COMMITTEE ON SCIENCE

U.S. HOUSE OF REPRESENTATIVES

HEARING CHARTER

NASA’s Organizational and Management Challenges

in the Wake of the Columbia Disaster

Wednesday, October 29, 2003

10:00 a.m. to 12:30 p.m.

2318 Rayburn House Office Building

1. Purpose

On Wednesday, October 29, 2003 at 10:00 a.m., the House Committee on Science will hold a 

hearing to address the organizational and management issues confronting the National Aeronautics 

and Space Administration (NASA) in the aftermath of the Space Shuttle Columbia accident. 

According to the Columbia Accident Investigation Board (CAIB), NASA's "organizational culture 

and structure" had as much to do with the Columbia's demise as the physical causes of the accident. 

During the course of its nearly seven months of investigation into the causes of the accident, the 

CAIB encountered an ineffective and disengaged safety organization within NASA that "failed to 

adequately assess anomalies and frequently accepted critical risks without qualitative or quantitative 

support." Based on its findings, the CAIB recommended significant changes to the organizational 

structure of the Space Shuttle Program (detailed below).

To give a sense of some of the ways NASA could be restructured to comply with its 

recommendations, the CAIB report provided three examples of organizations with independent 

safety programs that successfully operate high-risk technologies. The examples were: the United 

States Navy's Submarine Flooding Prevention and Recovery (SUBSAFE) and Naval Nuclear 

Propulsion (Naval Reactors) programs and the Aerospace Corporation's independent launch 

verification process and mission assurance program for the U.S. Air Force.

This hearing will provide an opportunity to examine each of these examples in depth, as well as the 

safety programs of the Dupont Corporation (an acknowledged industry leader in safety), to help 

determine how NASA should be reorganized.

2. Critical Questions

The CAIB determined that reorganizing NASA is a critical requirement if the Shuttle is to fly safely 

over the long term. To provide adequate oversight of NASA's reorganization plans, the Committee 

needs to understand how different organization structures can contribute to safety. To that end, the 

following questions were submitted in advance to each of the witnesses:

a. What does it mean for a safety program to be "independent?" How can safety organizations be 

structured to ensure their independence?;

b. How can safety programs be organized to ensure that they are robust and effective, but do not 

prevent the larger organization from carrying out its duties?;
c. How do you ensure that the existence of an independent safety program does not allow the 

larger organization to absolve itself of responsibility for safety?; and

d. How do you ensure that dissenting opinions are offered without creating a safety review process 

that can never reach closure?

3. Background

Recommendations of the CAIB and previous reports

Since the loss of the Space Shuttle Challenger in 1986, numerous outside experts have reviewed 

NASA's human space flight safety programs and found them lacking. For instance, in the 

immediate aftermath of the Challenger accident, the Rogers Commission issued recommendations 

calling for the creation of an independent safety oversight function. Despite NASA's compliance 

efforts, the U.S. General Accounting Office concluded in 1990 that NASA still "did not have an 

independent and effective safety organization." Nine years later, the Shuttle Independent 

Assessment Team and NASA Integrated Action Team likewise issued findings that were critical of 

NASA's safety programs and echoed the Roger Commission's call for the creation of an 

independent safety oversight function. Finally, in 2002, the Space Shuttle Competitive Task Force 

reiterated the call for an independent safety assurance function at NASA with "authority to shut 

down the flight preparation processes or intervene post-launch when an anomaly occurs."

In August of 2003, the CAIB released Volume I of its report on the Columbia accident. Consistent 

with previous analyses of NASA's safety programs, the CAIB Report discovered fundamental, 

structural deficiencies in NASA's safety programs. For example, the report states, "the Shuttle 

Program's complex structure erected barriers to effective communication and its safety culture no 

longer asks enough hard questions about risk....[T]he mistakes that were made on [the Columbia 

mission] are not isolated failures, but are indicative of systemic flaws that existed prior to the 

accident....[A successful safety process] demands a more independent status than NASA has ever 

been willing to give its safety organizations, despite the recommendations of numerous outside 

experts over nearly two decades[.]"

According to the CAIB Report, NASA's current approach to safety and mission assurance "calls for 

centralized policy and oversight at Headquarters and decentralized execution of safety programs at 

the enterprise, program, and project levels." Under the existing organizational rubric, "safety is the 

responsibility of program and project managers" who are given flexibility "to organize safety efforts 

as they see fit."

To remedy the current organization deficiencies, the primary CAIB recommendation on 

organization calls on NASA to "establish an independent Technical Engineering Authority" that 

would be "responsible for technical requirements and all waivers to them" and that would be 

"funded directly from NASA Headquarters, and should have no connection to or responsibility for 

schedule or program cost." The CAIB's fundamental goal is to separate the responsibility for safety 

from the Shuttle program's responsibility for cost and schedule. The current NASA structure, in 

which the Shuttle program itself is ultimately responsible for cost, schedule and safety inevitably 

leads to "blind spots" - serious safety problems that are not properly analyzed or addressed, the 

CAIB concluded. The CAIB did not specify precisely how NASA should be reorganized to 

implement its recommendations, leaving that up to the agency.
While the CAIB report does not label the implementation of a new organizational structure as a 

"return to flight" requirement, the report does say that NASA must "prepare a detailed plan for 

defining, establishing, transitioning and implementing an independent Technical Engineering 

Authority, independent safety program, and a reorganized Space Shuttle Integration Office" prior to 

returning to flight.

NASA is in the process of preparing such a plan. Administrator Sean O'Keefe has tasked the 

Associate Administrator for Safety and Mission Assurance, Bryan O'Connor, with coming up with a 

proposed reorganization plan. O'Connor has circulated a "white paper" outlining his ideas for 

reorganization among NASA staff. Before being implemented, any reorganization plan will be 

reviewed both by the Stafford-Covey Task Force (the task force of outside experts set up by 

O'Keefe to evaluate return-to-flight activities, which is headed by former astronauts Tom Stafford 

and Richard Covey) and by the Space Flight Leadership Council, which comprises top NASA 

officials. NASA is also in the process of setting up a new NASA Engineering and Safety Center 

(NESC), which would be able to "independently" review aspects of programs. It is not clear how 

the NESC would relate to a new Independent Technical Engineering Authority, but Admiral Harold 

Gehman, the chairman of the CAIB, has testified that the NESC does not, by itself, fulfill the 

CAIB's recommendations related to organization.

Model safety organizations

The CAIB Report cites three examples of organizations with successful safety programs and 

practices that could be models for NASA: the United States Navy's Naval Reactors and SUBSAFE 

programs and the Aerospace Corporation's independent launch verification process and mission 

assurance program for the U.S. Air Force.

The Naval Reactors program is a joint Navy/Department of Energy organization responsible for all 

aspects of Navy nuclear propulsion, including research, design, testing, training, operation, and 

maintenance of nuclear propulsion plants onboard Navy ships and submarines. The Naval Reactors 

program is structurally independent of the operational program that it serves. Although the naval 

fleet is ultimately responsible for day-to-day operations and maintenance, those operations occur 

within parameters independently established by the Naval Reactors program. In addition to its 

independence, the Naval Reactors program has certain features that might be emulated by NASA, 

including an insistence on airing minority opinions and planning for worst-case scenarios, a 

requirement that contractor technical requirements are documented in peer-reviewed formal written 

correspondence, and a dedication to relentless training and retraining of its engineering and safety 

personnel.

SUBSAFE is a program that was initiated by the Navy to identify critical changes in submarine 

certification requirements and to verify the readiness and safety of submarines. The SUBSAFE 

program was initiated in the wake of the USS Thresher nuclear submarine accident in 1963. Until 

SUBSAFE independently verifies that a submarine has complied with SUBSAFE design and 

process requirements, its operating depth and maneuvers are limited. The SUBSAFE requirements 

are clearly documented and achievable, and rarely waived. Program managers are not permitted to 

"tailor" requirements without approval from SUBSAFE. Like the Naval Reactors program, the 

SUBSAFE program is structurally independent from the operational program that it serves. 

Likewise, SUBSAFE stresses training and retraining of its personnel based on "lessons learned," 

and appears to be relatively immune from budget pressures.
The Aerospace Corporation operates as a Federally Funded Research and Development Center that 

independently verifies safety and readiness for space launches by the United States Air Force. As a 

separate entity altogether from the Air Force, Aerospace conducts system design and integration, 

verifies launch readiness, and provides technical oversight of contractors. Aerospace is indisputably 

independent and is not subject to schedule or cost pressures.

According to the CAIB, the Navy and Air Force programs have "invested in redundant technical 

authorities and processes to become reliable." Specifically, each of the programs allows technical 

and safety engineering organizations (rather than the operational organizations that actually deploy 

the ships, submarines and planes) to "own" the process of determining, maintaining, and waiving 

technical requirements. Moreover, each of the programs is independent enough to avoid being 

influenced by cost, schedule, or mission-accomplishment goals. Finally, each of the programs 

provides its safety and technical engineering organizations with a powerful voice in the overall 

organization. According to the CAIB, the Navy and Aerospace programs "yield valuable lessons for 

[NASA] to consider when redesigning its organization to increase safety."

4. Witnesses

First Panel

a. Admiral Frank L. "Skip" Bowman, United States Navy (USN), is the Director of the Naval 

Nuclear Propulsion (Naval Reactors) Program. In this capacity, Admiral Bowman is responsible 

for the program that oversees the design, development, procurement, operation, and 

maintenance of all the nuclear propulsion plants powering the Navy's fleet of nuclear warships. 

Admiral Bowman is a graduate of Duke University and the Massachusetts Institute of 

Technology.

b. Rear Admiral Paul Sullivan, USN, is the Deputy Commander for Ship Design Integration and 

Engineering for the Naval Sea Systems Command, which is the authority for the technical 

requirements of the SUBSAFE program. Admiral Sullivan is a graduate of the U.S. Naval 

Academy and the Massachusetts Institute of Technology.

c. Mr. Ray F. Johnson is the Vice President for Space Launch Operations for the Aerospace 

Corporation, located in El Segundo, California. Mr. Johnson is responsible for Aerospace's 

support for all Air Force space launch programs, including Aerospace's certification reviews 

prior to launch. Mr. Johnson holds a B.S. degree in mechanical engineering from the University 

of California at Berkeley and an MBA from the University of Chicago.

d. Ms. Deborah L. Grubbe is the Corporate Director for Safety and Health at Dupont. In this 

capacity, Ms. Grubbe is tasked with leading new initiatives in global safety and occupational 

health for Dupont. Ms. Grubbe and is a past director of DuPont Nonwovens, where she was 

accountable for manufacturing, engineering, and safety. Ms. Grubbe holds a B.S. degree in 

chemical engineering from Purdue University and a Certificate of Post-Graduate Study in 

chemical engineering from Cambridge University.

Second Panel

Admiral Harold Gehman, Jr., USN (retired), chaired the Columbia Accident Investigation Board.

5. Attachment
Excerpt from the Columbia Accident Investigation Board Report, Volume I (August 2003), Chapter 

7, Section 7.3 (pp. 182-184).