Expert: Rules Blinded NASA to Risks

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CAPE CANAVERAL, Fla., April 23 (UPI) — Even if investigators probing the Columbia disaster nail the technical causes of the shuttle’s demise, NASA runs the risk of another fatal accident unless it changes its cultural mindset, an expert on organizations warned Wednesday.

“The problems that existed at the time of Challenger have not been fixed, despite all the … insights that the presidential commission (which investigated the fatal 1986 accident) found,” Boston University sociologist Diane Vaughn told the Columbia Accident Investigation Board during a public hearing.


“These problems have still remained … That’s what I believe happened in the Columbia accident,” she said.

NASA’s allegiance to rules — which enable a hugely complex program to fly people and rockets in the unforgiving space environment — also blinds it to following through on engineering hunches and intuition — a key component of any advanced technological program, said Vaughn, author of a well-respected book on the Challenger accident that has become a case-study for organizations and businesses seeking to minimize risk.

Without hard data, engineering insights would not warrant high-level attention, she said.

In the case of Challenger, which exploded just 73 seconds after liftoff, some engineers felt very uncomfortable with the idea of launching with temperatures at record lows, said Vaughn. However, without data to back up their subjective assessments, the warnings were dismissed.

During Columbia’s mission, groups of engineers wanted more images of the shuttle’s wing, which had been hit by an unusually large piece of foam insulation shed from the fuel tank during launch. The request for spy satellite pictures was nixed by top managers, who said that proper channels had not been followed.

“In both situations, following normal rules and procedures seemed to take precedence,” said Vaughn. “In times of uncertainty, people do follow habits and routines. However under these circumstances … that is not the time for hierarchical decision-making.”

The culture creates an environment where, in the absence of hard data, people do not bring forth their concerns, said Vaughn.

Board members struggled to apply Vaughn’s insights into principles to guide them in writing a report about the accident, which is expected in June.

Some questioned why NASA was so good at nailing some problems early on, such as the potentially dangerous issue with shuttle wiring, which required the fleet to be grounded for several months for repairs.

Avoiding what Vaughn calls “the slippery slope” requires organizational changes, such as independent and more visible engineering assessments, an expanded safety oversight program and regularly opening the inner sanctums of the NASA decision-making process to outsiders.

Many personnel changes were made after Challenger and the technical flaws were found and fixed, yet the agency lost another shuttle due to what may be oversights and a failure to spot dangerous trends, said Vaughn.

“You need to understand your culture,” she said. “It works in ways you don’t even realize.”

Vaughn’s testimony followed the official announcement that shuttle program manager Ron Dittemore would be leaving the agency. NASA’s associate administrator for space flight Michael Kostelnik said Dittemore had planned to retire before the Columbia accident and delayed his departure to manage the crisis.

“This is not something we would have asked for or would have wished,” said Kostelnik. “He is not going to be an easy person to replace.”

Dittemore, who has managed the $3.5 billion shuttle program since 1999, said he plans to stay on until his successor is found and trained to ease the transition as NASA shifts from searching for the cause of the accident to preparing for return to flight.

“The last thing on my priority list are my personal opportunities,” said Dittemore, who declined to discuss his plans.

Copyright 2003 by United Press International. All rights reserved.