NASA promises to break culture of silence

Some say that's not enough

Sunday, July 27, 2003 Posted: 10:42 PM EDT (0242 GMT)

NASA administrator Sean O'Keefe

JOHNSON SPACE CENTER, Texas (AP) -- The space shuttle engineers who desperately wanted zoom-in satellite pictures of the damaged Columbia in orbit never spoke up at key meetings and never told the manager in charge of the flight.

They were too uncomfortable. Too afraid.

Whatever the reason for the chilling silence, NASA chief Sean O'Keefe is promising dramatic change. He told employees this past week he is committed to "creating an atmosphere in which we're all encouraged to raise our hand and say something's not right or something doesn't look safe."

"We all have a responsibility," he said, "to redouble our efforts to create that atmosphere."

For starters, employees will be able to go to the NASA Web site and "file anything anybody sees as being off," O'Keefe said. "It will make it really easy for anybody to participate and voice their concerns anonymously or through any other means they want to," including NASA's longtime safety-reporting hot line and printed forms.

But James Oberg, a noted author and former shuttle flight controller, doubts that will solve the problem.

"I've heard that before. In fact, I heard that 17 years ago," Oberg said, referring to the 1986 Challenger accident.

"The NASA team leaders think they're way smarter than their record indicates, and they can use a little more humility and a little more anxiety in the way they approach this profession -- or find another."

To the Columbia Accident Investigation Board, the foul-up over satellite images is a prime example of what is wrong deep within NASA -- and the 13 members intend to highlight management failures in their final report, due out in late August.

As the investigators see it, poor management was as responsible for the February disaster as the foam that knocked a hole in the wing.

Disaster could have been avoided

On both counts, they say, the Columbia disaster could have been avoided.

"There's not any doubt about it," said Air Force Brig. Gen. Duane Deal, a board member. "All these things contributed to allow these foam pieces to continue to come off" the external fuel tanks over the years -- "until it finally did catastrophic damage."

Board member John Logsdon blames the problem, at least in part, on so-called tribalism: "It's a particular culture, has its own rules and its own behavior patterns."

As an example, Logsdon cites the competitive and sometimes strained relationship between Johnson Space Center in Houston -- the nucleus of NASA's human spaceflight -- and Marshall Space Flight Center in Huntsville, Alabama -- the propulsion hub.

"Foam is Marshall's problem. Orbiter is Johnson's problem. Who looks at foam hitting the orbiter? There's kind of a hole in the middle," said Logsdon, director of George Washington University's space policy institute.

As for the fracture in communications that quashed the quest for spy satellite images, "it was a mess ... it shouldn't have happened, but it did," Logsdon said.

Workers afraid to speak up

The crew of STS-107 was lost when space shuttle Columbia disintegrated, just minutes before landing.

NASA's previous boss, Daniel Goldin, scared many workers with his abrasive, demanding demeanor, and the effects of that may have lingered after he left NASA in late 2001, Logsdon noted. "There were people afraid to tell Mr. Goldin things he didn't want to hear," he said.

Jose Garcia, a retired shuttle operations manager, was one of the few who openly voiced his complaints about NASA safety cutbacks not only to Goldin, but to the White House.

What surprised the former Kennedy Space Center worker was not the loss of another shuttle -- he predicted that back in 1995 -- but the fact that he was not fired or even demoted for speaking out.

"Thinking back, it was probably smart on their part. If it had cost me my job, I might have gotten more response than I got," Garcia said. "Plus, there were some people who were pretty high up, and I shouldn't mention any names, but from astronauts to deputy center directors to center directors, telling me, 'Go for it."'

Garcia believes those people were too worried about their own careers to speak up, but that they may have helped protect his.

Oberg, too, spoke up when he was at Johnson Space Center in the mid-1990s, warning of the dangers of Mir and the Russian space program. He ultimately was right; a fire and decompression crippled the orbiting station. But he was shunned for his efforts, taken off critical e-mail lists and hauled in for frequent job reviews. Eventually, it got so bad he quit in late 1997.

Communication breakdown

NASA official Linda Ham, who led the mission management team during Columbia's doomed flight.

Perhaps no one was more stunned about the breakdown in communication during Columbia's doomed flight than the head of the mission management team, Linda Ham.

In her first public appearance since the disaster, Ham told reporters last week that she was notified six days into Columbia's 16-day flight about a possible request for spy satellite pictures of the orbiting ship.

She said she spent the day trying to find out who was making the request, by making some phone calls. But she could not pin it down, and so she spiked the appeal and "that was the beginning and the end of it." At mission management meetings, she never asked about the potential request -- never even mentioned it.

Ham says she did not learn the identities and concerns of those seeking the satellite images until weeks after Columbia shattered in the Texas sky during re-entry because of the hole in the left wing from a flying piece of insulating fuel-tank foam. All seven astronauts were killed.

Six long, agonizing months later, Ham acknowledges the system failed and needs to be fixed before shuttle flights resume, possibly by next spring. She has been reassigned and does not know yet what her next job will be at NASA.

One of the NASA engineers who wanted the satellite pictures, Rodney Rocha, was part of the assessment team put in place by Ham and other mission managers to study the foam impact. Because of equipment problems, NASA's camera views of the launch were too blurred to show exactly where the debris struck or the damage left behind.

"Without better images it will be very difficult to even bound the problem," Rocha wrote to colleagues in an e-mail dated January 21, five days after Columbia's launch. A chief structural engineer at Johnson Space Center, he said given all the uncertainty about the foam strike, the analyses could result in answers "ranging from acceptable to not acceptable to horrible."

"Can we petition (beg) for outside agency assistance?" he wrote, putting the question in bold type.

When Rocha learned of Ham's decision not to seek satellite photos, he was flabbergasted. In an e-mail to colleagues -- which he drafted around January 22 but never sent -- he wrote: "In my humble opinion, this is the wrong (and bordering on irresponsible) answer."

Rocha ended the draft e-mail with: "Remember the NASA safety posters everywhere around site stating, 'If it's not safe, say so?' Yes, it's that serious."

He has never explained publicly why he did not send the e-mail, but he did talk over the matter at the time with a colleague and engineering management.

On January 24, during a mission management team meeting, Ham put the matter to rest.

'Nagging at me underneath all of that was, we might be wrong'

This is a very personality-dependent thing, and these large meetings can be intimidating. -- Sally Ride, former astronaut

"No safety of flight, no issue for this mission, nothing that we're going to do different," Ham said. She went on to discuss the maintenance, or turnaround, issues before Columbia's next launch and ended the conversation by asking if there were any questions.

Ham paused three seconds. There was only silence, and so she moved on to the next item on the list.

In a recent interview with ABC News, Rocha recalled the pause and the way Ham looked around the room, "like it's OK to say something now." He said he just couldn't do it.

"I was too low down here in the organization and she's way up here," Rocha told ABC. He said that even though it sounds like a contradiction, he believed the team had done a competent job analyzing the foam strike.

"But subconsciously or nagging at me underneath all of that was, we might be wrong."

They ended up being very wrong.

Former astronaut Sally Ride, part of the accident inquiries for both Challenger and Columbia, noted how human behavior plays a role -- and how difficult that is to fix.

"This is a very personality-dependent thing, and these large meetings can be intimidating," said Ride, a physicist who became the first American woman in space 20 years ago. "Some people are more reticent, less talkative, more easily intimidated than others."

While acknowledging mistakes, a former flight director who served on Columbia's mission management team, Phil Engelauf, has "trouble accepting the idea that this flight failed because one individual was afraid to say something in one particular meeting."

"I wouldn't look at this case as being all of NASA was wrong except one guy who had the answer," Engelauf said. "There has to be a more fundamental structural problem with how the communication broke down here."

In the end, accident investigators are uncertain whether spy satellites could have detected the estimated 6- to 10-inch gouge in Columbia's left wing, a black hole in the dark-colored shielding.

No one will ever know.