Friday, September 26, 2003

The Failure of NASA Management

Excerpts from long New York Times article.

New interviews and newly revealed e-mail sent during the fatal Columbia mission show that the engineers' desire for outside help in getting a look at the shuttle's wing was more intense and widespread than what was described in the Aug. 26 final report of the board investigating the Feb. 1 accident, which killed all seven astronauts aboard.

The new information makes it clear that the failure to follow up on the request for outside imagery, the first step in discovering the damage and perhaps mounting a rescue effort, did not simply fall through bureaucratic cracks but was actively, even hotly resisted by mission managers.

In interviews with numerous engineers, most of whom have not spoken publicly until now, the discord between NASA's engineers and managers stands out in stark relief.

Mr. Rocha, who has emerged as a central figure in the 16 days of the Columbia's flight, was a natural choice of his fellow engineers as a go-between on the initial picture request. He had already sent an e-mail message to the shuttle engineering office asking if the astronauts could visually inspect the impact area through a small window on the side of the craft. And as Mr. Rocha was chief engineer in Johnson Space Center's structural engineering division and a man with a reputation for precision and integrity, his words were likely to carry great weight.

Mr. Rocha's experience provides perhaps the clearest and most harrowing view of a NASA safety culture that, the board says, must be fixed if the remaining shuttles are to continue flying.

For Mr. Rocha, the Columbia disaster began on the eve of its final liftoff. That afternoon, he and other engineers were stunned to learn of new tests at a NASA laboratory showing that a ring attaching the rocket boosters to the external tank had not met minimum strength requirements. As he watched, managers hastily considered the problem at a prelaunching meeting beginning at 12:10 a.m. on Jan. 16.

Instead of halting the launching on the spot, Mr. Rocha said, the shuttle manager, Linda Ham, granted a temporary waiver that reduced the strength requirements, on the basis of data that the investigation board later found to be flawed. Mr. Rocha would draw on an old rocketry term — "launch fever" — to describe what had happened at the meeting.

The launching went ahead that Thursday morning. The ring held, but an unrelated problem turned up when insulating foam tore away from an attachment to the external tank 81.7 seconds after liftoff and struck the orbiter's left wing.

Mr. Rocha said that when he learned of the foam strike in a phone call on Friday afternoon, he gasped. All weekend he watched the video loop showing the strike, and at 11:24 p.m. on Sunday, he sent an e-mail message to the manager of the shuttle engineering office, Paul Shack, suggesting that the astronauts simply take a look at the impact area.

On Wednesday, an official Mr. Schomburg had spoken to — Ms. Ham, the chairwoman of the mission management team — canceled Mr. Rocha's request and two similar requests from other engineers associated with the mission, according to the investigation board. Late that day, Mr. Shack informed Mr. Rocha of management's decision not to seek images.

Astonished, Mr. Rocha sent an e-mail message asking why. Receiving no answer, he phoned Mr. Shack, who said, "I'm not going to be Chicken Little about this," Mr. Rocha recalled.

"Chicken Little?" Mr. Rocha said he shouted back. "The program is acting like an ostrich with its head in the sand."

On the day he talked with Mr. Shack, Mr. Rocha wrote an anguished e-mail message that began, "In my humble technical opinion, this is the wrong (and bordering on irresponsible) answer." He said his finger hovered over the "send" key, but he did not push the button. Instead, he showed the draft message to a colleague, Carlisle Campbell, an engineer.

"I said, `Rodney, that's a significant document,' " Mr. Campbell said in an interview. "I probably got more concerned or angry than he did at the time. We could not believe what was going on."

But Mr. Rocha still decided he should push his concerns through official channels. Engineers were often told not to send messages much higher than their own rung in the ladder, he said.

The next day, Mr. Rocha spoke with Barbara Conte, a worker in mission operations, about spy telescopes. In a written response to reporters' questions, Ms. Conte said her colleague "was more keyed-up and troubled than I had ever previously encountered him."

"We informed LeRoy of the concern from Rodney" and offered to help arrange an observation by military satellites, Mr. Oliver wrote on March 6 — a month after the accident — in a previously unreleased e-mail chronology of shuttle events. The message continued, "LeRoy said he would go talk to Linda Ham and get back to us."

About two hours later, at 12:07 p.m. that day, Mr. Cain sent out his own e-mail message saying he had spoken with management officials, who had no interest in obtaining the images. Therefore, Mr. Cain wrote, "I consider it to be a dead issue."

It was not over for Mr. Rocha, though. On Thursday afternoon, Jan. 23, he encountered Mr. Schomburg, the expert on the heat-resisting tiles, on the sixth floor of Building 1, where most of the managers had offices. They sat down in the anteroom of an office and began arguing about the need for imaging, said Mr. Rocha and the investigative board's report.

Mr. Schomburg insisted that because smaller pieces of foam had broken off and struck shuttles on previous flights without dire consequences, the latest strike would require nothing more than a refurbishment after the Columbia landed. Mr. Rocha maintained that the damage could be severe enough to allow hot gases to burn through the wing on re-entry and threaten the craft.

As their voices rose, Mr. Rocha recalled, Mr. Schomburg thrust out an index finger and said, "Well, if it's that bad, there's not a damn thing we can do about it."

On Jan. 24, eight days into the mission, engineers and managers held a series of meetings in which the debris strike was discussed. At a 7 a.m. meeting, Boeing engineers presented their analysis, which they said showed that the shuttle probably took the hit without experiencing fatal damage.

Those results were hastily carried into the 8 a.m. meeting of the mission management team, led by Ms. Ham. When a NASA engineer presented the results of the Boeing analysis and then began to discuss the lingering areas of uncertainty, Ms. Ham cut him off and the meeting moved along. The wing discussion does not even appear in the official minutes.

Mr. Diggins, the accident board investigator, said it should not be surprising that such a critical issue received short shrift. A mission management meeting, he said, is simply "an official pro forma meeting to get it on the record." The decision to do nothing more, he said, had long been made.

Being There for Re-entry

On Feb. 1, the last day of the Columbia's flight, Mr. Rocha rose before dawn. He wanted to be in the mission evaluation room, an engineering monitoring center on the first floor of NASA's Building 30, by 6:45 a.m., well before the shuttle fired its rockets to drop out of orbit. Normally, he would just watch the landing on NASA-TV, the space agency's channel, but he said he wanted to see the data from the wing sensors.

Mr. Rocha recalled that Ms. Hansen, trying to console him, said, "Oh, Rodney, we lost people, and there's probably nothing we could have done."

For the third time in two weeks, Mr. Rocha raised his voice to a colleague. "I've been hearing that all week," he snapped. "We don't know that."

He was instantly ashamed, he said, and thought, "I'm being rude."

The next days passed in a blur. Mr. Rocha was assigned to the team to investigate the mission. At the same time, he was working with the team that was looking into the attachment ring problem that nearly scuttled the mission the night before liftoff, while handling his other duties.

At one point he got to ask Ralph Roe, a shuttle manager, why the photo request had been denied. He got no direct answer, he recalled. Instead, Mr. Roe replied: "I'd do anything now to get a photo. I'd take a million photos."

Mr. Rocha's sleep was still troubled — now, by nightmares, he said, describing some: he was in the shuttle as it broke up; his relatives were on the shuttle; "Columbia has miraculously been reassembled, and we're looking at the wiring and it's got rats in there."

Since the accident, Mr. Rocha said, engineers and other colleagues have thanked him enthusiastically for speaking up, saying things like, "I can't imagine what it was like to be in your shoes." His immediate supervisor has been supportive as well, he said, But from management, he said: "Silence. No talk. No reference to it. Nothing."

Except, that is, from the highest-up higher-up. One day Mr. Rocha read an interview with the NASA administrator, Sean O'Keefe, who wondered aloud why engineers had not raised the alarm through the agency's safety reporting system. This time, Mr. Rocha broke the rules: he wrote an e-mail message directly to Mr. O'Keefe, saying he would be happy to explain what really happened.

Within a day, he heard from Mr. O'Keefe, who then dispatched the NASA general counsel, Paul G. Pastorek, to interview him and report back. In a recent interview, Mr. O'Keefe said Mr. Rocha's experience underscored the need to seek the dissenting viewpoint and ask, "Are we talking ourselves into this answer?"

NASA, following the board's recommendation, has reached agreements with outside agencies to take images during every flight. And 11 of the 15 top shuttle managers have been reassigned, including Ms. Ham, or have retired.

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