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89–216PS 2004

THE COLUMBIA ACCIDENT

INVESTIGATION BOARD REPORT

HEARING

BEFORE THE

COMMITTEE ON SCIENCE

HOUSE OF REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

SEPTEMBER 4, 2003

Serial No. 108–27

Printed for the use of the Committee on Science

(

Available via the World Wide Web: http://www.house.gov/science

(II)

COMMITTEE ON SCIENCE

HON. SHERWOOD L. BOEHLERT, New York, Chairman

LAMAR S. SMITH, Texas

CURT WELDON, Pennsylvania

DANA ROHRABACHER, California

JOE BARTON, Texas

KEN CALVERT, California

NICK SMITH, Michigan

ROSCOE G. BARTLETT, Maryland

VERNON J. EHLERS, Michigan

GIL GUTKNECHT, Minnesota

GEORGE R. NETHERCUTT, JR.,

Washington

FRANK D. LUCAS, Oklahoma

JUDY BIGGERT, Illinois

WAYNE T. GILCHREST, Maryland

W. TODD AKIN, Missouri

TIMOTHY V. JOHNSON, Illinois

MELISSA A. HART, Pennsylvania

JOHN SULLIVAN, Oklahoma

J. RANDY FORBES, Virginia

PHIL GINGREY, Georgia

ROB BISHOP, Utah

MICHAEL C. BURGESS, Texas

JO BONNER, Alabama

TOM FEENEY, Florida

RANDY NEUGEBAUER, Texas

RALPH M. HALL, Texas

BART GORDON, Tennessee

JERRY F. COSTELLO, Illinois

EDDIE BERNICE JOHNSON, Texas

LYNN C. WOOLSEY, California

NICK LAMPSON, Texas

JOHN B. LARSON, Connecticut

MARK UDALL, Colorado

DAVID WU, Oregon

MICHAEL M. HONDA, California

CHRIS BELL, Texas

BRAD MILLER, North Carolina

LINCOLN DAVIS, Tennessee

SHEILA JACKSON LEE, Texas

ZOE LOFGREN, California

BRAD SHERMAN, California

BRIAN BAIRD, Washington

DENNIS MOORE, Kansas

ANTHONY D. WEINER, New York

JIM MATHESON, Utah

DENNIS A. CARDOZA, California

VACANCY

(III)

C O N T E N T S

September 4, 2003

Page

Witness List ............................................................................................................. 2

Hearing Charter ...................................................................................................... 3

Opening Statements

Statement by Representative Sherwood L. Boehlert, Chairman, Committee

on Science, U.S. House of Representatives ........................................................ 23

Written Statement ............................................................................................ 24

Statement by Representative Ralph M. Hall, Minority Ranking Member,

Committee on Science, U.S. House of Representatives ..................................... 25

Written Statement ............................................................................................ 27

Statement by Representative Dana Rohrabacher, Chairman, Subcommittee

on Space and Aeronautics, Committee on Science, U.S. House of Representatives ..................................................................................................................... 28

Written Statement ............................................................................................ 29

Statement by Representative Bart Gordon, Member, Committee on Science,

U.S. House of Representatives ............................................................................ 29

Written Statement ............................................................................................ 30

Prepared Statement by Representative Joe Barton, Member, Committee on

Science, U.S. House of Representatives ............................................................. 31

Prepared Statement by Representative Nick Smith, Chairman, Subcommittee

on Research, Committee on Science, U.S. House of Representatives .............. 31

Prepared Statement by Representative Vernon J. Ehlers, Chairman, Subcommittee on Environment, Technology, and Standards, Committee on

Science, U.S. House of Representatives ............................................................. 33

Prepared Statement by Representative John Sullivan, Member, Committee

on Science, U.S. House of Representatives ........................................................ 33

Prepared Statement by Representative J. Randy Forbes, Member, Committee

on Science, U.S. House of Representatives ........................................................ 34

Prepared Statement by Representative Jerry F. Costello, Member, Committee

on Science, U.S. House of Representatives ........................................................ 34

Prepared Statement by Representative Eddie Bernice Johnson, Member, Committee on Science, U.S. House of Representatives ............................................ 35

Prepared Statement by Representative Michael M. Honda, Member, Committee on Science, U.S. House of Representatives ............................................ 35

Prepared Statement by Representative Sheila Jackson Lee, Member, Committee on Science, U.S. House of Representatives ............................................ 35

Panel

Admiral Harold W. Gehman, Jr., U.S. Navy retired, Chairman of the Columbia Accident Investigation Board, accompanied by Board members Major

General Kenneth W. Hess, Dr. James N. Hallock, and Dr. Sheila E. Widnall

Oral Statement ................................................................................................. 37

Written Statement ............................................................................................ 39

Discussion

Risk ....................................................................................................................... 43

Crew Escape ......................................................................................................... 45

Shuttle Replacement ............................................................................................ 47

Page

IV

Continuing Shuttle Operations ........................................................................... 48

NASA’s Culture and Management ..................................................................... 48

Vision .................................................................................................................... 49

International Space Station and Space Shuttle Mishap Interagency Investigation Board Charter ..................................................................................... 50

Defining Benchmarks for Progress and Past Reports ....................................... 50

Schedule Pressure ................................................................................................ 51

Inaction to Previous Foam Loss .......................................................................... 52

Reduction in Safety Procedures .......................................................................... 52

Shuttle Servicing of Hubble ................................................................................ 52

Schedule Pressure ................................................................................................ 53

Independent Technical Authority ....................................................................... 55

Vision .................................................................................................................... 56

Budget ................................................................................................................... 58

Benchmarks of Implementation .......................................................................... 59

Shuttle Design Compromises .............................................................................. 60

One-year Review .................................................................................................. 61

Following Through on the Report’s Recommendations ..................................... 62

Workforce .............................................................................................................. 62

Characteristics of a Follow-on Vehicle ............................................................... 64

Manned vs. Unmanned Science .......................................................................... 66

Defining Cultural and Organizational Problems ............................................... 67

The Culture of Safety .......................................................................................... 70

Accountability ....................................................................................................... 73

NASA Recruiting and Retention ......................................................................... 74

Prioritizing Space Research Within the Federal Budget .................................. 74

The Value of Research in Space .......................................................................... 75

The Process of Defining a Vision ........................................................................ 76

The Difference Between ‘‘Observations’’ and ‘‘Recommendations’’ in the Report .................................................................................................................... 77

NASA Engineering and Safety Center ............................................................... 78

SFOC Board of Investigation .............................................................................. 79

Cost Estimates and Mission Parameters of a Follow-on Vehicle ..................... 79

ISS Supply ............................................................................................................ 80

Shuttle Support of ISS Construction .................................................................. 80

Funding as a Factor in the Accident .................................................................. 81

Accountability ....................................................................................................... 82

Appendix 1: Answers to Post-Hearing Questions

Admiral Harold W. Gehman, Jr., U.S. Navy retired, Chairman of the Columbia Accident Investigation Board ........................................................................ 86

(1)

THE COLUMBIA ACCIDENT INVESTIGATION

BOARD REPORT

THURSDAY, SEPTEMBER 4, 2003

HOUSE OF REPRESENTATIVES,

COMMITTEE ON SCIENCE,

Washington, DC.

The Committee met, pursuant to call, at 10 a.m., in Room 2318

of the Rayburn House Office Building, Hon. Sherwood L. Boehlert

[Chairman of the Committee] presiding.

2

3

HEARING CHARTER

COMMITTEE ON SCIENCE

U.S. HOUSE OF REPRESENTATIVES

The Columbia Accident

Investigation Board Report

THURSDAY, SEPTEMBER 4, 2003

10:00 A.M.–12:00 P.M. 2318 RAYBURN HOUSE OFFICE BUILDING

1. Purpose

On Thursday, September 4th at 10:00 a.m., the Science Committee will hold a

Full Committee hearing on the findings and recommendations of the Columbia Accident Investigation Board (CAIB). The Committee will receive testimony from retired

Navy Admiral Harold Gehman, Chairman of the 13-member Board, along with three

members of the Board.

2. Background

This is the first in a series of hearings the Science Committee will hold this fall

on the Space Shuttle accident and related problems highlighted in the CAIB report.

This hearing provides an opportunity for Admiral Gehman to present the report to

the Committee and will set the stage for the follow-up hearings. The overall goal

this fall is to fully understand the risks, costs, and benefits of the human space

flight program, including the Space Shuttle, and to determine what actions need to

be taken to reform NASA.

While the CAIB has said it intends the report to help NASA in safely getting back

to human space flight, the report is hard hitting. It describes in detail the specific

physical causes of the Shuttle Columbia’s demise and documents the failures of

NASA’s organization in recognizing and dealing with the dangers the Shuttle faced.

The CAIB makes a number of recommendations to remedy both problems, some that

NASA must meet before the Shuttle returns to flight, and others that the report

suggests will take longer to implement. It is likely that Congress will ultimately be

responsible for ensuring those recommendations are met.

The CAIB report also cites as contributions to the Shuttle accident NASA’s reluctance to realistically assess its ability to conduct human space flight missions on a

constrained budget and the lack of a national commitment to an ambitious and

probably expensive vision for human space flight. The report sets the stage for a

thorough public policy debate regarding the future of human space flight, the prospects for a Shuttle replacement, the appropriate balance of human and robotic missions, future priorities in space exploration, and the level of resources that should

be allocated for such activities. The Committee’s findings will, among other things,

form the basis of a NASA reauthorization bill next year.

3. Witnesses

Admiral Harold Gehman (retired), Chairman, Columbia Accident Investigation

Board. Formerly Co-Chairman of the Department of Defense review of the attack

on the U.S.S. Cole. Before retiring, Gehman served as the NATO Supreme Allied

Commander, Atlantic, Commander in Chief of the U.S. Joint Forces Command, and

Vice Chief of Naval Operations for the U.S. Navy. Gehman earned a B.S. in Industrial Engineering from Penn State University and is a retired four star Admiral.

James Hallock, Ph.D., Manager, Aviation Safety Division, Volpe National Transportation Systems Center, Massachusetts. Dr. Hallock contributed to Group III of

the CAIB, which focused on engineering and technical analysis of the accident and

resulting debris. He has worked in the Apollo Optics Group of the MIT Instrumentation Lab and was a physicist at the NASA Electronics Research Center, where he

developed a spacecraft attitude determining system. He joined the DOT Transportation Systems Center (now the Volpe Center) in 1970. Hallock received B.S., M.S.

and Ph.D. degrees in Physics from the Massachusetts Institute of Technology (MIT).

He is an expert in aircraft wake vortex behavior and has conducted safety analyses

on air traffic control procedures, aircraft certification, and separation standards, as

well as developed aviation-information and decision-support.

4

Major General Kenneth W. Hess, Commander, Air Force Safety Center, Kirtland

Air Force Base, New Mexico, and Chief of Safety, United States Air Force, Headquarters U.S. Air Force, Washington, D.C. Major General Hess contributed to Group

II of the CAIB, which scrutinized NASA training, operations, and the in-flight performance of ground crews and the Shuttle crew. Hess entered the Air Force in 1969

and has flown operationally in seven aircraft types. He has commanded three Air

Force wings—the 47th Flying Training Wing, 374th Airlift Wing, and 319th Air Refueling Wing—and commanded the U.S. 3rd Air Force, RAF Mildenhall, England.

Hess also has extensive staff experience at the Joint Staff and U.S. Pacific Command. He holds a B.B.A. from Texas A&M University and a M.S. in Human Relations and Management from Webster College.

Sheila E. Widnall, Ph.D., Institute Professor and Professor of Aeronautics and Astronautics and Engineering Systems, Massachusetts Institute of Technology (MIT),

Massachusetts. Dr. Widnall also contributed to Group III of the CAIB, which focused on engineering and technical analysis of the accident and resulting debris.

Widnall has served as Associate Provost, MIT, and as Secretary of the Air Force.

She is currently Co-Chairman of the Lean Aero-space Initiative. A leading expert

in fluid dynamics, Widnall received her B.S., M.S., and Ph.D. in Aeronautics and

Astronautics from MIT.

4. Attachments:

• Executive Summary, Columbia Accident Investigation Report.

• Chapter 11, Recommendations, Columbia Accident Investigation Report.

• CRS Report, NASA’s Space Shuttle Columbia, Synopsis of the CAIB Report

(RS21606).

• CRS Report, NASA’s Space Shuttle Columbia: Quick Facts and Issues for

Congress (RS21408).

5

Attachment 1

COLUMBIA ACCIDENT INVESTIGATION BOARD REPORT

VOLUME I

AUGUST 2003

EXECUTIVE SUMMARY

The Columbia Accident Investigation Board’s independent investigation into the

February 1, 2003, loss of the Space Shuttle Columbia and its seven-member crew

lasted nearly seven months. A staff of more than 120, along with some 400 NASA

engineers, supported the Board’s 13 members. Investigators examined more than

30,000 documents, conducted more than 200 formal interviews, heard testimony

from dozens of expert witnesses, and reviewed more than 3,000 inputs from the general public. In addition, more than 25,000 searchers combed vast stretches of the

Western United States to retrieve the spacecraft’s debris. In the process, Columbia’s

tragedy was compounded when two debris searchers with the U.S. Forest Service

perished in a helicopter accident.

The Board recognized early on that the accident was probably not an anomalous,

random event, but rather likely rooted to some degree in NASA’s history and the

human space flight program’s culture. Accordingly, the Board broadened its mandate at the outset to include an investigation of a wide range of historical and organizational issues, including political and budgetary considerations, compromises,

and changing priorities over the life of the Space Shuttle Program. The Board’s conviction regarding the importance of these factors strengthened as the investigation

progressed, with the result that this report, in its findings, conclusions, and recommendations, places as much weight on these causal factors as on the more easily

understood and corrected physical cause of the accident.

The physical cause of the loss of Columbia and its crew was a breach in the Thermal Protection System on the leading edge of the left wing, caused by a piece of

insulating foam which separated from the left bipod ramp section of the External

Tank at 81.7 seconds after launch, and struck the wing in the vicinity of the lower

half of Reinforced Carbon-Carbon panel number 8. During re-entry this breach in

the Thermal Protection System allowed superheated air to penetrate through the

leading edge insulation and progressively melt the aluminum structure of the left

wing, resulting in a weakening of the structure until increasing aerodynamic forces

caused loss of control, failure of the wing, and break-up of the Orbiter. This breakup

occurred in a flight regime in which, given the current design of the Orbiter, there

was no possibility for the crew to survive.

The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original compromises that were required

to gain approval for the Shuttle, subsequent years of resource constraints, fluctuating priorities, schedule pressures, mischaracterization of the Shuttle as operational rather than developmental, and lack of an agreed national vision for human

space flight. Cultural traits and organizational practices detrimental to safety were

allowed to develop, including: reliance on past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing

in accordance with requirements); organizational barriers that prevented effective

communication of critical safety information and stifled professional differences of

opinion; lack of integrated management across program elements; and the evolution

of an informal chain of command and decision-making processes that operated outside the organization’s rules.

This report discusses the attributes of an organization that could more safely and

reliably operate the inherently risky Space Shuttle, but does not provide a detailed

organizational prescription. Among those attributes are: a robust and independent

program technical authority that has complete control over specifications and requirements, and waivers to them; an independent safety assurance organization

with line authority over all levels of safety oversight; and an organizational culture

that reflects the best characteristics of a learning organization.

This report concludes with recommendations, some of which are specifically identified and prefaced as ‘‘before return-to-flight.’’ These recommendations are largely

related to the physical cause of the accident, and include preventing the loss of

foam, improved imaging of the Space Shuttle stack from liftoff through separation

of the External Tank, and on-orbit inspection and repair of the Thermal Protection

System. The remaining recommendations, for the most part, stem from the Board’s

findings on organizational cause factors. While they are not ‘‘before return-to-flight’’

recommendations, they can be viewed as ‘‘continuing to fly’’ recommendations, as

6

they capture the Board’s thinking on what changes are necessary to operate the

Shuttle and future spacecraft safely in the mid- to long-term.

These recommendations reflect both the Board’s strong support for return-to-flight

at the earliest date consistent with the overriding objective of safety, and the

Board’s conviction that operation of the Space Shuttle, and all human space flight,

is a developmental activity with high inherent.

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

Chairman BOEHLERT. The hearing will come to order. I want to

welcome everyone here for the first of what will be an extensive series of hearings on the future of the Shuttle program, and of the

manned space flight programs, in general. This is a pivotal moment

in NASA’s history, and this committee intends to lead the way in

examining the issues that will enable Congress and the White

House to chart NASA’s future. Perhaps I should say in ‘‘confronting

the issues’’ because moving forward will require asking tough questions and facing up to tough choices.

We will be better able to do that because of the extraordinary

work that has been done by Admiral Gehman and the entire membership and staff of the Columbia Accident Investigation Board.

The Board members have been inspiring models: independent, focused, inquiring, tough, candid, and accessible. The Board report

has to be the starting point for setting NASA’s future course.

If the Shuttle is to return to flight, then, at a minimum, every

single one of the CAIB’s return-to-flight recommendations must be

implemented. That includes the recommendation that NASA have

a detailed plan for addressing the organizational and cultural deficiencies the CAIB has so convincingly described. Indeed, Mr. Hall

and I wrote to Admiral Gehman back in the early summer suggesting just that sort of recommendation to help ensure that NASA

would act on the central recommendations concerning organization

and culture.

I think all of us need to face up to the rather disheartening picture of NASA that has been so painstakingly drawn by the CAIB.

If we fail to do so, it is readily apparent that we will just have to

go through this same and sad exercise again. NASA’s experience

may be the ultimate proof of Santayana’s famous observation about

those who fail to learn from the past being doomed to repeat it.

The sad fact is that the loss of the Columbia and her crew was

preventable. This is not even close to being a case in which the

problems could only be seen in hindsight. We need to clearly identify and root out each of the systemic and individual failures that

led to this accident. The CAIB report is a blueprint for doing so.

The memory of the Columbia crew compels us to do no less.

I have to say that I am concerned about some of the ways NASA

has been approaching the return-to-flight thus far. I admire Administrator O’Keefe and I am pleased he has embraced the CAIB

report with his words. But deeds are what count. And I am concerned that NASA may already be rushing to meet unrealistic

launch dates instead of examining this report closely and moving

deliberately.

I am also concerned that NASA has been trumpeting changes in

its safety organization that do not appear to address any of the

problems that have been persuasively identified in the Board’s report. Delay is not the goal, but if safety is to improve, NASA must

not be judging itself by how quickly it can send the Shuttle back

into orbit.

And undue haste is ill advised for another reason, too. We, as a

Committee, and as a nation, need some time to consider our overall

space policy.

We need to make fundamental decisions about the future of the

Shuttle program and of the manned space flight program. We need

24

to get, perhaps for the first time, accurate cost estimates of what

it will cost to run the Space Shuttle and other manned programs

safely and accurate descriptions of what they will be able to accomplish. I, for one, am not willing to write NASA a blank check for

the Shuttle program.

We also need to have a better appraisal of what the risks are of

operating the Space Shuttle, because even after implementing the

CAIB recommendations, the Shuttle will continue to be a risky vehicle, and I am not willing to see the Shuttle fly without regard to

the level of risk.

Finally, we need to better define NASA’s overarching human

space flight vision: something that has been lacking for more than

a generation. That won’t be easy, and it can only be done after

hearings that will enable us to make a clear-eyed appraisal of the

costs, benefits, and risks of different options.

So I approach today’s hearing soberly because of the tragedy that

has brought us here and the daunting tasks that lie ahead. But I

also approach today with eagerness, because we have a rare chance

to reshape our nation’s space program, and we will be able to benefit from the outstanding work of Admiral Gehman and his team.

I look forward to hearing from them.

Mr. Hall.

[The prepared statement of Mr. Boehlert follows:]

PREPARED STATEMENT OF CHAIRMAN SHERWOOD BOEHLERT

I want to welcome everyone here for the first of what will be an extensive series

of hearings on the future of the Shuttle program, and of the manned space flight

programs, in general. This is a pivotal moment in NASA’s history, and this committee intends to lead the way in examining the issues that will enable Congress

and the White House to chart NASA’s future. Perhaps I should say in ‘‘confronting

the issues’’ because moving forward will require asking tough questions and facing

up to tough choices.

We will be better able to do that because of the extraordinary work that has been

done by Admiral Gehman and the entire membership and staff of the Columbia Accident Investigation Board (CAIB). The Board members have been inspiring models—independent, focused, inquiring, tough, candid and accessible. The CAIB report

has to be the starting point for setting NASA’s future.

If the Shuttle is to return to flight, then, at a minimum, every one of the CAIB’s

return-to-flight recommendations must be implemented. That includes the recommendation that NASA have a detailed plan for addressing the organizational and

cultural deficiencies the CAIB has so convincingly described. Indeed, Mr. Hall and

I wrote to Admiral Gehman back in July suggesting just that sort of recommendation to help ensure that NASA would act on the central recommendations concerning organization and culture.

I think all of us need to face up to the rather disheartening picture of NASA that

has been so painstakingly drawn by the CAIB. If we fail to do so, it’s readily apparent that we will just have to go through this same sad exercise again. NASA’s experience may be the ultimate proof of Santayana’s famous observation about those

who fail to learn from the past being doomed to repeat it.

The sad fact is that the loss of the Columbia and her crew was preventable. This

is not even close to being a case in which the problems could only be seen in hindsight. We need to clearly identify and root out each of the systemic and individual

failures that led to this accident. The CAIB report is a blueprint for doing so. The

memory of the Columbia crew compels us to do no less.

I have to say that I am concerned about some of the ways NASA has been approaching the return-to-flight thus far. I admire Administrator O’Keefe and I’m

pleased he has embraced the CAIB report with his words. But deeds are what will

count. And I’m concerned that NASA may already be rushing to meet unrealistic

launch dates instead of examining this report closely and moving deliberately.

I’m also concerned that NASA has been trumpeting changes in its safety organization that do not appear to address any of the problems that have been persuasively

25

identified in the CAIB report. Delay is not the goal, but if safety is to improve,

NASA must not be judging itself by how quickly it can send the Shuttle back into

orbit.

And undue haste is ill-advised for another reason, too. We, as a committee, and

as a nation, need some time to consider our overall space policy.

We need to make fundamental decisions about the future of the Shuttle program

and of the manned space flight program. We need to get, perhaps for the first time,

accurate cost estimates of what it will cost to run the Space Shuttle and other

manned programs safely and accurate descriptions of what they will be able to accomplish. I, for one, am not willing to write NASA a blank check for the Shuttle

program.

We also need to have a better appraisal of what the risks are of operating the

Space Shuttle—because even after implementing the CAIB recommendations, the

Shuttle will continue to be a risky vehicle—and I am not willing to see the Shuttle

fly without regard to the level of risk.

Finally, we need to better define NASA’s overarching human space flight vision—

something that has been lacking for more than a generation. That won’t be easy,

and it can only be done after hearings that will enable us to make a clear-eyed appraisal of the costs, benefits and risks of different options.

So I approach today’s hearing soberly because of the tragedy that has brought us

here and the daunting tasks that lie ahead. But I also approach today with eagerness because we have a rare chance to reshape our nation’s space program, and we

will be able to benefit from the outstanding work of Admiral Gehman and his team.

I look forward to hearing from them.

Mr. Hall.

Mr. HALL. Chairman, thank you for a good opening statement,

and I think it is a statement that we all need to keep and to refer

back to as we proceed and as we adhere to and recognize the findings of the Admiral and his colleagues. So I say to you, Admiral,

again, good morning. And thanks for your openness. Thanks for

your being available to anyone who wanted to talk to you about

anything. And thanks for the work you have done, you and all of

your colleagues. And thanks for the work we will be expecting you

to do and the oversight we will expect of you in the days that are—

lie ahead. The Nation owes a great debt of gratitude to all of you

and to your staff for your very dedicated service. I am grateful to

you, and I think every Member up here is.

When you began your work seven months ago, it was not at all

clear that we would ever unravel the physical cause of the accident.

And there will be some who are not totally satisfied with the findings, but I think you have a lot of backup material there and—that

they can refer to, and I just—indeed, your report, I think, makes

it very clear that a series of reviews over the years, since the Challenger, had uncovered some of the same sorts of problems that you

found during your investigation. This committee needs to get your

best assessment of why these problems have continued to occur and

what will be required to keep them from causing another accident.

Your answers will help me shape legislation that I am developing.

It will help others of us shape legislation that we are developing

to provide for continued oversight. And the end of the two-year period, the first really important two-year period, we don’t want this

thing just to dwindle away like it did after the Challenger. We

want to keep it before people and keep the goal in sight, and that

goal in sight should be safety, safety, safety. If real estate people

say location, location, location, I think the American people today

are calling for safety.

I know that there are a lot that want to know who is at fault

for the Columbia accident. Maybe they wanted names and things

like that, but—and that is understandable, but your report makes

26

it clear that the conditions that ultimately led to the accident were

not just a result of a few individual actions. I personally am not

as interested in assigning the blame as I am to working to fix the

problems identified by your investigation. We are going to need

your help in determining the best way to proceed from here on out.

In that regard, I am very interested in your recommendations for

returning the Shuttle fleet to flight. This committee needs to know

why you included the items you did, and equally important, why

some potential tasks were not included in your recommendations.

Mr. Chairman, the Columbia Accident Investigation Board has

performed a very important service. Now it is up to Congress, I

think, in cooperation with the White House and in cooperation with

the NASA Administrator to make this report work to seek and find

and figure out every area of safety that we can to consider issues

that are beyond the Board’s charter. And namely, we need to decide on some concrete goals for the human space flight program

and be willing to commit the resources necessary to meet those

goals.

There will be those who will say that we should walk away from

human space flight as a result of this accident. It has been said.

I disagree. The question is not whether we should have a human

space flight program. The real question is how to make that program as safe and productive as possible. My view is that we should

complete the International Space Station as originally planned so

that it can be a productive research facility. We need to fix the

Shuttle, and as part of that effort, take a serious look at how best

to protect the crews that are going to be flying the Shuttle for the

next 10 to 20 years.

Finally, we need to get some concrete goals for human exploration beyond the Space Station. Establishment of human exploration goals would ensure that we make the appropriate investments in our space program, would revitalize the NASA workforce

and would serve as a source of inspiration for both the NASA workforce and the American people.

With respect to crew safety, I would note that just a month ago,

the House of Representatives unanimously approved an amendment that I offered up that many of us on this committee had offered up at the Committee level here. We all agreed on safety, we

just couldn’t agree exactly on how it was to be done, so my amendment simply said to launch out onto a program for safety, a study

as to how to get that safety and who ought to do it, not to assess

blame, but to be grateful to those that made the program great

that put these people, magnificent men and women, into the air

and brought them back safely so many, many, many times. I think

we are going to continue to rely on the Shuttle for a lot of years

to service the Space Station. We need to do everything we can to

ensure that if this Shuttle comes under threat in the future the

crew is given every possible opportunity to survive.

I didn’t send up that amendment to cause any problems or to

nudge anybody, but I sent it up simply to say to the world that we

are interested in safety, we care about safety, and we are going to

launch a program designating and designing how we can make it

safe. And if we don’t do that, we may not have the Shuttle as safe

as it should be, if we should have another tragedy in the next five

27

years or eight years or six years or six months or 10 months, but

we better be on our way. And we better have a program to show

the American people that we are trying to make it safe for the men

and women who will man the Shuttle. We have to do that. That

is our goal. That is my goal. And if we don’t have that well underway or completed when we have another tragedy, we can forget

about the space program. I don’t want to do that.

I yield back my time, Mr. Chairman.

[The prepared statement of Mr. Hall follows:]

PREPARED STATEMENT OF REPRESENTATIVE RALPH M. HALL

Good morning. I’d like to welcome Admiral Gehman and his colleagues from the

Columbia Accident Investigation Board to today’s hearing. The Nation owes a debt

of gratitude to all of the Board members and staff for your dedicated service.

When you began your work seven months ago, it was not at all clear that we

would ever unravel the physical cause of the accident. It is a tribute to your efforts

that we can now be highly confident that a foam strike did in fact lead to the loss

of the Space Shuttle Columbia and its crew.

At the same time, your report makes a persuasive case that other factors made

an equal contribution to the Shuttle accident. It is painful reading, because the

Board essentially has concluded that NASA never really learned the lessons of the

Space Shuttle Challenger accident more than 17 years ago. Indeed the CAIB report

makes it clear that a series of reviews over the years since Challenger had uncovered the same sorts of problems that you found during your investigation. This committee needs to get your best assessment of why those problems have continued to

occur, and what will be required to keep them from causing another accident. Your

answers will help me shape legislation that I am developing to provide for continued

oversight of the implementation of the Gehman recommendations.

I know that there are some who want to know who was at fault for the Columbia

accident. That is understandable. However, your report makes it clear that the conditions that ultimately led to the accident were not just the result of a few individuals’ actions. I personally am not as interested in assigning blame as I am in working to fix the problems identified by your investigation. We are going to need your

help in determining the best way to proceed from here on out.

In that regard, I am very interested in your recommendations for returning the

Shuttle fleet to flight. This committee needs to know why you included the items

you did, and equally importantly, why some potential tasks were not included in

your recommendations.

Mr. Chairman, the Columbia Accident Investigation Board has performed an important service. However, it is now up to Congress—in coordination with the White

House—to consider issues that are beyond the Board’s charter. Namely, we need to

decide on some concrete goals for the human space flight program and be willing

to commit the resources necessary to meet those goals.

There will be those who say that we should walk away from human space flight

as a result of this accident. I disagree. The question is not whether we should have

a human space flight program—the real question is how to make that program as

safe and productive as possible. My view is that we should complete the International Space Station as originally planned so that it can be a productive research

facility. We need to fix the Shuttle, and as part of that effort take a serious look

at how best to protect the crews that will be flying the Shuttle for the next 10 to

20 years. Finally, we need to set some concrete goals for human exploration beyond

the Space Station. Establishment of human exploration goals would ensure that we

make the appropriate investments in our space program, would revitalize the NASA

workforce, and would serve as a source of inspiration for both the NASA workforce

and the American public.

With respect to crew safety, I would note that just a month ago, the House of Representatives unanimously approved my amendment providing adequate funds for

NASA to at least begin assessing Space Shuttle crew rescues options seriously. If

we lose another Shuttle and its crew, the impact on the space flight program will

be disastrous. We are going to continue to rely on the Shuttle for many years to

service the Space Station, and we need to do everything possible to ensure that if

the Shuttle comes under threat in the future, the crew is given every possible opportunity to survive.

Mr. Chairman, I will close by again expressing my appreciation for the Board’s

efforts.

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Chairman BOEHLERT. Thank you very much, Mr. Hall.

Mr. Rohrabacher.

Mr. ROHRABACHER. First of all, I would like to thank Ralph Hall

and our Democratic colleagues for the bipartisan spirit that we

have had in this committee since this tragedy. This could be a very

tumultuous time for us all, but we have worked together and we

have kept politics out of it, and we have all been trying our best,

as just demonstrated by Ralph Hall’s wonderful statement, and so

we appreciate that and all the work you have done.

I would also like to thank Chairman Boehlert for his leadership

and Chairman Boehlert for his good judgment during this very vexing time. It is—now it is our time to pick up this job. And Admiral

Gehman and his crew have done a terrific job, a wonderful job.

Now it is time for us to do our job. It is our work—actually, you

might say our work actually begins today.

Today’s hearing is the first step in understanding, on this end of

the hearing anyway, what went wrong with the Space Shuttle Columbia, what went wrong with NASA, and what choices we have

in the future, what type of vision we must have in order to achieve

the goals that we set as part of that vision.

We are greatly indebted to Admiral Gehman and the whole Columbia Accident Investigation Board for what they have done and

for a terrific and an outstanding job. Their work will be an invaluable resource for us as we now move forward to solve the problems

at NASA and to set a course for NASA in the future.

A key element of NASA’s success in the past was a clear national

objective and purpose when it came to our space program. Mercury,

Gemini, Apollo, all were involved, of course, with beating the Russians to the moon and all of that was something that Americans

understood, all of us in—as American citizens, of people in the government, people in the Legislative Branch, people in NASA, we all

knew what that goal was and the vision. We were behind it, and

we were part of the team. Our civil space program today suffers

from a lack of strategic vision and a lack of broader national goals.

Putting America’s space program back on track means more than

fixing a flawed piece of Shuttle technology. In fact, the Shuttle

itself remains a major question mark as we go through the findings

of the Gehman report. For the last 30 years, NASA may well have

been on the wrong path when it comes to the Shuttle. The Shuttle

has failed miserably to meet its original goals, and our reliance on

such a complex, high-risk technology has drained billions of dollars

from our Treasury and billions of dollars from other space programs. And it has regrettably cost us too much money and cost too

many lives.

Now there have been successes in the Shuttle program as well.

I was part of the Reagan Administration when the first Shuttle

landed, and I know how important the Shuttle was to inspiring the

American people at a time when we had our—when our national

spirits needed inspiring. And who can say what type of a contribution that made, seeing that Shuttle land and knowing it was probably one of the most magnificent engineering feats in all of human

history. That did inspire us. And how many billions of dollars were

added to our economy? Hundreds of billions by that inspiration.

And that has to be put into the equation as well.

29

Yet when focusing on the loss of our bravest astronauts and our

brave astronauts, we must want to make sure that we look at

human space travel in the future that we do, as Ralph has just

stated, our utmost to ensure that we are protecting those astronauts and those people’s lives in the line as well. But with that in

mind, we should not close the door on human space travel. The astronauts who have given their lives would not want us to turn

around, would not want us to be earthbound because lives were

lost. They knew the risks they were taking, and that is why they

are unique among American heroes today, and we honor them in

this hearing and we honor them by moving forward. It is a risky

venture to move forward into space with human beings, but I

would submit today that it is worth the risk.

We have the rare opportunity to help NASA today. And with Admiral Gehman’s help and with his team’s help to break the bureaucratic malaise that has gripped the NASA bureaucracy for too long.

Our space program should be about expanding American freedom

into a new frontier and to carry all of humankind to new heights

into the heavens above and to a better life here on this planet. It

is not the time to turn around; it is the time to move forward and

do what is right to finish the Space Station and to move forward

with new technologies that will carry us to greater heights.

Mr. Chairman, thank you for your leadership, and I look forward

to working with you in the weeks ahead.

[The prepared statement of Mr. Rohrabacher follows:]

PREPARED STATEMENT OF REPRESENTATIVE DANA ROHRABACHER

I’d like to thank Chairman Boehlert for his leadership in calling this important

hearing. Today’s hearing is the first step in understanding what went wrong with

the Space Shuttle, what went wrong with NASA, and what choices we have as we

strive to set a new vision for our space program. We are greatly indebted to Admiral

Gehman and the Columbia Accident Investigation Board for their dedicated service

and their outstanding report. Their work will be an invaluable source to us as we

grapple with the problems at NASA.

A key element of NASA’s success in the past was a clear national objective and

purpose. Mercury, Gemini, and Apollo were about beating the Russians to the Moon

and beating the Russians in the Cold War. Unfortunately today, our civil space program suffers from a lack of strategic vision and a lack of any connection to such

broader national goals.

For the last 30 years, I believe, NASA has been on the wrong path with the Space

Shuttle. The Shuttle has failed miserably to meet any of its original goals. Our reliance on such a complex and high-risk technology has drained billions of dollars from

our treasury and has regrettably cost too many lives.

We should not close the door on human space travel, however. It is a risky venture, but worth the risks. We have the rare opportunity to help NASA break the

bureaucratic malaise that has gripped it for so long. Our space program should be

about expanding American freedom into a new frontier.

Mr. Chairman, I believe your leadership and this committee will help frame this

critical debate.

Chairman BOEHLERT. Thank you very much, Mr. Rohrabacher.

Mr. Gordon.

Mr. GORDON. Thank you, Mr. Chairman. I will be brief, because

I think that you did an excellent job in laying out our charge before

this committee. And I think that if we will follow your outline, we

will all be well served. And let me also say that I think we all

should be grateful to Mr. Hall’s tenacious efforts before, and I am

sure they are going to be continuing to bring us back to flight, but

also in a safe manner. And I look forward to working with my

30

friend from California as our Committee works to oversee the

progress of this report.

So Admiral Gehman, let me join everyone in welcoming you and

certainly your Board here—or the members of the Board that came

today, and more importantly, I want to thank you for seven long,

I am sure, months. You—they were longer for you than for a lot

of folks. You have done a good job. Excuse me.

Admiral Gehman, you—your report warrants a thorough public

hearing, and this hearing will be an important initial step in that

regard. And as I reviewed the report, I found that there were a

number of things that were troubling to me. And let me mention

just a few. I am troubled that NASA failed to heed early reviews

that identified many of the same problems that you described in

your Board’s report. I am troubled by your finding that NASA’s

safety system has repeatedly fallen short of the mark. I am troubled by your conclusion that, in your words, ‘‘years of workforce reduction and outsourcing have cowed from NASA’s workforce the

layers of experience and hands-on systems knowledge that once

provided a capacity for safety oversight.’’ I am troubled by your report’s finding that the pressure by NASA’s headquarters to meet an

artificial Space Station Core Complete milestone may have unduly

influenced Shuttle Manager’s decisions. And I am worried that we

have seen echoes of that pressure in some of the headquarters’ pronouncements on the timetable for Shuttle return-to-flight.

So Admiral Gehman, fixing the problems identified by your report will take time and money. We should not kid ourselves in that

regard. And I would like to get your views on how expensive and

how time-consuming that effort is likely to be. When NASA submits its proposed budgets for fixing the problems, we need to know

whether they are going to be realistic. And I would also like to get

your views on what benchmarks this committee should be seeking

for NASA to determine whether or not they are complying with

your report’s finding.

We have got a lot to cover today. I am anxious to hear what you

have to say. And once again, thank you, and all of you, for being

here with us.

[The prepared statement of Mr. Gordon follows:]

PREPARED STATEMENT OF REPRESENTATIVE BART GORDON

Good morning. I want to join my colleagues in welcoming Admiral Gehman to this

hearing. I also want to add my thanks for the hard work all of the Board members

did over the last seven months in investigating the causes of the Columbia accident.

Your report warrants a thorough public airing, and this hearing will be an important initial step in that regard.

Admiral Gehman, your report ranges over a number of important issues. As I reviewed your report, I found much that was troubling to me. Let me mention just

a few items:

• I am troubled that NASA failed to heed earlier reviews that had identified

many of the same problems you describe in your Board’s report.

• I am troubled by your finding that NASA’s safety system has repeatedly fallen short of the mark.

• I am troubled by your conclusion that ‘‘yeas of workforce reductions and

outsourcing have culled from NASA’s workforce the layers of experience and

hands-on systems knowledge that once provided a capacity fog safety oversight.’’

31

• I am very troubled by your Board’s finding that pressure by NASA Headquarters to meet an artificial Space Station ‘‘Core Complete’’ milestone may

have unduly influenced Shuttle managers’ decisions.

• And I worry that we’ve seen echoes of that pressure in some of the Headquarters pronouncements on the timetable for Shuttle return-to-flight.

Admiral Gehman, fixing the problems identified in your report will take time and

money—we should not kid ourselves in that regard. I’d like to get your views on

how expensive and how time-consuming that effort is likely to be. When NASA submits its proposed budgets for fixing the problems, we need to know whether they

are realistic. I’d also like to get your views on what ‘‘benchmarks’’ this committee

should be seeking from NASA to determine whether or not they are complying with

your report’s findings.

Well, we have a great deal to cover today. I again want to welcome you to today’s

hearing, and I look forward to your testimony.

Chairman BOEHLERT. I want to thank all of my colleagues for

their opening statements and all of the Members will have leave

to insert their opening statements in the record at this juncture.

[The prepared statement of Mr. Barton follows:]

PREPARED STATEMENT OF REPRESENTATIVE JOE BARTON

Thank you, Mr. Chairman, for holding this important hearing. I also want to

thank Admiral Gehman and his colleagues of the Columbia Accident Investigation

Board (CAIB) for accomplishing the daunting task of investing the accident. We are

here today to learn more about the causes of the accident, both physical, and intangible, such as the organizational culture at NASA.

The crew of the Columbia risked their lives in pursuit of knowledge that might

improve the quality of life for all mankind. I am very supportive of NASA and realize that if we are to learn about the mysteries of this universe, space exploration

must continue. However, in exploring space, we should not unnecessarily risk lives.

The CAIB report mentioned the need to create a new vehicle for manned spaced

flights. It also cautioned against falling into the trap of trying to do too many things

with one vehicle. I fully echo this view. I am hesitant to send seven more astronauts

on a vehicle that is unsafe. To that end, we need to move toward building a newer

and safer space vehicle—whether that is a new Space Shuttle, or an Orbital Space

Plane. The current fleet of Space Shuttles can be improved, but they cannot be

made 100 percent safe. We cannot allow manned space flights on a continuing basis

until safer vehicles are developed.

I also hope that we, as a Congress and also the Nation as a whole, take this time

to develop the goals of our space program. In the 1960s, President Kennedy laid

down a broad agenda for our nation to become the first to walk on the moon. The

Columbia accident has given us the opportunity to regain that national enthusiasm

and spirit toward the space program. I will continue to work with my Science Committee colleagues to investigate the best possible steps through which to move the

program forward.

[The prepared statement of Mr. Smith of Michigan follows:]

PREPARED STATEMENT OF REPRESENTATIVE NICK SMITH

I want to thank Chairman Boehlert for holding this hearing to review the findings

and recommendations of the Columbia Accident Investigation Board (CAIB). I’d also

like to thank the witnesses for appearing here today, and for the tremendous work

that they provided in preparing this report. Admiral Gehman and his team should

be commended for delivering a thorough report that will be important to this committee as we move forward.

I understand that the CAIB was charged with assessing what caused the accident

and give recommendations for changes that need to be made at NASA to better assure safety. The Board determined that the accident was caused by a piece of insulating foam that damaged the left wing of the Columbia, eventually leading to a

thermal breakdown of the wing and breakup of the orbiter. The Board also concluded that bureaucratic pressures and cultural problems within NASA likely contributed to the circumstances that led to the accident. This morning we begin the

process of learning more about NASA’s internal workings and what went wrong in

the days, months and years leading up to February 1, with the aim to guide Congress and the Administration through important crossroads.

32

Since the successful Soviet launch of Sputnik in 1957, our country’s space program has been an integral part of our national sense of identity. Space exploration

has captured the imagination of the American public while generating a wealth of

scientific discovery. I remember the pride and awe that I felt when Neil Armstrong

took his first steps on the moon. Other missions, like in 1998 when the Sojourner

Rover landed on Mars and sent back color pictures of the landscape, have continued

to fuel our fascination with space exploration.

Unfortunately, the space program has also been associated with a number of national tragedies, such as in 1967, when Apollo 1 exploded on the launch pad, in

1986, when the Space Shuttle Challenger was lost shortly after takeoff, and again

last February, when the Space Shuttle Columbia broke up during the final stages

of re-entry into the Earth’s atmosphere. It has taken this latest disaster to focus

needed scrutiny on the state of our country’s space program.

Americans want to know how the Columbia accident happened, but they also

want to know the cost-benefit of manned space flight. The CAIB report is very thorough in assessing what caused the Columbia breakup and how NASA’s management

structure and safety procedures contributed to this. It goes on to recommend certain

changes that should be made in order to continue human space flight. The report

does not address the basic question of whether the cost and priority now given to

manned space flight is justified.

One of the important decisions that needs to be made is what balance should be

struck between funding for manned and unmanned space flight. As Chairman of the

Research Subcommittee, I am interested in a more quantitative evaluation of the

value of science research performed on both types of space flight, as well as on the

International Space Station (ISS). Advancements in nanotechnology, miniaturization, and robotics will eventually accommodate most outer space research and exploration. Sending humans into space may be necessary in order to continue important

life-science research. However, most functions of space flight can be accomplished

without the cost and danger of involving astronauts.

I have often questioned witnesses on the justification for manned space flight because I am concerned that the costs are high and the benefits too few compared to

unmanned flight or for that matter spending those dollars on research through the

National Science Foundation or National Institutes of Health. With limited dollars

for research in tight budgetary times, it is imperative that Congress direct funding

toward investments that give us the greatest scientific return that hopefully can result in economic returns!

The Washington Post has reported that the International Space Station, if completed, is expected to cost $17 billion over budget. In addition, the three-person crew

spends a majority of their time simply doing maintenance as opposed to doing actual

research—an effort the Wall Street Journal appropriately referred to as ‘‘the modern

equivalent of a New Deal program to keep spacemen busy digging holes and filling

them in again until we can find some more productive goal.’’ While manned Shuttles

do provide us with some useful scientific information, the major objective of many

missions is simply to re-supply the Space Station. At this time of tight budgets in

the U.S. and with a growing reluctance in other contributing countries, these costs

may have been given a higher priority than is justified. With NASA already spending nearly half of its $15 billion budget on human space flight, serious consideration

should be given to the continuing viability of the Shuttle program and ISS.

In contrast, unmanned space missions have provided us with extremely useful

and interesting information, and at a much lower cost. For instance, according to

the ‘‘Bulletin of the Atomic Scientists,’’ the Galileo project discovered and analyzed

oceans and volcanoes on Jupiter’s moons, and sent back information on the planet’s

weather patterns at a cost of $1.35 billion over 14 years. The Mars Pathfinder mission, which operated three times longer than its original planned lifetime, cost $270

million, provided our scientists with more than 16,000 images from Mars, 15 chemical analyses of rocks, and large amounts of useful information on Martian winds

and weather. The Kepler space telescope, which will cost an estimated $286 million

and is expected to be operational by 2006, will be able to observe nearly 100,000

stars and any planets in orbit around them. This will allow us to estimate how

many Earth-like planets capable of sustaining life exist in the universe.

I fear the exercise of debating all potential changes to NASA will be futile if we

first do not closely scrutinize the costs and benefits of our space science efforts, particularly with regard to manned versus unmanned exploration.

[The prepared statement of Mr. Ehlers follows:]

33

PREPARED STATEMENT OF REPRESENTATIVE VERNON J. EHLERS

I want to express my thanks to Admiral Gehman and the entire Columbia Accident Investigation Board for producing an excellent and thorough report. The Admiral and the Board have taken the lead in rigorously determining not only the technical cause of the accident, but also in outlining underlying cultural and organizational factors which contributed to the loss of the orbiter. The Board has identified

the need for changes at NASA; it is now Congress’ task to make sure those changes

take place.

Most importantly, Congress must lead the Nation in determining whether, and to

what extent, we should continue human space exploration. If we continue with

human exploration of space, we must have a clear vision and mission, and be willing

to pay the price of human space exploration—which will not be cheap.

We could decide to simply maintain the status quo in human space exploration,

with missions to the International Space Station and low earth orbit exploration as

has been done by the Space Shuttle. The Shuttle could be recertified and refurbished for this purpose in the near-term for relatively limited costs.

However, to continue human space exploration over the long haul, we must admit

that, though the Space Shuttle has served us well, it is aging and has outlived its

usefulness. A new vehicle will be needed. The replacement vehicle should be safer,

more efficient, cost less to operate, and have shorter turn-around times than the

Shuttle if the vehicle is reusable. These are achievable goals with modern technologies; however, we must bear in mind that development and initial deployment

of the vehicle will be expensive. However, if the vehicle is designed well enough, we

may actually save money in the long-term compared to the expensive maintenance

cost of the Shuttle.

If we consider going even further into space, for example, a manned flight to Mars

and back, the cost and the risk to personnel greatly increases. While landing a robot

on Mars costs about $150 million, a manned mission would cost 1,000 times that

amount, approximately $150 billion. Crew safety is also a significant issue. Personally, I do not believe we should attempt a human expedition to Mars until our technological capabilities have improved. In particular, we need better propulsion systems and light life support systems for a mission to be viable.

Furthermore, we need to remember that, although the American people are enamored by the glamour of space travel, the basic mission of NASA is scientific. Dollar

for dollar, far more scientific knowledge is gained from unmanned missions than

missions involving human space flight. The current unmanned exploration of Mars

has yielded significant results at relatively low cost and the Hubble Space Telescope

has provided scientists with a better understanding of our universe than we will

ever get from the International Space Station—at a small fraction of the cost.

I look forward to a vigorous debate on these issues and a stronger, revitalized

NASA.

[The prepared statement of Mr. Sullivan follows:]

PREPARED STATEMENT OF REPRESENTATIVE JOHN SULLIVAN

Thank you Mr. Chairman, I appreciate your calling this hearing today on the findings and recommendations of the Columbia Accident Investigation Board. As a

Member of the Space and Aeronautics Subcommittee on the House Science Committee, I consider it an honor to be a part of this investigation and I appreciate Admiral Gehman and his board for their tireless work on behalf of our nation and for

coming to testify here today.

The Columbia Accident Investigation Board has provided this committee with an

excellent blueprint to start the long-term investigation into the organizational and

technical factors that led to the loss of the Columbia. Today we will learn exactly

what went wrong with the Columbia when she disappeared into the heavens on

February 1, 2003, and review remedies to thwart future safety risk with human

space flight.

Our hearing today is one of many that will undoubtedly raise difficult questions

with regard to the costs and benefits of human space flight and what actions need

to be taken to reform NASA to return our Space Shuttle fleet to operational status.

Ultimately, this committee will be charged with making decisions on the level of financial resources that will be allocated to human space flight in NASA’s reauthorization next year.

The loss of the Space Shuttle Columbia affected our entire nation. This hearing

is undoubtedly one of many that will determine the structure of NASA and the future of human space flight. As a nation of explorers, I view this hearing as an opporVerDate 11-MAY-2000 16:28 Mar 25, 2004 Jkt 089216 PO 00000 Frm 00037 Fmt 6633 Sfmt 6621 C:\WORKD\FULL03\090403\89216 SCIENCE1 PsN: SCIENCE1
34

tunity to plot the course for NASA’s future and revitalize our priorities for manned

space exploration.

[The prepared statement of Mr. Forbes follows:]

PREPARED STATEMENT OF REPRESENTATIVE J. RANDY FORBES

Thank you, Mr. Chairman. Admiral Gehman, Dr. Hallock, Major General Hess,

and Dr. Windall, I would like to thank you and all members of the Columbia Accident Investigation Board for their hard work in completing this comprehensive report, and for appearing before the Committee today.

America’s space program is a symbol of our success as a scientifically and technologically advanced nation. However, tragedies like the Space Shuttle Challenger and

Columbia make some think twice about whether it is worth continuing to send humans into space. The crew of the Columbia took this important scientific assignment knowing the risks involved, but recognized that this mission was not only a

service to the Nation, but to all of humanity. With that said, it is chilling to read

the Columbia Accident Investigation Board (CAIB) report and learn that this accident could have been prevented. There is no excuse for poor management to lead

to the untimely deaths of these brave explorers.

NASA needs to take these recommendations to heart and fix the problems that

could lead to another Shuttle tragedy. We must now look at this disaster as an opportunity to rebuild our space program to the finest in the world. As the Committee

proceeds with its hearings on the Space Shuttle accident and related problems highlighted in the CAIB report, it is my hope that we can redefine the objectives of the

space program to find solutions to the failed organizational structure at NASA.

We have a long road ahead of us in getting our space program back on track.

[The prepared statement of Mr. Costello follows:]

PREPARED STATEMENT OF REPRESENTATIVE JERRY F. COSTELLO

Good morning. I want to thank Admiral Harold Gehman for appearing before our

committee to present the Columbia Accident Investigation Board report to the Committee.

In discussing the Columbia accident, we must remember to honor the seven astronauts, their vision and their legacy. Space Shuttle flights are what many people consider a routine event; however, each mission has an extremely high risk. Both our

nation and our world benefit enormously from each mission.

These seven extraordinary men and women aboard the Space Shuttle Columbia

gave their lives for the pursuit of science and discovery. We are fortunate to have

an astronaut corps comprised of highly trained men and women who regularly bear

this risk. Their strong passion for space exploration has immeasurably benefited our

nation and the world. We will never forget the dedication and sacrifice of the crew

of the Columbia.

Today’s hearing serves as an opportunity to fully understand the risks, costs, and

benefits of the human space flight program, including the Space Shuttle, and to determine what reforms need to be made at NASA. The report describes that a foam

strike during launch caused the Shuttle to break apart during re-entry; however,

NASA’s inconsistent safety culture was equally responsible for this disaster.

The report describes a Shuttle program that failed to learn the lessons from the

1986 Challenger accident, the first Shuttle disaster. In the case of the Challenger,

and it seems now with Columbia, safety requirements were ignored because of

schedule pressures, budget constraints, and workforce reductions.

NASA presented Space Shuttle safety upgrades to Congress in its FY 2001 budget. These upgrades were designed to keep the Shuttle flying safely and efficiently

to 2012 and beyond. However, the Space Flight Leadership Council accepted the upgrades only ‘‘as long as they were financially feasible’’ (CAIB, 188). The safety upgrade initiative had a short lifespan because of conflicting dates and the assumption

that upgrades would be a waste of money if the Shuttle were to be retired in the

near future. In the FY 2003 budget request, NASA submitted a request that reduced spending on safety upgrades by 34 percent. Proposed safety upgrades continued to be either not approved or deferred.

I am interested in the cost-cutting of the Shuttle safety upgrades and the continued budget constraints of NASA. NASA’s concept of mission safety appears rather

meaningless if it is funding a safety upgrade in order to fly safely and then canceling it for budgetary concerns.

NASA continues to be our gateway to the universe. It is through NASA’s efforts

that we will understand our planet, our solar system and beyond. Our investigation

35

and journey into space will continue; however, the agency governing such exploration will be forever changed.

I welcome Admiral Gehman and look forward to his testimony.

[The prepared statement of Ms. Johnson follows:]

PREPARED STATEMENT OF REPRESENTATIVE EDDIE BERNICE JOHNSON

Thank you, Mr. Chairman. I would like to thank you for calling this all important

hearing today, and I would also like to thank Admiral Gehman for agreeing to appear here today to answer our questions on this most important investigation into

the February 1 Space Shuttle Columbia disaster.

Today we are here to discuss the Columbia Accident Investigation Board (CAIB)

report. It is imperative that we conduct this investigation because the space exploration research program has been one of the most successful research programs in

the history of this country. To protect the safety and integrity of the future of this

country’s space program, we must learn from the mistakes of the past. The report

from this investigation will allow us to see what went wrong and how to prevent

it from happening again.

It was over 40 years ago that this nation’s leaders in human space travel were

given the foresight to recognize the importance of space research. We owe those

leaders some homage for their foresight, and I am hoping that we will then have

the foresight to continue this type of research.

Human space exploration is inherently risky. Distance, speed and an environment

that cannot support human life combine to make human space flights particularly

precarious.

That is why it is so essential that we put forth a concerted effort to protect the

safety of our astronauts.

Although we have lost a very precious group of national heroes, many lives have

also been saved because of the lessons we have learned. This most unfortunate and

tragic loss of five men and two women, representing a mosaic of races and nationalities, will be mourned and these great American heroes will not be forgotten.

[The prepared statement of Mr. Honda follows:]

PREPARED STATEMENT OF REPRESENTATIVE MICHAEL M. HONDA

I thank the Chairman and Ranking Member for holding this important hearing,

and I thank the members of the Columbia Accident Investigation Board for their

hard work on this difficult matter.

In preparing its report, the Columbia Accident Investigation Board received unsolicited comments from individuals at NASA who were becoming concerned that safety might be compromised as a result of pressure to hold firm to the launch date

of February 19, 2004 for Node 2. Those individuals attributed that date to Administrator O’Keefe.

The report concludes that ‘‘the environment of the countdown to Node 2 and the

importance of maintaining the schedule may have begun to influence managers’ decisions, including those made about the STS–112 foam strike,’’ and that during Columbia’s last flight, ‘‘Shuttle Program managers were concerned with the foam

strike’s possible effect on the launch schedule.’’

The report is also somewhat vague on budgetary numbers, but it does note that

the Administration’s FY 2003 budget request for Shuttle upgrades was a 34 percent

cut from the FY 2002 planned cut. This by itself seems quite significant, but in fact

the cut to Shuttle safety upgrades was even greater because for the FY 2003 budget,

OMB required both Shuttle safety upgrades and Shuttle infrastructure revitalization projects out of the same pot of money.

I look forward to hearing Admiral Gehman’s thoughts on the impact of schedule

pressure and funding cuts in Shuttle safety upgrades on the safety lapses that the

Board found contributed to the Columbia accident.

[The prepared statement of Ms. Jackson Lee follows:]

PREPARED STATEMENT OF REPRESENTATIVE SHEILA JACKSON LEE

Mr. Chairman,

Thank you for moving so swiftly and convening this important hearing. I would

also like to commend Ranking Member Hall, as well as the Chair and Ranking

Member Gordon of the Space Subcommittee for their leadership, and tireless work

since the tragedy of February 1st to ensure that Congress and NASA and Admiral

36

Gehman’s team are all on the same page—working together to find the best way

to get NASA’s vital mission back on track. And, I would like to offer my sincere appreciation and commendation to Admiral Gehman and his excellent team at the Columbia Accident Investigation Board for their hard work, tenacity, creativity, dedication, and openness in service to this nation.

We are at a crossroads in the ongoing history of human space exploration. February 1st was a dark moment for people around the world who dream of pushing

the envelope of human existence. We now have a solid report before us that can

serve as a roadmap for the future of American space exploration, and we need to

start looking to the future because this mission is vital to our growth as an economy, and as a society. But first I would like to look back one more time on what

we have lost—seven of humankind’s greatest heroes, and for those of us from Houston—friends and neighbors: Colonel Rick Husband, Lieutenant Colonel Michael Anderson, Commander Laurel Clark, Captain David Brown, Commander William

McCool, Dr. Kapana Chawla, and Colonel Ilan Ramon. Those seven courageous explorers paid the ultimate price to improve our understanding of the universe, to advance our medical and engineering sciences, to keep the United States economy on

the cutting edge of technology, and to inspire young and old alike.

Mr. Chairman, I, with my colleague from Houston Congressman Nick Lampson,

have introduced H.R. 525, which would posthumously award the seven members of

the Columbia crew with the Congressional Gold Medal. It would also require the

Secretary of the Treasury to make bronze duplicates of that medal available for sale

to the public, to serve as an enduring reminder of the sacrifice of those brave pioneers and to pay for the cost of producing the Gold Medals. The bill now has 135

co-sponsors. I hope to see that bill go forward this year, and we continue to focus

on the Columbia, what it meant to us, and what it means to our future.

Again, Admiral Gehman, I would like to commend you and your team for putting

out this outstanding piece of work. I admit that a couple of days into February, with

debris from the Columbia scattered across the Southwest—I had doubts as to

whether we would ever know what caused this tragedy. But, with some great technical expertise and modern day sleuthing, you have put together a very compelling

story of how the Columbia went down. That will be enormously valuable as we move

forward.

Obviously, the most frustrating thing for all of us is realizing just how many opportunities there had been over the days, months, even years before the crash, to

prevent this loss. Knowing that there were people at NASA—and not just some interns with naı ̈ve notions—but experienced engineers, who had recognized the dangers, and tried to take prudent steps to get images that may have averted disaster;

these experts were ignored. That is truly painful to think about. Page 169 of the

report gives great insight into the broken culture of safety at NASA that impeded

the flow of critical information from engineers up to program managers. I quote:

‘‘Further, when asked by investigators why they were not more vocal about their

concerns, Debris Assessment Team members opined that by raising contrary points

of view about Shuttle mission safety, they would be singled out for possible ridicule

by their peers.’’

That reaffirms to me that strong whistleblower protections do not just protect

workers. They protect lines of communication and dialog that prevent waste, fraud,

and abuse, and, in this case, might have saved lives. I will be working this year

on legislation that will enhance whistleblower protections for the NASA workforce,

to make sure that critical information is never lost due to intimidation or fear.

The report gives clear recommendations for NASA, concerning technical and management changes, but there is still much work ahead to decide how Congress, and

this committee in particular, should respond to this disaster. The report makes it

clear that cuts in budget and workforce at NASA over the past decade had detrimental effects on the safety of the NASA mission. I believe that in this committee,

on this side of the aisle, we have been consistent in calling for increasing resources

for NASA programs. We have been calling for a clear mission from the NASA Administrator, that would enable us to make appropriate allocations for research, development, and upgrades when needed for the Shuttle. And this has not just been

about one Administrator, or one Administration, this has been a consistent push for

at least the four-plus terms that I have been here. It is time that we all realize that

the NASA mission is valuable, and is worth the investment, and cannot be done on

the cheap. Admiral Gehman has stated in the report that budget cuts hampered

safety. Today I would like to push him a bit harder to determine what kind of budget increases might be necessary to get safety programs where they need to be.

Another important area that I feel needs further exploration by this committee,

and advisement from the Admiral, is the subject of accountability. I respect and

commend Administrator O’Keefe for taking responsibility for what happened on his

37

watch. However, this report makes it clear that multiple middle-to-high level managers made seriously flawed decisions that jeopardized the mission and ultimately

cost lives. I am from Houston, and the people I am talking about are probably my

neighbors. I am not interested in pointing fingers just for the sake of it. However,

if holding people accountable will set an example and make future NASA managers

more diligent, and make the program safer, perhaps this committee should consider

a specific inquiry for that purpose. Also, I wonder if we owe it to the families of

the fallen crew of the Columbia, and those of the Challenger, who were promised

15 years ago that the ‘‘culture’’ would change.

A final issue that I believe demands our attention is: What about the International Space Station? Has it been immune to the management problems that are

described for the Shuttle mission? Of course, a space mission is at most risk during

take-off and re-entry—so I hope that the Space Station is stable and safe right

now—but we have two fine astronauts manning the Station now. I would like to

know if there is any reason to think that they might be in danger or that the Space

Station have its own ‘‘falling foam’’ that has been disregarded and might need attention? It seems that this could be an even more urgent issue than the Shuttle, since

we already have people at risk.

We have a lot of work ahead: management issues, budget issues, technical issues,

safety issues, and making sure that the NASA mission and vision match their potential. This report is an excellent foundation to work from. I look forward to the

discussion.

Chairman BOEHLERT. And now it is important that we get to our

distinguished witness—witnesses. And before anything, I want to

say, once again to Admiral Gehman and to all of the members of

the Board, how sincere we are in expression—expressing our appreciation for your thoroughness, for the scope, and for the independence you have demonstrated. You have done a great service, not

just for the program or for the Congress, but for the Nation, and

we thank you for that.

With that, let me present Admiral Harold Gehman and the members of the Columbia Accident Investigation Board. And Admiral

Gehman, you may wish to introduce your colleagues individually.

STATEMENT OF ADMIRAL HAROLD W. GEHMAN, CHAIRMAN,

COLUMBIA ACCIDENT INVESTIGATION BOARD; ACCOMPANIED BY JAMES HALLOCK, PH.D., MANAGER, AVIATION

SAFETY DIVISION, VOLPE NATIONAL TRANSPORTATION SYSTEMS CENTER; MAJOR GENERAL KENNETH W. HESS, COMMANDER, AIR FORCE SAFETY CENTER; AND, SHEILA E.

WIDNALL, PH.D., INSTITUTE PROFESSOR AND PROFESSOR

OF AERONAUTICS AND ASTRONAUTICS AND ENGINEERING

SYSTEMS, MASSACHUSETTS INSTITUTE OF TECHNOLOGY

(MIT)

Admiral GEHMAN. Thank you, Mr. Chairman, Mr. Hall, the distinguished Members of this committee. Thank you very much for

the compliments. And on behalf of the Board, I accept those kind

words for the Board members who are not here. I will introduce my

colleagues here, and then I would ask the Chairman to allow me

to introduce my opening statement into the record. And I will just

say a few words, and we can get right to the questions.

Chairman BOEHLERT. Without objection, so ordered.

Admiral GEHMAN. Thank you, sir. Beside me, to my left, is Dr.

Jim Hallock. Dr. Hallock is the manager of the Department of

Transportation’s Volpe National Transportation Systems Center

from Massachusetts. Beside him is Major General Ken Hess, the

Commander of the Air Force Safety Center and the Chief of Safety

of the U.S. Air Force. And beside Ken Hess is Dr. Sheila Widnall,

38

the Institute Professor and Professor of Aeronautics and Astronautics and Engineering Systems at the Massachusetts Institute of

Technology and previous Secretary of the Air Force.

I know that all of the Members of this committee feel as the

Board does, that the tragic loss that this nation suffered on 1 February 2003 is a price that we paid that is so dear that it demands

that we all do our part to ensure that an accident like this never

happens again. I want to thank this committee and the leadership

of this committee for helping this Board get over a rough start the

first couple of weeks, the first couple of months to enable us to be

at a position where we are right now that we are discussing the

merits of our report and not the process by which this Board was

founded. We can talk about that, too. But we could not have gotten

to this position had it not been for the guidance, cooperation, and

mentorship of both Branches of the Congress, and we appreciate it

very much.

Before I begin, Mr. Chairman, I would like to offer my thanks

to my 12 colleagues on the Board who gave up seven months of

their lives to produce this report. Approximately 120 full-time investigators and the thousands of NASA engineers and employees

who helped us with this, not to mention the nearly 30,000 volunteers who walked shoulder to shoulder across the State of Texas

picking up 84,000 pieces of debris, which turned out to be instrumental in our reconstruction and forensic work. And to all of those

unnamed and unsung heroes, we owe a great debt.

Let me just make a couple of points. I committed, a long time

ago, to this committee and to the public, that our report would attempt to put this accident into context. And by context, there—I

mean any one of several contexts. There is the context of the history of the human space flight program. There is a context of the

budget process. There is a context of management and leadership.

There is a context of all of the previous reviews and investigations

that NASA has gone through and whether or not they learned. And

then there is the context, as has been mentioned this morning, of

what is exactly our nation’s vision of what we want to do in space,

and how does the Shuttle program fit into it.

Obviously, the first thing we had to do was determine the physical cause of this accident. We did. The foam did it. For those of

you on this committee who may not be intimately familiar with the

foam, I would like to introduce you to it.

This is an actual piece of foam. This is the left bipod ramp. The

little black line here indicates approximately where it fractured. So

this part of it here came off. And this is about the right size. This

is the right size. And this is about what it weighs. And so this is

the party of the first part here. This is what it looks like, in case

somebody is not familiar with it. The Board was very deliberate in

how we chose our words about saying that the foam did it. We

didn’t say ‘‘most likely.’’ We didn’t say ‘‘all evidence supports.’’ We

didn’t say ‘‘it was the conclusion of the Board.’’ We said, ‘‘The foam

did it.’’ And we are quite content with that, and we are quite sure

of it. And we would be delighted to discuss that, if you want to talk

about it some more.

If the foam did it, the Board was then interested in answering

the following question: if the foam caused this accident, was this

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a legitimate surprise, an anomalous event that had never happened

before? Or if not, was this something that happened before and

why wasn’t it fixed? What was the process by which NASA went

through attempts to understand and fix why it happened? Of

course, as has been reported in the press, it was not a surprise

anomalous event. This thing has happened before. And when we

got into a deep comprehensive analysis of how the Shuttle program

handles unknowns and risks and surprises and how they conduct

research and development to understand what is happening and

how they learn as an institution, we were not very pleased with

what we found. And that statement takes about 150 pages in our

report to document.

Being concerned, then, with what we found, we then took two simultaneous paths to come to a set of recommendations. The first

path was a path of academic and theoretical review of how to handle high-risk, high-technology institutions. How do you handle

risky activity safely? The second path was a review of what we call

‘‘best business practices’’ or ‘‘best safety practices.’’ And that is the

review of institutions in the United States that actually handle

risky enterprises and do a good job of it and what could we learn

from those enterprises.

From these two reviews, we took what you might call a sampling

or a recipe or a cookbook of the characteristics that we thought applied to NASA. We then took that template, applied it to NASA,

and we are not very pleased with what we found. We then concluded our report with what we considered to be concrete, specific,

actual recommendations to fix these management problems that we

believe would go a long way toward making the operation of the

Shuttle more safe in the future.

Let me just close by saying one word about accountability. The

Board does not believe that accountable persons can hide behind

the excuse of bad management or culture or any other subterfuge.

There is a role for personal accountability. And in our report, we

think that the report is full of evidence of personal performance.

But it is up to either the Administrator of NASA or this committee

if you decide to hold people accountable for their actions. The

Board decided long ago, announced publicly, and we have—and I

will defend, very strongly, the position that we took that it is not

our job to sit in judgment over other people. However, all of the

performance factors that you may be interested in are in the report. They are all in there. And if you or the Administrator of

NASA feels that some accountability is required, we did our job, we

laid it out for you, and we don’t think that that constitutes dodging

the issue of accountability.

Thank you very much, Mr. Chairman. And my panel and I of colleagues here are delighted to be here and ready to answer all of

your questions.

[The prepared statement of Admiral Gehman follows:]

PREPARED STATEMENT OF ADMIRAL HAROLD W. GEHMAN, JR.

Good Morning Mr. Chairman, Congressman Hall, distinguished Members of the

Committee.

I know Members of this committee feel as we on the Board do: that the price this

nation paid on February 1, 2003 was so dear, it demands we do our part to ensure

an accident like this never happens again.

40

It is an honor to appear today before the House Committee on Science. I thank

you for inviting me to pay tribute to the legacy of Rick Husband, Willy McCool,

Mike Anderson, Dave Brown, K.C. Chawla, Laurel Clark, and Ilan Ramon in presenting the findings of the investigation into the tragic loss of the Space Shuttle Columbia.

Before I begin, I would like to commend the efforts of my 12 fellow Board members, 120 investigation staff members, 400 NASA engineers, and more than 25,000

debris searchers who have contributed immensely to the investigation.

Today I will provide the Committee with the final conclusions of the Board with

respect to the following three areas:

• The physical cause of the accident

• The organizational characteristics of NASA that contributed to the accident

• Recommendations the Board has made in regards to the Space Shuttle Program

I. Physical Cause

The Board has determined that the physical cause of the loss of Columbia and

its crew was a breach in the Thermal Protection System on the leading edge of the

left wing. The breach was initiated by a piece of insulating foam that separated

from the left bipod ramp of the External Tank and struck the wing in the vicinity

of the lower half of Reinforced Carbon-Carbon (RCC) panel 8 at 81.9 seconds after

launch. During entry, this breach in the Thermal Protection System allowed superheated air to penetrate through the leading-edge insulation and progressively melt

the aluminum structure of the left wing, resulting in a weakening of the structure

until increasing aerodynamic forces caused loss of control, failure of the wing, and

breakup of the orbiter.

Entry data demonstrated that the flaw in the left wing was extant prior to entry.

The flight events are well documented, and establish that progressive destruction

occurred as the orbiter entered the atmosphere. Superheated air damaged the structure of the wing first, leading to the abnormal aerodynamic forces that caused the

eventual breakup. Once the orbiter began entry, there was no possibility of recovery.

The Board reached this conclusion after extensive analysis of five lines of evidence:

• The aerodynamic scenario

• The thermodynamic scenario

• The detailed system timeline from telemetry and recovered on-board recorder

• The videographic and photographic scenario

• Debris reconstruction and forensics.

Additionally, the Board conducted foam impact tests in order to determine that

this potential cause was indeed plausible. The tests proved this, and much more.

The tests demonstrated that External Tank foam shed during launch could create

considerable damage to the RCC panels and the tests also added to the body of

knowledge regarding RCC strength. The foam impact testing ends for all time the

common belief within NASA that foam strikes are just a flight turnaround issue,

and also serves as a dramatic stimulus to change some people’s attitudes about

what we really ‘‘know.’’ Furthermore, it demonstrates the Board’s finding that the

characterization of the Space Shuttle as operational rather than experimental was

flawed. The direct result of this mindset was the lack of testing on such matters

as the cause of foam shedding, the force of foam projectiles, and the strength of the

RCC panels to withstand such debris strikes.

II. Organizational Causes

Mr. Chairman, the Board believes very strongly that complex systems almost always fail in complex ways. Most accident investigations fail to dig deeply enough

into the causes beyond identifying the actual physical cause of the accident; for example, the part that failed and the person in the chain of command responsible for

that failure. While this ensures that the failed part receives due attention and most

likely will not fail again, such a narrow definition of causation usually does not lead

to the fixes that prevent future accidents.

Our investigation into the loss of the Columbia was designed to get to the heart

of the accident, and reveal the characteristics of NASA that allowed the accident

to occur. As everyone knows, NASA is an outstanding organization, with highly

skilled and motivated people and a long history of amazing accomplishments. However, there are long-standing management issues that led to the Columbia disaster.

41

The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original compromises that were required

to gain approval for the Shuttle Program, subsequent years of resource constraints,

fluctuating priorities, schedule pressures, mischaracterization of the Shuttle as operational rather than developmental, and lack of an agreed upon national vision for

human space flight.

Cultural traits and organizational practices detrimental to safety were allowed to

develop including:

• Reliance on past success as a substitute for sound engineering practices (such

as testing to understand why systems were not performing in accordance with

requirements)

• Organizational barriers that prevented effective communication of critical

safety information and stifled professional differences of opinion

• Lack of integrated management across program elements

• The evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules

The Board believes that these factors are just as much to blame as the foam. We

began an analysis of how high reliability organizations handle risky enterprises, creating a template for us to use to examine management and culture at the Space

Shuttle Program. The Board has concluded that the Space Shuttle Program does not

have the characteristics of a high reliability organization. Furthermore, history and

previous studies demonstrate that NASA, as a whole, does not ‘‘learn’’ well.

The results of our very intrusive investigation into the Space Shuttle Program

demonstrate clearly that gradually and over a period of many years, the original

system of checks and balances has atrophied. Instead of using a system of checks

and balances provided by independent engineering and safety organizations, the

Shuttle Program placed all responsibility and authority for schedule, manifest, cost,

budgeting, personnel assignments, technical specifications and the waivers to those

specifications and safety in one office. That action created an office that could make

programmatic trades to achieve whatever goals were set for it by a higher authority.

For example, if meeting the schedule were priority number one, the program could

trade safety upgrades against schedule. We find this to be an excellent system if

one’s goal is to know whom to blame if something goes wrong, but NOT an excellent

system if one’s goal is to maximize safety.

III. Recommendations

The Board does not believe that the Space Shuttle is inherently unsafe, and we

were under no pressure to say that it was safe. However, there are things that must

be done to make it more safe than it is and many of these things must be accomplished before return-to-flight. Furthermore, if the Shuttle is to continue flying past

the next few years, there are even more safety requirements necessary. Our recommendations and observations also constitute an attempt to find items that might

be dangers in the future.

There are three types of recommendations in the report. The 15 Short-Term recommendations outline the fixes needed for return-to-flight. The 14 Mid-Term recommendations refer to the needs for continuing to fly for the next three to 12 years.

The Long-Term recommendations discuss the considerations that must be made for

continuing to fly the Space Shuttle beyond 12 years, including recommendations for

replacing the Shuttle.

In addition to the cultural and organizational considerations that NASA must address, there are several recommendations that stand out. One of these is the call

for NASA to take an integrated approach to the issue of the danger posed by debris

by combining steps to reduce debris creation in the first place, an overall toughening

of the orbiter, both in the RCC components and the other parts of the Thermal Protection System, including the tiles, and developing a capability for on-orbit inspection and repair. The Board studied scores of other findings of significance with respect to how exactly to prevent the next accident. Among the numerous recommendations is the need for better engineering drawings, better safety and quality

assurance programs, and improved documentation. Additionally, there are specific

ways to improve the orbiter maintenance down period without sacrificing safety, as

well as recommendations on what to look for on bolt fractures, holdpost anomalies,

Solid Rocket Booster attach rings, test equipment and training needs.

Conclusion

Mr. Chairman, at the beginning of this investigation, I promised a final report

that places this accident in context, rendering the complete picture of how the loss

of the Columbia fits into the complicated mosaic of budget trends, the myriad preVerDate 11-MAY-2000 16:28 Mar 25, 2004 Jkt 089216 PO 00000 Frm 00045 Fmt 6633 Sfmt 6621 C:\WORKD\FULL03\090403\89216 SCIENCE1 PsN: SCIENCE1
42

vious external reviews of NASA and the Shuttle Program, the implementation of

Rogers Commission recommendations, changing Administrations and changing priorities, previous declarations of estimates of risk, work force trends, management

issues and several other factors. We have done this to the best of our ability and

I believe we have succeeded.

It is our intent that this report be the basis for an important public policy debate

that needs to follow. We must establish the Nation’s vision for human space flight,

and determine how willing we are to resource that vision. From these decisions will

flow the debate on how urgent it is to replace the Shuttle and what the balance

should be between robotic and human space flight, as well as many other pressing

questions on the future of human space flight. Let the debate begin.

Thank you Mr. Chairman. This concludes my prepared remarks and I look forward to your questions.

Columbia Accident Investigation Board Selected Biographies

Adm. Harold W. Gehman Jr., U.S. Navy retired, completed more than 35 years

of active duty in October 2000. His last assignment was as NATO’s Supreme Allied

Commander, Atlantic, and as the Commander in Chief of the U.S. Joint Forces

Command, one of the five U.S. Unified Commands. Immediately after retiring,

Gehman served as Co-Chairman of the Department of Defense review of the terrorist attack on the USS Cole. Gehman graduated from Pennsylvania State University with a Bachelor of Science degree in Industrial Engineering and a commission

in the Navy from the Naval ROTC program. He served at all levels of leadership

and command and was promoted to four-star admiral in 1996. He became the 29th

Vice Chief of Naval Operations in September 1996. As Vice Chief he was a member

of the Joint Chiefs of Staff, formulated the Navy’s $70 billion budget, and developed

and implemented policies governing the Navy’s 375,000 personnel.

Maj. Gen. Kenneth W. Hess is the Air Force Chief of Safety, Headquarters U.S.

Air Force, Washington, and Commander, Air Force Safety Center, Kirtland Air

Force Base, N.M. Hess entered the Air Force in 1969 through Officer Training

School at Lackland Air Force Base, Texas, and has extensive staff experience at

Headquarters U.S. Air Force, the Joint Staff and U.S. Pacific Command. He has

commanded three Air Force wings: 47th Flying Training Wing, 374th Airlift Wing

and 319th Air Refueling Wing. Prior to assuming his current position, Hess was

Commander of 3rd Air Force, Royal Air Force Base, Mildenhall, England. He is a

command pilot with more than 4,200 hours in various aircraft.

Dr. James Hallock is Manager of the Aviation Safety Division at the Department

of Transportation’s Volpe Center. He received BS, MS and Ph.D. degrees in Physics

from the Massachusetts Institute of Technology and authored or co-authored two

patents and more than 135 papers and reports. He worked in the Apollo Optics

Group of the MIT Instrumentation Lab (now the Draper Lab) from 1963 to 1966,

dealing with the selection of Earth landmarks for updating guidance computers on

Apollo and the potential effects of solar flare radiation on Apollo’s optical systems.

From 1966 to 1970, he was a physicist at the NASA Electronics Research Center

and did research in modern optics (holography and spatial filtering) and developed

a spacecraft attitude determining system. In 1970 he joined the DOT Transportation

Systems Center (now the Volpe Center) and studied aircraft wake vortices, developed aviation safety systems, and conducted many detailed safety studies.

Dr. Sheila Widnall, Professor of Aeronautics and Astronautics and Engineering

Systems. Massachusetts Institute of Technology (MIT), Cambridge. She has served

as Associate Provost, MIT, and as Secretary of the Air Force. As Secretary of the

Air Force, Dr. Widnall was responsible for all affairs of the Department of the Air

Force. Dr. Widnall was also responsible for research and development and other activities prescribed by the President or the Secretary of Defense. Since returning to

MIT, she has been active in the Lean Aerospace Initiative, with special emphasis

on the space and policy focus teams. Her research activities in fluid dynamics have

included the following: boundary layer stability, unsteady hydrodynamic loads on

fully wetted and supercavitating hydrofoils of finite span, unsteady lifting-surface

theory, unsteady air forces on oscillating cylinders in subsonic and supersonic flow,

unsteady leading-edge vortex separation from slender delta wings, tip-vortex aerodynamics, helicopter noise, aerodynamics of high-speed ground transportation vehicles, vortex stability, aircraft-wake studies, turbulence, and transition.

43

DISCUSSION

RISK

Chairman BOEHLERT. Thank you very much, Admiral Gehman.

The report states that the Board believes that the Shuttle is not

inherently unsafe, but it also says repeatedly that the Shuttle is inherently risky and should be treated as experimental. And parenthetically, let me say, I couldn’t agree more that it should be

treated as experimental when, in the view of most, it was treated

as operational. How do you reconcile those two statements? I assume that we’ll likely lose the Shuttle if the vehicle is flying another 10 to 20 years. At what point does something become so risky

that it becomes inherently unsafe? Did the Board ever receive any

convincing risk analysis from NASA for the Shuttle program?

Admiral GEHMAN. Mr. Chairman, we chose those words very,

very carefully. We very carefully used the sentence with two negatives in it. We—the statement that the Shuttle is not inherently

unsafe was chosen to allow us to send the signal that we didn’t

think it’s safe. It is not safe. It is risky. And we didn’t think it is

unsafe. If we thought it was unsafe, we would have recommended

that we suspend flying operations. We would have said that. The

Board was under no pressure to allow NASA to continue to fly this

thing. The Board completely divorced itself from cost and schedule

and International Space Station requirements. And we do believe

that with proper management and proper skill and a good, elegant

management scheme that the Shuttle can be operated reasonably

safely. But as you said, it can not—it is a risky enterprise and always will be. It always will be risky.

Chairman BOEHLERT. What level of risk is that?

Admiral GEHMAN. We—I am going to let my colleagues in on this

one, because we have actually seen numbers. My own view is that

the numbers have little or no validity. And numbers along the lines

of the probability of a failure in a mission of one in 200 are kind

of the most commonly accepted numbers. I am going to let—these

people have also seen other numbers. And then I will—I have a

comment I would like to make. Does the gentleman want to say

something?

Chairman BOEHLERT. Dr. Hallock.

Dr. HALLOCK. Yes, there are a number—a lot of numbers that

float around that we have been looking at. NASA has done a job

in the sense of trying to look at the various things that could affect

the Shuttle. For example, the number that Admiral Gehman just

mentioned, the one in 200, is the chance of actually having a problem due to a micrometeorite or an orbital debris strike and actually

cause loss of crew and vehicle. So the numbers are large. But there

are many other types of things that they can run into that can be

a problem, too, most of which have been looked at. But once again,

it is the compounding of all of these numbers that become important.

Yes, it is a risky venture, but, you know, we have a lot of other

risky ventures that we are involved with. In fact, sitting next to an

Admiral, I think immediately of submarines that go into an environment that is, you know, much like the space environment.

44

When you are well underwater, you are in a place where it is not

very easy to escape from to get back to the Earth.

Major General HESS. Yes, I obviously agree with the Admiral

and Dr. Hallock on this issue. And in the course of our seven

months, I think we became fairly intimate with the fact that truly

quantifying the risks in numeric terms for the Shuttle is, I think,

a little bit like dreaming. I don’t think you could actually do it. You

can’t quantify the risk of the human factor interfaces and all of the

different layers that are involved in making management and technical decisions as well as the work that is ongoing everyday with

the Shuttle. So you can probably estimate, but the error band is

fairly wide. And so hanging our hat on a number is—after our

study, nothing I would do with the Shuttle. And I am always reminded that, yes, the technology is risky and the uncertainty that

is involved always causes you to question whether or not it is safe

or unsafe to fly, but the difficulties in—that we have encountered

in both Challenger and Columbia were of the human management

decision style, not the technology itself. So I think the risk, in the

context, is manageable, but it takes some elegant operations to do

that.

Chairman BOEHLERT. Dr. Widnall, do you wish to add any?

Dr. WIDNALL. Sure, I will add a little bit. I think—I would certainly agree with my colleagues. And the phrase that I would use

about trying to put numerical values on risk is that it is perhaps

necessary but not sufficient. If you look at the risk of the Shuttle,

you can divide it into two parts. There is the physical characteristics or the hardware. You can sort of analyze and dig deep into how

the hardware was qualified, what depth of engineering analysis

was used, you know, how safe do we feel the actual operation of

the hardware is. But I think obviously more important are the organizational issues. And for me, the issue of how one decides to

waive a requirement, how one decides to treat an anomaly and continue flying, the depth of engineering analysis that was applied to

the various systems to, in some sense, certify them. I think these

are very important issues, and they are not quantifiable.

Chairman BOEHLERT. Thank you. Thank you very much for outstanding answers.

Admiral GEHMAN. Mr. Chairman, may—I wanted to add something.

Chairman BOEHLERT. After they spoke.

Admiral GEHMAN. To get to your issue, though, it is a lesser—

at least it was a lesser to me, that when you ask to—the answer

to your question depends on who you ask. For example, NASA has

a number. They actually have a calculated number for each mission. And if you go, for example, to the U.S. Air Force, which operates the eastern range where they launch it, and you ask them

what their risk number is, you find it to be much larger—much different than NASA’s number. It is very interesting. And in the case

of the Challenger investigation, the famous Dr. Feynman quote at

the end, he tried to address this question, too. And he kind of said

that, you know, kind of the best he could determine was 99 percent, one out of 100, which is, of course, much higher than NASA’s.

So the answer to your question depends on who you ask. And if you

45

ask an independent agency, you get a number which is more risky

than if you ask NASA.

Thank you, sir.

Chairman BOEHLERT. Thank you very much.

Mr. Hall?

Mr. HALL. Mr. Chairman, thank you.

Admiral, of course, I want to get back to safety. I want to visit

with you and the other three of you there. And the word ‘‘risk’’ and

‘‘risky’’ and ‘‘risk assessment’’ and ‘‘risk containment’’ and all of

that have been voiced, and of course, proper words for this situation and for this report. And how many times have I heard these

brave men and women astronauts referred to as the Columbuses

and the Magellans of space. And I often wonder how many ships

were lost at seas and how many crews were before Columbus or

Magellan or Amerigo Vespucci or whoever it was that hit this shore

first, how many we lost and how much risk they were assessing

and a different risk.

But I think we need to think in terms of we do have a risk, and

we can—and we get the last guess at how to fix it, how to fix that

risk. I know that even prior to the Challenger and prior to Columbia, I know that the President, after the Challenger, thought we

had assessed the risk and had attended to it and had addressed it.

I know the Congress thought we had. I know the NASA Administrator, whoever it was at that time, thought we had. But obviously

they thought we had a safe Shuttle. And now, complying with your

recommendations, we are going to think that we are making it

safe, and we are going to think we have addressed the risk. Now

we were wrong twice. We can’t afford to be wrong again. And I

think that now is the time to start the journey toward doing something about it if we are wrong again, that we haven’t assessed the

risk, that we haven’t pushed back any risk. I don’t suppose it is

possible to say it is absolutely, without any question, risk-free.

There is no way to do that. I wish we could.

CREW ESCAPE

But we can certainly—in case we are wrong, we can have a way

for those that are aboard that vehicle to survive. Now we have

asked for that before. I know that we have asked for it for at least

10 years since the last loss. And each time, we have been told that

we can’t have a vehicle aboard the vehicle. I think the gentleman

from California has addressed that a lot of times. And the answer

we always got was, ‘‘Well, the weight. It is a weight problem.’’ And

‘‘It is a money problem.’’ And it is both of those problems. But now,

before we send anybody else up, even though we think we have addressed the risks, we have touched every base that we can humanly touch, we need to touch one more base and have them have

a way out in case we are wrong again.

So with that, Admiral, let me say your report contains some ‘‘observations’’ about crew escape systems for the Shuttle. And it mentions the fact that the Aerospace Safety Advisory Panel’s 2002 report recommended that the NASA consider upgrading the Shuttle

to include crew escape systems in view of the Shuttle’s proposed

life extension. And that makes sense. That should have been done.

Yet your report does not actually make a recommendation one way

46

or the other, that I can see, about adding a crew escape system for

the Space Shuttle. Now you know that a lot of us feel very strongly

that this is an area that NASA needs to address if this decision is

made to fly the Shuttle for an extended period.

Without asking the question of why we sent this particular Shuttle, why we sent the oldest one we had, why we sent the one that

couldn’t dock at the Space Station, why we sent the one that

wouldn’t have available the telescope. All of those things are assuming blame to somebody. I am not interested in that. I am interested in causation. I am interested in doing something about it, if

we are wrong, again, on our risk assessment. So we owe it to them

to give them a fighting chance. The loss of another Shuttle would

not—should not inevitably, absolutely mean the loss of the crew.

So let me just ask you directly, if NASA plans to fly the Shuttle

past 2010, should NASA be required to develop escape systems for

the crews that will be flying those Shuttle missions? That is a good

yes answer, isn’t it?

Admiral GEHMAN. As long as you say they should consider, the

answer is yes. In my opinion, the answer is yes. The Board did not

do an in-depth study of that issue, so I am not speaking for the

Board here, but we did. We looked at that issue a little bit, and

as long as it is couched in the terms of should they consider it, the

answer, in my opinion, is yes.

Mr. HALL. Dr. Hallock, do you have anything to add to that?

Dr. HALLOCK. Well, I agree with that in the sense that one needs

to always look at possible ways to be able to allow the crew to survive.

Mr. HALL. We don’t need to just look at them. We need to do

something about them. We need to get underway with it.

Dr. HALLOCK. I agree.

Mr. HALL. I can find people that are more intelligent than those

of us in Congress, so all we have to do is come up with the money.

But finding those of you out there who are givers and are giving

your time here today, have given your life to what you are doing.

We need you to come up with a way for those people to get out of

there if something happens. You can be catapulted out of an F–16

or whatever. I can’t understand why, with all of the modern technology and all of the intelligence and the genius we have here, a

lady with MIT and the General that has given his life to this country, Dr. Hallock that has studied all of your life and been smarter

than almost everybody else that you knew or you were around.

Surely to God you can come up with some way to get people out

of there if they say, ‘‘Hey, the damn thing is knocking. There is a

rod knocking in it. Let us get out of here.’’ Dr. Widnall.

Dr. WIDNALL. Sure, I guess maybe what I need to do is define

the word ‘‘consider’’, because I think if one were—if one proceeds

down that road, and I think it is a good idea, it would take a really

in-depth engineering analysis and a consideration of, perhaps, design options and a calculation of what this would actually be, what

would its characteristics be, and in fact, would it make the Shuttle,

as a vehicle, more risky or less risky. And that is the calculation

that has to be done.

Mr. HALL. Sure, weight and structure——

Dr. WIDNALL. Weight, strength——

47

Mr. HALL. Sure.

Dr. WIDNALL [continuing]. Materials. Let me just mention as

a——

Mr. HALL. Jack Kennedy had the start of all of those things

before——

Dr. WIDNALL. Sure.

Mr. HALL [continuing]. He ever launched the first one.

Dr. WIDNALL. Yeah. Let me just indicate the particularly demanding environment that the Shuttle saw when it reentered. Reentering at mach 25, at those altitudes, those kinds of temperatures 10,000 to 3,000 degrees Fahrenheit, there are few materials

that will withstand those kinds of temperatures. And so it is a very

challenging engineering problem. But that would be my definition

of the word ‘‘consider.’’

Mr. HALL. Well, we knew the velocity of the foam that you shot

into that trial wing. We knew the speed at that time. We knew all

of those things before the Columbia loss. We knew that could happen. Why can’t we use that—why can’t we use our genius to come

up with a vehicle that will save these people if we are wrong about

attending to the risk assessment? Why can’t we do that?

Dr. WIDNALL. It is perfectly reasonable to start down that road.

Mr. HALL. And it—don’t—wouldn’t you be very uncomfortable if

you left here today and didn’t believe that we were going to start

down that road, whether we get down that road or not, that we are

underway trying to get down to that road and that we are lucky

enough and have enough support from up above that we don’t have

a tragedy before we get to the end of the road of finding that answer?

Dr. WIDNALL. I think it is——

Mr. HALL. We better dang well be underway hadn’t we—if we

have another tragedy.

Dr. WIDNALL. Yeah, it is a completely reasonable path to take.

Mr. HALL. Because I am going to support the NASA Administrator. I am going to work with him from this point forward. I am

going to try to comply with the Admiral’s recommendations. I am

going to work with everybody on this committee, but I want us to

be underway to find a way in case we are wrong and we are not

successful at doing what we think we are doing about risk that we

can get them out, if it happens.

I yield back my time.

Chairman BOEHLERT. Thank you very much.

The Chair of the Subcommittee on Space and Aeronautics, Mr.

Rohrabacher.

SHUTTLE REPLACEMENT

Mr. ROHRABACHER. Thank you very much. And with due respect

to Mr. Hall, I would like to sort of take this from the other side

of the coin. Is—Admiral Gehman, isn’t your finding that we should

be trying to minimize our reliance on the Shuttle rather than trying to invest more into the Shuttle and—so it could be used more

in the future?

Admiral GEHMAN. Yes, sir. Our recommendations are a series of

recommendations to make the present operations of the Shuttle

more safe, but our recommendation is to replace the vehicle as soon

48

as possible. And in our editorializing in chapter nine, we specified,

to get back to Mr. Hall’s point, that whatever it is that we replace

the Shuttle with that the concept of the operations should be to

separate the crew from the cargo, because as long as you keep the

crew and the cargo together, you have to suboptimize human safety. And that—and therein is the dilemma.

CONTINUING SHUTTLE OPERATIONS

Mr. ROHRABACHER. So we should do our best to phase out the

Shuttle and go to a new system rather than trying to bolster the

capabilities of the Shuttle?

Admiral GEHMAN. The Board wrote that the Board was surprised

and disappointed to find ourselves here at 2003 without a replacement vehicle, even on the drawing board.

Mr. ROHRABACHER. In terms of what we have to do and what the

Shuttle is necessary for in the future, Space Station is certainly

something that will not be completed without the Shuttle. And

even to make the type of safety upgrades that we are talking about

today will take a certain length of time that would go well into Station’s life span. Is it—do you have any recommendation at all in

terms of whether the Shuttle should be used to complete the Space

Station, given its current risks?

Admiral GEHMAN. The Board report, I believe, speaks very clearly to the subject of operating the Shuttle at what we call the midterm, that is like two to 15 years or two to 10 years. And in there,

we specify very clearly, I believe, that the present management

scheme is not adequate to operate the Shuttle safely. Technically,

hardware-wise, as long as you take care of the Shuttle and as long

as you aggressively investigate every single waiver and every single anomaly, we believe the Shuttle can be operated for another 10

years with a degree of safety.

NASA’S CULTURE AND MANAGEMENT

Mr. ROHRABACHER. So if we change the—one of the central findings, if we come to grips with one of the central findings of your

Commission, which is the culture or attitude of what was going on

safety-wise at NASA, that that might, in itself, enable us to reach

a safety threshold in which the Shuttle could be used to complete

the work on Station?

Admiral GEHMAN. That is correct. Are there any other Board

members who want to—but that is the central core of our recommendation. And that is that the present management scheme

tends to hide or overlook or not react to those little tiny signals

that something is going wrong. And it is those little tiny signals,

like foam coming off and things like that, that you have to go after

aggressively. And we can’t predict what the next thing to go wrong

with the Shuttle is, but we do know that the present management

scheme is not good enough to catch it.

Chairman BOEHLERT. Mr. Rohrabacher, just let me intervene, if

I may, and it won’t be taken out of your time. But little tiny signals, Shuttle after Shuttle, debris, foam comes off, assumed that,

since it came off, they assume too much that it was going to be the

size of the previous foam and no larger. And isn’t the basic thrust

49

of your whole report that too much was assumed and they weren’t

skeptical enough?

Admiral GEHMAN. Absolutely correct. And they didn’t have the

resources to have a robust research and development department.

And they—and the engineers were all funded from the Shuttle programs, so, you know, they are not going to tell their boss that he

is in trouble and et cetera, et cetera. But yes. Yes, sir. You are exactly right.

Chairman BOEHLERT. Thank you.

Mr. Rohrabacher?

Mr. ROHRABACHER. That, of course, is the difference between

being proactive and being reactive. And in fact, I think your report

suggests that the NASA attitude went beyond being reactive. It

was actually blase ́ toward some of these signs that Chairman Boehlert has just pointed out.

Let us go to that attitude now, as soon as we get done with these

beeps and buzzes. Did your Commission find that this lack of energy or this blase ́ attitude or bad culture, whatever we want to call

it, that this was part of the NASA culture in the past during the

Apollo programs and other programs, or was this something that

has just sort of evolved into place in these last 10 to 15 years?

Admiral GEHMAN. We spent a lot of pages trying to answer that

question, Mr. Rohrabacher. And it is our conclusion that it appears

to us that, as you study history and you study the previous reviews

of NASA management, and you know, NASA is never not being reviewed by somebody, so there are a lot of data points out there,

that it seems to ebb and flow. After a big tragedy, like Apollo or

Challenger, they take a whole lot of management actions to make

the program more safe and make it more sensitive to engineering

problems. And then, over the years, forces begin to act on NASA.

And some of these forces are external forces, by the way. Some of

these forces are budget pressure or schedule pressure put on by

both ends of Pennsylvania Avenue. And NASA then starts to—it

starts to migrate or morph its management scheme to be more effective, more efficient, more cost-effective. And we specifically

found, for example, that—in this particular case that we were looking at so carefully, the Space Shuttle program, the Space Shuttle

program management actually had been squeezed to the point

where the Program Manager had so much authority, so much responsibility, and so much authority that he could trade schedule

against safety upgrades. He could trade costs against research and

development. And we found this to be unhealthy.

VISION

Mr. ROHRABACHER. One last thrust here, and that is this attitude

and this evolution in the wrong direction, that does have something

to do with a lack of vision and a lack of goals of the whole space

program, does it not? We have a saying on top of us here that says,

‘‘Where there is no vision, the people perish.’’ And let us note

where there—when there is no vision, astronauts perish. And is

that not what we are talking about here?

Admiral GEHMAN. We noted in our report that a lack of an

agreed national vision causes NASA to have an unclear set of criteria on how to make decisions.

50

Mr. ROHRABACHER. And leads to that attitude?

Admiral GEHMAN. It absolutely does.

Mr. ROHRABACHER. Okay. Thank you very much.

Chairman BOEHLERT. Thank you very much.

Mr. Gordon?

Mr. GORDON. Thank you, Mr. Chairman. And Chairman Rohrabacher, I hope that you will continue this effort to try to find that

vision. I think it is very important.

INTERNATIONAL SPACE STATION AND SPACE SHUTTLE

MISHAP INTERAGENCY INVESTIGATION BOARD CHARTER

A couple quick questions, because, as you know, we are caught

in here with the bells. As you are well aware, Admiral Gehman,

you had to make a variety of changes to the original charter that

was set out in this Contingency Plan to develop a Commission that

you felt comfortable with. As I understand it, we revert back to

that original charter now if there is some problem in the future.

Would it be fair to say that this committee ought to review—reviewing that original charter and making some changes so that if

there is another occasion that we will be better prepared early on?

Admiral GEHMAN. To my knowledge, the NASA Contingency

Plan, which created this board, is still in existence and the words

haven’t been changed. And if you feel that those—that Contingency

Plan is not right, yes, it should be reviewed.

Mr. GORDON. Well, you obviously did, because you asked for it

to be changed——

Admiral GEHMAN. That is correct.

Mr. GORDON [continuing]. A variety of times.

Admiral GEHMAN. That is correct. Um-hum.

DEFINING BENCHMARKS FOR PROGRESS AND PAST REPORTS

Mr. GORDON. Okay. Now, as you have said on a variety of occasions outside the specifics of the foam, a lot of what your work was

was rehashing the McDonald report. And if NASA had done a better job of following the McDonald report, we may or may not be

here, but we would be in a better situation. I think it is very important, as our Chairman pointed out earlier, that, you know, when

the crowds diminish and you are gone home, that at least this committee doesn’t lose its enthusiasm for oversight and for setting up

benchmarks.

And again, as the Chairman said, that is more than just good

will, it is the deeds. So I will—what I am going to—because I think

we can’t get it all done today, but I am going to write you and ask

that you lay out your thoughts on how—what kind of benchmarks,

what type of processes that we need to set up to see that these

things are followed, as we had hoped the McDonald would be. And

you can do it more extensively later in that letter, but I will let you

go ahead now. And if you would like to give this committee advice

as to what kind of benchmarks we need to set up. And if you would

help us, also, talk a little bit about what kind of rough dollar figures that we need to be looking for.

Admiral GEHMAN. The Board agreed with me that we would not

be doing a thorough job if we did not study history. And we studied

51

history, the history of NASA and the history of the investigations—

previous investigations of NASA, including what we found in retrospect to be a very, very good report done just three years ago by

Harry McDonald. But also, we went back to the Rogers report and

the Norm Augustine report and the Kraft report. And all of these

reports, which we carefully documented, you might say we found

nothing new. NASA has been told over and over again that they

are—that a number of the things they are doing increase the risks

to the Shuttle. They are—I think your question, though, is really

an excellent one and that is two years from now or three years

from now or four years from now, how do we ensure ourselves that

the follow-up—that the progress is there and that the follow-up is

there and that this natural migration of these good traits back to

bad traits doesn’t occur again, like it has happened in the past.

And the Board has discussed this a little bit, and we would be delighted to dialogue with you on how you get at that, because I

think that is the central question.

Mr. GORDON. And you are going to be around a little longer. You

will have staff a little bit longer. And if you—I will send a letter

of request and would welcome your advice as to how we can follow

up on that.

There are lots more, Mr. Chairman, but I guess we better go.

Chairman BOEHLERT. Well, I think we can get in one more

round. We have eight minutes to go, so we will go to Mr. Smith

of Texas, and then we will take a brief pause. We have two votes.

We will get right back. This is very important.

Mr. SMITH OF TEXAS. Thank you, Mr. Chairman.

Admiral Gehman, let me get directly to my questions. The first

is that the report raised a concern about greater priority being

given to scheduling demands than safety. Who or what pushed

these scheduling—put these scheduling pressures on the individuals involved?

SCHEDULE PRESSURE

Admiral GEHMAN. The—we believe that we got right to the bottom of that in our report. And when you ask senior managers at

NASA to a person, 100 percent of them deny that there was any

schedule pressure. And then when you go down and talk to the

worker bees, the project people who are actually working on the

Shuttle program, to a person, they say that there was enormous

schedule pressure. So schedules, of course, are not bad things. I

mean, everybody uses schedules as a management tool.

Mr. SMITH OF TEXAS. Do you think the pressures were more internal than external?

Admiral GEHMAN. I think that there was a great difference of

opinion between the senior managers and the junior people. And of

course, any time you have got the senior managers working on one

set of script and the other people working on another one, you have

got a dangerous situation.

Mr. SMITH OF TEXAS. They are conflicting responses to——

Admiral GEHMAN. Complete miscommunications as to what the

truth was.

52

INACTION TO PREVIOUS FOAM LOSS

Mr. SMITH OF TEXAS. Admiral Gehman, none of the external advisory groups voiced concerns about the foam despite the fact, as

we know, that foam has been falling off consistently. What significance do you attach to the fact that none of those concerns were

raised?

Admiral GEHMAN. Thank you, sir. And by the way, that, of

course, struck the Board right in the forehead like a two-by-four

that these wonderful previous panels, including Rogers, missed the

significance of the foam coming off. If we are so brilliant that we

can see that foam is a hazard to the Shuttle, why didn’t all of these

other people see it?

Mr. SMITH OF TEXAS. Exactly.

Admiral GEHMAN. And the way we answered that was that

these—we have to set up a management scheme that can detect

this kind of stuff, not—knowing that it is very hard to detect. And

the management scheme that we put in place would be one in

which waivers or exceptions or violations to the specifications

would be reviewed by a group of people who have no interest in

cost and schedule. That is the only way we can see to safely get

things like foam and—oh, by the way, the Board felt it very important that we come up with others, by the way. We think it is kind

of a cheap shot to take a—to criticize NASA for missing the foam,

so we said, ‘‘Okay. If you are so smart, tell me what the other ones

are.’’ And we came up with half a dozen other ones that are very

dangerous in which they decided to waive. I know, and my panel

members, I know, for example, Dr. Widnall would like to—might

want to comment on the testing of bolt catchers and things like

that. So you know, there are others. So the answer to your question

is this independent technical review authority.

REDUCTION IN SAFETY PROCEDURES

Mr. SMITH OF TEXAS. And a couple more questions real quickly,

Admiral. You expressed concern in the report about the drastic reductions in government inspectors and the mandatory points of inspection, which actually started in the early 1990’s. Was this intended to shift greater responsibility to the contractor or was it to

meet budgetary constraints?

Admiral GEHMAN. It was both. It was—they assumed—their belief was——

Mr. SMITH OF TEXAS. Neither of which was good.

Admiral GEHMAN. Neither of which was good.

Mr. SMITH OF TEXAS. Okay.

Admiral GEHMAN. They assumed that the maintenance and preparation for launch of the Shuttle, they had done it so many times,

they thought it was a routine operation and could be contracted.

SHUTTLE SERVICING OF HUBBLE

Mr. SMITH OF TEXAS. Lastly, Admiral Gehman, if the Shuttle

flies again, and we hope that it does, is there any reason why it

would be limited only to servicing the Space Station? Is there any

reason why it couldn’t continue to service other science missions,

including the Hubble?

53

Admiral GEHMAN. No, there is no reason except that the on-orbit

inspection repair capability, which we recommended, would be different for the two missions.

Mr. SMITH OF TEXAS. All right. Thank you. Thank you, Mr.

Chairman.

Chairman BOEHLERT. Thank you. Just let me make an observation. Waivers are something we are going to get into in greater

depth a little bit later on. There are over 3,200 waivers that have

been granted. Over 1,000 of them hadn’t been reviewed in more

than a decade, so that is something you rightly emphasized and

that is something we should focus on. But before that focus, we

have to take leave for a few minutes to go respond to the call of

the House. We should be back within 15 minutes. If you have—if

you would like coffee or—I can’t give you a break to go sailing, Admiral, but we can give you a—we will try to—the staff will try to

accommodate anything you might want, if you want——

[Recess.]

SCHEDULE PRESSURE

Chairman BOEHLERT. Let us resume. Mr. Costello?

Mr. COSTELLO. Mr. Chairman, thank you. Admiral, you answered

a question earlier posed to you by my colleague, Lamar Smith, and

I would like to follow up on that. On pages 116 through 118 and

later in your report, you refer to the schedule pressure, the pressure that was put on NASA employees by the schedule that was

adopted by the Administrator. And I would like to ask a few questions concerning the pressures that may have been added because

of the schedule. And one is you apparently, according to your report, the Board’s report, you very carefully evaluated the impact

that the schedule pressure may have had on Shuttle safety. And

specifically, the Administrator seems to have laid out a management goal of completing node two of the International Space Station by February 19, 2004.

And my question is, from reading the report, is that most of the

NASA program people believed that that was an unrealistic goal.

They also believed that if they didn’t meet these arbitrary goals

that something bad was going to happen to them. And I wonder if

you might comment what you found regarding the schedule pressure and how that impacted safety.

Admiral GEHMAN. We did find that schedule pressure, undue

schedule pressure, excessive schedule pressure, was at work on the

workforce in NASA, even though as I indicated in my previous answer, the senior management will deny that. But we did find it

present in the workforce. And as the illustrations in our report indicate, we also were concerned that some of the measures that

NASA was taking to stay on schedule appear to be cutting into the

safety margin, such things as working on weekends, conducting

safety checks in parallel instead of series. They are all listed in

those charts in there. They all appear to be a—they all appear to

support our basic hypothesis that bad traits and bad engineering

habits had crept into the NASA organization. We don’t think—we

don’t say in our report, and I don’t think the Board feels that

schedule pressure caused this accident. That is not what we are

suggesting.

54

Mr. COSTELLO. The—you talk repeatedly in the report about the

communication failures at NASA concerning the Columbia disaster.

And you know, it is surprising to me that the Administrator and

top management never seem to hear from the people in the program level that the schedule, the Core Complete goal needed to be

adjusted or changed. Did you find any evidence at all of discussions

that may have taken place concerning the goal complete—Core

Complete goal among the top managers or any consideration of how

it impacted safety of the Shuttle? I know the top management said

that they never heard, but in your investigation, did——

Admiral GEHMAN. Yes. I will let General Hess answer that. He

is the expert on that area.

Major General HESS. Thanks. I think in our investigation of it,

and it is documented in some of the charts in the report, we know

that the International Space Station managers, as well as the

Shuttle managers, were briefing the number of days of slack in the

schedule. And the briefing charts were, in the last venue, I think,

in December of 2002 indicated to the leadership that they were projecting as much as a 45-day late, last line on the chart says, but

we are going to hold to the February date. And so I think that the

discussion was there that they were telling the NASA leadership

that their best estimates were that they were going to be behind,

but they were still sticking to the date.

Now how far the conversations went beyond the briefing chart,

I don’t think we know, but when we get back and look at the circumstantial evidence, how it unfolded with regards to decisions

made on STS–113 and then on-orbit decisions were made with this

particular mishap, it looks like it all came together to influence decisions.

Mr. COSTELLO. General, a follow-up question, if I can. Do you

have any concerns that the return-to-flight goal laid out by the Administrator may produce some of the same pressures?

Major General HESS. Well, obviously I would have concerns if

NASA doesn’t have a realistic timeline decided. I think that, perhaps giving them some credit here, the initial estimates about

when they wanted to return to flight were done before the full

value of the report was laid out before them so they could actually

see the recommendations and how long it was going to take them

to get from where they are currently to actually the return-to-flight

decision. And certainly some of the key return-to-flight recommendations will establish a timeline that may not have been apparent when the schedule set. So I think that they have every opportunity to fix the schedule that will be realistic.

Chairman BOEHLERT. Thank you very much.

Let me ask you, Admiral, before I go to Mr. Calvert, NASA has

indicated the return-to-flight report will be out next Monday, I

think, the 8th, or Tuesday. Will you be in a position to give a sort

of an instant evaluation of that plan?

Admiral GEHMAN. I, obviously—I am going to retain a small

staff, because we have more work to do, and we are at your disposal to do whatever you want to do. I would say that Mr. O’Keefe

indicated in testimony yesterday that the return-to-flight schedule

is events-driven, not calendar-driven. So he said we return to flight

when we are ready, not—and not on a date.

55

Chairman BOEHLERT. And you are due to be testifying before the

Committee with Mr. O’Keefe on the 10th——

Admiral GEHMAN. That is correct.

Chairman BOEHLERT [continuing]. And so I am sure you will

have some choice words on that.

Mr. Calvert.

INDEPENDENT TECHNICAL AUTHORITY

Mr. CALVERT. Thank you, Mr. Chairman. And thank you for having this hearing and the hearings we are going to have in the future. And I want to thank Admiral Gehman and certainly the Investigation Board for all of their hard work, and we certainly appreciate that.

I would like to spend a little bit of time on the issue that was

brought up during your testimony, Admiral, and that is the role of

independence. I am interested in learning more about the Board’s

suggestion that the responsibility and authority for decisions involving technical requirements and safety should rest with an Independent Technical Authority. And I agree with you. I agree with

the conclusion and the relating recommendation. NASA needs to

utilize independent assessment capabilities that will serve them

throughout the life cycle of the space system and human space generally. And as you know, Admiral, in your career in the United

States Navy, some of the oldest and best assessment—independent

assessment work came from the Navy’s painful experience from

World War II with torpedo fuses, which was well-documented and

the Navy learned their lesson and it created something that was

just in my District, the NAVSEA Corona, which I represent, which

trace back to that original problem. Within your recommendation

that NASA stand up on an independent assessment capability, is

there room, encouragement, direction for NASA to use the experience—that kind of experience and to follow agencies like DOD to

establish that authority?

Admiral GEHMAN. I thank you for the question. And the answer

is that—the answer to that question gets right to the core of our

recommendation. We tried to devise a practical, workable recommendation that would fix as many of the problems in one—at

one time as we possibly could. And the traits and the unhappy

characteristics that we saw in the ignoring of engineering advice,

the e-mail story about the images, all—many, many of these ills,

we thought could be fixed with one management fix. And that management fix is to take the ownership of the level one specifications

and requirements and all waivers to them, and the Chairman had

mentioned how many, 3,000 and some odd waivers we are flying

with right now, invest them in a technical engineering organization, which is divorced, isolated from cost and schedule pressure.

And this is done other places. We have found other places where

it is done. You mentioned NAVSEA Corona, which does not only

the—now it does missile—it does all kinds of analysis of weapons’

effectiveness. And they are completely independent from the guy

who has to shell the money out. And so you get an independent assessment. We find that to be a very attractive methodology for fixing a number of problems.

56

Mr. CALVERT. And when you say independent of NASA, would

they have a separate budget? Would NASA still control their budget? Would you kind of expand on how that organization will work

and how its—and the relationship with the Shuttle Program Manager?

Admiral GEHMAN. It is not our intent that they will be independent from NASA. It is our intent that they be independent from

the Shuttle program. Now they would still be within NASA, as we

viewed it. We were very careful in our report, and we discussed

among ourselves, at great length, the issue of not specifying in any

great detail how this organization should be set up. Since we are

not going to be around to micromanage it or be around to make the

fine-tuning that are necessary to any management change, we decided instead to specific in great—with great detail and great directness how this organization should work, what its function

should be, but not drawing the wiring diagram. So this organization would be within NASA, but it would be independent of the

Shuttle program.

Mr. CALVERT. I understand. Dr. Hallock, General Hess, Dr.

Widnall, any other comments on that, on the independent technical

board?

Dr. WIDNALL. Yes, I might make a comment. I think this, as the

Admiral has indicated, is an extremely important recommendation.

And from my way of thinking, what we have given NASA is a template or, as a scientist, I might say we have given them a set of

boundary conditions. I believe very strongly that it is in the working out that will take place within the agency of how this will

work, what processes will be used, how the interaction and interfaces between the Shuttle program and independent technical

agency, how that will all work I believe will go a long way toward

challenging the basic culture of NASA, because it will challenge

some of their basic assumptions about, you know, what is true,

what is fact, what is analysis, how do you make decisions. So I look

to it to have a really good effect on the agency, the working out of

the details within the template.

Mr. CALVERT. Thank you. Thank you, Mr. Chairman.

Chairman BOEHLERT. Mr. Lampson.

Mr. LAMPSON. Thank you, Mr. Chairman.

VISION

Well, Admiral Gehman, I want to join with my colleagues who

have passed commendations on to you and the other Board members and your staff are—the work that you have done on this report. I, too, remember back when—I guess in February when Administrator O’Keefe said, ‘‘We may never know the answer.’’ I think

that we can feel confident that you have, indeed, determined the

physical cause of this accident.

I read your report to say that NASA must see significant reform,

the agency must develop a vision for the future, and that the Administration and Congress must provide NASA with adequate

funding levels. And I see that as a new mantra for us. Let us do

what my Senator said the other—yesterday when she said, ‘‘Let us

throw out faster, better, cheaper in the garbage can. Let us start

looking at reform, vision, and funding and perhaps we can have

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some different successes.’’ It seems clear from your report in the

area of reform that NASA and the space community are comprised

of an enormously talented and dedicated group of men and women

who are capable of making the cultural changes that your report

indicates. How, specifically, do we continue to support their important efforts as NASA continues their return-to-flight process and

institutionalizes the changes that will support and sustain safe operations over the long run?

Admiral GEHMAN. That is a tall question, Mr. Lampson, but I

will give you a couple of answers to that. First of all, it isn’t NASA

that needs a vision. It is the country that needs a vision. NASA has

got lots of visions, but visions without resources are just dreams.

We need an agreed vision, and then NASA can execute that. The

reforms that we call for in our report can not be instituted by the

Administrator of NASA alone. He is going to have to have your

help. For example, this independent technical review authority that

we just discussed will have a manpower bill associated with it.

These are people that are going to have to be hired, and they are

going to have to be paid. They are going to have to have career

paths et cetera, et cetera. So they are going to—the Administrator

is going to have to come up here and get your assistance on this.

Some of the other reforms are going to require your assistance,

too, because they are not solely within the purview of the Administrator of NASA. The funding business—the Board, in order that we

weren’t affected by cost and funding, we kind of isolated ourselves

from costs, and we don’t know exactly what it is going to cost to

return to flight. I would say that our experience of working this

problem for better—just under seven months, indicates that none

of the things we have recommended are terrifically expensive. I

mean, they aren’t showstoppers. But some of the things that we

recommended for the midterm, for example, this completely independent new technical review authority, an independent safety organization with line authority over safety means more people, more

government people. And some of the other recommendations, having to do with the oversight of the contract needs more government

employees. So he is going to have to come up here and explain to

you how he is going to go about it, and you are going to have to

help him.

Mr. LAMPSON. You made the comment about vision, and in the

report, you also said ‘‘lack of agreed national vision for human

space flight.’’ Would you expand on that finding for just a few seconds, please?

Admiral GEHMAN. Well, we attempted to find everything that we

possibly could that contributed to bad habits and bad traits and

bad management at NASA. And there were a lot of things that contributed a little tiny bit and some things that contributed largely.

This was a contributor. It—for lack of an agreed national vision,

you don’t know how many years to amortize investment in infrastructure. It is hard to argue budgets before Congress if you don’t

have an agreed vision to where you are going. You don’t know

when to replace equipment. We saw, in some of their technical laboratories, 1960-era oscilloscopes and things like that, analog meters

when everybody is using digital meters, you know. And there are

basic infrastructure decisions and basic investment decisions,

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which NASA has a hard time arguing or justifying because we

don’t have a complete agreement on how long is a Shuttle going to

be around, what is it going to be used for in the future. And so it

is very difficult for them to make investment kinds of choices.

Mr. LAMPSON. Thank you very much.

I would like to ask, and I am not going to, because my time is

about to run out. I would like to ask, at some point in time, for

your advice on—and the Board’s advice on how to recognize in the

future when a lack of resources has pushed a program into an unsafe condition. And there might be something that you may want

to think about and at a future opportunity that we will have—but

let me take my last couple of seconds and close, if I may. I do believe that we should give NASA the funding that it needs, but first,

the agency must make necessary reforms and establish a vision.

Your report calls on the White House and on Congress and NASA

to honor the memory of Columbia’s crew by reflecting on the Nation’s future in space. And I couldn’t agree more. And now that

your report has been released, this Administration must provide

Congress and the American people with a vision and a concrete set

of goals for the Nation’s human space flight program after the

International Space Station. And I am hopeful that the agency will

establish a phased series of goals over the next 20 years, including

human visits to the Earth-Sun libation points, Earth-orbit crossing

asteroids, as we have been reading about, deployment of a humantended research and habitation facility on the moon, and human

expeditions to the surface of—and moons of Mars. And I attempted

to push such legislation, push NASA into the direction of my Space

Exploration Act legislation that I introduced in the last Congress.

I am going to do that again, Mr. Chairman, next week, and I invite

all of our colleagues on this panel to please take a look, please

make advice or suggestions to me as to how to make it the kind

of legislation that would fit into our discussion today.

And again, I thank you, Admiral Gehman. I yield back my time.

BUDGET

Chairman BOEHLERT. Thank you very much, Mr. Lampson.

I would note a particular passage in the report on page 209,

‘‘NASA has usually failed to receive budgetary support consistent

with its ambitions.’’ I would suggest that probably that would apply

to any agency of the Federal Government. And I am glad we are

focusing so much attention on vision, because we have to have a

shared vision. It has to be at the Executive Branch and the Legislative Branch, and we—and the American people signing on to that

vision.

But further, and I would report on page 105 of the report, we are

talking about budget reductions. We are all part of this process.

But let me just read a couple of things here. ‘‘Reductions have been

requested by NASA during the final stages of budget deliberations.

After its budget was passed by Congress, NASA further reduced

the Shuttle budget in the agency’s operating plan, the plan by

which NASA actually allocates its appropriated budget during the

fiscal year to react to changing program needs. These released

funds were allocated to other activities, both within the human

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space flight program and in other parts of the agency.’’ And then

it goes on to enumerate all of the changes that were made.

Of course we haven’t provided NASA, or any other agency, with

every dollar they have requested. And we have to be very mindful

of our special responsibilities. But when it is pointed out that we

don’t provide the budget to—consistent with an agency’s ambitions,

I would suggest that the agency better adjust its ambitions, and we

better sign on to what we agree on is the vision for a program for

the rest of the budget year and beyond.

With that, I go to Mr. Gutknecht, the Vice Chair.

Mr. GUTKNECHT. Thank you, Mr. Chairman.

BENCHMARKS OF IMPLEMENTATION

And again, I thank all of you for what you have done. And I

think your answers today have been very candid, and we appreciate that more than you can imagine.

I—yesterday, the Administrator, Mr. O’Keefe, testified before the

Senate Commerce Committee. And he indicated unequivocally that

he understood the message and would implement the recommendations of your report. But you know, success leaves clues, and good

management requires setting benchmarks and finding, you know,

as we go forward how are we doing in terms of implementing that.

And if you were sitting on this side of these desks, what would you

look for in terms of benchmarks so that we could actually have a

better confidence that they really are implementing the plan, at

least as you outline in your report? Any particular things we

should look for in the next six months to——

Admiral GEHMAN. I will take a—I will mention a couple things,

and I think I am going to ask Dr. Widnall, who has some comments about oversight and review and things like that. First and

foremost, of course, is the Stafford-Covey—well, the first and foremost is the waiting for the NASA return-to-flight plan. We have to

get it, and we have to look at it. Second of all I think very prudently, we have a very illustrious large panel, the Stafford-Covey

Return-To-Flight Review Group, which is going to provide an opinion, an evaluation not of our report, but they are going to provide

an evaluation of the adequacy of NASA’s response to it. And I

think that that is a very, very good step. But the real core of our

recommendations are recommendations which are—need to be implemented a year from now, two years from now, and three years

from now. And I think that the question remains open in my mind

as to how to follow up on that effectively. And setting benchmarks

is a good way to do it. There are other ways to do it. And I think

that Dr. Widnall wanted to make a comment about the efficacy of

some kind of a review panel, which might measure those things.

So if you will allow me, I will recognize Dr. Widnall.

Mr. GUTKNECHT. Please.

Dr. WIDNALL. Okay. Well, let me make a couple remarks. First

of all, I do believe that our recommendation that in the return-toflight, the—NASA should come forward with a plan on reorganization was actually inspired. It is one of those things that happens

when a group of people get together and, you know, talk deeply

about an issue. And I think it really was an inspired idea. From

my point of view, the organization that we have recommended, the

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Independent Technical Authority and the safety organization, have

specific attributes, and you could almost check them off. We leave

it to NASA to do the details to figure out where in the organization

it housed, who it reports to, and all of that. And the—but the processes, the fact of its independence is a specific attribute that can

be measured. And there is no fudging up of that. So I think that

is identifiable.

As to the issue of oversight, I think there has been a tendency

to simply recommend an oversight committee. I think there is a big

difference between oversight inside an organization and oversight

outside of an organization. I have not been a fan of standing outside oversight committees, because I think, with time, they tend to

atrophy. They lose, you know, the urgency. They have an initial

charter. They have an initial mission, and they set out on that mission, but then over time, it kind of dwindles away. So I am concerned about establishing yet another ‘‘outside advisory committee.’’ I am much more in favor of what I would call the sense

of urgency, short-time committee, such as we, ourselves, were. We

were a short-time committee, seven months. We had a sense of urgency about what we were doing. We were willing to work real

hard for a short period of time.

So those are some of the trade-offs that you might think about

as you look into the issue of how can you get adequate oversight

for some of the details that need to be followed up on. I do believe

that safety is a technical discipline. So you will need comments

from people who, basically, are safety disciplinarians and people

who have had experience at these kind of very intense investigations, such as our Board. But the question of follow and oversight

is a challenging question. And I know that you will be giving a

great deal of thought to this as you proceed.

SHUTTLE DESIGN COMPROMISES

Mr. GUTKNECHT. And speaking of urgency, and I know we all

have to run and vote, but I couldn’t let you go without at least

mentioning, and perhaps you could respond briefly, Homer

Hickham wrote a fairly blunt piece in the Wall Street Journal the

other day. And he titled the piece, ‘‘NASA’s Vietnam.’’ And in it,

he says, and if I could just read this into the record. He says, ‘‘Take

a look at the Shuttle’s stack and see what you see: a fragile space

plane sitting on the back of a huge propellant tank between two

massive solid rocket boosters. The Shuttle has to sit right in the

middle of all of this turmoil of launch, because we once believed

that it would be cheaper to bring back those engines and rebuild

them rather than to build new ones. That has proved not to be the

case, far from it. But it has left the crew sitting in the most vulnerable position possible in terms of design.’’ Would any of you like to

talk about it, because essentially what he says is that the whole

design is a flawed strategy and that we have to get serious about

coming up with a whole new way of launching a returnable vehicle? Would anybody like to comment? And I apologize, because our

time is short, and we don’t have enough time to discuss it in

length, but——

Admiral GEHMAN. We have felt so strongly about this, and we devoted the whole first chapter in our report to the issue of the comVerDate 11-MAY-2000 16:28 Mar 25, 2004 Jkt 089216 PO 00000 Frm 00064 Fmt 6633 Sfmt 6601 C:\WORKD\FULL03\090403\89216 SCIENCE1 PsN: SCIENCE1
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promises that were made when they built this thing. And because

we felt that the compromises—the original design compromises left

us with what we have got. I mean, it is—what we have got is what

we have got. And it is a compromised vehicle. Now it is an engineering marvel, but I know, as an aerodynamisist and Dr. Hallock

also is a physicist, we all constantly scratch our heads as to why

you have three 400,000 horsepower engines on a glider. And why

do you put them into orbit? And we know the answer. I mean, we

know the answer, but in retrospect, it is an interesting question.

But in—to make a long story short, we agree with you, and that

is why we devoted a whole chapter to the issue of the design compromises that were originally made when the original—when this

Shuttle was originally built.

Mr. GUTKNECHT. And that is why you essentially recommend

that as soon as possible, this vehicle be replaced.

Chairman BOEHLERT. Thank you. The gentleman’s time is expired.

Now we have another vote, but we will dash over, and I promise

you faithfully we will dash right back. And Mr. Wu will be first up.

We will see who dashes the fastest.

[Recess.]

ONE-YEAR REVIEW

Chairman BOEHLERT. Let me bring up a subject that you might

not want me to bring up. But Admiral Gehman, you indicated that

you are not going to be micromanaging and fine-tuning everything,

but we do need, and we have got our special oversight responsibilities. We have to be vigorous with them, and I can assure you we

will be. And I understand, Dr. Widnall, you said about all of these

external panels, appointing new panels. You are not quite certain

they always do the job that they intend to do, but at the risk of

offending you, this is a compliment to you, we need some help in

evaluating the plan and would the panel be receptive to, sort of,

a one-year review? Now I don’t know how practical that is, because

you are constituted under the authority of NASA. Maybe you could

be reconstituted under the authority of the Congress, but I think

you provide an invaluable service to the Nation. You have expertise. You have brought an awful lot to the table for us to consume

and digest. And I would like some help in the process. And I am

wondering if you would be receptive to, sort of, a one-year look

back, an evaluation, not micromanaging, not fine-tuning, evaluating how NASA has responded to what you have proposed, what

the Administrator says he embraces, which we are applauding. Admiral, would you care to comment on that?

Admiral GEHMAN. Yes, sir. I consulted my colleagues about that,

and I am authorized to say, on their behalf, that if it is requested

by the Congress, we would do that.

Chairman BOEHLERT. Thank you very much. And I appreciate

that. And I can almost assure you that it will be requested by the

Congress.

Now if Mr. Wu isn’t back but—Dr. Widnall, did you wish to offer

some supplementary comments for the record?

Dr. WIDNALL. Let me make two. Let me second what Admiral

Gehman said. And I see it—one of its virtues as providing some

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continuity, and in some sense, that is a force multiplier for the

time that we all put in on this. And so I think it actually gratifies

us, because we will feel that our work is even more effective if we

do provide this kind of continuity, so it is certainly something that

I welcome.

FOLLOWING THROUGH ON THE REPORT’S

RECOMMENDATIONS

Chairman BOEHLERT. I have been in Congress 21 years. I started

out at the lowest level on the first tier as a junior member. And

over these years, I have seen a lot of reports. They are issued. They

are produced by dedicated Americans who bring special expertise

to the table, and more often than not, they gather dust on the

shelf. The Rogers report was—there was immediacy in responding

to some of the recommendations, then the atrophy set in, as you

have referred to. We are going to follow through on this thing. We

have got to be vigorous. And we just can’t look to NASA and say,

‘‘All right. Now the problem has been identified. You know how to

fix it. Fix it.’’ We have got to be part of the solution. And so we

have to look ourselves in the mirror and say, ‘‘Are we as vigorous

as we should be in connection with our oversight responsibilities?’’

And so Mr. Wu is not back yet. We will——

Dr. WIDNALL. Well, the second point I wanted to make, which

was really the point that you called on me for, was just, as we finished the last round of questions, was really just to point out the

time scales involved in these sorts of endeavors in the space field.

I mean, when you talk about let us find a replacement Shuttle, you

know, you are talking ten years. You are talking a very high level

of technology. It also goes back to the issue that I discussed with

Mr. Hall. You know, what is the word ‘‘consider.’’ The word ‘‘consider’’ means to do an in-depth engineering analysis of what are

the possibilities, what are the trade-offs, what are the options. And

that certainly is a process that needs to go forward as we think

about replacing the Shuttle, new concepts for manned space vehicles, how do we service the Space Station. All of these things require an in-depth engineering analysis. And the time scale involved

is certainly measured in years, certainly up to ten years before one

would have a new generation of vehicles.

So that was really the only point I wanted to make.

Chairman BOEHLERT. Thank you very much.

And I see our distinguished colleague, Mr. Wu, is back. Mr. Wu

is recognized for five minutes.

Mr. WU. Thank you very much, Mr. Chairman.

Admiral Gehman, always good to see you and members of your

Board, although one always wishes under other circumstances.

Like others, I want to commend you for finding the physical cause

of this tragedy at the RCC panel 8 and also for identifying some

of the organizational and, one might say, cultural factors in NASA

that have contributed to this set of tragedies.

WORKFORCE

I want to encourage the panel here to look forward a bit and

focus on something related to the cultural and organizational

63

issues that you identified, but not exactly those. And that is the recruitment and retention of the best and brightest, especially young

people, but people of all ages. In my experience, as I have gotten

older, everybody else has gotten younger in various organizations.

My teachers have gotten a lot younger, in my eyes. As I visited

NASA sites, and this is with great respect to NASA personnel, they

seem older than I remember them when I saw them on television

when I was a young person watching the Apollo program and the

Gemini program and so on. And I know older folks, whether it is

at NASA or on the Board or in Congress can make great contributions, but back in the 1960’s, there were, you know—NASA was—

especially as Chairman of various committees. There were few

places to go. And NASA was probably the place to go if you were

really into technology and really hot to go. It was not only technologically and scientifically the most exciting place to go, but it was

also part of this competition with the Soviet Union that made it a

part of our national purpose.

You know, today, the Cold War is over. We were the first the

moon. And in addition to that, we have all of these private companies and other places where folks in technology can be drawn off

to, whether it is by higher salaries or nimbleness of movement—

adeptness of movement in the organization, what are some of the

things that can be done to help NASA recruit and retain people?

And some of the negative factors that are there, some of the positive things that can be built in for the future. And I would just like

to engage the panel to discuss that.

Admiral GEHMAN. Absolutely. And the panel has discussed it.

And I know, as an educator, Dr. Widnall has an opinion about that,

as do my other colleagues. I, very briefly, will say—list three

things. First and foremost is a mission. And it is not—a good mission, a good recognized mission, which excites people, will overcome

low government salaries and a whole bunch of other things. The

second place is you have to have a really great place to work. And

that—I am talking about the work attitude, the climate at work,

and all of that kind of stuff. And I think NASA is a good place to

work. It can be made better because of some of the traits that we

have talked about.

And the last one would be I would like to see NASA reduce the

number of times that they give the top really good jobs to outsiders. NASA, too often in my mind, takes the top, really best jobs,

and gives them and recruits outsiders rather than moving people

up from within. They like to hire Admirals and Generals for Center

Directors and things like that instead of taking the best NASA people and make them Center Directors and things like that, even

though I like Admirals and Generals. I really think that if you are

a career NASA employee and you want to get a—and you want to

rise to the top and then you see the top jobs going to outsiders, you

just have to scratch your head. As part of that, in the Space Flight

Operations Contract, the SFOC, a lot of very high level positions,

which I thought ought to be government positions, are now contractor positions. And once again, these are top level positions,

which have been contracted out to really competent people, but

what it is instills in the workforce is that you work for the government for 15 or 18 years, and then if you really want to go into the

64

top jobs, you have to go over to the contractor side to get to the

top job. I found—I find all three of these things that could make

the place a much better place to work.

And as an educator and a close student of this, I know that Dr.

Widnall may want to comment on it.

Dr. WIDNALL. Yeah. I knew this was coming. No. And as an educator, as an aerospace educator, I know that there is something

about aerospace that evokes the passion of young people. There is

no question about it. There is hardly any other field to which people are drawn because of the real excitement of the field. There is

no question about that.

As an aerospace educator, I feel that it is my responsibility to

take that passion and turn it into an appreciation for responsible

engineering. And I think that that is a challenge. I do think it is

no longer the case that NASA is the only place to go. I mean, this

committee knows more than any other Committee about the broad

range of science and technology that our nation is advancing: work

in the biological sciences, work in the computer sciences and miniaturization, new materials. Science and technology are advancing

across a broad front. Space is exciting, but it is not the only exciting thing that we, as a Nation, are doing.

So what I think is that we have to learn to operate in a much

more complex environment where young people, in fact, do have a

range of options, a range of exciting things to do. And I think we

have to ensure that across a broad range of disciplines. And I think

it will feed directly into our science and technological strength as

a Nation. Young people are excited by the development of new capabilities. And to the extent that NASA moves forward with a vision, a national vision for space and the development of new capabilities, I think young people will naturally be drawn to NASA as

a place for employment.

Mr. WU. I have a burning follow-up question, but I know better,

Mr. Chairman, than to ask if I could ask it under these circumstances. Thank you very much, Mr. Chairman.

Mr. EHLERS. [Presiding.] The gentleman’s time is expired. And

we will see if there can be a second round for burning follow-up

questions.

I apologize if my question is not relevant or has been answered,

because I have been popping in and out of three meetings this

morning, all of which, unfortunately, happen to be urgent. And I

apologize for that.

CHARACTERISTICS OF A FOLLOW-ON VEHICLE

But looking toward the future, it seems to me the very first thing

that we, in the Congress, and frankly, the American people have

to decide is whether we want to continue human exploration of

space. And I suspect the answer is yes just because, as Dr. Widnall

mentioned, there is some magic to aerospace that this is something

that we want to do. It is part of our background or ethic that we

should be out exploring in every dimension. So assuming the answer is yes, it seems to me that our highest priority has to be to

design, develop, and build a new type of space vehicle.

My first question is do you see that, and what do you regard as

the characteristics we need. It seems to me that, given modern

65

technology that has developed since the design of the Space Shuttle, that we can build it safer and better, more efficient, with less

turnaround time and higher efficiency and lower cost. And that,

perhaps, in the long run, we will, in fact, save money to have a new

vehicle if we can design one that satisfies those criteria. So that is

the first question.

And secondly, I would appreciate just a comment from you on the

balance between what one might call scientific research and what

one might call human exploration. We all know that, dollar for dollar, we get much more science done with unmanned experiments,

satellites, rovers, than we do with human exploration of space. I—

just—even though this was not your task, I am asking for your

opinion. What is the balance now and what do you think it should

be between those two? So two questions.

And we will start at——

Admiral GEHMAN. Well, I am going to ask Dr. Hallock to take a

shot at the first one, sir, and then we will rearm——

Mr. EHLERS. Okay.

Admiral GEHMAN [continuing]. To take a shot at the second one.

Mr. EHLERS. Dr. Hallock.

Dr. HALLOCK. When you look back at what we—this thing that

we were studying, the Shuttle, remember it came from the 1960’s

technology. And it also, as we point out particularly in chapter one,

it—when it was being put together, a lot of the requirements were

actually given to people. To follow up on a question that we discussed earlier this morning, you know, why do you put the Shuttle

where you do where it can get hit by all of this material that is

out there? Well, the reason is that one of the key requirements that

was levied upon these people back then was that you wanted to put

together a system that would be reusable. Things like those big engines and everything that you put on the Shuttle. In order for them

to be reusable, you had to put it on something that came back.

Well, the—what I am really saying is when you—if—I fully agree

that one needs to look at trying to come—look to the future and

redesign, come up with a design of a vehicle to get us safely into

space, but not burden it with so many things that actually were

compromises.

And these are the things that I think that have led to all of these

problems. For example, you know, if you look at the Shuttle and

look at some of the earlier designs, you know, you put the Shuttle

on the top. So what is going to fall on it? Nothing. If anything, it

is shedding material as opposed to having things that could come

off and hit it. So that is my point is that you really can do it, but

you need to have a clean slate. And as part of that clean slate, you

can also add in those other issues, which were what can we do to

allow ways for the crew to get out in case there is a real problem?

There are a number of things you can add.

Mr. EHLERS. So in your opinion, do you think that we can design

something that meets the criteria I mentioned: safer, less expensive, more efficient, less turnaround time?

Dr. HALLOCK. But once again, we have got 30 years of technology

now behind us at this point, and I firmly believe that you can do

that. Yes.

66

Mr. EHLERS. And can that be a good replacement for the tile system which is one of the biggest factors in the slow turnaround?

Dr. HALLOCK. Well, they even have an interim thing where they

have come up with a tile that is much stronger and can withstand

a lot of strikes more so than the existing. So there is some intermediate technology types of things that can be done, too. Yes.

MANNED VS. UNMANNED SCIENCE

Mr. EHLERS. Right. And the second question——

Admiral GEHMAN. First of all, I would—I agree with Dr. Hallock,

and I would ask you to factor into your equation of the—not only

the next vehicle, but also the robotics versus the human—the value

of the human space flight program, that as long as the only way

that we have to get outside of the Earth’s gravitational field, or to

get into orbit or to escape the Earth’s gravitational field is to sit

on top of an enormously explosive chemical reaction, which is—

right now, that is the only way we know how to do it. You are flirting with a very dangerous process. And there is no getting around

it, and we should not ever diminish how dangerous that is. And

then when you come home, you have to take all—every single

kilojoule of that same amount of energy and you have got to somehow dissipate it in order to slow yourself down from orbital speed.

And that is also extraordinarily dangerous. You have got to figure

out a way that you can reenter the Earth’s atmosphere and dissipate all of that energy in the form of heat. You have got to

change the speed into heat, and then you have got to dissipate all

of that heat, which puts the humans in a very dangerous situation.

And we should not minimize that danger.

And now the reason I gave that little lecture, if you will forgive

me, is because when you start—that is job one is to get the humans

safely up there and back in.

Mr. EHLERS. Well, I will just interject. That assumes a return vehicle. You are going to have a capsule come back and dispose of the

engines.

Admiral GEHMAN. But even if you bring the—even if you were

using a capsule, you still have a kinetic energy problem. You have

got to get up there, and you have got to get back down.

Mr. EHLERS. No, but you don’t have as much to dissipate.

Admiral GEHMAN. That is correct.

Mr. EHLERS. Considerably less.

Admiral GEHMAN. Considerably less. That is right. But if you

consider job one to be safely—get into orbit and safely get back,

then everything else that you add on to—every other requirement,

you are going to—and if you say you want it to be efficient and

cost-effective and reusable, et cetera, et cetera, et cetera, you are

whittling into that safety requirement. And so this Board, with this

experience that we have gained from this investigation, would say

let us not, in any way, diminish the danger and the physical challenges here and start adding additional requirements into this. Let

us just get them safely into orbit and safely home.

Now the robotics or the human thing, I would offer that we

didn’t really do much of a study in this, but we did educate ourselves into this matter as well as the vision thing so that we could

put our report into context. And my personal view is that every

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briefing I have listened to, every book I read on the subject indicates that no matter what your vision, long-range vision is for what

we are going to do with interplanetary travel or stations on the

moon or whatever it is, all visions, they all start in low-Earth orbit.

None of them start on the surface of the Earth. And therefore, we

have to perfect getting into and out of low-Earth orbit, no matter

what the plan for the future is. That is our view. And perfecting

getting into and out of low-Earth orbit is a worthy enough goal by

itself.

Mr. EHLERS. Okay. I have to excuse myself to go vote, and the

Chairman has returned. Thank you very much.

Chairman BOEHLERT. The Chair recognizes, Mr. Bell.

Mr. BELL. Thank you, Mr. Chairman.

DEFINING CULTURAL AND ORGANIZATIONAL PROBLEMS

Admiral Gehman, good to see you again. I want to commend you

for the report and also the way you and the committee conducted

yourselves throughout the investigation. It was impressive, and I

certainly respect the openness that you demonstrated both with

Members of this committee but also with the public throughout the

process.

I want to follow-up on something that my colleague, Mr. Wu, was

talking about in terms of the cultural and organizational problems

that you point out in the report. The day the report came out, I

had the opportunity to speak to a group of NASA employees that

evening. And while there seemed to be a general acceptance, certainly an expectation that the report would be critical, the one area

that they seemed to feel that there will be some difficulty with has

to do with changing the culture of NASA. And in looking at the report, in chapter seven, I wanted to go over some of the statements

therein and see if maybe you can expand on them so there is—

there will be a clear understanding of what we are talking about

when you say ‘‘changing the culture.’’

Starting with avoiding oversimplification, and I will just read

this particular part, ‘‘The Columbia accident is an unfortunate illustration of how NASA’s strong cultural bias and its optimistic organizational thinking undermined effective decision-making. Over

the course of 22 years, foam strikes were normalized to the point

where they were simply a maintenance issue, a concern that did

not threaten a mission’s success.’’ And when you read something

like that, I can—you point to a cultural bias, but was it so much

a cultural problem or was it a—caused by not having a system in

place that would help identify that kind of problem and address it?

Major General HESS. I think the answer to your question is basically yes in both counts. But what we are getting at is in the definition of organizational and cultural that we adapted is how does—

even absent rules react to—in the instance of oversimplification,

what we saw was an almost immediate assumption that there is

not a problem. And this is a learned behavior. It took 22 years for

them to learn that, perhaps there is not a problem with foam—but

when you put down one of the things that you need to avoid, if you

are a highly reliable organization that deals in high-risk technology

is that you don’t just assume that there are no problems. You start

by assuming that there is a worse case and by——

68

Mr. BELL. Admiral, did you want to comment as well?

Admiral GEHMAN. No, I agree. And we thought long and hard

about that particular section. And the relationship to culture is

that, as we carefully defined in our little blue sidebar in the front

of that chapter seven, that culture is, as we used it in here, in this

report, culture is how the organization acts kind of intrinsically. It

is how they act outside of the rules. It is how they act when their

boss is not in the room. And it is how they think.

And in this particular case, they have an oversimplified view of

a complex issue, and they stick to that oversimplified view. They

get rigid in it, and they do not realize that these are complex

things in which one flaw can affect another system.

Mr. BELL. And please, let me be clear. I am not, in any way, critical of what is stated. I just think there needs to be a clear direction going forward so that people understand exactly what you

mean when we talk about changing the culture, because I would

agree. There are obvious problems that need to be addressed, but

they can’t be addressed unless there is a clear understanding.

In the paragraph above, importance of communication. Every

manager knew the party line. We will wait for the analysis. No

safety of flight issue expected. In the course of the investigation

and the people that you talked to, what did—what was your understanding of how such a ‘‘party line’’ is developed?

Admiral GEHMAN. The—there are a number of factors, but the

one that I would point to is what I would call—I like to characterize it as an informal chain of command. That is, once the Space

Shuttle program opined on something, then other people, other divisions, other agencies, even though they are technically independent, were hesitant to move against that opinion. The Shuttle

program——

Mr. BELL. For fear of reprisal or——

Admiral GEHMAN. For fear of reprisal, for fear of being ridiculed,

but mostly, the problem was that even though on paper they had

a set of checks and balances, independent engineers and independent safety, the fact of the matter is the Shuttle program over

the years had become so powerful that all funding flowed from the

Shuttle program. All promotions go from the Shuttle program.

They had become so powerful that independent voices and minority

opinions were not welcome. And it takes—in a complex matrix organization, like the Shuttle program is, it takes a very elegant communication scheme carefully managed and carefully nurtured to

make a matrix organization work. And they had allowed some of

those characteristics to atrophy over time.

And I don’t know if General Hess, who is the expert on this,

wants to comment on it.

Mr. BELL. Well, so the goal would be to develop a system where

communication is encouraged rather than discouraged. And from

what you are saying, it sounds like perhaps it wasn’t discouraged,

but people feared.

Admiral GEHMAN. They did. They did. And we think that our fix

about having this independent technical review authority, which

owns all of the specifications and requirements, which would be full

of engineers and safety people who have no relationship to cost and

schedule of the program, would be free to discuss all of these

69

things, because they wouldn’t be intimidated by the guy who is

worried about cost and schedule.

Mr. BELL. Lastly——

Admiral GEHMAN. As a matter of fact, their reward system would

be based upon bringing problems up. That is how they get rewarded.

Mr. BELL. Lastly, I want to go to the section commitment to a

safety culture and the last line in that. ‘‘Organizations that successfully deal with high-risk technologies create and sustain a discipline safety system capable of identifying, analyzing, and controlling hazards throughout a technology’s life cycle.’’ Obviously that

system was not in place. How do you accomplish that, because that

has to be the number one goal that whatever is developed will last

throughout a technology’s life cycle?

Major General HESS. I think that the answer to that question

also rests in—that is their job. That is going to be their role in life

is to bring that life cycle and systems analysis look into the technology that is involved. The second part of it, obviously, in this

chapter we talk a great deal about the information systems that

are there that are supposed to be tracking anomalies and giving

trend information and the fact that they really don’t. So you know,

there is a fix that could happen just in information systems and

how you manage the information but having somebody whose job

it is to run risks and do trends and to control the level one requirements and the waivers is going to give you that life cycle that we

think is so very important.

Mr. BELL. Thank you, Mr. Chairman.

Chairman BOEHLERT. Proceeding along those lines, because of

the many important recommendations that you have made, two of

the most important are one, establish an Independent Technical

Engineering Authority and have that funded directly from NASA

headquarters so it has no connection to or responsibility for schedule or program costs. And the second one is the Office of Safety and

Mission Assurance should be independently resourced. I think

those are highlighted recommendations. And we are going to follow

through, and so is NASA.

Mr. Feeney?

Mr. FEENEY. All right. Thank you, Mr. Chairman. And thank you

to Admiral Gehman and your entire Commission. I haven’t thoroughly read from cover to cover the report yet, but my office staff

has several times, and we are going to continue to pay attention

to it.

I am impressed by the entire approach you have taken. I want

to thank you, particularly for being accessible. I got a briefing just

before our break personally from Admiral Gehman. I thank you for

that, for the time we spent together at the hangar where we were

putting together the Shuttle. And several other members of the

Board were there. It was certainly a quite moving experience. And

I will tell you that, you know, part of the appreciation for the way

you have memorialized the astronauts that have passed away in

human flight is in the emblem that you put on the back here. We

are not just talking about the most recent disaster. You include discussions about Apollo 1, the Challenger, and the Columbia as well.

And of course, the Latin phrase there—my Latin is a little rusty.

70

I got a D in Latin and had to quit the basketball team because of

it. And actually, the Latin teacher’s wife was the coach of the basketball team. He understood why I had to quit, but to the stars,

despite adversity, always explore. I think that that is the mission

that I believe in and that basically was the fundamental mission

of your report.

THE CULTURE OF SAFETY

I want to pick up where Congressman Bell left off talking about

the culture of safety, because it is sort of in amorphous concept to

some of us. It is not a technical issue. It is not a precise issue,

and—but it is a cultural issue that is very important. And as a

lawyer by background, I am under—I understand burdens of proof.

And I would like you, at one point, to describe for me the difference

between a culture in safety where you presume that everything is

okay unless you know otherwise as opposed to a culture that basically tells you that nothing is right unless you can prove that it is

functioning. And I want to ask you as you go through that sort of

switch and, say, a burden of proof approach, which is something

that I can understand, to talk a little bit about NASA’s history.

NASA originally approached the Board in its initial briefings and

espoused their confidence that they had developed a culture of safety and were surrounded by the culture, and yet, upon investigation,

this Board found out that that simply wasn’t accurate.

In the aftermath of Challenger, there were some interesting differences between the approach that NASA took and the lessons it

learned and the way it trained its inspectors and the way it dealt

with response to the disaster and say the Navy took. The Navy, for

example, developed the SUBSAFE program and the naval reactor

program. They trained some 5,000 Navy nuclear propulsion program personnel on the lesson specifically learned from Challenger.

And yet it seems like all too quickly, NASA, for a variety of reasons, fell right back into some of the same habits. And so I guess

I would like you to tell me number one, whether NASA has—understands in how their going to implement this shift in burden of

proof, number two, how they reacted to the lessons of the Challenger disaster, and number three, in a more generic sense, this

isn’t the only near disaster we have had.

We had the Apollo 12 issue. We had the fuel cell explosion on

Apollo 13. We have had launch pad aborts on Shuttles involving

non-personnel craft. We have got the commercial problems we have

from time to time, the military launches. How are we, on a routine

basis, going to learn from all of the, not only disasters with people

involved, but also the new disasters or situations where people

were not involved? And with that sort of open-ended question, Admiral Gehman, if you will refer the answer to the appropriate people or pick it up.

Admiral GEHMAN. Mr. Feeney, first of all, I will say something

about the culture of safety and something about learning and then

turn it over to my colleagues here who studied this more closely

than I did. I was quite confident and quite firm in my deliberations

with my colleagues about hammering this subject fairly strongly,

because of the way we defined culture. We were very careful in our

report to make sure that, for our readers, that we didn’t confuse

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management and we didn’t confuse leadership with culture. Culture is what you do rather than what you say.

For example, if you say that safety is the most important thing

we do and nothing we do is going to compromise safety, but I want

you to come up here to Washington, DC every 30 days and give me

a brief on how you are doing on making the node two complete

schedule, that is doing one thing and saying another. And that, of

course, trickles down to the workforce. I mean, that word gets out

as to what is important.

We studied at great——

Mr. FEENEY. By the way, if I can, Admiral, just to interrupt

briefly, but you have a wonderful definition of culture. It is not like

the—I mean, people that read the report on page 101 it is very specific and then later throughout the report but especially 177 you

talk about the organizational and cultural problems that exist in

NASA today, so you do a great job in the report.

Admiral GEHMAN. Yeah, we knew that there would be some misconstruing and blurring of what the terms meant, so we were careful to define them. We also found, if we go back to that list that

General Hess was referring to earlier, we tried to put a recipe or—

in there for what we considered to be the characteristics of a high

reliability organization, which we would certainly hope that NASA

would be a high reliability organization. And one of the characteristics is that the organization is a learning organization. And by

that, they not only learn from big disasters, but they learn from

the little things.

And just as you point out, in the organizations which we consider

to be high reliability organizations, they teach their people from big

disasters and little disasters. And they like to keep bringing up

Three Mile Island and they keep bringing up the Challenger and

they keep bringing up the loss of the submarine Thresher, and they

keep bringing these things up to see what we can learn from them.

NASA tends not to do that. And they tend not to do that, at least

our interviews, and our experience was they tend not to do that,

because for some reason they have gotten the idea that by bringing

up all of these failures or near-misses that somehow they are tarnishing the image of the employees or they are diminishing the impression that they are all perfect. And that, of course, is wrongheaded. And therefore, we determined, and we wrote in our report,

that NASA is essentially not a learning organization and they do

not learn from these mistakes. And of course, that is a very serious

problem.

General Hess, do you want to make any further comment on

that?

Major General HESS. That is right. And the part that I would

add in the overall construct of how they approach this cultural dynamic that we are trying to get it is just exactly the issue of, absent rules, they are going to react and respond in a way that is

dedicated to performing the mission reliably. Okay. And in almost

any check and balance that we talk about inside the program,

these attributes can be enhanced just by some of the organizational

changes that are there. But organization alone is not going to fix

the problem. You are going to have to lead your way through it.

You are going to have to get managers to understand and buy into

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this at all levels so that it becomes the way that the organization

responds in times of crisis and in times of planning as well.

Chairman BOEHLERT. The gentleman’s time is expired.

Ms. Jackson Lee?

Ms. JACKSON LEE. Thank you very much, Mr. Chairman, and

allow me to thank the Chairman and the Ranking Member of the

Full Committee and as well the Chairman and Ranking Member

of the Subcommittee for what will be, in think, a very effective line

of hearings that we will have and, as well, an ability to be able to

follow this line of reasoning that has been so ably played out for

us by this very strong report.

Might I say to the Board, thank you, also, for your good work.

And as I begin my remarks, allow me to put this in the focus that

I can recollect was the experience on that fateful day, February 1,

and that is that this whole debate is on the question of lives as

well as the mission and vision of this Nation on behalf of the American people. So I would like to note that what we do today is in

tribute to and reflection of the sacrifice that Rick D. Husband

made, William C. McCool, Michael P. Anderson, David N. Brown,

Kalpana Chawla, Laurel Blair Salton Clark, and Ilan Ramon.

Clearly, I think, this is a major tribute, if you will, or need for a

major tribute to their lives that we not allow what has occurred to

be repetitious.

I do want to also say to the Board that this is in no way a coverup. And we thank you for your forthrightness and your instructiveness. I will say again, referring back to February 1, that since it

was post-9/11, you can imagine the various thoughts that occurred.

So it was even larger than maybe incidents of the past that we do

not diminish any of the incidents of the past.

You have spoken about the question of a culture of safety, and

I want to refer to some of the language that you used in the report.

The Board found that there is a broken safety culture. You also

mentioned that schedule pressure related to the construction of the

International Space Station, budget constraints, and workforce reductions also were factors in the question of what caused the Columbia accident. One of the initiatives that I am going to propose

would be enhanced whistle blower legislation, specifically for NASA

personnel, because I think that the comment that the Ranking

Member made at the very beginning is so potent, and that is what

happened after Challenger and the emotions and the interests and

the commitment seemed to peter out.

I am holding in my hands a series of hearings over 1997, ’96, ’99

where we discussed the question of safety over and over again. And

I would refer you to some words that I offered in 1996: ‘‘So that

there is no mistake, I do have questions and concerns regarding

some of the issues involving NASA, the personnel reductions which

continue to take place, and the safety of the Space Shuttle.’’ That

was in 1996, March 28. On September 23, 1999: ‘‘We want NASA

to provide safe vehicles for our brave astronauts, yet it would be

an aim of us to demand a strong Space Shuttle safety policy when

we are cutting the very resources that would fund this policy.’’

Now you have already shied away somewhat from numbers, but

allow me to ask these questions on the safety element, and I applaud this freestanding organizational structure that deals with

73

safety and oversight from NASA headquarters. I want you to comment on the responsibility of NASA headquarters aside from directly the Administrator as it relates to your report. I would like

you also to explore the idea of holding managers accountable for errors, because when we talk about the safety culture, how do we

break that line of reasoning? And you might add your thoughts

about whistle blower protection overall. You haven’t seen the legislation, so I would imagine you couldn’t comment on that.

And finally, Admiral, would you put yourself—and others that

might want to comment, would you put yourself, Admiral, in the

position of being an Admiral and finding or having an incident

such as this occurring under the military structure? What would be

your reaction or your actions as it relates to personnel who were

directly associated with the responsibility of ignoring information

that came directly to them that questioned whether or not there

was a sense of safety? My last point is for Dr. Widnall, because I

was fascinated by your comments with respect to education. How

do we retain the bright and the best as we have moved toward

outsourcing over the last decade? I remember growing up looking

to those bright folks at NASA. And you admired them and wanted

to be like them. How do you restrain—have that—solve that problem?

And I thank you very much for your presence here today.

Mr. SMITH OF MICHIGAN. [Presiding.] The gentlelady from Texas’

time has expired in asking the question, but we will now turn it

over to Admiral Gehman.

ACCOUNTABILITY

Admiral GEHMAN. Thank you very much, Ms. Jackson Lee, and

thank you for your support during this—during the time of this investigation. We enjoyed talking to you several times about it.

The Board, while, indeed, it decided not to make judgments

about the responsibility of individuals, the Board, in no way suggests that our position—suggests that individuals should not be

held accountable for their actions. They should be held accountable,

and they should be held accountable by their appropriate supervisory chain of command. On page 203 of our report, we have a little editorial in there about the role of leaders and the role of managers and their responsibility for setting the conditions for either

success or failure. And they are, indeed—we do believe that the top

level managers are responsible for setting the conditions up, and

if they set conditions in which free and open communications were

stifled or engineers were intimidated or safety was shortchanged,

and they are responsible for that, and they have to hold responsibility for that. I believe that we document in our report, and we

are pretty careful to do this. I mean, we wanted to be very careful

about this. These bad traits and these ill characteristics that we

are all numbering here came about gradually and slowly over a

long period of time due to budget constraints, manpower constraints, and lots of other reasons.

But these things didn’t happen all in one year or one month or—

they happened over a long period of time, and they happened in response to forces, both internal and external. I think that we have

kind of—it is all there in the report, I think. And I think I kind

74

of agree with your comment that there probably is some account

taking that probably needs to be done by the proper authorities.

We just didn’t feel we were——

Mr. SMITH OF MICHIGAN. Admiral Gehman, I—excuse me for interrupting. I would ask everybody to be brief in reacting to Congresswoman Jackson Lee, and we will try to get one more fiveminute series in before we——

Admiral GEHMAN. Maybe I will let Dr. Widnall respond to the

last point.

NASA RECRUITING AND RETENTION

Dr. WIDNALL. I would like to respond to that question a little

more broadly with respect to this question of how do we retain the

best and the brightest, because this is the very Committee that is

charged with that responsibility. I believe the Nation has been

richly rewarded by the investments that we have made in science

and technology education and research across a broad range of scientific and engineering disciplines. So it isn’t just the question of

how we retain these individuals in NASA. I think the question goes

much deeper. How do we strengthen our science and education system? How do we encourage young people to pursue professional careers in science and engineering? And how do we utilize their talents once they graduate? I think in order to do that, it really requires a vigorous program of research and technical development

across a broad front. And I would certainly include NASA within

that.

I do think, as an aerospace educator, that NASA has a built-in

advantage with, what I view, as the innate passion that goes along

with the exploration of space. But we really need to pursue these

issues across a much wider front.

Mr. SMITH OF MICHIGAN. The gentlelady’s time has expired.

PRIORITIZING SPACE RESEARCH WITHIN THE FEDERAL

BUDGET

I will proceed with my five minutes. And let me start out by suggesting that since the successful Soviet launch of Sputnik in 1957,

certainly our country’s space program has been an intricate part of

our excitement as Americans and certainly a stimulus to more students getting into science and math. I think we have lost some of

that.

Congress is charged with setting priorities. As some of you may

know, I Chair the Research Subcommittee, and we have had testimony in terms suggesting that much of the scientific research could

be better accommodated as effectively on unmanned space flight,

and some of the research could be accomplished in ground labs.

And so not only manned versus unmanned flight, but also should

some of these research dollars go into NIH to cure cancer rather

than man’s exploration of outer space?

It would seem to me that we need to analyze the costs and the

benefits of this program. And really, as I understand the Board,

and congratulations for the time that you have sacrificed and the

efforts you made to do this, such a good and thorough job, but your

charge really was what went wrong and how do we keep it from

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going wrong again. But in terms of the costs and benefits, how do

these compare with that of unmanned space flight or other science

research that we might conduct, and did the Board look at these

issues?

Admiral GEHMAN. We did not, Mr. Smith. What we attempted to

do to help you with that question was to properly characterize the

risks and properly characterize the costs of the Shuttle program.

And we did not look into those other issues. And I am going to

have to defer on that. I don’t have any knowledge of the value—

the cost value of——

THE VALUE OF RESEARCH IN SPACE

Mr. SMITH OF MICHIGAN. Well, as I talk to other scientific

groups, including JPL, we don’t have a good quantitative evaluation of the science research. Some have suggested, well, once we

get the Space Station up and running and get it fully manned,

maybe we can do some really constructive research. But it would

be my opinion, and for any Board member that—for any of the witnesses that would like to comment, that manned space flight can

contribute a great deal to the additional information of how humans acclimate themselves in outer space. And maybe part of that

is do we intend to put people of this country into outer space for

longer periods of time. We have been in this endeavor for quite a

while. And with the new technology of, not only robotics, but of

nanotechnology and miniaturization, a tremendous potential for

unmanned space flight, it seems to me. Does—would there be any

comment from the witnesses?

Admiral GEHMAN. We did not evaluate that, but if anybody

wants to comment, help themselves. We did not look into that.

Mr. SMITH OF MICHIGAN. What—how might we best—you know,

and I think it is exciting to have high school students put in research projects, but in terms of real valuable scientific research, it

is probably not substantial in contributing to our research efforts.

We are now reducing funding for NIH for—to develop better research on health. We are now reducing research dollars for the National Science Foundation, which I oversee in our Research Subcommittee, in terms of basic or fundamental research. So a tremendous challenge, I think, for this committee and this Congress as we

evaluate how quickly do we want to push the program and maybe

a comment that you might react to is NASA projected the March

launch before you came out with your final report. It seems like

this is pushing more rapidly than NASA’s ability to totally react to

some of the recommendations in your report. Admiral Gehman?

Admiral GEHMAN. I—yes, sir. I would—I believe Mr. O’Keefe and

I are going to have an opportunity to appear beside each other next

week before your Committee. But yesterday, before the Senate, he

reiterated to that question—reiterated an answer to that question

several times in which he said that NASA’s return-to-flight plans

are events-driven, not calendar-driven. And that date out there is

just a hypothetical mark on the wall. It is not the—it is not a firm

date. I will let him answer that question.

Mr. SMITH OF MICHIGAN. And I just say to Dr. Hallock and General Hess and Dr. Widnall that part of my bias, which I have expressed in my statement, which, without objection, will be entered

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into the record, is my son and daughter were—both worked at JPL,

and so they led me down the road of the kind of information of how

valuable unmanned space flight was and—in the reductions of

budget that limits a tremendous potential in that arena.

Any other comments from the witnesses? If not, the Committee

stands in recess. Oh, here he is. The Committee does not stand in

recess. I thought you were one of the upper ranking staff people

that said I have only got three minutes left.

Chairman BOEHLERT. And he promptly ignored it. I never ignore

it.

We are going to have a series of votes all day, unfortunately. But

let me, while we are waiting for—Mr. Nethercutt, you are here.

Thank you.

THE PROCESS OF DEFINING A VISION

Mr. NETHERCUTT. Thank you, Mr. Chairman. Ladies and gentlemen, thank you for being here.

Admiral, I appreciate all the work you and the Board have done.

I think you have done a great job of being frank, both personally

and privately, in giving a clear indication of your independence. I

noted that the Board noted: ‘‘It is in the Nation’s interest to replace

Shuttle as soon as possible as the primary means to transporting

humans to and from Earth orbit.’’ And it strikes me, as I listen to

the questioners and the Chairman and others have an exchange

with you witnesses, that it seems to me the question of vision has

come up a number of times. What do we really want the space program to do? Where do we want to go? How do we invigorate our

young scientists to be excited about working at NASA, and so

forth?

And I have thoughts about a vision, and that is not necessarily—

certainly not the point of this hearing. But I know that you all

have become very familiar with the culture at NASA, the process

that NASA goes through, the experts that are employed there. And

I am wondering whether you feel that NASA can organizationally

be capable of defining its vision, a vision, an adequate, thoughtful

vision, or the future of the agency. Is the organization, perhaps, too

risk-averse at this point, given the seriousness of your report, to

define some sort of a grand national vision for human space flight?

It is a little theoretical, but I think it is a valuable theoretical question to have answered, because it sort of defines where we are

headed with respect to the agency and human space flight. I mean,

my sense is maybe we ought to be looking at the moon and have,

sort of, a lunar expedition policy that guides us. There is great

science, I think, that can come from there. But there is Mars and

there are other places. So I am wondering if you could answer

those questions for the record and for me.

Admiral GEHMAN. I think we ought to ask all four Board members, but I will answer very briefly and say I have confidence in

NASA. I think it is a great organization. I think they are capable

of proposing and staffing a national vision. But of course, NASA’s

vision doesn’t count. It is the—we were very careful to say it has

to be an agreed vision. So it has to be your vision and the White

House’s vision. I don’t believe NASA is too risk-adverse or that

they are in any kind of a defensive crouch as a result of this acciVerDate 11-MAY-2000 16:28 Mar 25, 2004 Jkt 089216 PO 00000 Frm 00080 Fmt 6633 Sfmt 6601 C:\WORKD\FULL03\090403\89216 SCIENCE1 PsN: SCIENCE1
77

dent. I think they are fully capable of leading us and proposing us,

but they can only propose. The—my view is that NASA is fully capable of that challenge.

I will ask my colleagues to help.

Dr. HALLOCK. I agree, too. The issue, though, is that one can

have quite a few visions. There are so many, many things, as some

of you have already talked about today, whether—from the robotics

issues to the manned space flight issues as well as is it—should we

be going to the moon at this point or should we be thinking about

putting Space Stations further out? Someone mentioned libation

points, too, as being places. So the hard part is—I think we can all

come up with visions of them.

The problem is how do we constrain them, because there are only

so many things we can do. I think it is important for the country

to have one, because it really does have a lot of secondary issues,

secondary things. And one of the main ones that pops to mind is

one that we have been talking about here, and that is the education thing. We need to stimulate people to start thinking about

these very technical issues and want to go into those fields and

work on them. But picking what the vision should be? Oh, boy. I

would like to be a part of picking it, but I—it would be very hard

to say this is the one and only thing we should be doing.

Mr. NETHERCUTT. General Hess, do you care to—Dr. Widnall?

Dr. WIDNALL. Sure. Yeah. You know, when you raised the issue

of vision and NASA constructing a vision, I wrote down the word

‘‘partner.’’ And then I wrote down the word ‘‘tough.’’ I think NASA

needs a tough partner. If I had to make a comment about NASA,

it is not that they are risk-averse. It is that they have often overreached technologically. They have been overoptimistic in looking

for the leapfrog in accomplishing certain goals. Another—and my

Board members basically said it before I said it. An unconstrained

vision is not a vision. NASA needs a tough partner to rub right up

against and get a common agreement about what the vision is that

is—matches the resources that the Nation is willing to provide to

accomplish this vision. So tough partner. And that—it would be

you guys.

THE DIFFERENCE BETWEEN ‘‘OBSERVATIONS’’ AND

‘‘RECOMMENDATIONS’’ IN THE REPORT

Mr. NETHERCUTT. Yeah, I understand. And I think we are willing

to be partners. I just—culturally, I am willing to be sure—I think

we look to the experts there to make these judgments. Let me ask

a question for—on behalf of the Committee that—for the record,

that I hope will be helpful to all of us, if I may. The report provides

29 recommendations and 27 observations. ‘‘Please explain the substantive differences between an observation and a recommendation.’’ And I am wondering whether NASA can ignore the observations and still be in compliance with your report.

Admiral GEHMAN. Well, we started off with this—the first draft

of this report back in June was 1,000 pages. And after some hard

negotiating, I got it down to 400 pages. What you see now are 248

pages after some more arm-twisting. And we had to do some

prioritizing. The observations are—they are all true. They are all

serious. They all are potential danger points for maybe some future

78

accident, but they didn’t affect—they aren’t talking about this accident, and that is kind of how we made the differentiation. We

think that they are offered as serious matters. They are offered as

things that we observed and as we saw as we traveled around and

talked to people. They are potential problems for NASA. One of

them could be the cause of a future accident. So they do need to

be addressed by NASA, but they aren’t related to this accident.

So——

Mr. NETHERCUTT. So you want the recommendations followed up

on and responded to, but you want the observations to be noticed

and acted upon, I assume, as well?

Admiral GEHMAN. That is correct. That is correct. As a matter

of fact, we say in there that NASA must take action on these

things.

Mr. NETHERCUTT. Thank you, Mr. Chairman, for the extra time.

Chairman BOEHLERT. Thank you very much.

And vision has been thrown around very loosely today. We all

want vision, you know. Proverbs. But the vision, you have got—

tough partnership is very important, Dr. Widnall. And part of that

vision has to include what you hope to accomplish, at what cost,

and at what risk. So we can talk about vision all day, you know.

I still remember Martin Luther King’s speech of his vision, a nation where the people are judged not by the color of their skin but

the content of their character. And we are still not there yet. So

the vision we need is a vision where the Executive Branch and the

Legislative Branch are the senior partners. NASA is part of the Executive Branch, so—well, enough sermonizing.

NASA ENGINEERING AND SAFETY CENTER

Let me get to a couple of very pertinent questions on my mind.

You have made some specific recommendations, the Board has.

And NASA has established a new safety center at Langley. Incidentally, it was established before the report was out. I know you

have had interaction with NASA, but can you tell us, Admiral and

members of the Board, whether you believe that the new center reflects any of the changes you have recommended in the report?

Admiral.

Admiral GEHMAN. The way I would answer that is that I would

suggest that if you—if one were to write down the specifics of our

recommendation for this independent technical review authority

and make out a checklist or a template that the emerging and still

changing engineering and safety center at Langley does not match

up, not exactly. That doesn’t mean that it is not good and they

shouldn’t do it, but it does not match up exactly.

Am I—Board members, am I—have we got it right? Yeah. I don’t

want to speak for them, but I think we are in agreement on that.

Chairman BOEHLERT. Have you had any conversations with Administrator O’Keefe? Is this—should this be considered, as I feel it

should be, a work in progress?

Admiral GEHMAN. Yes. That is my understanding that they

haven’t even agreed on their charter. They haven’t agreed on——

Chairman BOEHLERT. Okay. Fine. So this is not the be-all-andend-all. This is——

Admiral GEHMAN. That is correct.

79

Chairman BOEHLERT. Okay. All right. Next question I want to

ask is——

Admiral GEHMAN. Mr. Chairman. Mr. Chairman, can Dr.

Widnall stick her——

Chairman BOEHLERT. Oh, by all means. I would never silence Dr.

Widnall.

Dr. WIDNALL. No. Just let me add that I consider safety to be a

professional or technical discipline. And it would not be a bad idea

to have an organization—the one that is described at Langley, as—

I would view as almost like a research organization to look at the

fundamentals of safety as a technical discipline. That is independent from the line organization that we have suggested that

would have a function in the actual conduct of operations. So both

organizations could exist and be mutually supportive.

Chairman BOEHLERT. Thank you. And I just want to make sure

we have the record clear so we don’t have presentation from NASA

that says, ‘‘Well, look at what we are doing at Langley. Boy, we

have addressed the problem.’’ That is only a very small part of the

problem.

SFOC BOARD OF INVESTIGATION

This is a quickie, Admiral Gehman. I want to get it on the

record. In the section of Space Flight Operations Contract between

NASA and USA, there is a section of the contract dealing with the

fee reduction for catastrophic loss. That provision requires the

NASA Contracting Officer, in conjunction with the Board of Investigation, to make a determination as to the cause of the loss. There

has been some confusion about whether the Columbia Accident Investigation Board is the Board of Investigation referenced in the

SFOC. Is the Columbia Accident Investigation Board the Board of

Investigation referenced?

Admiral GEHMAN. No, sir.

Chairman BOEHLERT. All right. Thank you.

COST ESTIMATES AND MISSION PARAMETERS OF A FOLLOWON VEHICLE

Next—that was an easy one. In chapter nine, the Board talks

about designing the Shuttle replacement without regard to cost.

But isn’t that just a recipe for getting into the same problem we

did with the Shuttle? Does it make sense to design something without cost parameters and then reassess it once we know real budget

projections? Doesn’t that just encourage the disconnect between

ambition and resources that you cite in the report?

Admiral GEHMAN. I am sorry we didn’t make ourselves more

clear. What we are suggesting, we are actually—we were—what we

were doing there is criticizing the current process of our Democratic—wonderful Democratic institutions of trying to design the

next vehicle with a start and stop kind of a process before there

was complete agreement on what the vehicle is supposed to do.

And what we suggested is that the right process would be we have

a good healthy debate on what we want to do in space, we agree

on what it is we want this vehicle to do, then you go into the design process and the cost process. And what we suggest is that it

80

is a—it would be a wonderful leap forward if you agreed that the

only—that we—that what it is we want to do is to get into and out

of orbit safely. And that would—even that would be a giant leap

forward.

And then once you decide what it is you want to do, then the design and the cost of the vehicle follows that. We—I am sorry we

weren’t clear on that, but we recommend that you and the Senate

and the White House, first of all, agree on what it is that you want

this vehicle to do then go into the design process. We are hearing

things about people have even got pictures of this vehicle and we

haven’t even decided what it is going to do yet. And then the process is reversed.

Chairman BOEHLERT. Thank you very much for that clarification.

Now here is the deal. We have promised our very distinguished

panelists that we would have them out by 2. Mr. Rohrabacher, you

are next, followed by Ms. Jackson Lee. Mr. Nethercutt, do you have

any more?

Mr. NETHERCUTT. No.

Chairman BOEHLERT. All right. Mr. Rohrabacher is recognized.

ISS SUPPLY

Mr. ROHRABACHER. As we move forward with certain decisions

that need to be made and our discussions with NASA, it will be

helpful to us to have certain issues totally clarified. And I think

this is pretty clear, but I want to ask you very specifically. Is it the

recommendation of the Commission that if the Space Station can

be supplied by an alternate system rather than the Space Shuttle,

that it should be supplied by the alternate system?

Admiral GEHMAN. It is our recommendation that we separate the

people from the cargo as soon as possible.

SHUTTLE SUPPORT OF ISS CONSTRUCTION

Mr. ROHRABACHER. As soon as possible? Mr. Chairman, I would

like you to note that answer. That is——

Chairman BOEHLERT. Duly noted.

Mr. ROHRABACHER [continuing]. Something that we have been receiving some—a lot of resistance from NASA, for safety reasons

and every other reason, it sounds like. It is unclear to us. In terms

of using the Shuttle, when necessary, would the Commission agree

that the Shuttle would be necessary to finish the construction of

Space Station?

Admiral GEHMAN. Oh, we believe that the Shuttle can be safe—

could be operated in a more safe manner than it is now, easily, for

another decade.

Mr. ROHRABACHER. Thus, Mr. Chairman, in making a decision as

to whether to move forward and finish the Space Station and the

Shuttle, the Commission is deciding that it would be safe—well, at

least we can change and develop the situation so that the Shuttle

is safe in completing the mission of building the Space Station.

Chairman BOEHLERT. That opinion is duly noted.

81

FUNDING AS A FACTOR IN THE ACCIDENT

Mr. ROHRABACHER. Right. Finally, is it the finding of the Commission that funding is not—was not a major cause of the Columbia tragedy? That—is it your finding that even if we would have

funded the Shuttle at a higher level, that the complacency that you

have spoken about in your testimony may well have continued and

that that was an issue at least as big, if not bigger, than the—any

funding issue at hand?

Admiral GEHMAN. The Board did not evaluate the relative contribution of the factors that we listed, but constrained and

squeezed budgets was a factor as a—it was a contributing factor to

this Shuttle——

Mr. ROHRABACHER. Okay. So funding was a contributing factor

as was, of course, what you have been saying——

Admiral GEHMAN. A lot of other things.

Mr. ROHRABACHER [continuing]. Along with complacency

within——

Admiral GEHMAN. That is correct.

Chairman BOEHLERT. If the gentleman will yield?

Mr. ROHRABACHER. Certainly.

Chairman BOEHLERT. There is always—we are all partners to

this venture. We all have to share our part of the responsibility,

but let me tell you, if we had written a blank check to NASA, that

wouldn’t have changed the decision or the manner in which the request for imagery was treated. If we had written a blank check to

NASA, that wouldn’t have changed the manner in which they responded to the repeated instances of foam debris falling. So while

we are not going to just wipe our slate clean in the Legislative

Branch, as I enumerated earlier, and your report put out very specifically. It was within NASA that decisions were made to transfer

funding——

Admiral GEHMAN. Right.

Chairman BOEHLERT [continuing]. Out of the program. It is within NASA that the decision was made to sort of not give the proper

responsibility authority and independence to the safety function. So

I don’t want this to be misinterpreted by anybody as this is an

apology for the Congress. We will share part of the responsibility.

We have got to stand up to that, but the fact of the matter is

changes are needed, they are needed, and they are clearly articulated in your report. I will have some closing comments in a moment.

Mr. ROHRABACHER. Just finish?

Chairman BOEHLERT. Just one more, and then we will go to Ms.

Jackson Lee.

Mr. ROHRABACHER. And finishing up on that area, the funding—

the institutional process of funding may well be what you were

looking at in terms of the way we fund NASA, not necessarily the

specific funding decisions made by the Congress. I just—for the

record, as well, there are numerous occasions which we—which I

heard Members of this committee, on both sides of the aisle, talk

to people who are sitting right in the spot that you are in right now

and say anything that in any way affects safety should be taken

care of without regard to budget and that we will back you up if

82

that is what—if you tell us that this is the reason you need that

money. However, Mr. Chairman—our internal—sometimes there

are internal deadlines that are made based on funding that is already agreed to and those internal deadlines of NASA sometimes

are reflected in the decisions we have made at—funding certain

projects.

Chairman BOEHLERT. Thank you very much, Mr. Rohrabacher.

Ms. Jackson Lee.

ACCOUNTABILITY

Ms. JACKSON LEE. Thank you very much, Mr. Chairman. The importance of this warranted me in staying with you, Admiral. And

I do not—and the Board, I do not want to keep you away from

tasty cuisine. And I thank you very much for your patience.

I want to just reinforce my earlier remarks with respect to reciting the names of those who lost their lives on Columbia 7, because

this is about them and their families. And particularly, it is about

them because there are how many in line following them, meaning

astronauts in training, who would do it at a drop of a hat, meaning

go into space ready, courageous. And I hope that my colleagues will

join me in sponsoring the Congressional Gold Medal that we have

now filed to be able to honor them. But I believe it is important

to restate their names and to note their families, because I don’t

think one family member publicly did anything to suggest that we

should not continue whatever our vision and our mission is. And

I think this question of probing responsibility is not simply finger

pointing, and I think the Chairman has just said we all can stand

in line right now. And I want to put on the record that when I

made the comment about safety, it was in 1999 where there was

a billion dollar cut through the appropriations process out of this

Congress for the NASA budget. I might suggest that the belt tightening was their way of saying, ‘‘We can handle it.’’

And I want to get back to you were in the middle of saying the

word ‘‘accounting.’’ And I would like to be able to have you answer

that along the lines of your role militarily on how you would deal

with that. And I would like Major Hess to comment that if a tragedy of this moment occurred, I am recalling the submarine issue

with the Japanese fishing boat and the sort of scenario that occurred. I would appreciate your comment on that. I also would appreciate a comment as to whether or not we should be concerned

about the International Space Station. Is that susceptible to the

same management problems that tragically helped, if you will, result in the Columbia 7 tragedy? And I would also like to find out—

as I look at this report globally, you are not condemning human

space flight. There is vitality to humans going in space. I didn’t see

it in the report. I don’t want to miss it. And I would appreciate you

commenting on the value of that through your work and interviews

with individuals.

Admiral, you were in the middle of the accountability question

and who we should hold, how we should hold those responsible.

Admiral GEHMAN. Right. I will let General Hess, who has conducted many, many safety—accident investigations in the aircraft

accidents and comment on that. But generally speaking, in our

military experience, we conduct two separate investigations. And

83

one investigation is—does have an accountability, responsibility

kind of a goal. And the other one is an investigation to really find

out, no kidding, what happened and every single contributing cause

that may have contributed to that accident in which we assure people that no accountability will be—there will be no punishment, no

intimidation of any witnesses or anything like that. And what we

tried to do in this investigation is to roll those two kinds of investigations into one in which we brought out the performance of people. We documented it in our report. And if the proper authorities

want to hold those people accountable, I think they should. We are

not escaping the issue of accountability. We just decided that we

aren’t the judges. But we did—we were the investigators, so we put

it all in the report.

Ms. Jackson Lee, we did not examine the International Space

Station program, but I suspect that many of the things that we unearthed in this investigation probably might be good to look at in

that program, also, not that it is not well run and not well managed. I have no evidence whatsoever to indicate that it isn’t well

run and well managed, but if we have cultural problems with communications and openness and the role of engineers and things like

that, it probably is in more than one program.

General Hess, do you want to comment on the military—how

military would handle a loss of life like this?

Major General HESS. I think that there is—a good way to approach the answer to your question is that when we investigate accidents, it is very likely that outcomes can kind of fall in three general areas. One, if you find culpability on the part of leadership, a

removal from position is not an unheard of event. Two, if you find

that in the case of, let us say, a pilot flying an airplane and he flew

it outside of the rules, that pilot going to a flight evaluation board

to determine whether or not he retains his wings as a result of that

event is not unheard of. In the cases where, for example, there is

a mechanical failure, for example, F–16s, being a single-engine airplane, we were dropping them out of the sky left and right in the

late ’90’s because of mechanical failures, those are problems that

you go back and you fix logistically. Well, there is not any personal

culpability in the operation. So accountability is part of what we

do. And we think it is very, very important, because it helps us

continue to follow the rules.

Chairman BOEHLERT. General, you have had the last word. We

are going to—your—the gentlelady’s time has expired.

Ms. JACKSON LEE. Thank you, Mr. Chairman.

Chairman BOEHLERT. And we are going to be faithful to our

promise to our distinguished panelists to have them permitted to

exit. And incidentally, the fine cuisine, they each grabbed half a

sandwich——

Ms. JACKSON LEE. Oh, did—that you provided, Mr. Chairman?

Chairman BOEHLERT [continuing]. Provided to them here. Yeah.

Ms. JACKSON LEE. Mr. Chairman, would you yield for a moment

so that you can—so that he could have the last word? I just want

to—I will pose it to you.

Chairman BOEHLERT. Who is ‘‘he’’ going to have the last word?

Ms. JACKSON LEE. You indicated this witness, but I will pose it

to you. I assume I heard Admiral Gehman say that we would be

84

able to speak with him directly one on one and have the opportunity to visit with at least Admiral Gehman and maybe some of

the Board members.

Chairman BOEHLERT. Not right now. I mean, let me tell you, it

has been my experience, and we are finished now, because we are

going to be faithful to our promise to the panelists. It has been my

experience that this Board, Admiral Gehman, every single member

of the Board, has been accessible——

Ms. JACKSON LEE. Right. That is all I needed.

Chairman BOEHLERT [continuing]. And very receptive to any requests we have made of them. Let me tell you, I just want to stand

and applaud you for what you have done for us and for America.

[Applause.]

Chairman BOEHLERT. We are now adjourned.

[Whereupon, at 2 p.m., the Subcommittee was adjourned.]

(85)

Appendix 1:

ANSWERS TO POST-HEARING QUESTIONS

86

ANSWERS TO POST-HEARING QUESTIONS

Responses by Admiral Harold W. Gehman, Jr., U.S. Navy retired, Chairman of the

Columbia Accident Investigation Board

Questions submitted by Representative Ralph M. Hall

Q1. You made 15 return-to-flight recommendations and 14 recommendations that do

not have to be completed before return-to-flight. How did you go about deciding

what is a return-to-flight requirement and what isn’t? Four example, your report

just says ‘‘initiate an aggressive program to eliminate all External Tank Thermal Protection System debris-shedding at the source. . .’’

Q1a. If you are concerned enough to call for an aggressive program to eliminate all

ET Thermal Protection System debris-shedding, why shouldn’t NASA keep the

fleet grounded until they have completed the task?

A1a. The exposure of the Orbiter to some amount of debris is a feature of the Shuttle’s original design and cannot be eliminated at this time. The Board concluded

that it would be impossible to eliminate all debris-shedding but NASA needed to

take a three-pronged approach which will improve the safety of the Shuttle: reduce

the level of debris to the minimal level possible, work to strengthen the orbiter to

take any debris hits and establish the capability for inspection and repair on orbit.

If NASA follows all the RTF recommendations, redesigns the Bipod area, improves

the photographic capability on launch, develops a capability to do an on-orbit inspection, develops a repair capability for the tile and RCC in orbit and has the Space

Station as a possible sanctuary, the safety level increases for RTF.

Q1b. How much time should NASA have to complete the program?

A1b. We did not specify a specific time for the non-RTF recommendations, but it

is considered a mid-term recommendation, which means one-three years.

Q1c. The bipod problem is being fixed by getting rid of the ramp entirely. There is

another area of ET foam where shedding has been noted—the so-called flange

areas at the edges of the inter-tank zone. Shouldn’t this area be fixed before return-to-flight?

A1c. The Board believed that NASA could make some significant improvements in

the flange areas with proper testing and understanding why foam debris has originated from this area.

Q1d. In another critical area, do you think the Shuttle flight should remain grounded until NASA has fully developed a means to repair reinforced-carbon-carbon

leading edge panels while in orbit?

A1d. The Board was very clear on this issue—‘‘. . .develop a practicable capability

to inspect and effect emergency repairs to the widest possible range of damage to

the TPS, including tile and RCC. . .’’

Q1e. In another critical area, in view of the early warning signals that NASA is getting of a potential problem, as well as the potential catastrophic consequences

of a failure, why shouldn’t redesign of the ‘‘hold down’’ bolt system be a returnto-flight requirement?

A1e. The ‘‘hold down’’ bolt system is already a redundant system, but the Board felt

it had the potential to be a catastrophic failure. Specific observations were made

and this significant issue should be addressed by NASA because it fell into the category of ‘‘weak signals’’ that could be indications of fixture problems.

Q2. The CAIB calls on NASA to ‘‘initiate a program designed to increase the Orbiter’s ability to sustain minor debris damage by measures such as improved impact-resistant Reinforced Carbon-Carbon and acreage tiles.. . .’’

Q2a. Again, the Board does not require installing an improved thermal protection

system on the Orbiter before the next flight. Why not?

A2a. The Board feels it is NASA’s responsibility to develop and implement the technical solution.

Q2b. The specification for the TPS tiles and panels requires that the maximum impact they are designed to sustain is 0.006 foot-pounds. This is quite small. We

now know that foam can inflict massive damage on the leading-edge panels.

Why should anyone have confidence that the Orbiter can return to flight until

the plans for replacing the Orbiter thermal protection system are completed?

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A2b. Risk will always be inherent in space flight but the Board felt that if NASA

followed through on the RTF recommendations, the Space Shuttle would be safe to

fly in the short-term. If NASA redesigns the Bipod area, improves the photographic

capability on launch, develops a capability to do an on-orbit,inspection, develops a

repair capability for the tile and RCC in orbit and has the Space Station as a possible sanctuary, the safety level increases for RTF. Furthermore, the RCC is actually much more impact resistant than this specification, but no one knows for sure

how much tougher. This recommendation is aimed at requiring NASA to test its

flight hardware rather than rely on analysis.

Q3. The Board dissects at some length the weaknesses of the ‘‘Crater’’ model as used

to analyze the foam damage during the Columbia’s flight. As a result of the investigation, do you have any indication of the extent to which NASA is relying

on equally weak analytical models in the Shuttle or Station programs?

A3. There is clear guidance that NASA must update its model regarding the evaluation of TPS damage: ‘‘Develop, validate, and maintain physics-based computer models to evaluate TPS damage from debris impacts.’’ One area NASA needs to look into

is the use of hydrodynamic structural codes. The Board found other areas where

systems were certified for flight by analysis rather than actual testing, such as the

Bolt Catchers, and the Board found that this was not proper for a flight development vehicle.

Q4. Your report was critical of the 1995 Kraft report’s assumption that the Shuttle

could be viewed as a mature fleet of ‘‘operational’’ vehicles. You argue quite

forcefully that the Shuttle is still an R&D vehicle—not an operational vehicle.

Then in your discussion of a proposed approach to improving NASA’s Shuttle

safety system, you highlight the safety programs of the nuclear Navy as being

a good model to emulate. However, the nuclear Navy consists only of operational

vehicles—no one would argue that our nuclear missile submarines are R&D vehicles. As a result, the differences between the Shuttle fleet and the Nation’s submarine fleet would seem to be far greater than any perceived similarities—and

the safety model would not seem to be relevant. Would you care to comment?

A4. There will never be a perfect match on benchmarking. The Board was impressed with the fact that the nuclear Navy manages a complex system and it can

be argued they continually learn about nuclear power as it ages and matures and

it has comparable responsibilities in research, design, construction, testing, training,

operation, and maintenance—there are some valid lessons learned that can be applied to NASA regarding: communication and action; recurring training and learning from mistakes; encouraging minority opinions; retaining knowledge; worst-case

event failures. The Board’s Report takes the best safety practices from several case

studies, not just Naval Reactors.

Q5. While rejecting the premiers underlying the Kraft Report, the Board was silent

on the future structure of a Shuttle contract.

Q5a. Why didn’t you provide some guidance to the agency, the Administration and

Congress on the wisdom of continuing with the Space Flight Operations Contract as it stands?

A5a. In the Board’s investigation, we did not find any direct relationship between

the SFOC and the cause of the mishap. However, there was clear mention that

outsourcing has an unintended consequence of reducing the in-house engineering

and technical capabilities in the civil servant side of NASA and complicating the

issues of safety independence. The Board clearly said, ‘‘. . .In the aggregate, these

mid-1990s transformations rendered NASA’s already problematic safety system simultaneously weaker and more complex.’’

Q5b. Are the incentives in the SFOC contract, which includes an incentive for cost

savings for both NASA and the contractor, a part of the problem here?

A5b.

The Board found no evidence that the extensive use of incentives contributed to

this accident. However, the Board did find what are apparently unintended consequences on the NASA work force that it felt were worth noting. Among those unintended consequences were: migration of technical expertise, increased communications challenges, systems of informal hierarchies, loss of truly effective checks and

balances.

Q6. After the Challenger tragedy, part of NASA’s return-to-flight action required the

cancellation of all existing waivers and the review of all existing documentation

relating to critical items, failure modes, and the hazards of flying the vehicle.

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Much of the time needed to return to flight was consumed by this effort. The

Board does not recommend a similar effort as a requirement for returning to

flight this time, although you do recommend a re-certification program if the

Shuttle is to be flown past 2010. Why shouldn’t we re-certify the vehicle now?

Do you think the Shuttle would pass a re-certification in 2010?

A6. The Board shares this concern, and based its fundamental recommendation to

create an independent technical authority with the ownership of all technical specifications and all waivers to those specifications on the premise that certification to

‘‘continue to fly’’ should be very carefully monitored. Included in the duties of this

independent authority will be the requirement to understand and safeguard the systems specifications over time. The Mid-Life Certification program will bump up

against this authority, just as we intended.

The Mid-Life Certification (MLC) is a necessary process that will require NASA

and Shuttle program managers to review all the basic vehicle design and certification criteria and revalidate them. This re-certification will uncover design and

manufacturing assumptions that were made using the limited 10-year/100-launch

life span of the system. Shuttle program management has delegated the development of MLC to the individual elements and subsystem managers. Approximately

80 percent of the effort will reside in the orbiter itself. The orbiter element is beginning its MLC program development using a three-step process, an expanded Certification of Flight Readiness (called CoFR plus), certification verification, and certification extension.

CoFR plus is the first step for orbiter return to fly as well as MLC. This more

rigorous certification will begin this summer in preparation for the anticipated first

flight after Columbia. In addition to the normal subsystem-by-subsystem review of

flight certification, reported upchannel to the program management, the orbiter

MLC office wants to add a horizontal check to verify certification between subsystems. Essentially, they want to look at known problem areas in one system and

determine if there’s a risk to other systems. An example of this horizontal review

is the integrated approach used to alert other systems of the problem with the flex

hoses. This will facilitate an integrated approach to certification of all the subsystems as part of the overall system as well as their interaction. The intent is to

integrate this process improvement into all future certifications.

The SSP’s extended life raises several questions about the vehicle and component’s original certification. The verification of certification step is envisioned to be

a review of the CoFR process with intent to verify that the program is reviewing

the right areas, prior to flight approval, with regard to the current operating environment (as compared to the anticipated operating environment in the late ’70s).

The long-term exposure to salt air and the high wear induced by maintenance are

two examples of environments that the original certification did not anticipate. The

flex hoses, mentioned previously, failed under low frequency vibration induced

stress that was not anticipated in the original certification. This MLC process is expected to be a one-time review. The orbiter office is planning to complete this

verification for all CRIT 1.1 systems in time for the next CoFR. The remaining CRIT

systems will be accomplished thereafter.

The extension of the SSP certification beyond 2020 is the final step. This data intensive process will include a review of the NASA and contractors’ databases with

intent to mine all the original certification criteria and assumptions that may not

be valid today. Their intent is to do this archival review as well as current trend

analysis using UA, PRACA, CARS data et al. This information will then be used

to build new certification criteria and maintenance or modification programs to sustain the SSP. Additionally, this review will build a database to be used in future

certifications and provide training for younger engineers in the program invaluable

experience relating to system certification processes. The extension program will be

designed as a one-time review as well.

The MLC is currently ranked in the third tier of SLEP projects, at the top of a

list of undefined projects. This list of undefinitized projects, including Mid-Life Certification, Fleet Leader and Corrosion Control, are the core of a service life extension

for this system. Funds to start MLC are programmed to begin in ’04 and include

adding 50 to 100 additional personnel to get this program started. MLC is expected

to increase certification confidence and build a sustainment program complete with

maintenance, inspection and modifications that will extend the life of the Shuttle

program. The key to success will be in its funding and rigor as the program office

integrates the various systems toward one goal.

The Shuttles next certification and the SLEP program should be founded on the

basis of a thorough Mid-Life Certification. The SLEP management recognized this

problem at the 7 May 2003 program review; ‘‘We need a focused effort to move these

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activities from the undefinitized to the definitized portion of the budget. Progress

should be targeted to support the 2004 Summit.’’ The orbiter program is starting

out with some outstanding ideas on how to organize this tremendous MLC task. The

program office should standardize the approach between the systems to ensure rigor

and accuracy of the final product. NASA has most of the necessary ingredients for

a successful sustainment program for the Shuttle Program. The only impediment to

building it is a centrally organized sustainment office with authority to integrate the

various SSP systems and sites.

Q7. Your report did not address the issue of the role played by the astronaut corps

in agency management. Do you have any opinions on the subject? Is it on balance healthy or unhealthy?

A7. The Board was disappointed in the Astronaut office participation in the MMT.

The representation at these meetings was random and there was little consistency

in tracking valuable information. In fact, the Astronaut office did not know there

was even a foam debris issue until after the Columbia mishap. The Board also believes simply assigning mal-prepared Astronauts to management positions is not a

course of action with high probability of success. If Astronauts are to be encouraged

to enter the management field, they require proper education and training.

Q8. Admiral Gehman, your report devoted a great deal of space to a discussion of

the pressure exerted by NASA Administrator O’Keefe to meet the artificial milestone of Space Station ‘‘Core Complete’’ by February 19, 2004. Do you think that

the explanation that ‘‘all of the Shuttle launches were delayed anyway, so it

wasn’t real pressure’’ is plausible, or was the reality that each Shuttle launch

delay simply added to the pressure perceived by the NASA workforce?

A8. If a Shuttle launch is delayed, it may not mean that all subsequent launches

slip. Many times the next mission moves ahead of the delayed mission. During this

investigation the Board found that people who work at NASA have the legendary

can-do attitude, which contributes to the agency’s successes. But it can also cause

problems. When workers are asked to find days of margin, they work furiously to

do so and are praised for each extra day they find. But those same people (and this

same culture) have difficulty admitting that something ‘‘can’t’’ or ‘‘shouldn’t’’ be

done, that the margin has been cut too much, or that resources are being stretched

too thin. No one at NASA wants to be the one to stand up and say, ‘‘We can’t make

that date.’’ It should also be noted that the number of days delayed is not a oneto-one match on the amount of margin lost. The Board found sufficient evidence that

schedule pressure was felt at the working level.

Q9. Your report is critical of the ‘‘NASA culture’’ and you say that it needs to be

changed, that it is a question of ‘‘leadership.’’ What specifically needs to be done

and how we will in the Congress be able to confirm that the culture has successfully changed?

A9. Changing culture is a very difficult thing to do in any organization. The Board

feels that it will require management changes that include the CAIB recommendations for an: independent technical engineering, a truly independent safety authority

and a fully integrated Shuttle program. Secondly, the Board feels it will require

leadership from the top that must come from the senior levels of NASA. The Report

clearly defines what we mean by ‘‘culture.’’ Good cultural habits can only be established by consistent and steady demands by management over a prolonged period

of time.

Q10. At several points in your report, you seem to be critical of the fact that the number of mandatory inspection points for Shuttle launch processing has been cut

back dramatically over the years, but you don’t produce a clear recommendation on this point.

Q10a. Did the Board think that there were too few mandatory inspection points? If

so, what was the specific basis of your concern?

A10a. The Board observed that the GMIPs changed from over 40,000 in the early

1990s to approximately 8500 in 2003. There was a general movement in the Government to outsource to contractors. While the Board could not tie this reduction in

GMIPs to a causal relationship to the accident, there is a concern that NASA went

too far in reducing the GMIPs that resulted in a decreased engineering expertise

in NASA civil servants for proper oversight.

Q10b. If you think significantly more mandatory inspection points are needed, why

wasn’t that one of the report’s recommendations?

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A10b. The Board did not have the expertise to recommend specific additions to the

GMIPs but clearly was concerned that this needed to be reviewed by NASA in the

observation: . . .Perform an independently led, bottom-up review of the KSC Quality Planning Requirements Document to address the entire quality assurance program and its administration. This review should include development of a responsive system to add or delete government mandatory inspections.’’

Q11. The report’s discussion of the budgetary history at NASA, especially in the

Shuttle upgrade and safety programs, is incomplete.

Q11a. What documents did you receive from NASA and OMB that detailed upgrade

requests from the Shuttle or Safety programs to the NASA Headquarters

budget office, from NASA to OMB, and pass-backs from OMB to NASA?

A11a. We received no documents from OMB, and no documents containing predecisional budget data from NASA.

Q11b. Technically, your Board was a NASA panel, so why couldn’t the Board at a

minimum have gotten all the material in the possession of the agency?

A11b. Executive privilege protects pre-decisional, NASA-executive office communications. We could have requested such information from NASA, but we were advised by NASA general counsel’s office that the request would have been denied on

the basis of executive privilege.

Q11c. Did anyone advise you not to pursue the budget document requests? If so,

who?

A11c. Executive privilege protects pre-decisional NASA-Executive office communications. We could have requested such information from NASA, but we were advised

by NASA general counsel’s office that the request would have been denied on the

basis of executive privilege.

Q11d. Do you have any strong opinion about the current mix of Shuttle upgrades

and the appropriateness/robustness of the Shuttle upgrades program? On

what is that opinion based?

A11d. The Board does not have a strong opinion regarding this question.

Q12. The report notes on page 78 that the tests conducted to validate the hypothesis

that the foam had damaged the thermal protection system did not meet with

wholehearted approval from NASA. Please describe the circumstances surrounding the conduct of the test program? Is this episode related to the Board’s

comment that, ‘‘The changes we recommend will be difficult to accomplish—

and will be internally resisted?’’

A12. The foam impact testing became so important to the investigation that the

Board felt we must have control over the entire process. There initially was resistance from some NASA personnel as to the type of testing that was required and

the importance of testing to the final outcome of the investigation. The Board concluded that the most effective method for conducting the test was for the Board to

have final authority over the entire foam-testing program. This issue was not specifically related to the Board’s concern that changes would be internally resisted,

but did contribute to the overall sense that NASA is resistant to outside criticisms.

Q13. One thread running through the Board’s review of NASA’s budget history is

the continuing quest to find efficiencies in the Shuttle program, to reduce the

annual request for appropriations. Congress has heard testimony on many occasions that budget cuts have safety impacts, but there is no metric by which

a particular reduction in budget can be tied directly to a specific reduction in

safety. Group IV John Logsdon has been contacted and is responding.

Q13a. Is it fair to say that your report concludes that because of budget pressures

the Shuttle program was operating at thin margins, but that you couldn’t tie

this accident directly to budget cuts? If so, why couldn’t you make a stronger

statement about the effect on safety of the declining Shuttle budget?

A13a. Precisely because there was no way of establishing a direct causal link, we

felt that what is said in the report was as strong as we could substantiate.

Q13b. Does the Board have any advice for us on how to recognize in the future when

a lack of resources has pushed the program into an unsafe condition? How

will we know? Who will be competent to make this assessment?

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A13b. Both the independent technical authority and the independent safety authority we recommend in the report will be able to make these judges, as would a reconstituted and effective ASAP.

Questions submitted by Representative Bart Gordon

Q1. Please provide some specific ‘‘benchmarks’’ that will allow Congress to assess the

extent to which NASA is complying with the recommendations of the Columbia

Accident Investigation Board (CAIB) over the next several years.

A1. The HSC has asked that the CAIB be reconvened in one year to track the

progress of the recommendations. The CAIB is prepared to do this.

Q2. Many of the findings and recommendations in your report were in fact clearly

stated in the 2000 report of the Space Shuttle Independent Assessment Team

(SIA), chaired by Dr. Henry McDonald. One could conclude that if SIAT report

had been embraced by the agency, the Columbia accident might never have happened.

Q2a. Can you explain why NASA failed to heed Dr. McDonald’s report in the three

years after its release?

A2a. It is unfair to say that NASA failed to heed the SIAT report since there was

follow-up on some of the report’s recommendations by NASA; however, NASA did

not agree with all the recommendations of the SIAT report. The reasons NASA resists implementing recommendations from outside reviews are complex. Among the

chief reasons are: NASA thinks it knows better; budget constraints have caused

shrinkage of R&D activities and independent, in-house engineering work; schedule

pressure; and, leadership shifts toward managers and away from engineers.

Q2b. What will have to occur for your report to receive a more favorable reception,

and how likely do you think that is?

A2b. The Stafford-Covey RTF group will be one means to track the short-term recommendations. A newly chartered ASAP, periodic reconvening of the CAIB and Congressional oversight may be a means to ensure mid-term and long-term recommendations are followed. The Board Report predicts resistance to change, which

are the primary reasons we recommended an independent technical/engineering authority with the authority to safeguard and/or grant all waivers to basic system requirements and specifications.

Questions submitted by Representative Sheila Jackson Lee

Q1. What actions would you recommend be taken by NASA and the Congress to ensure that the International Space Station program is not facing safety concerns

similar to those uncovered by the CAlB investigation?

A1. The investigation of the ISS was not part of the Charter of the CAIB so we do

not feel qualified to answer this question. However, the lessons learned from the

Columbia Accident should be studied by the ISS program management for

benchmarking purposes. The NASA IG is capable of using the Columbia Accident

Investigation Board’s report as a roadmap to use in the case of the ISS.

Q2. Your report seems to be quite critical of the amount of downsizing of the government employees and the amount of contracting out that has occurred at the

agency.

Q2a. Is that true? If so, what is the basis of your concern?

Q2b. How many government employees do you think will need to be added to address the concerns raised in your report?

A2a,b. Since NASA was established in 1958, its civil service workforce has fluctuated widely. In 1967, at the height of the Apollo program, the workforce reached

approximately 35,900 personnel. In the mid-70s an involuntary separation program

decreased the workforce by several thousand employees. By 1980, the workforce had

stabilized near 21,000. It remained close to that level until 1986, when the Space

Shuttle Challenger accident forced a re-examination of NASA, adding significant

man-hours to Safety and Quality Assurance processes.

NASA began some ambitious new programs in the late ’80s and its workforce

began to grow again peaking in 1992 at more than 25,000. When the Clinton Administration took office in 1993, it initiated steps to reduce the size of the overall

federal workforce. Total NASA headcount went from approximately 25,000 civil

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servants in FY 1993 to slightly more than 18,000 (full-time permanents) by the end

of 2002. As the NASA workforce declined, the continuing strategy was to lose junior

personnel first, resulting in an experienced but aging workforce. In November 1995,

NASA selected United Space Alliance—a Rockwell International and Lockheed Martin partnership—as the prime contractor for space flight operations. Thus, fewer

civil servants were required to manage the program, NASA estimated that it would

be able to make personnel reductions in the range of 700 to 1,100 full-time equivalent personnel (FTEs) at the Kennedy Space Center alone. The challenge to Space

Shuttle contractors, including United Space Alliance, was to address the aging

workforce concerns through a continual influx of inexperienced personnel who could

stay with the industry for many years. Contractors have much more flexibility in

their personnel decisions than does the Federal Government. Compensation packages, including both wages and benefits, are tailor made to address the shortages

that face the industry while correcting oversupply in some skills.

All SSP contractors, including United Space Alliance, have been given financial

incentives to reduce the cost of performing the contract. Personnel costs can be reduced by eliminating personnel in overhead support or management functions, or

by encouraging efficiencies in the direct labor elements. United Space Alliance,

through the Space Flight Operations Contract, is accountable for professional, managerial and technical workforce support to the Space Shuttle Program. Jobs range

from maintenance personnel at Kennedy Space Center to subsystem managers within the Mission Control structure. USA recognized its obligation to maintain a balanced workforce in the professional skills, and that there must be a flow of personnel through the ‘‘pipeline’’ to guard against future shortfalls in critical skills.

United Space Alliance stated that while they accepted the challenge to reduce the

headcount on the Space Shuttle program, they intended to do so without reducing

the direct headcount. They would do this primarily through efficiencies achieved by

consolidations. USA did not place the same emphasis on the retention of the nonprofessional, technician workforce. USA has stated that they do not suffer from the

same concerns as with engineers and has never faced a shortage of applicants for

these jobs.

United Space Alliance closely tracks personnel trends, especially with respect to

engineering manpower. USA has a nearly bi-modal distribution with respect to age

or experience. There are a significant number of personnel over 40 years of age as

well as a significant number in the under 30 age group. This illustrates a pipeline

from which the workforce of the future will be drawn. Other Space Shuttle contractors may not have had the flexibility to make these kinds of ‘‘overhead only’’ process

gains, as elimination of direct as well as indirect personnel was necessary. While

reducing the cost of labor through lay-offs, the contractor must continually guard

against creating an impression of the company as an unattractive workplace. Contrast the United Space Alliance distribution with ATK Thiokol Propulsion in Utah,

the supplier of the Reusable Solid Rocket Motor (RSRM) since the 1970’s.

During the peak production of the RSRM in the 1980’s, Thiokol employed over

4,000 personnel. Today, with production of the RSRM at less than 30 units annually, their personnel count is stable at 1350. Demographics at the Utah plant show

a spike in the 45–49 age group, with the majority of the workforce being over 45

years old. This trend is true for engineering as well as plant personnel. ATK Thiokol

has identified their aging workforce as a significant issue in relation to the Shuttle

program Service Life Extension Program (SLEP). ATK Thiokol recognizes that they

must ‘‘pump significant new energy into recruiting new talent and retaining/training the younger ones currently in our workforce now.’’ The contracting community

at Marshall Space Flight Center recognized the risk associated with downsizing and

has eliminated incentives associated with cost cutting in the latest RSRM contract.

The Michoud Assembly Facility workforce has been declining over the past five

years. In 1998, there was some increase in hiring as a result of the RLV and X–

33 programs. However, after that, hiring was limited to budget driven replacements

only. Budget challenges have led to the involuntary separations which approached

ten percent in 2002. One of the risks of multiple periods of downsizing is that it

may lead to a perception among the workforce of limited potential for both growth

and reliable employment. This has been highlighted as one of the most significant

reasons for the voluntary attrition over the past three years. The average age of the

employee at Michoud is now 47.8 years, but the skilled labor (represented) employees average 48.2 years. In conclusion, the issues associated with aging workforce

present formidable challenges to the future of the Shuttle Program, especially if the

vehicle is expected to serve until 2020 and beyond. Of the major contractors only

USA has a recruiting effort with significant numbers.

Additionally, while USA’s benefit packages have been considered by some to be

below the industry standard, we have reviewed DCAA documentation that reflects

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that the packages are among the better in the industry and may actually be considered excessive. It is essential that NASA take actions to ensure a stable experienced

base of support for the Shuttle programs. This may require modifications to way

contract incentives are used or other contractual changes. It may benefit NASA to

continue the bundling of Space Shuttle element contracts, ETR, SSME, and RSRM

under the SFOC and USA in order to maximize the return on leverage of personnel

recruitment efforts.