The real world isn't so black and white. In the case of Columbia no action or inaction by any individual - or even small group of individuals caused the accident or could have prevented it. As the CAIB discovered in its examination of NASA's culture the problem was deep seated practices which evolved over many years.
The last point the accident could have been avoided was the STS-113 Flight Readiness Review where managers made the decision to continue flying even though a large chunk of the bipod fell off on the STS-112 mission. You can blame Jerry Smelser, the Marshall Spaceflight engineer who made a presentation declaring that "The ET is safe to fly with no new concerns (and no added risk)". You can blame NASA safety head Bryan O'Connor and shuttle head William Readdy for accepting the logic that it was okay to continue flying. And certainly anybody at the meeting who had reservations about continuing to fly even after a serious in-flight incident didn't speak up.
After launch you could blame the Mission Management Team (MMT) for what they did and didn't do. Many chose to focus their hatred on MMT chair Linda Ham, often implying that the only reason she was given the position was because she was a woman. Ham became the scapegoat for many. But she was just one of many involved. Ham has readily acknowledged that there were major communications problems - engineers had plenty of communications with each other but not between the engineers and higher level managers, and that was the MMT's fault. But it was a fault in place for many years, not something which happened when Ham became the MMT chair. Just as important, even if engineers felt Ham was unapproachable or wouldn't listen to their concerns she wasn't the only one they could talk to. Phil Engelhauf was the MOD (Mission Operations Directorate) representative, a senior flight director. Ralph Roe was the head of the Space Shuttle Vehicle Engineering Office. Ron Dittemore was the shuttle program director. etc. etc.
Unfortunately Ham became the scapegoat for many involved. While it's true she didn't do everything which was humanly possible, she did do everything she could. Could another manager have done a better job? Some think so - but the picture isn't so black and white. Many point to Wayne Hale who became the shuttle program manager after the accident and led the changes in NASA's culture. Hale was supposed to become the Mission Management Team lead on February 1, 2003 and if the STS-107 mission had been delayed one more time he would have had the position occupied by Ham. Many think Hale would have acted differently and maybe the crew could have been saved - but not Hale. Hale said, “If I had been sitting in the MMT team chair I probably would have made the same decisions [which were made during STS-107]. I have no defense. I find it a little disheartening that Linda Ham was tarred-and-feathered over this when if I had been sitting in the [MMT] chair I probably would have made the very same decisions for very similar reasons. Linda was not the ultimate culprit.”
The bottom line is no individual was responsible for the actions or inactions which led to the Columbia accident. But the overall NASA culture had gradually decayed over time for a wide variety of reasons inside and outside of NASA which eventually led to the accident.However ...
The entire aviation and aerospace industries have a simple definition for Foreign Object Debris (FOD – pronounced “fod”): anything that doesn’t belong around or on flight hardware. NASA's Kennedy Space Center redefined FOD in January 2001, adding the new category “processing debris,” meaning out-of-place items found during the routine processing of the flight hardware. Processing debris was considered acceptable. Why change the industry standard by adding a non-standard and potentially risky definition? Any FOD found in flight hardware after final closeout inspections would harm prime shuttle contractor United Space Alliance’s performance awards, but “processing debris” did not affect the bonus payments.
What's truly amazing is the gall of whoever proposed this change, and the fact that the change was approved by NASA's safety department, and contractor oversight personnel. But it was done. The KSC unique definition pretending that “processing debris” was acceptable was eliminated after the Columbia accident.
In a scathing article on NASA's view of safety CAIB member Brigadier General Duane Deal said,
"A glaring example of backing off of basics was in the foreign object damage (FOD) prevention program at Kennedy Space Center (KSC). KSC and its prime contractor agreed to devise an aberrant approach to their FOD prevention program, creating definitions not consistent with other NASA centers, Naval reactor programs, Department of Defense aviation, commercial aviation, or the National Aerospace FOD Prevention, Incorporated, guidelines. In the KSC approach, NASA implied there was a distinction between the by-products of maintenance operations, labeled processing debris, and FOD-causing foreign object debris. Such a distinction is dangerous to make since it is impossible to determine if any debris is truly benign. Consequently, this improper and nonstandard distinction resulted in a FOD prevention program that lacked credibility among KSC workers and one that allowed stray foreign objects to remain present throughout shuttle processing."
In the STS-114 mission's 147-page press kit’s description of all of the improvements to the shuttle after the Columbia accident, KSC’s acceptance of the industry standard definition for FOD is presented as a positive. In a spin doctoring attempt it’s described how new FOD procedures improve safety, and ignores that FOD rules existed until two years before the Columbia accident when the rules were reduced in a conscious move to make more bonus money for the contractor.While there were problems at NASA which eventually resulted in the Columbia accident none of those were caused by negligence. People made mistakes, warning signs were not noticed, and there was a lack of communications. But nobody involved made any conscious decisions to reduce safety or increase the risk for an accident.
But the decision at the Kennedy Space Center to water down the definition of Foreign Object Debris was a conscious decision which increased risks.
Home