Original Source
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Professor: NASA Repeated Some Mistakes

By JUAN A. LOZANO>
Associated Press Writer
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April 24, 2003, 8:30 AM

HOUSTON -- NASA never fixed the underlying institutional problems that led to the 1986 Challenger disaster and many errors were repeated during Columbia's doomed flight three months ago, a sociology professor told a board investigating the latest accident.
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Boston College's Diane Vaughan told the board during a daylong public hearing Wednesday that a similar culture at the space agency during both accidents hindered free thinking and truly open communication.
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Vaughan said one of the alarming parallels she sees between the two catastrophes comes from e-mails engineers wrote each other during Columbia's mission, in which they discussed damage the shuttle might have suffered when a piece of foam broke off during liftoff Jan. 16.
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The investigation board said this week that evidence supports the theory that the foam hit a seal on the left wing, creating a slit large enough to let in hot atmospheric gases as the spacecraft re-entered the atmosphere.
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But many of the NASA engineers who worried about the implications felt they "were marginal to the process and felt they didn't have the same information that other people had," Vaughan said.
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"They were concerned they didn't have any hard numbers. Intuition and hunch didn't carry any weight," she said. "In critical situations, people are disempowered from speaking up by the very norms of the organization."
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Columbia's seven astronauts were killed when the shuttle broke up over Texas as it aimed for a Florida landing on Feb. 1.
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There have been at least four flights since 1983 where foam broke off from shuttle fuel tanks. But NASA concluded such damage was not a safety threat even though it considers any debris striking the shuttle unacceptable.
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Vaughan said some engineers didn't think the repeated debris strikes were a real danger, much like engineers nearly 20 years ago didn't view as a serious problem the deterioration of O-rings, the cause of the Challenger explosion.


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"So what to us in hindsight seemed to be clear signals of danger that should have been heeded, looked different to them," said Vaughan, who spent nearly a decade studying and writing about the Challenger disaster. "What we saw as signals became routine."
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Earlier Wednesday, five retired NASA engineers and program directors who helped develop the shuttle and worked on the Mercury, Gemini and Apollo programs testified before the board and said that shuttle wings were never designed to be struck by anything.
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Milton Silveira, who at one time was NASA's chief engineer in Washington, D.C., told reporters he believes officials should have understood the foam was a potential problem that needed to be resolved.
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"You had a trend but were not paying attention," he said. "I don't understand how that was not fixed earlier."
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Robert Thompson, who headed the shuttle program during the 1970s and helped design the spacecraft, said he hasn't lost faith in NASA but was surprised by an engineering analysis of the foam strike while Columbia was still in orbit that concluded the shuttle was not seriously damaged and could safely return.


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When Vaughan's book, "The Challenger Launch Decision," came out in 1996, it generated quite a bit of publicity and she heard from numerous organizations interested in reducing risks and errors, including hospitals, submarine safety groups, nuclear regulatory operations and the Forest Service. However, NASA never contacted her.
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"Everybody called. My high school boyfriend called," she said, generating a big laugh. "But NASA never called."
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As the hearing was in progress, shuttle program manager Ron Dittemore announced he will leave NASA as soon as the investigation is completed. He said he had planned long before the accident to resign this spring, but stayed on to help in the aftermath.

* __ On the Net:


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Columbia Accident Investigation Board:

http://www.caib.us/
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