operations.
Astronaut Training and Evaluation
Standards for fitness for duty and for flight assignment are
determined, measured, and documented using a number of processes and
tools. Formal training, which is subject to both qualitative and
quantitative evaluation, is accomplished by each astronaut in many
different fields. Most of the training is conducted by the Space Flight
Training Division within the Mission Operations Directorate at the
Johnson Space Center. Comments and evaluations by instructors about
each astronaut are documented in every phase of training and included
in each astronaut's personnel file. These training records are
accessible by the individual astronaut, and reviewed by the astronaut's
branch chief, and the Chief of the Astronaut Office.
The main areas of training include the following:
Space Shuttle Systems and Operations, International Space
Station System and Operations (including all International
Partners' systems), and Crew Resource Management training
ranges from tests of basic systems knowledge, to life-like
simulations that test a crew's ability to work together to
solve challenging failure scenarios.
Robotics (including the Shuttle 6-joint arm, the ISS 7-joint
arm and new robotic arms from Japan and Europe), Spacewalking
(which we refer to as Extra-vehicular Activity or EVA), and
Rendezvous training follow formal curricula objectives;
quantitative evaluations of astronauts during qualification
simulations are documented in a database as part of the
training records.
Aircraft training, including periodic check flights, prepares
all astronauts for the high-stress, multi-task space
environment, and Shuttle commanders and pilots receive detailed
feedback on the hundreds of simulated Shuttle landing
approaches that they fly.
Expedition Interpersonal Training is a program conducted by
the Astronaut Office to provide an in-depth awareness of issues
that may develop in an isolated and confined environment, such
as during an extended stay on the ISS. Training includes
workshops, outdoor team building and supervised leadership
courses, and missions in extreme environments such as an
undersea facility that place astronauts in the most realistic
space analog environment available. These operational
opportunities are integrated into the astronaut training
program and used to provide feedback both to the astronauts and
to astronaut management.
NASA also conducts various other types of training, such as
Russian language training. Like the operational training
discussed above, astronauts are rated and their evaluations are
provided to each crew member and the Chief of the Astronaut
Office on a periodic basis.
Other processes that NASA uses to prepare and evaluate astronauts
include the following:
The Space Shuttle Instructor Astronaut Program provides
standardization and evaluation of astronaut candidate training,
continuing currency training (with a special emphasis on
robotics and EVA), and assigned crew training. This program
also reinforces an environment in which mentoring and knowledge
sharing thrive.
The Commander Upgrade Program prepares mission commanders to
manage crew and mission issues pre-flight, during flight, and
post-flight. This program has been implemented for all Shuttle
commanders since 2000; NASA plans to implement a formal program
for ISS commanders to support the six-person crews that will
start in 2009.
The Astronaut Evaluation Board is periodically convened by the
Astronaut Office to review astronauts completing flight
assignments, astronaut candidate training, or other astronauts
recommended for review. The purpose of the Astronaut Evaluation
Board is to determine the flight status of each astronaut, to
decide upon corrective actions if necessary, and to pass
recommendations of flight status and corrective actions to the
Chief, Astronaut Office for final disposition. Astronauts who
have been reviewed by the board are debriefed by the Chief of
the Astronaut Office, and the results are documented in their
personnel file.
Mission performance feedback is provided by Commanders to each
crew member after completion of a space mission. This personnel
information on each crew member's performance includes
strengths and any areas for improvement. Suggested areas of
feedback include interpersonal interactions, knowledge base,
attitude and work ethic, skills, and ability to balance
technical assignments with training.
Flight Assignments
All of the policies, processes, and feedback described above are
used by the Chief of the Astronaut Office in the flight assignment
recommendation process. A particular crew assignment is based foremost
on the specific mission requirements, and crew members are recommended
based on their performance during training, systems knowledge and their
ability to apply it in an operational environment, previous flight
performance, effectiveness in technical job assignments, and
assessments of leadership capability, teamwork, and judgment.
Other factors considered in flight assignment include international
partner agreements, skill mix, appropriate mix of veteran and rookie
crew members, anthropometric constraints due to EVA suit and vehicle
sizing, and medical eligibility.
Medical Fitness for Flight and Duty
As noted in Dr. Williams' testimony, medical standards for fitness
for flight and fitness for duty are developed by the Space Medicine
Division of the Space Life Sciences Directorate at the NASA Johnson
Space Center, in concert with experts in various medical fields
internal and external to NASA. The standards are reviewed and approved
at several levels, and are used by the Flight Medicine Clinic and
Aerospace Medicine Board to make certification decisions. Certification
results are reported to the Astronaut Office in weekly and monthly
reports.
Astronaut medical issues affecting flight status for aircraft, and
short and long duration space flight are also addressed during biweekly
meetings between the Chief of the Astronaut Office and the Chief of the
Space Medicine Division. Any medical issues that affect a member of an
assigned crew are also coordinated with me and the Director of Space
Life Sciences.
The communication and relationship between Flight Crew Operations
and the Space Medicine community is strong and effective, allowing NASA
to effectively address concerns regarding safety and crew health.
Flight surgeons are aware of their responsibility to assure that an
astronaut's health or behavior does not present a risk to themselves or
the mission, and the Flight Crew Operations management, as well as
NASA's leadership, support their efforts to do so. Medical issues that
arise immediately pre-flight or in-flight are discussed among
operational, medical, and astronaut management on a need-to-know basis,
giving due consideration to privacy, crew member health and safety, and
mission impact. NASA currently employs a system for reporting any
situation requiring attention that may impact safety of flight that
utilizes multiple and independent technical authority pathways outside
of the flight program management to elevate and resolve concerns.
Similar to the independent technical authority chain of command that
deals with any technical issues related to flight safety, the agency
governance structure provides a path for dissenting opinions to be
raised through the Health and Medical Technical Authority chain of
command. Additional program independent pathways for elevating concerns
include the Johnson Space Center Safety and Mission Assurance Director
or Center Director, the Center Ombuds, or to NASA Headquarters via the
Chief Safety and Mission Assurance Officer, Bryan O'Connor. This
governance structure is often reiterated to our employees and we have
again re-emphasized these pathways to our astronauts and flight
surgeons.
The flight crews are very fortunate to have a group of flight
surgeons who are not only excellent physicians, but who understand the
training and operational environment of an astronaut and the
implications of that environment to astronaut health. The flight
surgeons are tireless in their efforts to obtain the best possible care
for an astronaut, during training anywhere in the world as well as in
space, and they work long hours to ensure that any issue is thoroughly
addressed. They are dedicated to maintaining or returning astronauts to
flight status when at all possible, keeping within the medical
standards that protect astronaut health and mission success.
NASA's Response to the Astronaut Health Care Review Committee Report
Following the events of last February, Johnson Space Center
conducted an internal assessment to review and recommend changes to
astronaut behavioral health screening and assessment, and NASA
Headquarters chartered an Astronaut Health Care Review Committee in
order to more broadly review astronaut medical care, including
behavioral health. There were some recommendations common to both
reviews, including adding a behavioral health assessment as part of the
annual astronaut physical examination. In addition, the Health Care
Review Committee made a number of suggestions concerning behavioral
health care, which are being followed up on by the Space Medicine
Division.
While those recommendations were the focus of the review and the
report, the report also included a number of comments related to
astronaut office behavior and processes, based on meetings between some
Committee members and some astronauts, astronaut dependents, and flight
surgeons. The Committee did not attempt to determine the veracity of
any statement, nor was there any request for information on astronaut
office processes, procedures, policy, or anything that could be broadly
characterized as astronaut office culture.
In response to the Committee report, NASA has taken decisive steps.
As Bryan O'Connor has already testified, his thorough investigation
confirmed my own personal experience as both a crew member and a
manager of flight crew: we have found no instance where astronauts have
used alcohol in the immediate pre-flight period, no instances of
astronauts being under the effects or influence of alcohol at launch,
and no case where a flight surgeon or astronaut has raised a concern
about this to management, and, therefore, in no case was that concern
ignored. To ensure that there is no future question regarding use of
alcohol, I have taken the opportunity to clarify our space flight
alcohol policy, and, based on Bryan O'Connor's review, will determine
whether any revision or expansion of the policy is warranted.
NASA has also responded to the Committee's report by developing a
systematic, comprehensive, and anonymous survey to determine what, if
any, issues actually exist, which will be provided to the Astronaut
Corps and flight surgeons later this month. Both astronauts and flight
surgeons will be asked to respond to questions probing the relationship
between the two groups and their respective managers as determined by
level and quality of communication, trust, and clarity of
responsibilities and authorities. Another objective is to understand
any potential concerns in raising or responding to issues with flight
safety or crew suitability for flight or any barriers that might exist
to raising concerns. Additionally, astronauts will be asked about their
understanding of and suggested changes or clarifications to policies
and procedures dealing with astronaut performance and feedback, crew
assignment, and space flight alcohol use. After a preliminary analysis
of the survey responses has been conducted, the Chief of the Astronaut
Office will hold astronaut all-hands meetings to clarify and validate
the analysis in preparation for a final report. NASA will then develop
a plan to address any issues identified through the survey. This is a
course of action that the committee itself has indicated they intended
as NASA's response to their report.
I am committed to understanding and addressing any issues that are
identified by the survey, as are the Chief of the Astronaut Office,
Steve Lindsey, the Chief of the Space Medicine Division, Dr. Mike
Duncan, and the Director of Space Life Sciences, Dr. Jeff Davis. We are
fully accountable to the Director of Johnson Space Center, Mike Coats,
who in turn is accountable to the NASA Administrator. We will
accomplish this while appropriately balancing these efforts with our
primary duties of ensuring mission success and safety of round-the-
clock flight operations on-board the ISS Program, and the planning and
execution of the challenging Space Shuttle missions to complete the
assembly of ISS.
Conclusion
I am extremely proud to represent the Astronaut Office, both within
NASA at many different agency and program forums including flight
readiness reviews and mission management team meetings, as well as
externally--to the Members of this committee, to the media, and to the
public. I admire and respect what America's astronauts accomplish day
in and day out, while in space, in the air, and on the ground. Their
hard work, dedication, and continual commitment to excellence and
flight safety are the hallmarks of their profession.
I am confident that our astronauts are well-prepared to carry out
the Nation's human space flight program and our next great era of
Exploration; they take their responsibility very seriously. The same
can be said of the entire NASA team that prepares and executes human
space flight missions. The real proof of that lies in the tremendous
accomplishments of our human space flight programs.
We just successfully completed STS-118, our 119th Shuttle mission,
and the 22nd Shuttle mission to the ISS. Through 92 EVAs totaling 548
hours, we have learned to successfully construct complex structures,
and repair and maintain them, even when the individual parts have been
built and tested in several different countries with no opportunity to
do end-to-end tests prior to launch. A total of 13 countries have sent
140 people to the ISS. With the European and Japanese laboratories
scheduled to launch in the near future, international cooperation will
extend beyond the operational communities to the science communities.
We are able to accomplish these extraordinary feats because of the
extraordinary people at NASA, our engineers, flight controllers,
scientists, doctors, and our astronauts.
I would be happy to respond to any questions that you have.
Chairman Udall. Thank you, Dr. Ochoa.
Mr. O'Connor.
STATEMENT OF MR. BRYAN D. O'CONNOR, CHIEF, SAFETY AND MISSION
ASSURANCE, NATIONAL AERONAUTICS AND SPACE ADMINISTRATION
Mr. O'Connor. Mr. Chairman, Members of the Subcommittee and
the Committee, thank you for this opportunity to address you on
the subject of space flight crew safety.
As NASA's Chief of Safety and Mission Assurance, I report
directly to our Administrator on matters dealing with ground
safety and flight safety, and I also have policy and functional
oversight responsibility for this agency, for the safety
organizations assigned to each of the centers across the
agency. My organizational relationships with flight crew
operations and with the Chief Health and Medical Officer are
included in my written remarks.
In its final report dated 27-July-2007, the Astronaut
Health Care System Review Committee found the following:
``Interviews with flight surgeons and astronauts identified
episodes of heavy use of alcohol by astronauts in the immediate
pre-flight period which led to flight safety concerns. Two
specific instances were described where astronauts had been so
intoxicated prior to flight that flight surgeons and or fellow
astronauts raised concerns to local, on-scene leadership
regarding flight safety. However, the individuals were still
permitted to fly.''
In response, the Deputy Administrator appointed me to
review the reported allegations. The purpose of my review is
two-fold. Number one, evaluate the committee's finding related
to the inappropriate use of or abuse of alcohol by astronauts
in the immediate pre-flight space flight period. And two,
evaluate relevant existing policies covering alcohol use and
abuse at NASA.
My approach to the review was to learn as much as I could
about the reported allegations through interviews, data
searches, and history review. The goal here was to establish
the nature and the scope of any flight crew alcohol abuse, thus
enabling a more informed course of action in our policies,
procedures, risk mitigation strategies, our authority
structure, and communication systems.
The scope of my review was limited to space flight, with
focus on the activities on launch day from crew wake up until
launch. For this potential flight safety issue, the relevant
question was, did we have an instance where a crew member
presented on launch morning in an impaired state, was it
observed as such by the flight surgeon or another crew member,
and then over their objections was cleared to fly that day by
operational management?
Consistent with our standard approach to anonymous safety
concerns, my investigative method included a search of over
1,500 anonymous reporting system and confidential hotline
reports going back to 1987, when we first established the NASA
Safety Reporting System. And with the help of the NASA Safety
Center we searched literally tens of thousands of mishap and
close call records going back that same length of time. I
received inputs by phone, e-mail, in person, from over 130
individuals who have been involved one way or another in
activities during the last few days before launch, either at
the Kennedy Space Center or at the Baikonur Cosmodrome in
Kazakhstan. I heard from every one of our current operational
flight surgeons and nearly 80 percent of the current Astronaut
Corps and many former astronauts.
I also talked to suit technicians, medical staff,
operational managers, crew quarters managers, food preparation
and service staff, and closeout crew technicians. The closeout
crew are the last people to see the crew before launch.
To supplement this review I reminded members of the flight
community at all times that they should use the hotlines and
the NASA Safety Reporting System for any flight safety
information they felt reluctant to provide to me in an open
forum, and I reviewed those hotlines and NSRS System
throughout.
Also, NASA's preparing a focused anonymous survey as a
follow up to this. This survey will try to flush out any
residual concerns in this or other areas covered by the
committee report.
Within the scope and the limitations of my review, I was
not able to verify any case in which an astronaut space flight
crew member was impaired on launch day or any case where a NASA
manager disregarded recommendations by a flight surgeon or
another crew member that an astronaut crew member not be
allowed to fly on the Shuttle or the Soyuz. Should such a
situation present itself in the future, I am confident from my
review that there are reasonable safeguards in place, including
such things as the flight surgeon check that morning, the
presence of flight crew managers, TV cameras, suit technicians,
and other technical and administrative staff and supervisors
that would keep us from ever allowing an impaired crew member
from boarding a spacecraft.
As for the chance that we will disregard a flight surgeon
or a crew member's safety concerns, I found that although there
may be occasional disagreements among operations and medical
team members, all parties understood their roles and
authorities and the multiple safety reporting and appeal paths
we have put in place, some as late as the last two years.
My report makes one recommendation to improve flight
surgeon oversight during launch day activities and several
recommendations concerning relevant agency policies that should
be improved for scope and clarity. This review is complete, but
I have reminded our workforce that any alcohol abuse or other
flight safety threats should be reported in an open forum or if
necessary, through any one of the several anonymous reporting
systems we have in place at NASA.
Thank you.
[The prepared statement of Mr. O'Connor follows:]
Prepared Statement of Bryan D. O'Connor
Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to address the Subcommittee on the subject of flight crew
safety.
My name is Bryan O'Connor, NASA's Chief, Safety and Mission
Assurance. I report directly to Dr. Griffin on matters dealing with
ground and flight safety, and I have policy and functional oversight
responsibility for the safety organizations assigned to each of the
Centers across the Agency, as well as to all Agency programs. My
counterpart for health and medical matters is Dr. Rich Williams, NASA's
Chief Health and Medical Officer, as well as the Agency's Designated
Safety and Health Official. He has policy and functional oversight over
of all health and medical activities at NASA. We both have oversight of
astronaut-related activities; my emphasis is on safety and his is on
health. I have a close relationship with the Johnson Space Center
Director, Mike Coats, who is responsible for the health and safety of
the astronauts. We and our delegates all share seats at readiness
reviews and management councils as the agendas dictate. I have no
direct oversight over health or behavioral issues except as they become
or threaten to become safety issues. We ensure that appropriate safety
and medical experts are members of human experimentation safety
reviews, and we require medical or human factors professionals on all
of our mishap investigation boards. Finally, following a recommendation
from the Challenger accident, there is a standing flight safety panel
chaired by an experienced astronaut who supports my human space flight
activities, including selected assessments and readiness reviews.
There are several high level directives outlining NASA's health and
safety programs, the highest being NPD 8710.2, NASA Safety and Health
Program. Below that policy directive are other policy documents that
outline responsibilities and contain requirements and standards for our
programs. Examples are directives on occupational health and safety,
emergency preparedness, and mishap reporting. Under our program
management policies is the NASA Human Rating Requirements directive.
All of these directives outline responsibilities for people in
operations, medical and safety organizations. My organization has the
authority to assure compliance with these policies and requirements.
When we conduct audits, we always include appropriate operational and
medical professionals to evaluate compliance with requirements in their
areas of expertise.
The Astronaut Health Care System Review Committee Report
In its final report, dated 27 July, 2007, the Astronaut Health Care
System Review Committee found the following: ``Interviews with flight
surgeons and astronauts identified episodes of heavy use of alcohol by
astronauts in the immediate pre-flight period, which has led to flight
safety concerns.'' Specifically, the report noted that ``Two specific
instances were described where astronauts had been so intoxicated prior
to flight that flight surgeons and or fellow astronauts raised concerns
to local on-scene leadership regarding flight safety. However, the
individuals were still permitted to fly.'' The report findings, if
true, describe a serious close call. NASA takes this matter very
seriously as it represents a threat to our mission, and is a clear
affront to NASA's core values of safety, integrity, teamwork and
mission success. To address this potentially serious safety risk, NASA
decided that a review of the events and circumstances was required. The
Deputy Administrator chartered me to conduct a review that would
evaluate the Committee's finding related to the inappropriate use or
abuse of alcohol by astronauts in the immediate pre-flight period. My
charter further calls for a review of existing policies and procedures
related to alcohol use and space flight crew medical fitness during the
immediate pre-flight preparation.
The Committee report offered three recommendations related to their
alcohol abuse finding which cover policies dealing with alcohol use and
abuse as well as communication management of safety concerns by crew
members and flight surgeons. My approach to the review was to learn as
much as I could about the reported allegations in order to establish
the nature and scope of any flight-day impairment and subsequent
override of legitimate flight surgeon or crew objections. This would
enable a more informed course of action in our policies, procedures,
risk mitigation strategies and communications systems. This review
would be supplemented by ongoing safety and health actions responsive
to other parts of the Committee report, an anonymous survey being
prepared for distribution in September, as well as the several open and
anonymous safety reporting systems already in place.
Scope and Method
Consistent with the serious implications of the Committee's report,
my focus was on alcohol use or abuse that would have resulted in
impairment on the day of launch. Equally important in my review was the
reported disregard by management for the flight surgeon's or crew's
recommendation against flight. I did not review alcohol use in general
or as an aircraft safety issue, although I did review relevant policies
to ensure that they are or will be consistent for space flight,
aircraft flying and other mission critical activities. My question was,
``did we actually have a case where we strapped, or almost strapped, an
impaired astronaut into a spacecraft over the objections of his or her
flight surgeon, and if so, how did we get to that point, and what
policies, procedures, risk mitigators do we need to change to avoid
such an event in the future?''
The Committee Chairman provided a few important details about these
incidents in his press conference, and a subsequent discussion with me,
but he was unable to give us more information, references, timelines or
sources for the reported allegations due to promised anonymity for
witnesses. Therefore, I resorted to investigation techniques consistent
with our other anonymous reporting systems. I reviewed relevant
policies, procedures and near-launch timelines and staffing. I
inspected the crew quarters facilities at both Johnson and Kennedy
Space Centers, and interviewed managers familiar with the Cosmonaut
crew quarters in Kazakhstan. I reviewed results from the Johnson Space
Center and Space Shuttle Program hotlines, the NASA Safety Reporting
System (NSRS), and NASA's close call and mishap reporting systems for
evidence related to astronaut alcohol abuse and space or aircraft
flight. My data search went back 20 years, a time-span where U.S.
astronauts flew 94 Shuttle missions and 10 Soyuz missions.
I also reached out to people who spent time as crew members or in
support roles in the crew quarters at the Kennedy Space Center and the
Baikonur Cosmodrome in Kazakhstan. This included current and former
astronauts, flight surgeons, research and operations support nurses,
Shuttle suit technicians, close-out-crew technicians, and the managers
and staff of the crew (quarantine) quarters. I asked them to volunteer
any information they could give me about this matter. Consistent with
safety investigation techniques, I avoided leading questions, and
medical privacy matters not directly related to flight safety, allowing
the individuals to give me whatever information they considered
relevant. I heard from more than 90 individuals representing all of the
groups mentioned. Although I received a good response, there are,
understandably, still some who might be reluctant to come forward
without a guarantee of anonymity. Therefore, I made it clear to all
possible witnesses that they could use the confidential hotline or the
anonymous NASA Safety Reporting System to tell me their story. In
summary, this was a safety review, not a disciplinary investigation.
The NASA Inspector General has announced his intent to review the
results of this review, and if necessary to follow as appropriate to
his authority and oversight responsibilities.
Results
The results of my inquiry and data search to date are as follows:
1. Alcohol, mostly wine and beer, is available in the crew
quarters quarantine facilities for use by astronauts during
off-duty hours. This practice exists under a combination of
societal norms and local standard operating procedures.
2. Of the thousands of government mishaps and close calls
recorded since the inception of our electronic mishap databases
in the late 80s and early 90s, none involved alcohol or drug
use or abuse by an astronaut.
3. Of the 680 anonymous safety concerns reported to and
investigated by the NASA Safety Reporting System since its
inception in 1987, none involved astronaut alcohol or drug use
or abuse.
4. Of the 863 Safety Hotline reports recorded since its
inception in 1991 to the present, none involves alcohol or drug
use or abuse by an astronaut.
5. Although Johnson Space Center does not reveal the
identities of personnel involved in disciplinary actions, the
most recent report to OSHA covering the years 2002 through 2006
includes a total of seven such actions related to alcohol or
drugs at the center. Informal input from Flight Crew Operations
was that none of these involved astronauts.
6. Of the more than 90 individuals who answered my call for
information, not one offered any evidence of alcohol use or
abuse in the immediate pre-flight timeframe: Shuttle, Soyuz, or
T-38, and none revealed any cases where management disregarded
flight surgeon or crew concerns about crew alcohol and space
flight.
7. Regarding relevant policy, there are some gaps in scope,
and some areas in need of clarification.
My review revealed that, although alcohol is available to crew
members, it is not known to be used during work hours or beyond the
start of the mandatory sleep period, which begins at about 18 hours
prior to launch for rendezvous missions (i.e., Space Station), and 12
hours before launch for other missions. Most people involved in the day
of launch activities in crew quarters found it hard to imagine that a
crew member would put his/her mission and fellow crew members at risk
by reporting on the day of launch impaired for space flight. Crew
members reminded me that each one of them must be fit enough for an
unaided emergency pad egress should there be a fire or other major
emergency before liftoff. They practice this drill in the simulator and
in the actual vehicle in the Terminal Countdown Demonstration Test
normally held a couple of weeks before scheduled launch. Even a few
seconds delay in unstrapping and egressing from the Shuttle could cost
lives, and executing this demanding task while wearing heavy flight
equipment takes the speed, coordination, judgment, and situational
awareness that only exist in a sober crew member.
Then there is the lack of privacy. From the time the crew wakes on
launch morning until they lift off, they are surrounded by crew
members, managers, support crew, television crews, still photographers,
crew quarters staff, etc. Breakfast, the first scheduled event,
normally half a hour after wakeup, is in a room shared by their
managers and other crew members. Shortly after breakfast, each crew
member receives a short final visit from the flight surgeon. Although
this last medical checkup is limited, the doctors tell me that it is
adequate to reveal signs of alcohol impairment. Lunch is in front of
live television cameras and, after lunch, the live television cameras
are there for close-ups as the suit technicians, one per crew member,
work closely with them through donning and system integrity checks. The
doctors observe this activity as well. Walkout to the Astrovan is on
live television and, when they reach the launch pad, the Close Out Crew
helps the crew members don their parachute harnesses and strap them
into their seats. These highly supervised, very public activities offer
many opportunities to spot an impaired crew member, whether from
alcohol or some other sudden medical problem, before their impairment
could affect the mission. Finally, the crew commanders know that they
are responsible for the performance of their crew in the training and
flight environment. They know that thousands of people and millions of
dollars are involved in getting a Space Shuttle to this point in the
countdown, and they know the challenges and risks inherent in space
flight. They know that if one of their crew members reported for work
on launch morning impaired by alcohol, and a crew commander failed to
report that and take other appropriate actions, that they would be held
accountable nearly as much as the offending crew member.
The operation in Kazakhstan is similar to that at Kennedy Space
Center, with some small differences. The crew members typically go to
the Cosmonaut Hotel for quarantine two to three weeks before launch.
Again, alcohol is available for off-duty hours, and there is a special
ceremony held before the crew goes to the launch pad that involves a
champagne toast. Those who have participated in this event told me that
the amount of alcohol is very small, and most of the time, the crew
members, Russian and American, only touch the glass to their lips. NASA
flight surgeons did not express any concern to me about this ritual,
even though it does violate the letter of most aviation alcohol
policies. Another important difference in the Soyuz operation is that
either the Russian or the U.S. flight surgeon has the authority to pull
an impaired crew member from the flight up to and including launch
morning. The Soyuz crews have fully trained backups for just such
emergencies. One area of concern was that there is not always a room
for the NASA flight crew management representative, who must then live
across the street with the crew families in another building. This
could limit crew management presence in off hours. My report recommends
that NASA work with the Russian Space Agency to ensure full time
accommodation for crew operational manager(s) in the Cosmonaut Hotel,
thus duplicating the full time oversight situation at KSC.
As for T-38 and other aircraft flight activities, astronaut pilots
come to NASA only after years of operational and flight test
experience. Any pilot with a prior record of poor judgment would not be
competitive in the selection process. So, it is commonly expected that
those selected for the Astronaut Corps have a reasonable level of
maturity as well as flying skill. They are trusted implicitly to fly
professionally, and the relatively low mishap rate of NASA T-38
operations speaks to that (no class A mishaps in over 20 years and
nearly 160,000 flying hours). Technically, it would not be difficult
for a crew member to drink and fly impaired, especially when he or she
is flying solo cross country. NASA's T-38 policy calls for 12 hours
between the last drink and takeoff, and prohibits flying impaired.
Also, most NASA astronaut T-38 pilots are active duty military
detailees, and thus subject to the Uniform Code of Military Justice.
They know that flying impaired, or acting in any manner unbecoming an
officer on or off the job could be the first step to a court-martial.
Having said that, some whom I interviewed admitted that it is possible
that someone could have inadvertently violated the 12 hour rule by a
small amount at some time in their military or NASA flying career
(note: the FAA imposes an eight-hour restriction on airline pilots).
However, none of them admitted to ever violating or witnessing a
violation of what is arguably the more important part of any alcohol
policy--that flying while impaired is prohibited.
As I looked at our policies regarding alcohol and flight, I found
several areas where they conflict with one another, or are lacking in
scope, specificity or clarity. For example, shortly after the Committee
report was published, we realized that there is no specific ``bottle to
throttle'' rule for space flight, as had been in place for many years
for T-38 operations. As an interim step, and while we review all our
policies and procedures in this area, we have since applied the T-38
rules to space flight.
Summary
Although my review by nature was not, and probably could never be,
exhaustive, it represents a great deal more investigation than what I
would normally do in response to an anonymous safety concern. I
received over 80 percent participation of the astronaut and 100 percent
participation of the flight surgeon communities. These are high
percentages of survey participation, considering the substantial
numbers who were engaged in the recent Shuttle mission, training in all
corners of the globe, or on summer leave.
I cannot say conclusively that none of the incidents reported to
the Committee ever happened. However, I was unable to verify that they
did. I am confident that there are enough safeguards in the form of
doctors, managers, and witnesses in place to prevent an impaired crew
member from being strapped into a spacecraft. As for the relationships
among flight crews, flight surgeons and operations and medical
managers, I found as good a situation as I personally have seen in many
years. The flight docs point with pride to the fact that, in over 25
years of Space Shuttle operations, including 119 Shuttle flights, not
one has had to be terminated early for a crew medical problem. Although
there may be occasional disagreements, I found that all parties
understand their roles and authorities and the multiple safety
reporting and appeal paths. Some or all of the reported incidents could
possibly have happened during earlier times in the countdown where
there are fewer witnesses and, if so, they would represent ground
safety and flight schedule threats. Moreover, disregarding duly
assigned flight surgeons on crew health matters is a serious matter,
but the flight surgeon community was unanimous in their assurance that
they have never been overruled or disregarded on a space flight safety
call at launch time. This review was a focused look at the most serious
implications of the Committee report. We will continue to monitor our
anonymous reporting and other systems for indications of these kinds of
problems. And, the safety community will continue to support the agency
as it moves forward on the Health Committee's recommendations.
I will be happy to answer any questions you may have.
Discussion
Chairman Udall. Thank you, Mr. O'Connor. Thank you to the
panel. We should give everybody an update. We have a looming
set of votes, but we are going to start now with the first
round of questions, and we will play it by ear because we do
really want to hear from everybody on the panel and give
everybody a chance to ask their questions.
At this point the Chair recognizes himself for five
minutes.
Contrasting Views and Findings From the Astronaut Health Care
System Review Committee
Colonel Bachmann, I would like to focus on your testimony,
and I speak for myself, although I think I might speak for
other Members of the Subcommittee when I say it is hard for us
to hear your testimony followed by that of the NASA witnesses
and not be somewhat troubled. On the one hand your committee
found that, quoting you, ``Several senior flight surgeons
expressed their belief that their medical opinions regarding
astronaut fitness for duty, flight safety, and mission
accomplishments were not valued by leadership other than to
validate that all medical systems were go for an on-time
mission completion.''
And to continue, ``Instances were described where major
crew medical or behavioral problems were identified to
astronaut leadership, and the medical advice was disregarded.''
And finally, your testimony and your committee relayed the
following. ``Crew members raised concerns regarding substandard
astronaut task performance which were similarly disregarded.''
I then contrast that with Mr. O'Connor's space flight safety
review report in which he includes an e-mail letter from all of
the JSC mission operations flight surgeons in which they state,
``In the course of astronaut mission, operations, and training
our safety and medical concerns have not been ignored by NASA
medical operations, the Astronaut Office, Mission Operations
Directorate, the Aircraft Operations Directorate, NISS, and
Shuttle Program Management.''
And then with Dr. Ochoa's written testimony which states
that, ``The communication and relationship between flight crew
operations and the space medicine community is strong and
effective, allowing NASA to effectively address concerns
regarding safety and crew health.''
To pick up on what Chairman Gordon said in his remarks, it
almost seems as though we are hearing about two completely
different organizations. Why did your committee paint such a
different picture than the one that NASA personnel is
describing to the Subcommittee? And could you provide some
specifics to help us better understand the basis for your
committee's findings?
Colonel Bachmann. Yes, sir, and I agree that the pictures
that are painted by the two reports are diametrically in
opposition.
Any answer about why would be speculation on my part. What
the committee gathered together and wrote in the report and
unanimously supports is what the astronauts and flight surgeons
told us either face to face or over the phone during the course
of our committee investigation, evaluation.
The fact that they are not coming forward with similar
concerns when NASA asks the question, I believe still
represents a problem. The why I think is an area of
communication and concern about what is going to happen to them
and what is going to be done with the information. That is why
we really put a great deal of emphasis on the anonymous survey
so that people feel that they can speak freely.
Chairman Udall. Returning to your report, Colonel, ``Many
of the cultural and structural issues identified in this
report,'' I am again quoting from what your committee wrote,
as--let me start over. ``Many of the cultural and structural
issues identified in this report as problematic have existed
for many years and some have existed since the earliest days of
the astronaut programs. These issues are so engrained and
longstanding that it will take senior leadership action to
remediate them.''
These are sobering words, and could you give me one or two
examples of the cultural and structural issues your committee
is talking about?
Colonel Bachmann. Please keep in mind that the makeup of
the committee was very diverse. We had military, flight
surgeons, and health experts. We had civilians. All but one of
the members of the committee had some military experience, but
we did have a member from the VA, who did not. We are familiar
with the military environment, behavior of highly-skilled,
highly-professional, highly-selected groups of people that
still have human issues. They still fall victim to all the same
kinds of issues that we do. There are doctors and military
pilots and airline pilots who have trouble with drinking
alcohol when they shouldn't. We have behavior problems that
come as a surprise to co-workers.
And I think NASA is no different in that regard, and not to
speak poorly of the Astronaut Corps, we think very highly of
the astronauts, but we still remember that they are humans and
fall victim to the same kinds of things we do.
The issues of the kinds of behaviors that are described
should not come as a surprise to anybody who deals with people.
The concern for us was that they are--they seem to come as a
surprise because NASA astronauts are so very good. It is still
unreasonable to think that they won't have individuals that
have problems with alcohol, that they won't have individuals
have problems with marital relationships, with money, and they
need to set up a system where they can identify folks that are
straying from the path sooner and do something about it before
it becomes a major issue.
Chairman Udall. Thank you, Colonel Bachmann. I want to
recognize the Ranking Member, Mr. Feeney, and I am hopeful we
might also be able to recognize the Chairman of the Full
Committee, Mr. Gordon before we have to go to the Floor to
vote. We will recess the Committee temporarily.
Mr. Feeney.
Risks of Pre-flight Alcohol Consumption
Mr. Feeney. Well, thank you, and I guess I am hesitant to
ask what may be the silliest question of 2007, but Mr.
O'Connor, just why would it be a great risk if an astronaut or
astronauts had too much to drink before flight? I have been in
the simulator. I know that the medical risks, for example,
vomiting into your mask are important, but if the launch is
successful, the truth of the matter is that it is all technical
and computer-driven. It is actually the emergency landing that
is a concern, and other than it being poor practice, are there
other concerns with, because the Soviets do have this tradition
where shortly before takeoff they have a toast and you outlined
that it is basically just touching to the lips, but in any
event, it may be a silly question, but what other threats other
than vomiting or the inability for somebody to safely land if
there is an emergency landing would there be if astronauts were
drinking immediately prior to flight?
Mr. O'Connor. Well, sir, let us say we had a crew of seven
members getting ready to fly the Shuttle, and one of those
members really didn't have much to do for the first three days
of the mission. And then on day four they start working on some
experiment. Even that crew member needs to be ready for an
egress on the launch pad. Every single one of those crew
members has to be able to convince their commander when they
get onboard that they would be able to in emergency get out
without assistance in case of an emergency on the launch pad,
no matter what. And that really is the first challenge, I
believe even before they light off the vehicle and launch, is
to have a crew that is fit, and they have their minds in order,
and they are not going to need to be pulled out of the cockpit
by somebody else, putting the crew at risk.
Mr. Feeney. Not to mention that if one of them were caught
to be drinking, you would have to cancel the whole flight
potentially if you didn't have anybody to step in.
Mr. O'Connor. Well, that was part of my review was to look
at that launch day. Is it possible that someone could actually
wind up in the cockpit impaired? And if so, what sort of
factors do we have in place to prevent that from happening? I
found it really hard to imagine that you could get there, but
let us say it wasn't alcohol. Let us say somebody fell down the
stairs on their way to get suited up or banged their head into
something or had a stroke, and they were perfectly fine the
last time the flight surgeon looked at them. We still need to
be able to look them in the eye, have the flight surgeon nearby
even to the point where they walk out of the building, and I
think that is one of the concerns that we had was that
impairment by any means is something we want to prevent.
And we would hold off a launch, just as we did on STS-36
some years ago when the crew had a sick crew member. The flight
surgeon went to management, said we got a sick crew member,
management really didn't want to hear this. They were right in
the middle of the launch countdown, and yet they had to agree
the crew member was sick, let us know when he is ready to go,
and we will launch. So he held off for two days.
Differences and Methods of the Reviews
Mr. Feeney. I mean, Colonel Bachmann and Mr. O'Connor, on
the much bigger issue, and that is whether there is still a
cultural problem with the comfort of reporting safety, whether
it is technical, and by the way, I was there when Mike Griffin
recognized, a technician that recognized on the wing I think it
was, maybe he will address it later, in front of God and
country and the press and other NASA employees and
administrators, he recognized somebody that was literally a
hero because he was a technician and discovered a problem with
the exterior or the wing.
If that cultural change hasn't made its way to the medical
area, that seems to be the crux of what this committee hearing
is about.
Colonel Bachmann, because of the process that he used,
voluntary, anonymous witnesses, finds one set of consistent
testimony, and he has got a very credible panel. Mr. O'Connor
finds a very different set of availability of communications
and independent communication avenues and finds that nobody is
reluctant to come forward. Could this be a bias in sampling
error? I mean, I remember the headlines, Dewey defeats Truman
because the pollsters call only people that owned telephones at
the time. You got 80 percent to participate, Mr. O'Connor.
Could it be that the 20 percent that didn't were part of
Colonel Bachmann's report? Could it be? And he suggested in his
testimony, which was not in his written testimony, that it may
be an indication that there is continued fear on the part of
some.
So maybe I ought to ask Mr. O'Connor that, because you have
read his report. You had 80 percent compliance. Could we have a
bias error here? Could we have people making false accusations
to the Bachmann committee, or could we have people that
participated in his committee different than the 80 percent
that participated in yours? And that would be my last question.
Mr. O'Connor. Well, sir, you have touched on several areas
where there could have been differences. My review was
conducted on a little bit different method. I put the word out
to people that they can come and talk to me about whatever they
feel comfortable about. I did not do, use any leading
questions. I used standard safety investigation techniques.
I have to say that I got a lot more participation in this
than I have ever gotten on one of these before. There were over
130 people who came forward or who answered my call
specifically, because I did reach out to some people that were
on certain missions that I wanted to make sure I have coverage
of all the flights back through 1987. And so those weren't just
people coming forward. It was me actually asking them to talk.
So it was a little bit different method. I also tried to
define flight safety in a way that everybody understood, meant
no kidding, impaired crew member in the cockpit. That is a
different story than maybe flight safety from a generic view
might be.
Chairman Udall. Mr. O'Connor, if I might interrupt you.
Mr. O'Connor. Yes, sir.
Chairman Udall. I want to make sure the Chairman given
these pending votes has a chance to make any comments or ask
any questions.
So the Chair recognizes the Chairman of the Full Committee,
Mr. Gordon.
Chairman Gordon. Thank you, Chairman Udall. I will just
make a quick--some observations.
One, Mr. O'Connor, I am a little surprised that your review
was so narrow that it was--that the charge was simply as you
stated limited to alcohol use on the day of launches. I would
have hoped it would have been a broader view.
Dr. Ochoa, I am pleased that you are going to follow up
there with this anonymous survey. I think that would be very
helpful.
Dr. Williams, I thought you had a very constructive
testimony. I would like if you would, you said you were going
to accept, had accepted and would accept most of the
recommendations. If you would, please, if you would send to us
a written statement on which recommendations you will not
accept and why and what kind of reporting process you are going
to have.
[The information follows:]
Material Requested for the Record
NASA Astronaut Health Care System Review Committee Report
Recommendations
(October 5, 2007)
NASA will address all the recommendations of the Astronaut Health
Care System Review Committee Report, and will satisfy at least the
spirit and intent of each recommendation. However, there are several
health and medical recommendations that NASA will not implement as
written for the reasons outlined below.
Recommendation 3.b.i.--Review flight surgeon task assignments and
restructure where possible to enhance continuity of care. Consider
empanelling each astronaut to a team of 2-3 flight surgeons who are
responsible for providing or overseeing every episode of care, whether
or not they are the assigned crew surgeon.
NASA agrees that optimizing continuity of care is highly
meritorious and reflects best practice. However, NASA does not believe
empanelment is a solution that will be viable in the Agency's astronaut
health care system. NASA flight surgeons are multi-tasked with
activities that include: supporting astronaut training schedules;
supporting deployed astronauts; providing health and medical support to
ongoing International Space Station and Shuttle Program operations;
participating in operational mission management activities; supporting
the growing review board activities of the Constellation program;
participating in simulations; supporting atmospheric flight operations;
providing aeromedical certification services for astronauts, pilots,
and flight controllers; and providing clinical care.
While NASA believes empanelment would be impractical in this multi-
tasking practice setting, the Agency will review flight surgeon task
assignments, including flight medicine clinic assignments, and identify
any opportunities for task off-loading to enhance continuity of care.
Recommendation 6.a.i.--Develop privacy procedures that ensure that
individual astronaut EMRs are viewable only on a strict need-to-know
basis by those clinicians who are directly involved in relevant aspects
of their care. Privacy policies should be consistent with civilian
standards of practice and federal privacy laws.
NASA's electronic medical records (EMR) system is in compliance
with the Privacy Act of 1974 and is consistent with civilian methods of
practice. NASA's current EMR system privacy policies are similar to
those in use by the Department of Defense and the Department of
Veterans Affairs. NASA infers from this recommendation that access to
individual EMRs should be password protected, and that only certain
directly involved providers be granted access. In most EMR systems, as
in NASA's, all appropriately credentialed and privileged providers can
access the system, which is password protected, and then are able to
access all EMRs. If NASA were to strictly interpret the model outlined
in the Review Committee's recommendation, there could be untoward
patient safety implications in some circumstances, such as a need for
an appropriately credentialed and privileged provider--without specific
individual records authority--to access a patient's record in an urgent
or emergency situation. Impeding provider access to important or
critical information from the record in such a situation could result
in a problematic clinical outcome. NASA recognizes the critical
importance of maintaining privacy and patient confidentiality. We are
confident that our current EMR system provides the appropriate levels
of privacy protection, balanced with patient safety, and is consistent
with federal privacy laws.
Recommendation 6.f.i.--All behavioral health providers should have
access to the EMR. A patient seen in behavioral health should have the
clinical contact recorded in the EMR, and an explicit aeromedical
disposition should be made by a flight surgeon. The full behavioral
health note does not need to be included in the EMR. The behavioral
health provider can discuss the case by phone or in person with the
flight surgeon.
Behavioral health clinical contacts are recorded in the behavioral
health records. NASA does not agree that all behavioral health episodes
of care should be recorded in the EMR. We believe this could compromise
privacy and serve as a disincentive for seeking behavioral health care.
NASA does agree that behavioral health visits due to conditions that
bear on a crew member's ability to perform their duties safely or that
could impact a crew member's aeromedical certification should be
recorded in the EMR, with appropriate aeromedical disposition. We also
agree that the policy should be clarified to define the appropriate
behavioral health information for documentation in the EMR. This will
involve the development of inclusion criteria. NASA health and medical
managers will coordinate the proposed criteria and policy with the
Astronaut Office leadership.
And finally, it seems that, and, again, Colonel Bachmann,
you know, you have the most unpleasant job here. We thank you
for that. It seems that you were looking at a broader issue
with more anonymous reports, although anonymous face to face,
not just over the, you know, where Mr. O'Connor was looking at
a more narrow, on-the-record. So I think this can, might play
some role there, and that is why I think Dr. Ochoa, your
surveys would be helpful.
Scope of Investigation
We are going to have to go, but I want to ask a question
that I hope that you will answer when you come back, Mr.
Bachmann. I quote, ``Peers and staff fear ostracism if they
identify their own or other problems.'' That is a very
troubling statement. What was your review panel's basis for
making that statement, and how confident are you that it
doesn't represent just the view of one or two malcontents,
particularly in respect to the letter that came in from the
various flight surgeons?
And if you will think about that and answer that when we
get back. Thank you, sir.
Chairman Udall. Thank you, Mr. Chairman. We, the Committee
stands in recess. We will return as soon as we can. Thank you.
[Whereupon, at 10:59 a.m. the Subcommittee recessed, to
reconvene at 11:25 a.m., the same day.]
Chairman Udall. I will thank you all for your patience. We
will now return to questions of the first panel, and it is a
great privilege to recognize the Ranking Member, the Judge and
Congressman from the great State of Texas, Mr. Hall.
Mr. Hall. Thank you, Mr. Chairman.
Mr. O'Connor, the Chairman of the big Committee asked you
some questions and inquired about why it was relegated to
alcohol. There is a reason for that, is there not? What your
scope was.
Mr. O'Connor. Yes, sir. The scope of my investigation was
to look at the specific case that the two instances reported
represented, and that was space flight safety, Soyuz, Shuttle,
and to try to deal with that and try to understand whether or
not we had adequate controls in place. If something like this
happened, what was the nature of it so we could deal with how
to remedy it?
We did not expand that to look at alcohol use among
astronauts in a broader sense. That might take a different kind
of study, a little longer if we were to do something like that.
We didn't really need to do that. What we did was we kind of
triaged this whole thing. When we first saw the words, flight
safety, that, of course, raised a flag in my shop, and the very
first thing we do, we did was we talked to the crew that was
getting ready to launch the Shuttle. And we sat down with them,
and we talked to them about communications, about dissent, what
happens if the flight surgeon and the managers disagree, do
they know how to use the system properly. And that was the
first step.
The second step was to do this investigation, focused on
flight safety for Soyuz and Shuttle. The third step then is the
follow up with the anonymous survey that we will be doing that
has a much broader scope. It looks at the whole aspect of
communications and relationships among flight crew and flight
surgeons in the broader sense.
Anonymity of Survey
Mr. Hall. And with not having all the purported facts at
your disposal, you were somewhat at a disadvantage, were you
not?
Mr. O'Connor. Well, when I, I was at a sort of a
disadvantage in that there is always a chance that someone may
not feel comfortable talking to their safety guy.
Mr. Hall. Well, with no complaints against Colonel
Bachmann, you weren't given the benefit of the many interviews
that he made----
Mr. O'Connor. Oh, yes, sir.
Mr. Hall.--on many thrusts of this. Tell us about that, and
I am going to ask Colonel Bachmann to give us that information,
too.
Mr. O'Connor. Well, after we got Colonel Bachmann's report,
he added some more information after that on two occasions for
me, but he was hesitant and really could not give me more than
that because of the promises that they had made to their own
witnesses.
Mr. Hall. You are appearing in this committee and in this
Congress you soon learn who you can depend on and whose word is
good, and if their word is not good, nothing else is very good
about them usually. And I think you took that attitude toward
Colonel Bachmann, that he was keeping his word.
Mr. O'Connor. Yes, sir. That is why I didn't challenge it
and treated it as I would any other anonymous report we get
through out anonymous systems.
Mr. Hall. Colonel Bachmann, you couldn't give him all the
facts because you had agreed to those from whom you extracted a
lot of those facts that you wouldn't reveal their identity nor
their employer. Is that correct?
Colonel Bachmann. Yes, sir. That is correct. We acknowledge
that they are all NASA personnel and astronauts and flight
surgeons, but that is really as far as we were willing to go.
Mr. Hall. And you did that only because you didn't believe
you could extract some of the answers from them that you
extracted had you not agreed to give them the full cover. That
is a correct statement, isn't it?
Colonel Bachmann. Yes, sir. Really two-fold. We wanted them
to speak freely, and we were focused on systems issues rather
than any one individual.
Mr. Hall. They spoke freely knowing you weren't going to
reveal their names and their employment to be scrutinized
further by others who had the duty to scrutinize them further.
Isn't that correct?
Colonel Bachmann. Absolutely. Yes, sir.
Alleged Instances of Alcohol Abuse
Mr. Hall. All right. Mr. O'Connor, then it came down to
you, and you have scrutinized and observed many mishaps and
many close calls, and have there ever been any that involved
alcohol or drug use or abuse by astronauts since you have been
doing that? Yes or no?
Mr. O'Connor. No, sir.
Mr. Hall. And have you, of the, I think you said 680
anonymous safety concerns, they were anonymous to Colonel
Bachmann, reported to and investigated by the NASA Safety
Reporting System since its inception in 1987, none of them
involved alcohol, astronaut alcohol or drug use or abuse. Is
that a correct statement?
Mr. O'Connor. That is correct.
Mr. Hall. And of the 863 safety hotline reports recorded
since its inception in 1991, to the present, none involved
alcohol or drug use or abuse by an astronaut. Correct?
Mr. O'Connor. That is correct.
Mr. Hall. And although Johnson Space Center doesn't reveal
the identities of personnel involved in disciplinary actions,
the most recent report to OSHA covered the years 2002, through
2006, includes a total of seven such accidents related to
alcohol or drugs at the Center, and formal input from flight
crew operations was that none of these involved astronauts.
Mr. O'Connor. That is correct.
Mr. Hall. And for the last, more than 90 individuals who
answered your call for information, not one offered any
evidence of alcohol use or abuse in the immediate pre-flight
timeframe. Isn't that correct?
Mr. O'Connor. Yes, sir. With the one exception that since
then there have been----
Mr. Hall. Yes.
Mr. O'Connor.--40 more, so I would raise that number to
130.
Policies to Insure Employee Openness
Mr. Hall. All right. And I would ask you this. I know in
the aftermath of the Challenger and the Columbia accidents NASA
has tried very hard to insure that there are open, independent
communication paths to raise safety concerns. That is something
I have been very involved in. Module, that was an escape hatch
and insisted on it and had money in the budget for it a couple
or three times. One time I think maybe one of the older
astronauts that went up there after he was my age used a little
some of that to go up and back, and I didn't like that, but I
did like the fact that you were letting older astronauts go now
and then.
But for those safety concerns, would you please discuss
policies and or procedures that are now in place to insure
employees are encouraged to report any safety flight issues,
and would you please discuss how, if at all, you are changing
or revising these policies?
Mr. O'Connor. Yes, sir. As you mentioned, we put the NASA
Safety Reporting System into place after the Challenger
accident. The purpose of it was to address those occasional
cases where an employee does not feel comfortable using normal
open means of communication. Maybe they had a disagreement with
their supervisor and didn't feel they could go any higher. We
put this system in place as a last resort for safety
communications. Since its inception as you heard we have had
680 people who have used it for various reasons, including lack
of communications or disregard for my concern, the kind of
things that we talked about in, today. Those things have been
part of that reporting system over the years.
Mr. Hall. And as my last question, I know my time is up,
you, in your duty to report to the NASA Administrator, you
were, as we would say in Texas, not on the ranch. You were kind
of bridle haltered in that you didn't have the full facts to
report to him because they weren't available to you. Is that
correct?
Mr. O'Connor. That is one way of putting it. Yes, sir.
Mr. Hall. I yield back my time. Thank you.
Mr. Lampson. [Presiding] The gentleman's time is expired,
and I will now claim five minutes for myself.
I want to start with Colonel Bachmann. First of all, I sort
of feel a little bit like what Ralph Hall's comments were at
the very beginning awhile ago. I think I am in so much awe and
hold the Astronaut Corps in such respect that I wonder why we,
it is unfortunate we had to have this kind of hearing. But I
have a great deal of respect, and I know that the astronauts
are committed to their families and to NASA and to our country
and to our communities, and I have a tremendous amount of
respect for everything that they do.
Extent of Alleged Alcohol Abuse
Colonel Bachmann, I know that there are a lot of astronauts
who feel that the reports of alcohol use in your report have
tarnished the reputation of the Astronaut Corps unfairly. As we
have heard today, your report included two instances of alcohol
use that NASA says it was unable to verify.
With all the confusion we have had since the report came
out, I would like to sort of ask you to help us clear the air
and ask just a few questions on that. Does the alcohol, does
the inclusion of the alcohol incidents in your report indicate
your committee thought, indicate that your committee thought
that there was widespread abuse of alcohol in the Astronaut
Corps?
Colonel Bachmann. Sir, as we said in the report and as we
said in the press conference when the report was released, the
committee does not have sufficient information to describe the
extent of alcohol use, alcohol problems in NASA in the
Astronaut Corps. What we had were specific instances described
to us, and we felt not as an underlying alcohol problem but as
an underlying risk communication, human factors problem. And
that the astronauts and flight surgeons were so concerned about
how this information was handled that they brought those to us
as kind of the prime examples, although they had many others.
Those were the ones that were concerning most of them.
Mr. Lampson. How many people on your committee actually
heard reports from individual astronauts regarding the alcohol
use?
Colonel Bachmann. The interviews took place over the space
of several days. The bulk of them took place with multiple
members of the committee in the room. The concerns brought
forward by the flight surgeons, as best we can recall, we had
at least three committee members in the room at the time that
that particular story was told to us, the instance was
described.
Mr. Lampson. How many people were on the committee?
Colonel Bachmann. There are eight altogether.
Mr. Lampson. Eight. And three heard the----
Colonel Bachmann. Sir, I would say at least three. Again,
people were coming and going, but I know that at least three,
if not more. The astronaut described alcohol incident was
described to one member of the committee who brought that
information back to the rest of us, and we discussed it.
Mr. Lampson. What were you trying to say when you included
the two incidents that were volunteered to your committee by
interviewees? Was there--what did you want to try to accomplish
with that?
Colonel Bachmann. Sir, again, we were highlighting the
concerns that the NASA individuals felt, and they used these
particular instances and others, but these particular instances
were of greatest concern to them, that they used as examples of
how significant safety issues did not receive traction when
they were sent forward, that their professional opinions about
the fitness for duty or the ability of the astronauts to do the
task did not receive what they considered to be sufficient
attention.
Mr. Lampson. Do you think that there is any real evidence
to indicate that there is a significant problem with alcohol
abuse in the Astronaut Corps?
Colonel Bachmann. Sir, as we said in the report and during
the press conference, we don't have a sufficient number of
interviews to tell you how pervasive alcohol use problems might
be. The description that we provided of the rules or lack of
rules that governed use of alcohol in the crew quarters or the
lack of a 12-hour rule explicitly defined for space flight, all
have been validated by NASA, and in fact, those were some of
the first actions they took was to institute explicit rules on
the use of alcohol in those settings. So, we believe that makes
the rest of the story more credible as well, the rest of the
situation that they described has actually been validated by
NASA.
Openness of Safety Reporting/Recommendations and Future
Programs
Mr. Lampson. Before he left Chairman Gordon had asked some
questions, and I am going to take the remaining time to give
you an opportunity to answer those. He had said what was your
review panel's basis for making the statement of peers and
staff fear ostracism if they identify their own or others'
problems, and how confident are you that it doesn't represent
just the view of one or two malcontents.
Colonel Bachmann. Sir, the first part of that is how do we
know that these don't represent just an isolated individual or
a collection of individuals, and how do we reconcile that with
the signed letter by it looks like the bulk of the flight
surgeons at NASA. I would have to defer the answer back to the
flight surgeons. In the group of people that told us that story
I am confident that some of the members that signed that letter
saying that they essentially, everything is fine, were present
in the room when the story was told.
So I can't answer how they could tell one thing to us and a
different, and sign a different letter out to NASA.
And as far as the statement about ostracism and issues with
their peers, again, those were the words that the astronauts
and the flight surgeons told to us. Those were not our
interpretation. It is more of a summary, but those are the
words that were used when the NASA people described the issue
to the committee.
Mr. Lampson. I know my time is up, but I am going to take
some of the time that Bart Gordon gave up awhile ago to get his
questions in and answers, and he had gotten down to the point
where he made a statement of, restatement of, ``NASA must
insure that people can identify such safety and performance
concerns within NASA without fear of reprisal or career
injury,'' and asked were you told of any instances where your
interviewees had been subjected to reprisals or had witnessed
other individuals being subjected to them?
Colonel Bachmann. Several vignettes were described where,
and in this particular case flight surgeons described instances
where they brought concerns forward, and they were subjected to
what they called public humiliation. We didn't pursue it
further than that, again, because the point of the issue was
their reluctance to bring things forward because of how similar
issues had been handled in the past.
Mr. Lampson. What does NASA need to do to fix the problem
your review panel discovered? Uncovered?
Colonel Bachmann. I think the most important thing, again,
is for the NASA leadership at the highest levels to clearly
state that they are concerned, and I think they have done that,
and make every effort to get appropriate information that
really will give them a sense for the scope of the issue. Face-
to-face interviews are not the best way to get sensitive
information when people feel their jobs might be at risk or
that they might have other career consequences. That is why,
again, we emphasized the need for a valid and anonymous survey
that is not seen as a mere exercise but actually seen as vital
to the success of NASA's future missions, where people will
feel that they can speak freely.
If it is narrowly scoped or not clear to people that they
can respond without somebody being able to figure out who said
it, I am afraid that you could certainly get a useless piece of
information back. And that is where I think the whole crux of
the follow up to this hearing and this committee's work is to
get good information from all NASA personnel affected by these
issues.
Mr. Lampson. And the folks that I have spoken with, the
leadership at NASA, areas where I have talked I believe that
their commitment is to accomplish that. I think they are, I
hold them in very, very high regard, and I know that they are
concerned about safety and success both at NASA, and I know
that we will be going forward with it.
I have gone way over my time, and I will now recognize Mr.
Neugebauer from Texas. I am sorry. Mr. Bonner. Jo, excuse me.
Mr. Bonner. No problem, Mr. Chairman. Randy is a handsome
fellow.
Mr. Lampson. Neither of you have much hair.
Mr. Bonner. I noticed that when I looked in the mirror this
morning.
Colonel, let me follow up to the answer you just gave the
Chairman, because I think it is timely. Could you expand on any
recommendations that you would like to see that would help
guide NASA in the future toward a development of more adequate
follow-up surveys or questionnaires?
Colonel Bachmann. Yes, sir. In fact, in the Air Force we
have what is called a unit climate assessment that we routinely
do upon taking command of a new organization, and since I have
had the privilege of being a commander for a number of
organizations, certainly nothing as large as NASA, but the
survey is constructed with questions that you can answer on a
one to five scale about how important or less important or
critical or going well. You can give them the scope, you can
put a number, and that actually generates some interesting
data, but the more interesting data as a commander have been
the free text blocks where people can type as much as they see
fit to tell you what they are thinking. And honestly, if you
see a comment made once and you never see it pop up again on
anybody else's survey, that is interesting, and maybe you will
want to go ask some more questions. But if you see similar
issues come up in different voices, all pointing in the same
direction, whether the number scale is consistent with that or
not, you know you have got a problem, and you have to go figure
out what is going on.
And the Air Force at least is, I think from where I sit,
pretty good at keeping the information on who said it pretty
secret. They have rules about demographics. If it asks you if
you are a woman and you only have two, it will hide that
information from you so you can't go figure out who the woman
over 40 was in your unit that said that.
And, again, I would say that the questions need to be
broadly or at least start broad and then they can get as
specific as NASA sees fit, so they can answer specific
questions. Are you aware of alcohol use, you know, in the
immediate pre-flight period so that they were intoxicated when
they went to a vehicle. That is one question. But a much
broader question is are you aware of human factors issues that
you feel didn't get appropriate attention. And then give them a
text block where they can type in as many examples as they can
think of.
So I think there is a science to conducting surveys, and I
am certainly not an expert in that, but there are people who
are, and I think that is who NASA is or should be looking at to
help them build a survey that will get them the information
they need.
Mr. Bonner. As a follow up, and this is really for the
whole panel, how should NASA deal with an astronaut's natural
reluctance to raise health or behavioral issues that they fear
or believe may jeopardize their selection for future missions
or assignments? And especially the two who have gone up. Based
on your experience are your colleagues, are members of the
Astronaut Corps confident that they can raise health issues or
emotional or family problems without fear of jeopardizing their
NASA careers? But it is really open to the whole panel.
Dr. Ochoa.
Dr. Ochoa. I will take that question, and first I would
like to say that I am glad to hear that Colonel Bachmann and I
are on the same page regarding the survey. We are planning a
survey exactly as he has described. It will have a combination
of qualitative and quantitative questions so that people do
answer on a five-point scale as well as have the opportunity to
write in comments in a number of cases.
I have not actually noticed astronauts being shy about
bringing up issues of many different types of natures, but we
want to make sure that they do feel comfortable. We believe
this survey will give us some very good information about that.
We have a number of other programs in place where we
emphasize to astronauts continuously about looking out for
themselves and their crew mates. One of the main programs that
we have is known as either crew resource management or cockpit
resource management, and you probably heard about it from the
aviation industry. But a lot of it is to prevent crew error,
obviously in critical situations, and what they are really
looking at is not skills and knowledge but how do you
understand when you or one of your crew mates may be tired, may
be distracted, may not be feeling well, may be more prone to
make errors. So any time we do a training session where we have
a group of astronauts as a crew training together, the very
first thing that we debrief is the crew resource management.
And so we are always talking about looking out for each other
and making sure that we are working as an effective team.
We also have a program in place called the Expedition
Interpersonal Training Program, which was started several years
ago because we wanted to prepare people for the long duration
missions that they were going to have on the space station and
also beyond. And part of that program we have workshops where
we learn from previous expeditions, not only space expeditions
but Antarctic expeditions, things like that, how people have
dealt with interpersonal issues. We have cross cultural
training since we fly with astronauts from different countries,
and we sent people on outdoor leadership classes with trained
supervisors where they talk about human factors issues. They
talk about leadership styles, they talk about how do you keep a
team going even if there are issues with one or more members of
the team. The astronauts are given verbal feedback from the
experienced leaders of those courses, and then each member of
the team that has gone out and done this course essentially
rates every other team member, sort of anonymously so at the
end of that course each astronaut that has participated has
feedback from every other person that they have been with to
understand how they did themselves and how they are perceived
by others.
Mr. Bonner. Thank you very much. We may have a follow-up
question in writing to get a little bit more specific answer to
the question, but thank you very much for that.
Mr. Chairman, thank you.
Chairman Udall. Thank you, Mr. Bonner. I know we have a lot
of additional questions for the panel, but we got to move to
our second witness, Dr. Griffin. If I might I would like to
pose one question for the record to Colonel Bachmann and also
let you know per the committee rules that any member can submit
additional questions for the record.
Before we broke for the votes, Colonel, I was talking about
your sobering words in the committee report that issues of
cultural and structural are so engrained and longstanding that
it would take senior leadership action to remediate them. I
would ask you to provide the Subcommittee with some specifics
on the type of senior leadership action that you think are
needed. Another way to put it would be what are the most
important three things that NASA senior leadership needs to do
to resolve the problems identified in your report so that we
don't have to have another hearing like this a few years from
now?
So I am not asking you to answer that today, but if you
would just submit your thoughts for the record. I know the
Subcommittee would appreciate it.
Colonel Bachmann. Yes, sir. Will do.
Panel 2
Chairman Udall. Again, I want to thank the panel. This has
been very enlightening. I think I would speak for everybody on
the Subcommittee when it comes to clearly every one of your
commitment to NASA and to having the finest Astronaut Corps
anywhere in the world. We look forward to working with you
further. Thank you again, and at this point I dismiss this
panel, and we will ask Dr. Griffin to join us up at the table.
Dr. Griffin, thank you for joining us. I don't think the
good doctor needs an introduction of any length. We all know
his talents and his commitment to NASA and his many, many
successes. Thank you for joining us, and the floor is yours for
as long as you need it, Dr. Griffin.
STATEMENT OF DR. MICHAEL D. GRIFFIN, ADMINISTRATOR, NATIONAL
AERONAUTICS AND SPACE ADMINISTRATION
Dr. Griffin. Mr. Chairman, Ranking Member Hall from the
Full Committee, Members, thank you very much for--Mr. Feeney,
Members of the Committee, thank you for inviting me here today.
I do have to admit I wish it were under better circumstances.
We all recognize that the behavior that led to the arrest
of former astronaut Lisa Nowak, the murder of NASA engineer
David Beverly in his office at the Johnson Space Center, and
this recent report by a panel of outside experts containing
allegations of improper use of alcohol by astronauts has shaken
public confidence in NASA.
NASA is an institution comprised of our nation's best and
brightest, an institution responsible for carrying out one of
the noblest missions of our Government and our nation.
The personal conduct of NASA's workforce, including our
astronauts, must be of the highest standards, beyond reproach,
and day in and day out we do indeed demonstrate just such
professional excellence and dedication to our mission.
But in the face of the allegations and adversity which we
have encountered recently, we must ask and answer hard
questions, and we have done that. The case of former astronaut
Nowak is a matter for the courts to decide and is not an
appropriate subject of comment for me here today.
But as a direct result of that unfortunate incident we did
last February begin an in-depth review of how we might better
provide for the behavioral health of our Astronaut Corps. Shana
and I asked Dr. Richard Williams, NASA's Chief Health and
Medical Officer, to organize a committee with membership
external to NASA and having aerospace or having expertise in
aerospace medicine and psychiatry to review the medical and
behavioral health services provided to our astronauts.
We sought external advisors because we were concerned that
we might have missed something with which others in the field
with experience outside of NASA were more familiar. This review
committee, chaired by Dr. Bachmann, Commander and Dean of the
U.S. Air Force School of Aerospace Medicine, provided me with
their final report this past July.
Now, the report contained numerous findings and
recommendations, many of which will be useful to us as we go
forward. Without question, the portion of the report which has
received the most attention was the citation by the panel of
certain allegations of improper use of alcohol by astronauts
preparing to fly, and further, that concerns expressed by
flight surgeons on this point had been ignored by NASA
management.
Now, given the seriousness of these allegations, the only
responsible action we could take was to investigate them.
Accordingly, Shana and I asked NASA's Chief of Safety and
Mission Assurance, Bryan O'Connor, from whom you just heard, to
conduct a careful examination of claims that astronauts had
been impaired by alcohol in the immediate pre-flight period, as
well as claims that management had not been responsive to
concerns by flight surgeons and others about astronauts'
fitness to fly.
As you have heard from Bryan, his extensive review found no
evidence to support the claims that any astronauts were ever
impaired by alcohol at launch time. Further, NASA's flight
surgeons have voluntarily--I would say the bulk of NASA's
flight surgeons have voluntarily put their names on a
communication to Bryan saying that they had no evidence of
impairment by astronauts on flight day, nor any instance of
their concerns to management being disregarded, which has been
the subject of earlier discussion.
We take and I take these allegations very seriously, just
as we would any issue that could impact the safety of our
missions. But at the same time I have also said that the story
cited in the reports seem improbable to those of us familiar
with the astronauts' rigorous and very public activities in the
hours leading up to a space flight.
I personally began working with our astronauts more than 25
years ago, and I know many former and current members of the
corps as valued colleagues and personal friends. The cited
allegation of alcohol impairment prior to flight is simply not
in accord with the behavior that I have personally seen from
our flight crews.
Now, this allegation aside, the committee put substantial
time, thought, and effort into their report. They really did,
and we are grateful for their service in helping us to make
NASA a better agency, and we are taking action to address the
other concerns and recommendations from their report, which we
believe will improve our astronaut health care procedures.
I have enumerated the actions we are taking in response to
this report in my written testimony to this committee. One of
those is that NASA's Astronaut Office is developing a formal
code of conduct that will outline the professional standards
expected of members of the Astronaut Corps.
Now, Chairman Udall and other Members of the this
subcommittee, you will recall that many concerns about NASA's
culture were expressed in both, in the aftermath of both Space
Shuttle Challenger and Columbia accidents, and there were
indeed unfortunate similarities in how those accidents
occurred. A common theme was the reluctance of senior managers
to listen to and evaluate carefully concerns expressed by
subordinates.
Nothing is more important to me than this matter. I have
established as a non-negotiable criterion for management at
NASA starting with those who report directly to me, that we
must not fail to listen respectfully to our people. We must not
fail to investigate and adjudicate the concerns which they
express. We must not fail to act if necessary.
In today's NASA with the approach we have taken to
implementing the recommendation of the Columbia Accident
Investigation Board, to provide independent technical authority
at NASA, every employee has at least two independent pathways
which they may use to bring forth concerns to upper management.
I have made the point on numerous occasions that there will be
no retribution for employees at any level who bring forward a
concern, that there will be praise, and that there will be
respectful treatment of the concern, and it will be
adjudicated. I believe that this is a matter of trust, and that
this trust has been kept.
Now, I must point out that respectful treatment of an
opinion does not necessarily imply a decision in one's favor.
Any argument or dispute which reaches NASA managers has at
least two people and almost always more who disagree, and it is
not possible to decide in favor of all parties. But it is
possible to provide all parties with a careful and respectful
hearing, and that is what I seek for our agency.
Again, this is a matter of trust, and that is the culture
change which I believe was needed and is occurring at NASA.
Now, one cannot prove a negative. I cannot prove that no
one at NASA is afraid to speak up, but I hope that that is not
the case, and I will use this forum to ask once again anyone
who is watching this testimony, if you have a concern, please
come forward, directly to me if necessary, and if necessary, I
will protect your identity, but I must have facts, if they are
out there, in order to make decisions.
Mr. Chairman, in this and many other ways we hope to
restore any loss of public confidence in NASA that may have
resulted from these unfortunate incidents.
Thank you.
[The prepared statement of Dr. Griffin follows:]
Prepared Statement of Michael D. Griffin
Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to appear today to discuss NASA's Astronaut Medical and
Behavioral Health Care Program, and the report of the Astronaut Health
Care System Review Committee, released on July 27, 2007. In the wake of
the recent incident involving former astronaut Lisa Nowak, I directed
NASA's Chief Health and Medical Officer, Dr. Richard S. Williams, to
conduct a review of the medical and behavioral health services
available to NASA astronauts at the Johnson Space Center in Houston,
Texas. My goal was to determine whether the incident may have been in
any way foreseeable by those entrusted with the care of NASA
astronauts. I hoped to learn whether the screening and evaluation
procedures that the Agency employs for astronaut selection and
assignment are as effective as they can possibly be, and whether the
physical and mental health systems we have in place to support the
Astronaut Corps are serving their intended purpose to the maximum
possible extent.
In addition, Mike Coats, Director of Johnson Space Center (JSC),
led an internal review that outlined and evaluated JSC's extensive
health care programs for our astronauts, which includes their
behavioral health, and recommended improvements to those programs,
which we have already implemented. A more extensive behavioral health
assessment will be added to annual flight physical examinations for all
astronauts. We also are emphasizing the importance of behavioral health
support to Shuttle crew members, and offering time with behavioral
health providers before, during and after flight. And, we are committed
to improving the quality and usefulness of our psychological testing
and assessment during astronaut selection.
The Review Committee convened by Dr. Williams was comprised of
eight representatives of other federal agencies, highly experienced in
the disciplines relevant to aerospace medicine and mental health,
including a former astronaut and medical doctor. The Committee was
chaired by Air Force Colonel Richard Bachmann, Commander of the U.S.
Air Force School of Aerospace Medicine, from whom you have already
heard today. I wish to acknowledge the commitment of time, effort, and
dedication to the task put forth by Col. Bachmann and the members of
the Review Committee in conducting their review and providing their
report.
The Astronaut Health Care System Review Committee's report provided
a number of recommendations that we believe will clearly improve our
ability to provide comprehensive medical and behavioral health care
support to the Astronaut Corps. Dr. Williams and his staff at both NASA
Headquarters and the JSC, with the assistance of NASA's Medical Policy
Review Board, have begun the process of implementing enhancements to
NASA's Medical and Behavioral Health Care Program. We believe these
enhancements will contribute in great measure to ensuring a continued
history of stellar performance by the Astronaut Corps, while addressing
gaps in support that have been identified by the Review Committee.
Today you have heard Dr. Williams describe some of these improvement
plans and efforts.
The Review Committee's report also contained findings that were
based on anecdotal information provided to the Committee by
unidentified personnel at JSC. These findings, which have received a
particular focus of attention from the media, allege instances of
alcohol abuse by astronauts on active flight status, and further, cite
faults in communication between astronauts, their medical support
professionals, and their management. The specter of problems with
communication pathways between critical elements of the flight safety
support team is a very serious concern, and one that I take seriously.
Given the need for further information on which to make assessments
regarding these findings, I asked Mr. Bryan O'Connor, NASA's Chief of
Safety and Mission Assurance, to conduct an investigation into the
anecdotal statements in the report related to astronauts being impaired
by alcohol in the immediate pre-flight period and claims of management
not being responsive to concerns by flight surgeons and others about
astronauts' fitness to fly. Today you have heard Mr. O'Connor provide
details of his investigation and findings. After reviewing 20 years'
worth of records and interviewing scores of NASA personnel who are
personally involved in, or witness to, the critical path for astronaut
flight safety in the hours before launch, Mr. O'Connor was unable to
find any evidence to support the claims that astronauts were ever
impaired by alcohol at launch time. In fact, NASA's flight surgeons
have placed their names on a communication saying that they have no
evidence of alcohol impairment by astronauts on flight day, or any
instances of their concerns to management being disregarded. I have
stated previously that NASA takes these allegations very seriously-just
as we would any issue that could impact the safety of our missions.
But, at the same time, I also have said that the stories cited in the
report seem improbable to those of us familiar with the astronauts'
rigorous and very public activities during the hours leading up to a
space flight.
Nonetheless, I remain highly cognizant of Mr. O'Connor's forthright
acknowledgement, both in his summary findings and in person, that his
investigation was conducted within limitations regarding anonymity, and
that, in spite of overwhelming indicators that such behaviors could not
occur without undue notice or redress, he cannot report conclusively
that the incidents reported to the Review Committee did not happen.
Therefore, it is only prudent that NASA move forward with purpose to
close any gaps in policy and process, and take action to ensure that
such occurrences and the possible risks that they could engender, do
not ever become validated fact. I view the findings and recommendations
provided by Col. Bachmann and the Members of the Review Committee as an
opportunity for NASA to apply rigor and raise the standard for
performance in teamwork and communication among its astronauts and
their medical and behavioral flight safety team and operational flight
safety personnel.
To achieve these goals, NASA's Medical Policy Board, made up of
senior internal and external medical experts, is working with NASA's
medical managers to determine how many of the changes and initiatives
advocated by the Review Committee would fit into NASA health care
procedures in a way that improves their effectiveness. We have accepted
the report's recommendations concerning analysis and use of behavioral
health data to improve selection criteria, and will convene expert
working groups to advise us on any changes to our psychological
testing. NASA is evaluating the overall delivery of behavioral health
services to astronauts and is planning additional training for flight
surgeons in behavioral health assessments. As I have noted above, we
will add behavioral health evaluations to annual flight physicals for
all astronauts and we will strive to ensure better communication
throughout the astronaut health-care system. We will work to ensure
that astronauts understand fully the nature and purpose of all health
related testing and data collection. We are re-evaluating our
electronic medical records system to assure maximum utility and
security of private medical information. Further, we are examining
policies for assuring the quality of care we arrange for our astronauts
by outside medical providers to determine if changes are needed.
Importantly, we are working to ensure that everyone in the astronaut
health care system understands the multiple pathways which are
available to raise any health and safety concerns.
America's astronauts have always operated with the knowledge that
much is expected of them in many areas, including personal conduct. But
until now, these expectations and standards have not been codified into
an official document. The JSC Astronaut Office is developing a formal
code of conduct that will be a document outlining the expectations for
this highly skilled group of professionals. To address organizational
culture issues discussed in the report, NASA will conduct a number of
internal assessments, including anonymous surveys to be completed by
astronauts and flight surgeons, to provide feedback and gather
information that we will use to improve communication and ensure that
leadership is responsive to concerns and complaints, particularly those
involving flight safety.
I am confident that the comprehensive slate of actions that is
underway for improvements and enhancements to NASA's Medical and
Behavioral Health System will yield a program capable of delivering the
highest possible level of support to the Astronaut Corps and ensuring
its continued unsurpassed performance. I am particularly proud to be
making these statements today in the wake of another such demonstration
of personal, professional, and technical excellence provided by the
crew of the Space Shuttle Mission STS-118, which landed safely on
August 21, 2007, after a very successful mission. In addition to adding
a new segment to the International Space Station, successfully
navigating demanding spacewalks, and delivering needed supplies to the
Station, the crew and their NASA colleagues on Earth provided a fully
validated example of the superb ability of the NASA team to communicate
and engage in critical technical dialogue across disciplines to support
educated decision-making in the face of real-time challenges. And to
top it all off, through the efforts of Educator-in-Space Barbara
Morgan, America's students were offered new and focused interactive
opportunities to share in the excitement of this ongoing endeavor. This
is the positive story that often takes a back seat to the sensational
in news reports, but a story that I am honored to point out on behalf
of the NASA Astronaut Corps and the teams of technical professionals
that support them.
I would once again like to thank Col. Bachmann and the members of
the Review Committee for their efforts. I would like to reassure the
members of the Review Committee that, while much media attention has
been given to the allegations relating to alcohol use, I and other NASA
managers are giving the entire report the full and complete attention
it deserves. We appreciate their interest in helping us to make NASA a
better agency.
Again, thank you for the opportunity to appear before you today. I
would be please to respond to any questions that you may have.
Discussion
Chairman Udall. Thank you, Dr. Griffin, Administrator
Griffin.
I know the Subcommittee would now like to turn to some
questions, and the Chair recognizes himself for five minutes.
You talked about the recommendations in the report and your
intention to implement them. Do you have a timeline of which
you are operating when it comes to the implementation?
Implementation of Recommendations
Dr. Griffin. Well, I don't know by what date Dr. Williams
plans to bring recommendations or an assessment back to Shana
and I. He probably does. My own view is that this is both
important and urgent, but it is more important to get right
than to get done quickly. It is important that we treat this
advice as we, as respectfully as we treat all advice from our
advisory panels, whether of permanent standing such as the NASA
Advisory Council or the Aerospace Safety Advisory Panel or ad
hoc as was this panel. It is important that we treat their
advice respectfully and that we evaluate it carefully, while
nonetheless recognizing that at the end of the day you and
other oversight committees and committee chairmen hold NASA
responsible for our actions.
So we will evaluate the recommendations carefully. We are
already of a mind, as I have said several times, to accept most
of them. We will report to you any disagreement between the
recommendations we choose to accept and those that we possibly
think are not a good idea, and we will discuss. We will report
back to you on the implementation, how the implementation is
going.
And we will do it as quickly as we can do it and yet do it
well.
Chairman Udall. Thank you for that straightforward answer,
Dr. Griffin.
I would like to turn to the committee's--the external
committee's recommendation, in particular about carrying out a
thorough anonymous survey that is carefully worded to obtain
valid factual information. And Dr. Griffin, from the testimony
of Dr. Ochoa and others it sounds as if NASA's prepared to
conduct such a survey.
Dr. Griffin. I cannot wait to do that.
Chairman Udall. And it is not clear to me, however, that
NASA has a lot of experience in crafting that kind of a
carefully-worded, thorough survey that Colonel Bachmann
recommended.
Could I ask you if NASA is planning to have a proposed--
this proposed survey reviewed by any external organization that
has expertise in this area, and if that isn't your current
plan, would you be willing to do so in the interest of insuring
that NASA gets the best survey possible?
Dr. Griffin. I believe that Ellen expressed her agreement
with Colonel Bachmann on all the points regarding the survey,
and yeah, of course. We will craft what we think is the right
survey, and we will have it reviewed by external experts in
this matter to make sure that it is a well-done survey. In the
course of pursuing my studies for an MBA I had one course in
market analysis, and I feel that I am, if that course served no
other purpose, it served to sensitize me to the way in which
results purportedly obtained from a survey can depend on how
the survey is worded and what the sampling environment is and
who the target sample audience is.
So I join Colonel Bachmann in declining any expertise in
this matter except to know that it is fraught with concern, and
we will be very careful.
Chairman Udall. If I could editorialize briefly knowing
what I know of your private sector experience, I think you
learned a lot more from that class than you suggest given the
successes you have.
Dr. Griffin. Well, I didn't drive anybody into bankruptcy
if that is what you mean. So I will take that as an up-check.
Chairman Udall. Be careful. We may get you involved in the
sub-prime lending solutions.
Final question, Dr. Griffin. The independent review noted
that employees said if they were concerned about coworkers'
behaviors, they would raise concerns with a co-worker,
management, or flight medicine official. However, the external
reviews you have heard report notes that the flight surgeons
were demoralized because their concerns were not valued. Do you
have any specific plans at this point to do anything about this
apparent disconnect?
Dr. Griffin. Well, we, I mean, I do. Much of it will have
to be, will rely, again, I will use this forum to emphasize if
anyone has a concern, please use, I am sorry, NASA Safety
Reporting System to write it down and send it in. Your
anonymity will be protected. If anyone at NASA is concerned
about an immediate supervisor or a supervisor's supervisor,
then, and that concern exists, bring it to me. Many do so. My
inbox stays full, and I don't think there is a person out there
who can report back that a concern which was expressed to me
was not dealt with, meaning, let me avoid the double negatives.
I do deal with any concerns brought to me. I try to follow up.
Less formally than those mechanisms, I talk regularly,
periodically with, I visit with our flight docs as I am at
flight readiness reviews and Shuttle launch operations. I hope
that it is clear to our flight surgeons as it is clear to our
engineers and our scientists that not only do I want them to
feel free to speak up, but they have an obligation to do so.
In fact, at this point I have to insert a concern. If we
have people at NASA in today's environment who believe that
they can't speak up for fear of retribution or ostracism, then
I would urge them to go that extra mile and speak up, because
that is their obligation. I need people working for NASA in
this most demanding of environments where we launch people or
hundreds of millions or billions of dollars of hardware into
space, to work in this most demanding environment requires
much. And it requires that people have the courage to bring
forth their concerns through a management chain which has
stated openly over and over again that you will receive a
hearing.
I think our actions as a management team over the last two
and a half years have supported that. When I came on board, one
of the very first things I had to do was to delay a Shuttle
launch that I desperately wanted to go. I had to delay it by
several months because some engineers expressed to me their
concerns that we had not done an adequate job of calculating
all the debris trajectories, particularly ice debris and
particularly off of a lock's feed line. So we did that.
Then I had to address a few months later a concern by some
of our Earth scientists or some community Earth scientist who
felt that their research was being modified for public release
or that their concerns were not being appropriately heard, and
we got all over that. And I made it clear in an extraordinarily
clear written policy that the purpose of scientific and
engineering investigation is to get a truth, and we do that
through argument, through public discourse.
There have been other opportunities to address criticisms
of lack of openness at NASA and concerns over retribution, and
in every single case we have taken the side of open discourse,
and I will do it again here. So if there is anyone at NASA who
has a concern, bring it forward. I need to hear it.
Chairman Udall. Thank you, Dr. Griffin. I want to recognize
the Ranking Member, but before I do, I did want to, in the
context of a serious and important and substantive hearing
today, comment positively on the process by which the situation
with Endeavour was considered. I think it demonstrated the
cultural changes that outside and internal groups have
recommended, and perhaps it is the model also for what we are
trying to do here, which is to drive some changes in how we
manage the Astronaut Corps and how behavioral, medical problems
but also potential upsides are reinforced and supported.
Dr. Griffin. I think that process was NASA in action at its
finest, and we did not launch with unanimity. Some engineers
disagreed that the tile should fly, should re-enter and that a
repair was needed. Others felt that it was fine. I personally
heard all of the arguments on that matter, and we decided to
fly, and that was the right decision as it turned out. But the
people who felt we should not reenter that way were certainly
not ignored or disregarded.
During that same launch operation I had lunch or I had many
occasions to visit with flight docs, and I asked one of them
privately, is there any possible way that you would feel a
concern or an issue in bringing forth a concern, and the
gentleman laughed at me and said, you are worried about a
medical doctor bringing forth a concern. You know, this
particular gentleman said I have no respect for a medical
doctor who has a concern and fears that his job is in jeopardy.
That was an anonymous conversation, and it will stay
anonymous, but there is a point there.
Chairman Udall. Thank you. The Chair now recognizes the
Ranking Member, Mr. Feeney, for five minutes or whatever time
you----
NASA Safety Culture
Mr. Feeney. Well, I will try to keep it to five. Thank you,
Mr. Chairman.
And, again, I think this is an important hearing to clear
the air, number one, and get this behind us, and number two, to
improve any procedures that we can undertake that will help us
improve, and I think that you have taken it in that spirit. And
I want to tell you, you said more than once in your testimony
that in the light of Nowak discussion or the Nowak incident and
the discussion about astronauts flying while they may have been
intoxicated pre-flight, that there has been a loss of
confidence in NASA.
I really don't sense that, and I can tell you, I haven't
lost an ounce of confidence in NASA or in you. I am confident
that in complex organizations that have the most complex
obligations and challenges that things are going to go wrong,
and sometimes they will be technical, and sometimes they will
be human factors, and sometimes they will be bad luck. But this
is modern day America, 24/7 news, and bad luck doesn't happen.
Everything is somebody's fault, and I think you are learning
that, Dr. Griffin.
So like it or not, we are where we are, and I want to tell
you I sympathize with how frustrating it is, because there were
some specific anecdotes in the Bachmann report. By the way, I
don't dismiss anything about the Bachmann report. I don't think
you have either.
Dr. Griffin. Nor did I.
Mr. Feeney. Very credible people that I think undertook a
very important mission, but the specific incidents that have
made such news can't be documented or corroborated. And the
more general allegations, it is a cultural problem that needs
attention from the top senior leadership.
Fighting cultural problems is a little bit like shadow
boxing, because I think that your administration has undertaken
to change the culture of that reporting. And like I said, I
witnessed the one incident live as we watched a Shuttle go off.
But I guess in light of the fact that my goal is to go forward,
I think that is what the Chairman of the Committee wants to do,
it is what most of us want to do, and improve constantly the
operations of NASA. And I am glad that we have had focus on
this physiological, psychological, and physical well being.
The recommendations for the most part are not at issue that
the Bachmann committee has made, but what is at issue is
whether or not there is a cultural problem here. I mean, the
last thing that the Colonel told us is that we need to fix the
communications problem, and yet you and Dr. Ochoa and Dr.
Williams and Mr. O'Connor, have said there are multiple avenues
independently, anonymously that have been set in place in NASA
in the last few years. And that includes flight surgeons or
astronauts that have concerns about human safety.
So I guess the question I have is the Bachmann report
suggests there is a cultural problem which is decades old
involving communications about human well being. I am hearing
from the NASA team unanimously that you do not believe that to
be the case, even though you have adopted the recommendations
or most of them about how to fix that communications problem.
Can you address that? Because why are we fixing something
that is not broken I guess would be a simple way to ask that
question.
Dr. Griffin. And as the Administrator, actually, that is
the most important question for me. There is, I mean, I think I
have made it clear, and if anyone doubts my word, then I guess
they do, but there is nothing more important to me in an agency
like NASA than having an open, free, non-political discourse on
difficult topics. Because what we do is not easy. We have to
work very, very hard to get it right, and we don't always do
that. But when we get it right, when we decide what we think
the right course of action is, we should pursue that no matter
what. And we only arrive at that through extensive and open
discourse by all parties.
And I believe in that. Now, if we have had in the past
cultural problems and we are trying to fix those, I can't
guarantee that they are completely fixed. I can only, again,
entreat people to trust this management team. I believe it when
Colonel Bachmann says that the fact that people are willing to
speak anonymously and not willing to speak face to face on the
record is itself a problem. Yes, it is.
At the same time, I have no mechanism to deal with the fact
of somebody saying, I have a concern, but I am afraid if I
speak my concern that I will be ostracized, so I will keep it
to myself. I mean, you can see the logical conundrum there.
So all we can do is, again, create a record, create a
longstanding record of responding fairly, respectfully,
positively to any concern brought to us and hope that that
record of behavior will bring forth further behavior of the
type that we seek. That is what I am desperately trying to do.
Mr. Feeney. Thank you. I will yield back, Mr. Chairman.
Well, just briefly, and it is very hard sitting here to
tell, either the Bachmann report was correct, that multiple
witnesses consistently said there is a communications,
intimidation factor, or what the NASA team, including you and
the folks that testified before you, have said that you have
done everything reasonably possible to fix it, and you are
encouraging people. The recommendations that the committee
made, whether the communications system now works as well as it
can or not, will they do any harm if you adopt their--is it
going to add new bureaucracy costs, or will, do you think those
recommendations will enhance human safety regardless of whether
there is a communications problem?
Dr. Griffin. Well, our Medical Policy Board just looked at
those issues and expressed an early view that our response to
those recommendations being generally accepting of them was a
good thing, and I support that view. I certainly don't think
that they will do any harm. Yes, if we add additional process
and procedure there is an opportunity cost of that. That means
that some other activity of lesser importance will not get
done. We will try to be judicious about that, and we will try
not to impose a bureaucracy in our health care system.
But because communication is the sine qua non of all
organizational management, we must invest in improving
communication if, in fact, there are issues. I don't believe we
have the issues that have been raised, and I have said that,
but I am prepared to have my belief overturned by facts. I
absolutely am. I can assert to you beyond question that my
face-to-face communications, my telephone communications, and
my e-mail communications are filled up with people who do not
find me too intimidating to talk to.
But, of course, I can't identify those out there who find
me too intimidating to talk to and thus are reluctant to
express their opinion. So we will continue to work on
encouraging open communications.
I believe in and I love this agency. I love this
enterprise, you know. I love these people that we work with,
and we want to make it as, the best that it can possibly be. I
have never worked with finer people, and we have engaged in the
process of launching folks into space or the folks who go into
space. I have never worked with finer people. They are not
perfect, and by the way, I am not perfect either and trying as
hard as we can to get this right.
It is most difficult in the softer areas. If you want to
ask me about the thermal margin on a tile, I can deal with
that, probably until you fall asleep. If you want to ask me how
do we know we have the best possible communications processes,
I don't know. It is very hard, but we are trying.
Mr. Feeney. Well, a great philosopher, Woody Allen, once
said that 90 percent of life was just showing up, and what you
are telling people if they have got problems with NASA issues,
technical or human factors, they have got to show up.
Dr. Griffin. Please show up. The decisions are made by the
people who show up.
Mr. Feeney. I will yield back, Mr. Chairman.
Chairman Gordon. Mr. Hall is recognized.
Mr. Hall. Mr. Chairman, thank you.
I am a little disappointed in your testimony, because you
have always indicated to me that you were perfect.
Dr. Griffin. Don't tell my wife.
Anonymity and Authenticity of Reported Incidents
Mr. Hall. Right. Seriously, you know, you have to use the
information you have, and you are not going to discard any of
it because you need it. You need to know what the facts are,
and you will run down every fact if I know you very well. I
guess I can just cut mine short by saying when there is no
degree of authenticity and no completely confirmed testimony,
coupled with a cry or a whimper of anonymity, they don't want
to be, know who they are, they are afraid they will lose their
job, when you got that type witness compared with a witness
such as yourself and this panel of every one of these people
that are testifying, and you could testify under oath because
we could require that, and you would be willing to. And the
testimony is going to be read by the 435 members of the United
States House of Representatives and the hundreds of their
staffs over there and by millions of people that listen to you
call them forth to come forth and give me that information.
Not much else you can do, is there?
Dr. Griffin. If there is, I really wish someone would
suggest it to me, because I would try it.
Mr. Hall. Well, you can sure remember that there is a
difference in the authenticity of a guy who says I am going to
tell you this, but you can't tell anybody who told it and be
sure and don't tell them I work for them, and a guy that steps
up there and then tows the line and tells you what the facts
are and leaves you to make that decision. You are not so unfair
that you would fire a guy that gave you news that you didn't
like or shoot the messenger, are you?
Dr. Griffin. No. I truly, I would like to assert, and it is
an assertion, but I believe it can be backed up that I believe
that I am and that the management team I have hired consists of
people who can hear bad news, act on it, and deal with the
truth and not punish the messenger. I believe that is what we
have in place at NASA. If someone else believes to the
contrary, then, again, I would like to hear about that, because
I will fix it.
Mr. Hall. You are in the same situation of Mr. O'Connor
when he said I cannot conclusively--cannot say conclusively
that none of the incidents reported to the committee ever
happened, however, I was unable to verify that they did. And
you have to have verification, don't you?
Dr. Griffin. That is correct, sir.
Mr. Hall. And you have a Chairman here, Mr. Gordon, you had
the Chairman of the Subcommittee that have expressed their
belief in you and belief in the system and belief in the men
and women that go at great peril into a fragile mission that is
still fragile. I don't care what anybody says, and carry it out
for us. Those are the people you want to believe and that you
have to take testimony from, that you can rely on.
I yield back my time.
Chairman Gordon. Thank you, Mr. Hall, and Mr. Griffin or
Dr. Griffin, I thank you and all of the witnesses for your time
today. I apologize for the musical chairs. We have had
different meetings going on.
Let me just quickly conclude. Once again, complimenting you
and congratulating you on a successful Endeavour mission. I
think it once again proves that when things work you, you are
brilliant.
Charter of the NASA Astronaut Health Care System Review
Committee
Let me just quickly quote some conclusions from the earlier
report. ``Many of the cultural and structural issues identified
in this report as problematic have existed for many years, and
some of them have existed since the earliest days of the
astronaut program. The current medical and operational
leadership at NASA inherited most of the cultural and
structural issues identified in this report. These issues are
also engrained and longstanding and that it will take senior
leadership action to remedy them.''
To some extent it puts you in the position of having the
push the noodle from behind. I know that is difficult. You have
said all the right words today, and you meant it, and you were
sincere about your openness. You do have to keep in mind,
though, a lot of folks don't report directly to you, and so you
know all of this. We don't have to go through that.
So let me just once again say that I was pleased with Dr.
Williams' testimony, and I am sure he is going to get back to
us on those, you know, what will be done and what won't be
done. That will be very helpful.
I guess I will have to say why did you, or ask you why did
you so narrowly define Mr. O'Connor's mission as to only
inquire about alcohol abuse on the day of the mission rather
than what I think are the more, and I think everybody here, you
know, the larger issue of an openness and a feeling of comfort
with the folks involved, being able to come forward?
Dr. Griffin. Well, there is a bit of a misperception there.
Bryan did as part of his charter ask also of each and every
flight surgeon, have you felt uncomfortable coming forward? Do
you feel comfortable coming forward? So that was part of it.
Now, the restriction to dealing with alcohol abuse in the
immediate surroundings of a flight, distinguishing between
urgent and important was the most urgent aspect of all of this,
because that is an actual flight safety issue. Colonel Bachmann
pointed out the sad truth that we are all flawed human beings,
and that many very highly-accomplished people do have problems
with relationships or problems with alcohol.
But if there were to be, and I am not saying that there is
because I have not seen it, but if there were to be an
astronaut who had a problem with alcohol but managed to
suppress that problem in the immediate flight environment, we
would not have a safety or flight issue. Whereas if somehow
someone managed to show up impaired for a flight, that would be
a safety problem.
So with the limited amount of time to get on top of the
more urgent issues, we asked Bryan to focus on dealing with
those things which had been specifically raised in the report
that I felt as Administrator absolutely required an early
investigation.
Now, we have other things going on. We are not ignoring the
other aspects. You heard Ellen Ochoa talk about the survey. We
absolutely accepted that recommendation. As I said, I can't
wait for the results of that survey. I want to know. We have
re-emphasized NSRS. We, I have made person and public appeals
for any concerns to be expressed with promises of protection
for those expressing the concerns. So we are not ignoring the
other aspects, but the most urgent thing was to deal with
immediate safety of flight issues that potentially have been
raised by that report. And that is what I asked Bryan to do.
Chairman Gordon. I just read it differently. I read the
alcohol problems as isolated in the past and that he said that
the bigger problem was lack of comfort by surgeons and others
to be able to come, medical surgeons to be able to come
forward, whether it is a diabetes problem, you know, whether it
is a migraine headache that day, whether, you know, again, you
know, we saw the accident two different ways. I thought he
raised other issues that were more important, but I think that
through this anonymous and Dr. Ochoa, I congratulate you on
moving forward with that, and Dr. Williams, again, I think you
have a good plan, and I think simply by raising this issue in
an uncomfortable way for you, unfortunately, that it will
probably do more good than anything you can do to put people on
notice that these problems that you inherited need to be, or
potential problems that you inherited need to be changed.
And I, again, thank you for your candor, for your service
to the country, and for another successful flight. And this
meeting is adjourned.
Dr. Griffin. Thank you, sir.
[Whereupon, at 12:27 p.m., the Subcommittee was adjourned.]
Appendix:
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Answers to Post-Hearing Questions
Responses by Colonel Richard E. Bachmann, Jr., Chair, NASA Astronaut
Health Care System Review Committee; Commander and Dean of the
U.S. Air Force School of Aerospace Medicine
Questions submitted by Chairman Bart Gordon
Q1. In the lead-up to the findings and recommendations of the report,
you note that many of the cultural and structural issues in the report
have gone on for many years. Could you be more specific on cultural and
structural issues that are problematic? What was the basis for that
overarching finding?
A1. With regard to cultural and structural issues, the Committee was
referring to the dominance of science and engineering perspectives
(over medical and human factors analysis) within NASA and an
organizational structure that places the Astronaut Board and the NASA
research and engineering sciences in a position of vast empowerment as
contrasted to the NASA medical organization. Astronauts select those
who become Astronauts, perpetuating pre-existing perspectives and
potential biases. Committee members reviewed the detailed reports of
the Challenger and Columbia mishaps, as well as the Institute of
Medicine Report (concerning the challenges posed by long duration space
exploration missions). Many of the concerns raised in the Committee
report echoed the findings of those reports, suggesting to the
Committee that the cultural and structural issues were longstanding.
Q1a. The report states that ``these issues are so ingrained and
longstanding that it will take senior leadership action to remediate
it''? What actions should NASA senior leadership take?
A1a. As previously discussed, NASA should administer a well-
constructed, anonymous survey to determine the extent of the issues
identified to the Committee during the interviews. Next, NASA senior
leadership should initiate efforts to emphasize the importance of human
factors awareness starting with workplace functional areas in such a
way that appreciation of human factors concerns is vastly elevated from
the current state. Committee members were told that it was common for
NASA engineers to estimate that the likelihood of a human factors
related contribution to an adverse event was ``zero.'' While the
Committee recognized that the NASA Astronaut selection process was one
of the most rigorous in the world, selection of outstanding individuals
simply cannot eliminate human vulnerability, particularly when under
great stress. NASA leaders should instill concerns for mutual support,
recognition of signs of stress or interpersonal strain, small unit
empowerment to pursue those signs of stress or interpersonal strain,
and an aim to intervene early with an effort to head trouble off early,
with an effort toward avoiding interpersonal crises such as occurred
with former Astronaut Lisa Nowak, rather than conducting damage control
after the fact.
Q1b. How do the issues on NASA's culture that were raised by the
committee's assessment compare with the cultural environment of the Air
Force, Navy, or other high-risk operations?
A1b. Within U.S. military flying organizations there is a greater
appreciation for the possibility of adverse human factors degrading the
performance of aircrew, resulting in increased risk of mishap,
potentially to a point that those human factors issues become causal or
contributory to a mishap sequence. Certainly military flying units
pride themselves in mission accomplishment and take substantial risks
in training and in operational flying. Commanders and leaders of
military flying organizations appear far more concerned with the
potential impact of unchecked human factors than their NASA
counterparts. NASA rightly assumes they have selected the very best and
brightest personnel. To the Committee, NASA appeared to be
overestimating the durability of that selection process with resultant
complacency concerning human factors. Within military flying
organizations much time, energy, and attention is given to the aviator
showing possible signs of performance decrement owing to a troubled
marriage, recent disappointments, repeated time away from home (owing
to deployments), etc. Every interview of NASA personnel conducted by
the Committee encountered observations of NASA personnel that all of
those matters were the cost of doing business and the solution was to
``suck it up and press on.'' Four experienced military flight surgeon
Committee members were alarmed at the voiced under-appreciation for the
possibility of a human factors related catastrophe.
Q2. Do you believe that NASA's plans to include a behavioral
assessment at the time of an Astronaut's annual physical exam as well
as NASA's plans to include a behavioral assessment after short-duration
flights will identify what you testified as ``individuals that have
problems with alcohol. . .problems with marital relationships, with
money'' or other problems that could lead to behavioral or performance
risks?
A2. It was the Committee's opinion that NASA's planned annual and post-
mission assessments of psychosocial and behavioral factors is a major
step in the right direction. Astronauts may still be highly reluctant
to candidly communicate relevant human factors concerns if they fear
removal from space mission eligibility as a result. Several NASA
personnel interviewed expressed their personal belief that NASA had
become a ``one-mistake'' organization--meaning one more fatality and
the organization will face its demise. If self-identification of human
factors worries is perceived personally as the equivalent of that type
of ``mistake,'' Astronauts will white-knuckle those interviews and
press-on. Peers, supervisors, and trainers are more likely to
successfully detect such problems than reliance on an annual exam or
Astronaut self-identification.
Q3. Regarding your report's findings that ``issues of cultural and
structural. . .are so ingrained and longstanding that it will take
senior leadership action to remediate them,'' what was the basis for
historical context of that finding?
A3. The Committee's basis for the finding was based upon careful review
of the investigation reports following the Challenger and Columbia
mishaps and the Institute of Medicine Report regarding changes needed
in readiness for long-duration space exploration. Many of our
Committee's findings were previously identified in those reports.
Q3a. Dr. Ochoa testified that ``nor was there any request for
information on Astronaut Office processes, policies, or anything that
could be characterized as Astronaut Office culture.'' What was the
reason for not requesting and reviewing those documents during the
study process?
A3a. The Committee was physically present at Johnson Space Center in
the immediate aftermath of a murder-suicide at the JSC facility, and as
such determined that no untoward demands would be placed on the senior
leadership of NASA. The Committee met in person with two senior members
of the Astronaut Office and had two-way dialogue with them about key
issues. It was the Committee's view that the most helpful information
was going to come from interviews and personal interactions. These
interviews identified many Astronaut concerns regarding supervision,
mentorship, feedback and many other issues as outlined in our report,
which they felt were significant, regardless of what written policies
were in place. Furthermore, several senior Astronauts stated in person
that a variety of the written policies were regularly ignored with
regard to personnel feedback and supervision. As such, the Committee
opted to review NASA employees statements as to what was being done,
rather than what was in NASA's written guidance as to what should have
been done. The Astronaut Office insisted that feedback was being done;
the interviewed Astronauts told us it was not being done. We believe
that an assessment of Astronaut culture made on the basis of interviews
with multiple Astronauts is more likely to represent what is actually
happening than a review of written documents, policies or procedures.
Q3b. Could you please provide some specifics on the type of senior
leadership actions that you think are needed?
A3b. In the Committee's opinion, NASA senior leadership should initiate
efforts to emphasize the importance of human factors awareness starting
with workplace functional areas in such a way that appreciation of
human factors concerns is vastly elevated from the current state. NASA
leaders should instill concerns for mutual support, recognition of
signs of stress or interpersonal strain, small unit empowerment to
pursue those signs of stress or interpersonal strain, and an aim to
intervene early with an effort to identify problems early, with an
effort toward avoiding interpersonal crises. NASA senior leadership
should prioritize awareness of human factors concerns, mitigation of
early signs of human factors strain, and proactive interpersonal
interventions in an effort to create ``successes'' in managing human
factors issues while offsetting existing inertia and resistance to
these concepts as having too much risk of impacting mission assignment
to be worth the potential benefit to the individual Astronaut or small
group leader. In the Committee's opinion, such an effort would without
a doubt strengthen NASA's future abilities to manage human elements of
long-duration space exploration.
Q4. Your report states that ``peers and staff fear ostracism if they
identify their own or others' problems.'' What was your review panel's
basis for making that statement, and how confident are you that it
doesn't represent just the view of one or two malcontents, particularly
in respect to the letter that came in from the various flight surgeons?
A4. Response: The Committee was shocked and disappointed by the direct
contradiction of statements made by NASA personnel during in-person
interaction with Committee members versus the subsequent official
written statement obtained by NASA. During interviews, more than one
senior NASA physician directly stated the findings that the Committee
reported. Those statements were made in front of a sizable number of
NASA physicians. Not one of those physicians expressed a contradictory
opinion, or a differing opinion, or a re-framed perspective from what
was directly stated to the Committee. It is certainly possible that
those voicing those concerns were misinformed malcontents. (It remains
hard to understand the passivity and tolerance of all of the other NASA
physicians present should that be the case.) It is also possible that
those making these statements were subsequently identified as
``whistle-blowers'' or ``trouble-makers'' and that interpersonal
factors were brought to bear to silence and discredit their opinions.
Certainly our Committee's efforts did not include sworn or written
testimony, nor did it involve the use of law enforcement officials
trained in interrogation aimed to arrive at the ``truth'' in the midst
of reluctance to provide such information. It was and remains the
Committee's unanimous opinion that the statements made about fear of
ostracism and problems in communication were stated in sincerity and
are accurately addressed in our report. We believe that the subsequent
letter from the flight surgeons has very little, if any, credibility,
and in fact confirms the atmosphere of fear of reprisal that was
described to the Committee during the interviews. Similarly, the
Astronauts who were willing to come forward to the Committee with their
concerns did not repeat them to NASA when given the opportunity, but
without anonymity. While we are sympathetic to the difficult position
these flight surgeons and Astronauts were in following the release of
our report and the strongly negative NASA public response to it, their
subsequent silence, and the fact that this letter explicitly
contradicts the statements they made during the interviews, causes the
Committee to have grave concerns regarding the integrity of these
individuals, their leadership, or both.
(These responses represent the Chairman's personal opinion, based
on the Committee's findings and deliberations, and have been reviewed
by some, but not all, of the Committee Members.)
Questions submitted by Chairman Mark Udall
Q1. Regarding flight surgeons who reported a disregard for their
medical opinion on fitness for duty, flight safety, mission
accomplishment, how pervasive was the issue?
A1. Based on our interviews, it was the considered opinion of the
Committee that the NASA flight surgeons feel this disregard is a
pervasive issue. This issue was discussed extensively during a group
interaction with a significant number of NASA flight surgeons. Ample
opportunity was given for the expression of opposing or contrary
viewpoints and no dissenting opinions were raised, neither during the
group session nor individually. Every aspect of the communications made
to the Committee suggested that this was perceived to be a wholesale
problem and not an occasional isolated incident, or something
experienced by a few, but not the majority.
Q2. Your report states that ``Problems of communication were evident
among the four areas address: fight medicine, behavioral health, flight
medicine clinic, and the Astronaut Office.''
a. What drove your committee to that conclusion?
b. Could you elaborate on this issue?
A2a,b. During our interviews, the NASA behavioral health physicians
stated they were very reluctant to communicate with flight surgeons for
fear that a perceived violation of the confidentiality of their
communications (such as sharing the information with the appropriate
crew surgeon or flight surgeon) could cause a backlash from the
Astronaut Corps resulting in ``no Astronaut trusting the behavioral
health clinic staff again.'' Physicians in behavioral health openly
expressed uncertainty as to the ability of NASA flight surgeons to
maintain the strict confidentiality of sensitive mental health care
information, furthering their reluctance to share this information with
concerned flight surgeons. They expressed even greater concern about
sharing medical information with the Astronaut Office. Numerous
physicians discussed their perspective that involvement of the
leadership of the Astronaut Office would only be pursued (by them) in
the event that it appeared that an Astronaut had a clearly
disqualifying health issue, and that more subtle performance decrement
concerns would not be raised.
Q3. The report refers to anecdotes about risky behaviors. Could you
provide examples of the types of risky behaviors mentioned?
Q3a. In what ways were those behaviors risky?
A3a. NASA personnel related several specific incidents: of Astronauts
attempting to de-conflict ground-based communications to Space Shuttle-
borne personnel amongst the Astronaut's current wife, American
girlfriend, and Russian girlfriend, in violation of crew rest periods,
as well as similar efforts to de-conflict the attendees (amongst wife,
American girlfriend, Russian girlfriend) at launch, recovery, and other
official NASA functions. Numerous members of the current Astronaut
Corps expressed concerns about other U.S. Astronauts' excessive
drinking of alcohol (with episodes of public intoxication) while
completing training in Russia. While some portrayed this as a perceived
irritation over the Russian tradition of toasting the achievement of
milestones or of reaching significant agreements (even if it is nine in
the morning), others said they had personally observed American
Astronauts who had begun to drink excessively (evidenced by repeated
instances of public intoxication) while in Russia. Along the same
lines, American Astronauts stated that while in no way universal, it
was becoming common for married American Astronauts to begin extra-
marital relationships with Russian women during their periods of
training at Star City.
Q3b. How does the military handle such behaviors?
A3b. (At the outset it should be noted that civilian employees of NASA
cannot be held accountable under the UCMJ which applies to U.S.
Military personnel, although Army, Navy, Marine, and Air Force
personnel serving with NASA could be held so accountable.) Adultery is
a criminal offense under the UCMJ, although conviction requires
establishment of eyewitness testimony, confession, or photographic
evidence confirming sexual relations of a married person with someone
other than their spouse. However, the appearance of an adulterous
liaison is a relatively commonly encountered phenomenon with military
circles. It is usually approached by interview by the commanding
officer with subsequent admonishments to end the relationship owing to
its perceived impropriety, backed up by issuance of lawful orders to
cease contact with the other party. If these no-contact orders are
violated, that offense in itself is punishable without having to prove
adultery. With regard to alcohol-related misconduct, this is again the
province of the service member's commanding officer who has the option
to issue verbal counseling, written counseling, admonishment, or
reprimand, or to refer the individual for assessment by medical experts
in mental health for an evaluation of a potential alcohol use disorder.
Either problem-prone relationships or misuse of alcohol can be engaged
by US Navy Human Factors Board or Council. Within the USAF, ``Wingman''
concepts would apply to earliest possible intervention with regard to
risky use of alcohol. (Wingman concepts call for the earliest
involvement of friend, peer, supervisor, medic, chaplain, etc., with
aim toward heading off trouble before catastrophe strikes (such as a
DUI arrest, family violence, suicide, etc.). Similar codes of conduct
and expectations of behavior, both on duty and off, are in place at
most civilian workplaces, with the prohibition of ``office romances,''
due to their disruptive impact on office function, being very common.
These measures are taken, not only to protect the individual's health
and well-being, but to ensure safety and mission accomplishment.
Q4. The external review report states that ``The medical certification
of Astronauts for flight duty is not structured to detect such episodes
[of alcohol abuse], nor is any medical surveillance program by itself
likely to detect them or change the pattern of alcohol use.'' Could you
please elaborate on this finding? What, if anything, should NASA do
differently?
A4. At the time of the Committee's review, there was no structured
attention given at any regular interval with regard to the issue of use
of alcohol by Astronauts. Flight surgeons should make an assessment of
alcohol use at every annual Astronaut physical to provide an
opportunity for the Astronaut to self-identify alcohol concerns.
However, annual interviews, lab tests or other ``medical'' evaluations
typically have very low yield, even in the presence of frank
alcoholism. The most likely mechanism to identify alcohol problems is
based on the observation of inappropriate behavior as witnessed by
family members, co-workers or supervisors, and their willingness to
come forward and identify the problem. Off-duty use of alcohol was
characterized by Astronauts and flight surgeons as entirely a matter of
Astronaut personal choice and preference. Astronaut leaders
characterized it as ``not their business'' to observe use of alcohol by
other Astronauts. While Astronauts interviewed could readily recall the
policies of their parent military service (Navy, Air Force) regarding
possible courses of action or interventions when observing a colleague
drunk in public, they expressed uncertainty as to the applicability of
those same approaches within NASA, owing largely to the fact that NASA
is a civilian organization.
Q5. The report finds that ``Astronaut medical and behavioral health
care is highly fragmented and based on a medical disease model.'' Could
you please explain what is meant by ``fragmented''?
a. What, in your view, would be a better model for NASA to
follow?
A5. By ``fragmented'' the Committee was referring to the fact that
there was no system in place assuring that an Astronaut would receive
medical care from the same flight surgeon over as long as possible a
period of their NASA career. The exception to this was while assigned
to a mission, during which it was likely that an Astronaut would be
under the medical care of the same Crew Surgeon until their mission was
accomplished. Many Astronauts spent long periods of time without an
assignment to a specific mission. Those Astronauts could encounter
medical care by any of dozens of flight surgeons serving on duty at the
flight medicine clinic. Other than their annual medical examinations,
most Astronaut health care was driven by a medical complaint causing
the Astronaut to seek the care of whoever was on duty at the time they
pursued care. There was an informal network of ``preferred'' flight
surgeon providers often sought out by Astronauts for help with more
significant health issues, but there was no published guidance for how
that system was activated. Physician-Astronauts provided some medical
care and used their influence to involve ``preferred'' flight surgeons
in certain matters. The Committee believes that a ``better'' model for
NASA to follow would be the assignment of each Astronaut and his/her
family to the care of a team of one or two flight surgeons,
subsequently making every effort that those physicians would be
involved in the majority of medical care decisions for that Astronaut
and family during their NASA service. This would enhance the
development of a deeper relationship between flight surgeon and
Astronaut, improving trust and increasing the likelihood that
behavioral and medical problems can be identified and dealt with
sooner.
Q6. You testified that ``The general sense of disregard for human
factors described as demoralizing to the point where NASA personnel are
less likely to report concerns of performance decrement is the
fundamental concern NASA must investigate and remedy.'' What types of
performance decrement were mentioned by interviewees and do you believe
NASA's plans for an anonymous survey to Astronauts and flight surgeons
will capture such concerns?
A6. NASA flight surgeons and crew surgeons expressed belief that they
were valued members of the NASA team with regard to aerospace medical
subjects such as hazards of exposure to the microgravity environment or
to radiation hazards, but did not express similar confidence with
regard to their observations of human factors safety concerns which may
fall outside the usual ``clinical'' realms, yet are often mentioned in
post-accident safety investigations as causal or contributing factors.
Some Astronauts interviewed expressed concerns about the ability of
fellow Astronauts to perform technical aspects of their crew duties.
While they expressed confidence that in the event that a crew member
was marginally able to perform their assigned primary duties another
crew member aboard the same mission would be fully qualified to perform
those same duties, they felt there was a point in time where removal of
the marginal crew member would delay the NASA timeline to an
unacceptable degree, thus the discovery of this work-around solution of
redundant competency. In at least one instance, an experienced
Astronaut expressed the belief that human factors concerns related to
the health status of a family member would render another Astronaut
unable to perform up to expected standards, but would not result in
removal from a crew--the burden of this situation would be left to the
ingenuity of the mission commander to find a ``work around'' to prevent
mission failure.
We believe the best way to get accurate data on the prevalence of
problems at NASA is to conduct a well-constructed anonymous survey.
People are much more likely to speak freely when they are not at risk
of punishment for their answers. If a large percentage of NASA's
workforce completes the survey, it should be obvious whether the
problems brought to us during the interviews were single voices or
represent pervasive concerns. Clearly our Committee's provision of
anonymity during our interviews was less than fully acceptable to NASA
and much was made about the lack of ``proof' that anonymous information
provides. Our use of this approach opened the Committee's findings to
criticism with regard to the reliability and credibility of who said
what and why they said it. With regard to issues identified in NASA's
subsequent ``on-the-record'' safety investigation (by-name, in writing)
it was NASA's expressed opinion that their on-the-record survey was
valid and our Committee's anonymous interviews far less so. All of this
said, it would appear that NASA's planned anonymous survey may indeed
generate different data than their prior on-the-record survey did. The
usefulness of the data will depend on what is asked, how it is asked,
whether NASA personnel feel safe to speak freely and whether they feel
anything constructive will be done with the information. Once the
survey is administered, the crux of the matter would then be, ``What
will NASA do with such data?''--a concern both for NASA and for those
who provide oversight for NASA.
(These responses represent the Chairman's personal opinion, based
on the Committee's findings and deliberations, and have been reviewed
by some, but not all, of the Committee Members.)
Questions submitted by Representative Ralph M. Hall
Q1. The report of the NASA Astronaut Health Care System Review
Committee (the ``Report') states, ``NASA must ensure the people can
identify such safety and human performance concerns within NASA without
fear of reprisal or career injury.'' How does the military address this
issue, especially with regard to pilots?
A1. This is a broad and complex question. Within the context of a
military aircraft mishap investigation there are two investigational
boards conducted--one conducted in a non-attribution fashion, with an
aim solely to get to the truth in an effort to prevent future mishaps;
and a second to determine legal responsibility for the event, including
potential criminal charges, loss of pilot rating, administrative
reprimand, etc. Within the broader context of mishap prevention, the
military has a variety of processes (as do the airlines) that allow
both anonymous reporting (ironically the best known of these is under
the oversight of NASA) and on-the-record reporting (for example filing
of a Hazardous Air Traffic Report (HATR) following a near-miss mid-air
collision). Both the USAF ``Wingman'' concept and the U.S. Navy Human
Factors Boards emphasize the importance of, and the spontaneous
gathering of, human factors data in the flying environment, the
workplace, and even the social life of a military flying squadron. In
this regard, the Navy's program is more robust, better described, and
more clearly structured than is its Air Force counterpart, although
both are founded on the similar concept--early intervention following
earliest realization that there ``may be a problem.''
Q2. On page 10 of NASA's internal Space Flight Safety Review (led by
Bryan O'Connor) there is an e-mail rebuttal from the NASA's Flight
Surgeons. Without naming names, presumably these are some of the same
folks the NASA Astronaut Health Care System Review Committee
interviewed, and possibly some of the same folks who may have felt
their concerns were disregarded. How should our committee view this
proclamation by the flight surgeons? Can you make any recommendations
as to how a survey should be designed to minimize undue peer pressure
and elicit the free exchange of information?
A2. The Committee was shocked and disappointed by the direct
contradiction of statements made by NASA personnel during in-person
interaction with Committee members versus the subsequent official
written statement obtained by NASA. During interviews, more than one
senior NASA physician directly stated the findings that the Committee
reported. Those statements were made in front of a sizable number of
NASA physicians, including many who subsequently signed this letter.
Not one of those physicians expressed a contradictory opinion, or a
differing opinion, or a re-framed perspective from what was directly
stated to the Committee. It is certainly possible that those voicing
those concerns were misinformed malcontents. (It remains hard to
understand the passivity and tolerance of all of the other NASA
physicians present should that be the case.) It is also possible that
those making these statements were subsequently identified as
``whistle-blowers'' or ``trouble-makers'' and that interpersonal
factors were brought to bear to silence and discredit their opinions.
Certainly our Committee's efforts did not include sworn or written
testimony, nor did it involve the use of law enforcement officials
trained in interrogation aimed to arrive at the ``truth'' in the midst
of reluctance to provide such information. It was and remains the
Committee's unanimous opinion that the statements made by the NASA
flight surgeons during our interviews with them were stated in
sincerity and accurately addressed in our report. We believe that the
subsequent letter from the flight surgeons has very little, if any,
credibility, and in fact confirms the atmosphere of fear of reprisal
that was described to the Committee during the interviews. Similarly,
the Astronauts who were willing to come forward to the Committee with
their concerns did not repeat them to NASA when given the opportunity,
but without anonymity. While we are sympathetic to the difficult
position these flight surgeons and Astronauts were in following the
release of our report and the strongly negative NASA public response to
it, their subsequent silence, and the fact that this letter explicitly
contradicts the statements they made during the interviews, causes the
Committee to have grave concerns regarding the integrity of these
individuals, their leadership, or both. With regard to the question of
survey design, our Committee recommends a properly constructed,
anonymous survey of appropriate NASA personnel, with an aim toward
information gathering and interpersonal climate assessment, with senior
leadership support, assurances of confidentiality, and an explicit
intent to address any issues identified in order to improve safety and
enhance human performance.
(These responses represent the Chairman's personal opinion, based
on the Committee's findings and deliberations, and have been reviewed
by some, but not all, of the Committee Members.)
Questions submitted by Representative Tom Feeney
Q1. The report of the NASA Astronaut Health Care System Review
Committee (the ``Report'') recommends fostering a culture ``that hold
individuals and supervisors accountable for safe and responsible use of
alcohol.'' What conduct constitutes ``safe and responsible use?'' What
conduct constitutes unsafe or irresponsible use? Does such
accountability extend to off-duty alcohol use?
A1. Consumption of alcohol causes measurable, predictable suppression
of central nervous system function, including impairment of judgment,
balance and reaction time, to name a few effects. A precise definition
of what is ``safe and responsible'' would prove more difficult than
offering examples of what is not safe and responsible. None of the
episodes described to the Committee appeared to be subtle or open to
differences of opinion. Drinking and driving is neither safe nor
responsible. Drinking within 12 hours of scheduled T-38 flight duties
is neither safe nor responsible. Public intoxication is neither safe
nor responsible. The question concerning the extension of the concept
of safe and responsible consumption of alcohol to ``off-duty'' time is
an intriguing one. Our Committee would argue that such an extension to
off-duty behavior should be included in the whole person concept of
assessing and mitigating human factors and their potential impact on
safety and mission effectiveness. Off-duty drunkenness may (or may not)
signal the development of an alcohol-use disorder and may (or may not)
represent a hazard to aerospace operations. Along the same lines, off-
duty domestic violence may represent a threat to on-duty performance of
flying duties, particularly if the domestic turmoil has upset sleep
routines and caused distracting or upsetting daytime intrusions in the
individual's thought processes. All of these issues, and many others of
similar nature, represent human factors threats to safety and mission
completion, and must be taken seriously by the entire NASA team.
Q2. The Report recommends refocusing psychologist expertise towards
``providing performance enhancement to all Astronauts.'' Please define
``performance enhancement'' and provide some examples of such
enhancement in other disciplines.
A2. The discipline of performance enhancement refers to assisting
clinically normal people to improve their performance of challenging or
key tasks. Common performance enhancement approaches involve
improvement of public speaking ability, as well as improvement of team-
building and team-leading skills. The field of ``sports psychology''
abounds in examples of taking an athlete with talent and basic skill to
the next level of performance. Often the concept of performance
involves an individual's recognition of an area he/she would like to
strengthen, as contrasted with a suffering individual seeking relief of
distress. An example of performance enhancement with potential
relevance to Astronaut duties would be a veteran pilot with awareness
that in stressful, difficult circumstances he tends to become
increasingly authoritarian and issue orders, closing off discussion--
working toward more active team building, active listening, and rapid
work with a group to generate an active solution with group buy-in.
Q3. The Report recommends that behavioral health evaluations include
``recognized screening instruments for the above commonly occurring
behavioral health issues.'' Please identify each specific ``behavioral
health issue'' and the corresponding ``recognized screening
instruments.''
A3. With regard to screening for misuse of alcohol there are two
commonly used instruments (CAGE and AUDIT) that would be preferable
over the utilization of no screening instruments (which is the current
NASA approach). Of course, there are other approaches to alcohol misuse
screening as well. With regard to screening for general behavioral
health issues or for significant exposure to stress that might
predispose to the development of health problems there are also a host
of possible screening tools. One good prospect for such screening in
the NASA population is the Outcome Questionnaire-45 (OQ-45), which is a
screening tool (in widespread use throughout the USAF) that screens for
a wide variety of psychological and interpersonal concerns. Another
similar instrument is the Patient Health Questionnaire (PHQ, which
gives subscores for a variety of health concerns, including depression.
Another similar instrument, in widespread use throughout the U.S. DOD,
is the Preventive Health Assessment (PHA). These screening measures can
be followed by administration of more focused measures in the event say
that an OQ-45 suggests the possibility of clinical depression, The Beck
Depression Inventory (BDI) can be administered to amplify that finding.
All of the screening tools and tests mentioned in this paragraph are
low cost and require only a small investment of time. Likewise, any
results would need follow-up with a health care professional.
Q4. The Report found: ``Many anecdotes were related that involved
risky behaviors by Astronauts that were well known to the other
Astronauts and no apparent action was taken.'' Reasonable people hold
differing definitions of what constitutes a ``risky behavior.'' Without
violating the confidentiality promised by the NASA Astronaut Health
Care System Review Committee during its work, please define ``risky
behavior'' as used in the Report and provide examples of what does and
does not constitute such a ``risky behavior.''
A4. Risky behaviors referred to by the Committee as described by NASA
Astronauts and flight surgeons included openly adulterous relationships
(romantic relationships well-known to many co-workers acquainted with
both the Astronaut's spouse and the Astronaut's girlfriend);
interpersonal anxiety caused by attempting to maintain contact (during
Shuttle space missions in space flight) with current wife, American
girlfriend, and Russian girlfriend; drinking so much alcohol the night
before a space launch (from Russia) that severe signs of intoxication
became evident resulting in a NASA flight surgeon being assigned to
assure that the Astronaut did not vomit and choke upon his vomitus;
arriving at a NASA T-38 aircraft about to fly cross-country from
Florida to Houston with such notable alcohol hangover that another NASA
Astronaut refused to fly as fellow crew member with the Astronaut
suffering the hangover, and so forth. The majority of ``risky''
behaviors mentioned by Astronauts and NASA physicians centered upon
concerns such as these. It can be argued that any of these types of
behavior put a person on course to court disaster. It can be argued
that these represent variations on the theme of a consenting adult's
free choice. In military aviation such behaviors are seen as potential
signs of trouble brewing, including the kind of trouble that can be
associated with aviation mishaps, loss of aircraft, and loss of lives,
thus they are seen as the appropriate province of friend, wingman, and
commander with an eye toward mitigation of risk.
(These responses represent the Chairman's personal opinion, based
on the Committee's findings and deliberations, and have been reviewed
by some, but not all, of the Committee Members.)
Answers to Post-Hearing Questions
Responses by Richard S. Williams, Chief Health and Medical Officer,
National Aeronautics and Space Administration
Questions submitted by Chairman Bart Gordon
Q1. Could you please submit for the record which recommendations of
the NASA Astronaut Health Care System Review Committee you will not
accept and why?
a. What kind of reporting process will you use?
A1. NASA has developed a comprehensive response plan that integrates
recommendations and actions from all three existing reports: the NASA
Astronaut Health Care System Review Committee, the Space Flight Safety
Review of Alcohol Use in the Pre-Flight Period, and the Johnson Space
Center Internal Review. Progress will be reviewed quarterly by the
Medical Policy Board, and a briefing to the Aerospace Safety Advisory
Panel is anticipated early next year.
Q2. Your testimony notes that ``External review of our behavioral
medicine services was performed in February 2007. This review
determined that NASA provided a competent group of behavioral health
providers (BHP) rendering excellent clinical and occupational care.
Recommendations were also made for improvement, and actions were in
place to address many of these areas at the time of Dr. Bachmann's
review.'' Who conducted the February 2007 external review of behavioral
medicine services, what was the charge to the reviewers, what were the
main recommendations, and why did NASA perceive the need to solicit an
additional independent review of astronaut health care?
A2. The February 2007 review was conducted by Dr. Royden W. Marsh,
employed by the U.S. Air Force (USAF) School of Aerospace Medicine on
the Psychiatry consultation service. Dr. Marsh was known to NASA
behavioral medicine staff and is an experienced aerospace medicine
practitioner, having worked for many years in support of USAF
aeromedical behavioral health services and having previously worked at
Johnson Space Center. Dr. Marsh conducted his quality review of the
Behavioral Health office and clinical care on February 28 and March 1,
2007. This review was conducted as part of NASA's overall program to
insure quality of astronaut health care services. The scope of the
review included credentialing, privileging, primary source
verification, internal peer review, and external quality review of
office procedures, medical record-keeping, and review of clinical care.
Such a review is also done on a regular basis for the Flight Medicine
Clinic. It should be noted that the preparations for this review were
initiated in January 2007, approximately one month before the event
involving Lisa Nowak.
The main recommendations from the review were related to
credentialing and privileging, and external peer review. Dr. Marsh
recommended several improvements to our credentialing and privileging
procedures which have been incorporated. He also recommended
formalization of external consultant peer review by an aerospace
psychiatry consultant, and implementation of a formalized, quarterly,
internal peer review process to enhance review of the Behavioral
Medicine Clinic. NASA agreed with this recommendation and has
incorporated it in our planning.
Q3. Col. Bachmann's testimony noted that one of the three most
important issues identified by the external review is that ``medical
and behavioral health services should be integrated and focused on
astronaut performance enhancement.'' What steps, if any, does NASA plan
to take with regard to using medical and behavioral health services to
enhance astronaut performance?
A3. NASA has accepted this recommendation and is now considering the
appropriate changes to its services through its comprehensive response
to the NASA Astronaut Health Care System Review Committee Report. The
changes are being developed, and will be reviewed later this fiscal
year by the Chief Health and Medical Officer's Medical Policy Board, a
joint internal and external medical advisory group, whose members are
senior physicians from NASA and other federal agencies.
Questions submitted by Chairman Mark Udall
Q1. Your testimony refers to the creation of the Office of the Chief
Health and Medical Officer in 2000 as a result of recommendations of
external advisory groups. Who were those groups, and why did they see
the need to set up your office--what problem were they trying to fix?
A1. Prior to the establishment of the Office of the Chief Health and
Medical Officer, this function existed within the Office of Life and
Microgravity Sciences and the Office of Space Flight. The functional
entity thus did not constitute an Agency-wide authority, and influence
that could be exercised on behalf of health and medical policy and
oversight and protection of research subjects was limited. In 1998,
NASA requested that the National Academy of Sciences Institute of
Medicine (IOM) review NASA's biomedical structure for transitioning
from low-Earth orbit operations to exploration class human space flight
missions to Mars. The IOM completed their study over the next two years
and published Safe Passage: Astronaut Care for Exploration Missions
(2001). The IOM suggested a central authority responsible for all NASA
health and medical matters be developed The IOM specifically
recommended: ``To support safe human exploration of space, the National
Aeronautics and Space Administration (NASA) should pursue a two-
component strategy: (1) it should pursue a comprehensive health care
system for astronauts to capture all relevant epidemiological data, and
(2) it should pursue a long-term, focused health care research strategy
to capture all necessary data on health risks and their amelioration.
An occupational health model should apply to the first pursuit. . . To
accomplish this strategy, there should be an organizational component
within NASA that has authority over and accountability.for all aspects
of astronaut health.''
The Aerospace Medicine and Occupational Health Advisory Committee
(AMOHAC) of the NASA Advisory Council (NAC) (as constituted at that
time) also recommended that the position of NASA Chief Medical Officer,
at the NASA Administrator's staff level, be established. Establishing
such a position (with responsible staff) elevates cognizance of the
importance of health and medical issues at the Agency level, clearly
establishes policy and oversight authority for NASA's health care
delivery efforts, and clearly establishes functional responsibility for
health risk assessment and health standards definition. This allows
effective oversight of all health related issues within the Agency,
and, through health and medical standards development, provides
guidance to NASA's biomedical research program in support of human
space flight and the Vision for Space Exploration. NASA's current
governance model, which established technical authorities (including
Health and Medical Technical Authority), is well served by the Office
of the Chief Health and Medical Officer, in parallel with the Office of
the Chief Engineer and the Office of Safety and Mission Assurance.
Q2. Are alcoholism, alcohol abuse, and drug abuse/addiction
encompassed in the established medical standards for fitness for flight
and fitness for duty? If not, why not?
a. Can flight surgeons ground an astronaut due to behavioral
health and has this ever occurred?
A2. Yes, these issues are addressed by established medical standards.
Flight surgeons can ground an astronaut for failing any aeromedical
standard, including those covering behavioral health issues. NASA has
never grounded an astronaut (denied a waiver) or allowed an astronaut
to fly (issued a waiver) for failing to meet behavioral health
standards.
Q3. How are astronaut problems that do not violate a behavioral
standard (debt due to gambling, infidelity, etc.) but that could pose
behavioral and performance risks over time, handled?
A3. All NASA employees are subject to supervisory evaluation for
maintaining work proficiency. This means that unless a person is
incapacitated to a degree that they are not able to perform their job
to their supervisor's satisfaction, no additional direct intercession
is done without the explicit initiation and consent by the affected
employee. However, the NASA Occupational Health Program promotes
continued employee education related to stress at work, alcohol or
other substance use or abuse, and other health issues. NASA, encourages
employees to seek help, and makes available an Employee Assistance
Program. Additional resources are available for astronauts and their
families through the Behavioral Health Program. New processes are being
developed to include an annual behavioral health exam for astronauts
that should make behavioral health encounters routine and foster more
communication between care providers and the astronauts.
Q4. The external review notes that ``Astronauts are not required to
report illnesses, injuries or medication use unless they determine them
to be significant.'' What is the reason for this practice?
a. What protections exist to ensure that astronauts are not
impaired by medication use that may not have been reported to
flight surgeons?
A4. This practice is consistent with other aeromedical systems
including the FAA. The astronaut is required to report any medical
issue including medication that might represent a safety of flight
issue, but not all over the counter medications that arc approved for
flight status need to be reported. During the launch process, medical
examinations and laboratory evaluations are conducted 10 days and two
days prior to launch.
Q5. NASA has announced that it is accepting applications for the 2009
astronaut class. With the retirement of the Shuttle in 2010, the
astronaut class of 2009 will be conducting longer-duration missions,
making behavioral health an even more important factor for astronaut
crews. Could you please describe in specific terms if the behavioral
aspects of the selection process are being modified in response to the
independent health care system review, and if so, in what ways?
A5. NASA is reviewing its behavioral health data to determine if
changes need to be made to its process in light of the findings of the
Astronaut Health Care System Review Committee and corresponding
internal NASA reviews. Any recommendations for change would be
evaluated prior to the next scheduled selection.
Q6. Your testimony notes that several aspects of the Independent
Astronaut Health Care Review are being assessed and examined. What is
the plan and schedule, and how will progress be monitored?
A6. NASA has developed a comprehensive response plan that integrates
recommendations and actions from all three existing reports (NASA
Astronaut Health Care System Review Committee report, the Space Flight
Safety Review of Alcohol Use in the Pre-Flight Period, and the JSC
Internal Review). Progress will be reviewed quarterly by the Medical
Policy Board (MPB) and a briefing to the Aerospace Safety Advisory
Panel (ASAP) is anticipated early next year.
Questions submitted by Representative Jo Bonner
Q1. If astronauts have been conditioned to view emotional problems as
weaknesses to be suppressed and compartmentalized, of if they perceive
that disclosing personal problems could derail their careers, they will
understandably be reluctant to seek psychological counseling. How do
you foster a supportive, trusting relationship between the astronauts
and the behavioral health specialists?
A1. Several approaches, outlined below, are being pursued to foster a
supportive and trusting relationship between the astronauts and the
behavioral health specialists.
1) The behavioral health clinic is separate from the flight
medicine clinic to maintain privacy.
2) Privacy Act regulations are followed to further maintain
the privacy of behavioral health visits.
3) The behavioral health clinic is available for the astronaut
dependents as well. Thus the whole family can get the
appropriate psychological support.
4) New processes are being developed to include an annual
behavioral health exam for astronauts that should make
behavioral health encounters routine and foster more
communication between care providers and the astronauts.
Q2. The Committee's Report states that NASA has to grapple with many
cultural and structural issues, some of which have existed since the
earliest days of the astronaut program. Do you agree with this
assessment? If yes, what steps will you take to change such deeply
ingrained behaviors?
A2. NASA has made many cultural and structural changes based on the
Columbia Accident Investigation (CRIB) report recommendations (which
have been previously reported to the Congress). To determine if there
are other specific cultural or structural issues that need to be
changed, NASA is first pursuing an anonymous survey to further
characterize issues related to cultural and structural issues within
the Astronaut Corps and within the cadre of flight surgeons. The survey
is focused on communication, trust and decision-making. Results of this
survey will be utilized to guide any needed changes to address issues
of concern with the astronaut and medical communities.
From an Agency perspective, it is widely recognized that
improvement in safety culture can be derived from improvements in the
safety climate through active supervisory and peer involvement. The
safety climate of an organization is defined by many factors including
technical knowledge and behavior of its members with regard to safety.
This includes opportunities for personnel exposure to safety principles
and practices, dissemination of safety lessons learned, the ease of
safety communication up and down the organization, and the
consideration of safety in management decisions.
NASA is pursuing a multi-faceted approach for improving safety
climate across the Agency that will include the astronaut corp. This
approach is based on:
Integration of safety management with programmatic
and engineering decision processes
Achieving technical excellence in safety and mission
assurance activities
The former is being implemented through NASA's governance model.
The latter is being addressed by establishing the NASA Safety Center
(NSC) to expand and strengthen the safety training element of NASA's
safety program. Each approach is briefly discussed below:
NASA Governance Model--Over the past several years NASA has been
defining and implementing an overall governance model that is based on:
(1) responsible decision-making; (2) a balance of power; and; (3) the
establishment of checks and balances. These elements and the practices
are a direct outgrowth of the Columbia Accident Investigation Board
(CAIB) findings and establish a framework for a safety culture to grow
and thrive. These three elements permit ongoing lively discussion and
debate to occur unfettered at all levels within the NASA organization.
The NASA Administrator has set the overall tone for these discussions
and debates by consistently challenging decisions and established
policies looking for new ways to answer questions, and NASA has
codified a formal process for dissent in NASA Procedural Requirements
7120.51), NASA Space Flight Program and Project Management
Requirements. The visibility and clear definition of the overall
decision process along with the examples of these processes set at the
highest level of the Agency in the Program Management Council and other
top level councils establishes the benchmark for the rest of the Agency
to follow. Even so, NASA recognizes that even with these concepts
documented and regularly exercised, there will be people that remain
uncomfortable even in the most open of organizational safety climates.
Some of that lack of comfort might be attributed to a lack of technical
competency or standing among one's peers or from lack of confidence in
the openness of management. As discussed in the following paragraphs
NASA is taking steps to increase the competence (and confidence in the
competence) of the NASA workforce relating to safety and mission
assurance disciplines through the Technical Excellence activities, and
we are also developing the capability to measure the overall climate
with respect to safety.
Achieving Technical Excellence in Safety and Mission Assurance--NASA is
committed to increase the awareness and concern for safety at all
levels beginning with system safety in design and facility operations
to astronauts and flight operations. Increased excellence and awareness
in safety are necessary ingredients for strengthening our safety
culture. The Technical Excellence Program being developed at the NSC
will conduct educational programs to raise safety awareness,
disseminate safety lessons learned, and increase the safety emphasis of
NASA management and staff. Safety engineering and management courses
that are being planned will address not only safety in the operational
and design environment but also philosophy and doctrine that influence
the various management and technical levels at NASA. We believe that
the envisioned Technical Excellence Program will not only increase the
safety competency of our workforce but will also increase management's
awareness of the benefits that derive from sound safety management and
safety engineering principles and processes being applied uniformly
across the Agency.
Measuring and Communicating Safety Culture Using a Standard Process--
Recognizing the importance of safety culture, our Office of Safety and
Mission Assurance (OSMA), over the past two years, has developed and
maintained contacts with several faculty members of the Naval
Postgraduate School (NPS) and the University of California at Berkeley
(UCB) who have developed a web-based safety climate survey tool for the
Naval Aviation School. Recognizing the difficulty inherent in measuring
safety culture, this tool uses safety climate metrics as an indicator
of cultural strengths and weaknesses. After several exchanges of
information and views between the OSMA and the NPS/UCB faculty, it was
decided that a proof-of-concept should be undertaken to demonstrate the
feasibility of using a similar tool at NASA. The Goddard Space Flight
Center (GSFC) volunteered to participate in the first pilot study just
completed. On August 24, 2007, the preliminary results of this pilot
project were presented to OSMA. OSMA is currently evaluating the
results of this study and is planning to conduct a series of additional
pilot studies. These studies will allow OSMA to incrementally arrive at
an Agency-wide safety culture shaping and measurement process that will
be effective for both design and operational environments at NASA. OSMA
is also investigating whether this process will allow NASA on-site
contractors to participate on a voluntary basis; contractor
participation may be dependent on the specific contract. To this end,
the activities outlined below are being pursued by OSMA.
Examine the results of the GSFC study and past safety
culture assessment and shaping processes performed at NASA as
well as in other government and non-government organizations to
determine best practices and analyze what practices could be
adapted for NASA use.
Develop a safety culture assessment and shaping
process, or adapt/refine a currently employed process for NASA
use that incorporates the applicable government and industry
best practices. This process will include methods to educate
Center leadership on the process, measure safety climate,
analyze the survey data, and advise NASA Headquarters and
Center leadership as to the results and recommended strategies
to strengthen safety culture.
Together, these efforts will allow NASA to address many cultural
and structural issues, some of which have existed since the earliest
days of the astronaut program.
Answers to Post-Hearing Questions
Responses by Ellen Ochoa, Director, Flight Crew Operations, NASA
Johnson Space Center
Questions submitted by Chairman Mark Udall
Q1. NASA has noted that it is working with astronauts to develop a
code of conduct. Could you please describe what the code of conduct is
expected to entail?
a. How will it be communicated to new and current astronauts
and how will it be enforced?
A1. At NASA we not only abide by code of ethics regulations for
executive branch employees, we also have documented core Values for all
of us including our Astronaut Corps. These include safety, teamwork,
integrity, and mission success. Anything we develop will be further
definitions of expectations of behavior, acknowledging the visible role
that astronauts play in representing NASA. A senior astronaut is
currently leading a team of astronauts to develop these values and
attributes that astronauts are expected to exhibit. Once developed they
will be communicated to all astronauts and prominently displayed in
conference rooms and other key locations, as well as discussed during
new astronaut selection. We will discuss enforcement approaches after
reviewing proposed expected principles of behavior developed by the
astronaut team.
Q2. Col. Bachmann's testimony notes that ``an anonymous survey of the
relevant NASA populations, covered by this report-medical personnel,
astronauts, and training personnel'' is the most important first step
NASA needs to take. Will NASA's anonymous survey include all the groups
identified by Col. Bachmann? If not, why not?
A2. The survey included flight surgeons and astronauts only. The survey
tool was selected to appraise the issues raised by crew members and
flight surgeons because these were the specific groups that had raised
issues with the Review Committee and we felt it should remain focused
on these groups.
NASA leadership has other mechanisms in place to ensure that flight
safety and mission success concerns can be raised and discussed without
retribution by any personnel. In response to the External Committee
finding, the Johnson Space Center (JSC) took the opportunity to remind
affected staff of the importance of their responsibility to raise
concerns, and the mechanisms available to them for doing so, including
anonymous reporting systems such as the NASA Safety Reporting System
(NSRS).
Training requirements and all aspects of preparation for
aeronautical flight and space flight will continue to be rigorous and
focused. Crew members are routinely evaluated on their performance by
training personnel and we will continue to encourage open and honest
assessments.
Q3. NASA has announced that it is accepting applications for the 2009
astronaut class. With the retirement of the Shuttle in 2010, the
astronaut class of 2009 will be conducting longer-duration missions,
making behavioral health an even more important factor for astronaut
crews. Could you please describe in specific terms in what ways, if at
all, the selection process is being modified in response to the
independent health care system review?
A3. Both the External Committee and the Johnson Space Center (JSC)
Internal Review recommended that NASA evaluate enhanced usage of
suitability testing for ``select in'' purposes for acceptance into the
Astronaut Corp. This testing will ultimately need to be validated
against actual space flight performance. JSC will review the state-of-
the-art for suitability testing and determine if any changes need to be
made to the current astronaut selection process. This will include
consultation with NASA aerospace psychologists/psychiatrists, external
academic and industry-leading industrial and organizational
psychologists. Based on the results of the review, it may be
appropriate to develop a suitability standard for qualification of
astronaut applicants at selection.
Q4. You testified that an ``Astronaut Evaluation Board is periodically
convened by the Astronaut Office to review astronauts completing flight
assignments, astronaut candidate training, or other astronauts
recommended for review.'' Who are the members of the Board, when did it
last meet, and what issues did it address in that meeting?
A4. The Deputy Chief of the Astronaut Office usually serves as the
Chairperson of the Astronaut Evaluation Board (AEB). Board members are
senior astronauts, normally the Astronaut Office Branch Chiefs, whose
leadership, experience, knowledge, and skills are applicable to the
subject of concern and whose current job assignments make them
available to serve on the board. Input is also gathered from training
personnel in addition to other astronauts.
The last AEB was conducted on August 29, 2007. The purpose was to
review the Space Shuttle and International Space Station expedition
crew members recently returning from flight to determine if they were
eligible for another flight crew assignment.
Q5. Your testimony notes that ``NASA currently employs a system for
reporting any situation requiring attention that may impact safety of
flight. . ..'' Have those pathways, including the Independent Health
and Medical Technical Authority, been used to report issues regarding
astronauts that may have affected safety of flight? If so, could you
please elaborate?
A5. No issues with astronaut behavior that may impact safety of flight
have ever been reported using these avenues.
Q6. Your testimony notes that you have ``taken the opportunity to
clarify our space flight alcohol policy, and based on Bryan O'Connor's
review, will determine whether any revision or expansion of the policy
is warranted.'' What plans, if any, does NASA have to consult the Space
Life Sciences Directorate regarding the medical basis for the policy or
any final changes to the alcohol policy?
A6. The Flight Crew Operations Directorate will continue to consult the
Space Life Sciences Directorate regarding all medical aspects of this
and other policies. Bi-weekly meetings between space medicine and
astronaut office management are taking place and will continue. NASA is
in the midst of conducting an anonymous survey of astronauts and flight
surgeons to provide additional feedback and gather suggestions for
improvement in this and other areas as well.
Questions submitted by Representative Jo Bonner
Q1. If astronauts have been conditioned to view emotional problems as
weaknesses to be suppressed and compartmentalized, of if they perceive
that disclosing personal problems could derail their careers, they will
understandably be reluctant to seek psychological counseling. How do
you foster a supportive, trusting relationship between the astronauts
and the behavioral health specialists?
A1. No data exists to suggest that astronauts are conditioned to view
emotional problems as weaknesses to be suppressed. In fact, the
behavioral medicine patient numbers provided to your committee covering
the past several years highlights the availability of these specialists
and the extensive use of them by our astronauts and their families.
Several approaches are used to foster a supportive, trusting
relationship between the astronauts and the behavioral health
specialists. First and foremost, our approach relies on respecting
medical privacy policies and procedures. In addition, bi-weekly
meetings between space medicine and astronaut office management
continue to take place to help ensure regular and effective
communications. NASA is also in the midst of conducting an anonymous
survey of our astronauts and flight surgeons to provide additional
feedback, and suggestions for improvement, in a variety of areas
including level and quality of communications and trust.
Q2. The Committee's Report states that NASA has to grapple with many
cultural and structural issues, some of which have existed since the
earliest days of the astronaut program. Do you agree with this
assessment? If yes, what steps will you take to change such deeply
ingrained behaviors?
A2. In performing their jobs each day, astronauts provide input into
all aspects of operations and development activities including
readiness for flight, both within their chain of command, and
throughout human space flight program forums. It has not been my
experience that astronauts are reluctant to speak up, nor is there any
evidence to support that there is a culture that inhibits
communication. Nonetheless, Flight Crew Operations leadership is
committed to following up on the comments in the report, and a major
objective of the survey currently underway is to understand any
potential concerns in raising or responding to issues with flight
safety or crew suitability for flight or any barriers that might exist
to raising concerns.
Answers to Post-Hearing Questions
Responses by Bryan D. O'Connor, Chief, Safety and Mission Assurance,
National Aeronautics and Space Administration
Questions submitted by Chairman Mark Udall
Q1. Your testimony notes that ``Some or all of the reported incidences
could possibly have happened during earlier times in the countdown
where there are fewer witnesses and, if so, they would represent ground
safety and flight schedule threats.'' If such incidences were occurring
at earlier times in the countdown, what are the implications for ground
safety? What measures are in place to detect such threats to ground
safety and flight schedule?
A1. This statement is meant to distinguish a flight safety issue
(flying an impaired crew member) from a ground safety issue (impaired
crew member hurts himself the day before launch requiring first aid or
other medical help), and a schedule issue (crew member injures himself
so seriously as to cause the flight surgeon to withdraw his
certification for flight). In the Soyuz operation, a crew injury would
result in the backup crew member being assigned to fly, and there would
be no affect on schedule. For the Shuttle operation, where there are no
backups, a grounded crew member would necessarily cause a launch slip.
NASA would then have to wait until the crew member has recovered from
the injury, or train a substitute crew member.
Flight surgeons live in crew quarters with the crew members in the
United States and Russia. They are available for addressing any health-
related issue that might constitute a concern to ground or flight
safety. Further, examinations are conducted ten days and two days
before launch, and the flight surgeons are present on launch morning
including crew suit up.
In addition, the Johnson Space Center has a policy which requires
that assigned crew members abstain from high risk activities when they
are assigned to missions. Examples in the policy are skydiving,
volunteer firefighting, air racing, and (newly added since the study)
excessive use of alcohol.
Q2. Your testimony notes that ``some whom I interviewed admitted that
it is possible that someone could have inadvertently violated the 12-
hour rule by a small amount at some time in their military or NASA
flying career.'' Was this point included in your Safety Review? If not,
why not? Could you please describe how someone could have inadvertently
violated the 12-hour rule? Would that mean that someone was unaware of
the 12-hour policy?
A2. I did not record these verbal references (from long retired pilots)
in my report because they were not about space flight. One reference
was offered as a hypothetical: an airplane pilot could violate the rule
concerning the 12-hour period before launch, during which astronauts
are required to abstain from consuming alcohol, not because he was
unaware of the rule, but because he lost track of the time at the
restaurant or officers club the night before a scheduled morning
flight. The other was a general reference to military flying in the
1960s and 1970s where people sometimes bumped up against the 12-hour
rule due to sloppy time management, and peer pressure. The purpose of
both of these references was to compare the past and current cultures.
The message I took from these non specific references was that alcohol
and flying was a bigger issue 30-40 years ago than it is today, and
that today's airplane pilots, including those assigned to NASA, are
much better about separating alcohol from flying than their
predecessors were in the ``old days.''
Q3. How often are the appeals processes and the Health and Medical
Technical Authority being used and for what types of issues?
A3. The Health and Medical Technical Authority reviews all health and
medical waivers and exceptions for all three programs, the Space
Shuttle, International Space Station (ISS) and Constellation.
Programmatic issues have been addressed to date at the local Johnson
Space Center (JSC) level without needing to elevate an appeal or waiver
decision to the Chief Health and Medical Officer. All individual
medical waiver issues for astronauts are reviewed by the Chief Health
and Medical Officer, and permanent waivers for medical conditions are
also approved by the Chief Health and Medical Officer. Medical
disqualification of individuals is extremely rare, and over the last 10
years the appeals process for individual medical disqualification has
only been used twice. Active communication takes place between the JSC
Chief Medical Officer and the Headquarters Chief Health and Medical
Officer weekly for programmatic and aerospace medicine issues and
quarterly summaries are provided as well. In 2003, a minority opinion
was developed for ISS flight readiness concerning the availability of
exercise equipment and environmental monitoring; this was presented at
the Flight Readiness Review and all aspects of the issue were
considered by senior management. All participants were very satisfied
with the discussion and communication. This outcome is discussed within
the Health and Medical Technical Authority as an example of effectively
raising and addressing flight safety issues to senior management.
Questions submitted by Representative Ralph M. Hall
Q1. How should NASA deal with an astronaut's natural reluctance to
raise health or behavioral issues that they believe may jeopardize
their selection for future missions or assignments? Based on your
experience, are members of the Astronaut Corps confident that they can
raise health issues, or emotional or family problems without fear of
jeopardizing their NASA careers?
A1. The behavioral medicine patient numbers provided previously to the
Committee covering the past several years highlight the availability of
these specialists and the extensive use of them by our astronauts and
their families.
In order to continue to encourage astronauts to raise and address
behavioral health issues, several approaches are being pursued to
foster a supportive and trusting relationship between the astronauts
and the behavioral health specialists as outlined below:
1) The behavioral health clinic is separate from the flight
medicine clinic to maintain privacy.
2) Privacy Act requirements are followed to ensure the privacy
of behavioral health visits.
3) The behavioral health clinic is available for the astronaut
dependents as well. Thus, the whole family can get the
appropriate psychological support.
4) New processes are being developed to include an annual
behavioral health exam for astronauts that should make
behavioral health encounters routine and foster more
communication between care providers and the astronauts.
5) NASA is conducting an anonymous survey of our astronauts
and flight surgeons to provide additional feedback, and
suggestions for improvement, in a variety of areas including
level and quality of communications and trust.
Q2. In the aftermath of the Challenger and Columbia accidents NASA has
tried very hard to ensure that there are open, independent
communication paths to raise safety concerns. Would you please discuss
policies and/or procedures that are now in place to ensure employees
are encouraged to report any safety of flight issues, and would you
please discuss how, if at all, you are changing or revising those
policies as a result of the NASA Astronaut Health Care System Review
Committee report?
A2. NASA has many paths for communication and these paths are described
in NASA policy and NASA Procedural Requirements (NPR) such as NPR
8715.1 regarding NASA Occupational Safety and Health Programs. These
include:
1) reporting to Center or Component Facility Safety/Health
Official(s), as appropriate;
2) reporting to supervisory personnel or management;
3) reporting to Center Director;
4) reporting through the Safety and Mission Assurance (SMA)
organizations;
5) reporting through the Designated Agency Safety and Health
Official (DASHO);
6) anonymously reporting through the NASA Safety Reporting
System (NSRS);
7) anonymously reporting through Center hotlines such as the
Johnson Space Center (JSC) Hotline;
8) reporting to the Inspector Genera; and,
9) reporting directly to the Administrator.
NASA also recognizes that employees have external reporting options
including the Office of Federal Agency Safety and Health Programs--
Occupational Safety and Health Administration (OSHA)/Department of
Labor.
Following the Columbia Accident Investigation Board (CAIB)
recommendations, NASA instituted three technical authorities, one for
each of the following disciplines: engineering, safety, and health and
medical. Employees may bring their concerns to the technical authority.
If they are not satisfied with the way in which their concerns are
dispositioned, there is a reclama process by which all decisions are
elevated to the highest levels of NASA management.
Since the NASA Astronaut Health Care System Review Committee
report, the flight surgeons and astronauts also received refresher
briefings of these available pathways, and their use is encouraged and
supported. The Administrator and the Director, Johnson Space Center,
reemphasized their encouragement that any employee can communicate with
them directly for issues of concern.
Answers to Post-Hearing Questions
Responses by Michael D. Griffin, Administrator, National Aeronautics
and Space Administration
Question submitted by Chairman Bart Gordon
Q1. Col. Bachmann's testimony noted that ``organizations as diverse as
the military, the Federal Aviation Administration (FAA) and the
Veterans Administration (VA) have made great progress, with active
supervisory and peer involvement, in changing cultural attitudes
towards safety, accountability, empowerment, and alcohol.'' What plans,
if any, does NASA have for exploring and considering other federal
agency approaches to these types of issues?
A1. NASA is actively benchmarking against many organizations to improve
organizational effectiveness. Benchmarking for specific issues such as
those raised in the report with the Federal Aviation Administration,
Veterans Administration, and the Department of Defense will be added to
this process that is already underway.
NASA has initiated an activity to explore other federal agencies'
and non-government organizations' approaches to analyzing cultural
attitudes towards safety, accountability and empowerment and employ
techniques to improve safety climate across the Agency.
Recognizing the importance of safety culture, over the past two
years NASA's Office of Safety and Mission Assurance (OSMA), has
developed and maintained contacts with several faculty members of the
Naval Postgraduate School (NPS) and the University of California at
Berkeley (UCB) who have developed a web-based safety climate survey
tool for the Naval Aviation School. Recognizing the difficulty inherent
in measuring safety culture, this tool uses safety climate metrics as
an indicator of cultural strengths and weaknesses. After several
exchanges of information and views between the OSMA and the NPS/UCB
faculty, it was decided that a proof-of-concept should be undertaken to
demonstrate the feasibility of using a similar tool at NASA. The
Goddard Space Flight Center (GSFC) volunteered to participate in the
first pilot study just completed. On August 24, 2007, the preliminary
results of this pilot project were presented to OSMA. OSMA is currently
evaluating the results of this study and is planning to conduct a
series of additional pilot studies. These studies will allow OSMA to
incrementally arrive at an Agency-wide safety culture shaping and
measurement process that will be effective for both design and
operational environments at NASA. OSMA is also investigating whether
this process will allow NASA on-site contractors to participate on a
voluntary basis; contractor participation may be dependent on the
specific contract. To this end, the activities outlined below are being
pursued by OSMA.
Examine the results of the GSFC study and past safety
culture assessment and shaping processes performed at NASA as
well as in other government and non-government organizations to
determine best practices and analyze what practices could be
adapted for NASA use.
Develop a safety culture assessment and shaping
process, or adapt/refine a currently employed process for NASA
use that incorporates the applicable government and industry
best practices. This process will include methods to educate
Center leadership on the process, measure safety climate,
analyze the survey data, and advise NASA Headquarters and
Center leadership as to the results and recommended strategies
to strengthen safety culture.
NASA is pursuing a multi-faceted approach for improving safety
climate across the Agency. This approach is based on:
integration of safety management with programmatic
and engineering decision processes; and
achieving technical excellence in safety and mission
assurance activities.
The former is being implemented through NASA's governance model.
The latter is being addressed by establishing the NASA Safety Center to
expand and strengthen the safety training element of NASA's safety
program.
Questions submitted by Representative Ralph M. Hall
Q1. The NASA Astronaut Health Care System Review Committee Report
states that NASA has to grapple with many cultural and structural
issues, some of which have existed since the earliest days of the
astronaut program. Do you agree with this assessment? If yes, what
steps will you take to change such deeply ingrained behaviors?
A1. NASA has made many cultural and structural changes based on the
Columbia Accident Investigation Board (CAIB) report recommendations. To
determine if there are other specific cultural or structural issues
that need to be changed, NASA is first pursuing an anonymous survey to
further characterize issues related to cultural and structural issues
within the Astronaut Corps and within the cadre of flight surgeons. The
survey is focused on communication, trust and decision-making. Results
of this survey will be utilized to guide any needed changes to address
issues of concern with the astronaut and medical communities.
From an Agency perspective, it is widely recognized that
improvement in safety culture can be derived from improvements in the
safety climate through active supervisory and peer involvement. The
safety climate of an organization is defined by many factors including
technical knowledge and behavior of its members with regard to safety.
This includes opportunities for personnel exposure to safety principles
and practices, dissemination of safety lessons learned, the ease of
safety communication up and down the organization, and the
consideration of safety in management decisions.
NASA is pursuing a multi-faceted approach for improving safety
climate across the Agency that will include the Astronaut Corps. This
approach is based on:
Integration of safety management with programmatic
and engineering decision processes.
Achieving technical excellence in safety and mission
assurance activities.
The former is being implemented through NASA's governance model.
The latter is being addressed by establishing the NASA Safety Center
(NSC) to expand and strengthen the safety training element of NASA's
safety program. Each approach is briefly discussed below:
NASA Governance Model--Over the past several years, NASA has been
defining and implementing an overall governance model that is based on:
(1) responsible decision-making; (2) a balance of power; and, (3) the
establishment of checks and balances. These elements and the practices
are a direct outgrowth of the CAIB findings and establish a framework
for a safety culture to grow and thrive. These three elements permit
ongoing lively discussion and debate to occur unfettered at all levels
within the NASA organization. The NASA Administrator has set the
overall tone for these discussions and debates by consistently
challenging decisions and established policies looking for new ways to
answer questions, and NASA has codified a formal process for dissent in
NASA Procedural Requirements 7120.SD, NASA Space Flight Program and
Project Management Requirements. The visibility and clear definition of
the overall decision process along with the examples of these processes
set at the highest level of the Agency in the Program Management
Council and other top level councils establishes the benchmark for the
rest of the Agency to follow. Even so, NASA recognizes that even with
these concepts documented and regularly exercised, there will be people
that remain uncomfortable even in the most open of organizational
safety climates. Some of that lack of comfort might be attributed to a
lack of technical competency or standing among one's peers or from lack
of confidence in the openness of management. As discussed in the
following paragraphs NASA is taking steps to increase the competence
(and confidence in the competence) of the NASA workforce relating to
safety and mission assurance disciplines through the Technical
Excellence activities, and we are also developing the capability to
measure the overall climate with respect to safety.
Achieving Technical Excellence in Safety and Mission Assurance--NASA is
committed to increase the awareness and concern for safety at all
levels beginning with system safety in design and facility operations
to astronauts and flight operations. Increased excellence and awareness
in safety are necessary ingredients for strengthening our safety
culture. The Technical Excellence Program being developed at the NSC
will conduct educational programs to raise safety awareness,
disseminate safety lessons learned, and increase the safety emphasis of
NASA management and staff. Safety engineering and management courses
that are being planned will address not only safety in the operational
and design environment but also philosophy and doctrine that influence
the various management and technical levels at NASA. We believe that
the envisioned Technical Excellence Program will not only increase the
safety competency of our workforce but will also increase management's
awareness of the benefits that derive from sound safety management and
safety engineering principles and processes being applied uniformly
across the Agency.
Measuring and Communicating Safety Culture Using a Standard Process--
Recognizing the importance of safety culture, our Office of Safety and
Mission Assurance (OSMA), over the past two years, has developed and
maintained contacts with several faculty members of the Naval
Postgraduate School (NPS) and the University of California at Berkeley
(UCB) who have developed a web-based safety climate survey tool for the
Naval Aviation School. Recognizing the difficulty inherent in measuring
safety culture, this tool uses safety climate metrics as an indicator
of cultural strengths and weaknesses. After several exchanges of
information and views between the OSMA and the NPS/UCB faculty, it was
decided that a proof-of-concept should be undertaken to demonstrate the
feasibility of using a similar tool at NASA. The Goddard Space Flight
Center (GSFC) volunteered to participate in the first pilot study just
completed. On August 24, 2007, the preliminary results of this pilot
project were presented to OSMA. OSMA is currently evaluating the
results of this study and is planning to conduct a series of additional
pilot studies. These studies will allow OSMA to incrementally arrive at
an Agency-wide safety culture shaping and measurement process that will
be effective for both design and operational environments at NASA. OSMA
is also investigating whether this process will allow NASA on-site
contractors to participate on a voluntary basis; contractor
participation may be dependent on the specific contract. To this end,
the following activities are being pursued by OSMA:
Examine the results of the GSFC study and past safety
culture assessment and shaping processes performed at NASA as
well as in other government and non-government organizations to
determine best practices and analyze what practices could be
adapted for NASA use.
Develop a safety culture assessment and shaping
process, or adapt/refine a currently employed process for NASA
use that incorporates the applicable government and industry
best practices. This process will include methods to educate
Center leadership on the process, measure safety climate,
analyze the survey data, and advise NASA Headquarters and
Center leadership as to the results and recommended strategies
to strengthen safety culture.
Together, these efforts will allow NASA to address many cultural
and structural issues, some of which have existed since the earliest
days of the astronaut program.
Q2. What can you do as the NASA Administrator to verify that there is
no stigma associated with an astronaut seeking psychological
counseling, particularly for common emotional, or family related
issues?
A2. Several approaches are being pursued. The behavioral health clinic
is physically separate from the flight medicine clinic to maintain
privacy. Privacy Act regulations are assiduously followed to further
maintain the privacy of behavioral health visits. The behavioral health
clinic is available for both astronauts and their dependents providing
the whole family with appropriate psychological support. New processes
are being developed to include an annual behavioral health exam for
astronauts that should make behavioral health encounters routine and
foster more communication between care providers and the astronauts.
The NASA aeromedical certification boards would only consider a
health related issue if it represented a potential flight safety issue;
even in this circumstance, all efforts are made for any medical or
behavioral health issue, to restore or maintain the astronaut's health.
Behavioral and medical issues are considered equally and no stigma is
attached to any health care issue. NASA has also put in place more
frequent communication between the space medicine providers and
Astronaut Office so that any aeromedical certification issues are
clearly communicated including expected outcomes and resolution of the
problem.
Q3. Has the Aerospace Safety Advisory Panel (ASAP) been involved in
the findings of the report or made any recommendations to guide NASA
with implementation of the recommendations?
A3. The Aerospace Safety Advisory Panel (ASAP) is working with NASA, at
multiple levels, to better understand the issues highlighted and the
recommendations that were made. The ASAP has stated that their most
important contribution will be to provide the NASA Administrator with
independent counsel regarding changes implemented in response to the
report. The Panel has indicated to NASA that they believe the report
highlights both process issues and communication challenges that should
be taken to heart and expeditiously addressed. The Panel has also
indicated to NASA that they trusts the Agency's ``improving culture of
openness'' will enable the Agency to also take aboard the subtle, yet
important, messages contained in the report.
It should be noted that Dr. James Bagian, who served on the Bachman
Panel, is also a member of the ASAP.
Questions submitted by Chairman Mark Udall
Q1. NASA has focused an investigation on the incidents of alcohol
mentioned in the external review. Col. Bachmann's testimony notes that
these incidents were examples of bigger issues of ``human factors
concerns with significant safety implications [that] had been
disregarded when raised to local on-scene leadership.'' What are NASA's
plans for probing these larger human factors concerns and potential
safety implications?
A1. NASA has developed a comprehensive response plan that addresses all
recommendations in the NASA Astronaut Health Care System Review
Committee Report. Recommendations for addressing human factors concerns
are being developed by both the medical and astronaut groups and final
recommended changes will be presented to the Medical Policy Board (MPB)
early next year. The MPB will oversee the entire report implementation
including the human factors issues noted.
NASA is probing these larger human factors concerns related to open
communication and safety climate by pursuing a multi-faceted approach
for improving safety climate across the Agency. This approach is based
on:
Integration of safety management with programmatic
and engineering decision processes.
Achieving technical excellence in safety and mission
assurance activities.
The former is being implemented through NASA's governance model.
The latter is being addressed by establishing the NASA Safety Center
(NSC) to expand and strengthen the safety training element of NASA's
safety program. Each approach is briefly discussed below:
NASA Governance Model--Over the past several years NASA has been
defining and implementing an overall governance model that is based on:
(1) responsible decision-making; (2) a balance of power; and, (3) the
establishment of checks and balances. These elements and the practices
are a direct outgrowth of the Columbia Accident Investigation Board
findings and establish a framework for a safety culture to grow and
thrive. These three elements permit ongoing lively discussion and
debate to occur unfettered at all levels within the NASA organization.
The NASA Administrator has set the overall tone for these discussions
and debates by consistently challenging decisions and established
policies looking for new ways to answer questions, and NASA has
codified a formal process for dissent in NASA Procedural Requirements
7120.513, NASA Space Flight Program and Project Management
Requirements. The visibility and clear definition of the overall
decision process along with the examples of these processes set at the
highest level of the Agency in the Program Management Council and other
top level councils establishes the benchmark for the rest of the Agency
to follow. NASA recognizes that, even with these concepts documented
and regularly exercised, there will be people that remain uncomfortable
even in the most open of organizational safety climates. Some of that
lack of comfort might be attributed to a lack of technical competency
or standing among one's peers or from lack of confidence in the
openness of management. As discussed in the following paragraphs, NASA
is taking steps to increase the competence (and confidence in the
competence) of the NASA workforce relating to safety and mission
assurance disciplines through the Technical Excellence activities, and
we are also developing the capability to measure the overall climate
with respect to safety.
Achieving Technical Excellence in Safety and Mission Assurance
Activities--NASA is committed to increase the awareness and concern for
safety at all levels, beginning with system safety in design and
facility operations to astronauts and flight operations. Increased
excellence and awareness in safety are necessary ingredients for
strengthening our safety culture. The Technical Excellence Program
being developed at the NSC will conduct educational programs to raise
safety awareness, disseminate safety lessons learned, and increase the
safety emphasis of NASA management and staff. Safety engineering and
management courses that are being planned will address not only safety
in the operational and design environment, but also philosophy and
doctrine that influence the various management and technical levels at
NASA. We believe that the envisioned Technical Excellence Program will
not only increase the safety competency of our workforce but will also
increase management's awareness of the benefits that derive from sound
safety management and safety engineering principles and processes being
applied uniformly across the Agency.
Measuring and Communicating Safety Culture Using a Standard Process--
Recognizing the importance of safety culture, our Office of Safety and
Mission Assurance (OSMA), over the past two years, has developed and
maintained contacts with several faculty members of the Naval
Postgraduate School (NPS) and the University of California at Berkeley
(UCB) who have developed a web-based safety climate survey tool for the
Naval Aviation School. Recognizing the difficulty inherent in measuring
safety culture, this tool uses safety climate metrics as an indicator
of cultural strengths and weaknesses. After several exchanges of
information and views between the OSMA and the NPS/UCB faculty, it was
decided that a proof-of-concept should be undertaken to demonstrate the
feasibility of using a similar tool at NASA. The Goddard Space Flight
Center (GSFC) volunteered to participate in the first pilot study just
completed. On August 24, 2007, the preliminary results of this pilot
project were presented to OSMA. OSMA is currently evaluating the
results of this study and is planning to conduct a series of additional
pilot studies. These studies will allow OSMA to incrementally arrive at
an Agency-wide safety culture shaping and measurement process that will
be effective for both design and operational environments at NASA. OSMA
is also investigating whether this process will allow NASA on-site
contractors to participate on a voluntary basis; contractor
participation may be dependent on the specific contract. To this end,
the following activities are being pursued by OSMA:
Examine the results of the GSFC study and past safety
culture assessment and shaping processes performed at NASA as
well as in other government and non-government organizations to
determine best practices and analyze what practices could be
adapted for NASA use.
Develop a safety culture. assessment and shaping
process, or adapt/refine a currently employed process for NASA
use that incorporates the applicable government and industry
best practices. This process will include methods to educate
Center leadership on the process, measure safety climate,
analyze the survey data, and advise NASA Headquarters and
Center leadership as to the results and recommended strategies
to strengthen safety culture.
Q2. Deputy Administrator Dale noted during the press conference on the
external health care review report that NASA has ``explicitly
extended'' the T-38 policy on alcohol use to space flight.
a. Ms. Dale referred to it as an ``interim policy.'' Could you
please discuss how and when NASA will establish a final policy?
b. Has the T-38 policy that currently applies to space flight
been considered by NASA medical officials as to the medical
basis of the policy? If not, will medical officials be
consulted?
c. The Space Flight Safety Review identifies and makes
recommendations to strengthen policies related to alcohol use
and abuse. What are NASA's plans for making actual changes to
those policies?
A2a,c. Ms. Dale stated that NASA ``explicitly extended'' the T-38
policy on alcohol to include all spacecraft. Due to the urgent nature
of the policy clarification, NASA quickly issued this policy via an
interim policy memorandum to all astronauts signed by the Director,
Flight Operations Crew on July 27, 2007. (At NASA, interim policy is
issued when there is an urgent requirement that must be quickly
conveyed, and interim policy expires 12 months from the date of
issuance. This allows policy developers one year to integrate the new
policy into a formal policy directive or procedural requirement.) Prior
to the expiration of this interim policy, NASA will refine its policies
related to alcohol use across the Agency civil service and contractor
work force and will codify the revised policies and procedures in
permanent NASA directives.
The original policy, the Johnson Space Center document Aircraft
Operations Division (AOD) 09295: Aircraft Operations and Training
Procedures: T-38 Operating Procedures Volume 1 documented the general
practices that apply to the entire Flight Crew Operations Directorate
(all astronauts), but was titled Training Procedures for the T-38. To
prevent any confusion, on July 27, 2007, an interim policy memorandum
was generated to extend the 12-hour bottle-to-throttle policy to the
Space Shuttle. In addition, other efforts are underway to extend NASA's
policy on alcohol use. NASA has formed an Agency-level team to clarify
procedures and requirements for drug and alcohol testing of civil
servants, contractors, and subcontractors. This team is also working to
ensure supervisory and employee training addresses the policy,
procedures, and requirements. The team is evaluating the best method to
evaluate compliance with contract. This effort will include a process
to review the status of contractor drug and alcohol-free workplace
plans and their associated metrics to establish whether a contractor is
compliant with existing NASA requirements. The policy, procedure, and
training changes will be Agency-wide, ensure that NASA is compliant
with all applicable laws, and strengthen our efforts to ensure alcohol
use and abuse does not affect the safety of our missions. Any changes
related to alcohol use are governed by laws; therefore NASA's new
policies and requirements must be created and then circulated through
Health and Human Services and the Department of Justice. NASA
anticipates this entire process will not take more than 18-24 months
until completion.
A2b. The T-38 policy had previously been accepted by NASA medical
officials and will be reviewed by the Office of the Chief Health and
Medical Officer's Medical Policy Board advisory group.