NASA's self-protective culture and its reluctance to tackle safety problems head-on contributed to the fatal breakup of shuttle Columbia, just as technical factors tore the ship apart, independent investigators reported yesterday.
The Columbia Accident Investigation Board, set up after the Feb. 1 tragedy that killed seven astronauts, said in its final report that NASA needs to set up separate safety agencies that will be able to get the attention of top space officials when things go wrong.
The board found that NASA engineers raised questions soon after Columbia's launch on Jan. 16 about a piece of foam insulation that was seen falling from the ship's massive external tank about 81 seconds after liftoff.
Engineers asked three times during the 16-day mission for satellite images of Columbia in orbit to check on whether the foam struck and damaged the ship, but such images were never obtained.
The board's report said NASA officials missed eight opportunities to address concerns about the falling foam, which was ultimately found to be the accident's most probable cause.
"From the beginning, the board witnessed a consistent lack of concern about the debris strike on Columbia," the report said. "NASA managers told the board `there was no safety-of-flight issue' and `we couldn't have done anything about it anyway.'"
The report drew parallels between NASA management problems now and at the time of the 1986 Challenger disaster, which also killed seven astronauts.
Board members agreed early on that the foam hit the heat-shielding leading edge of the left wing, causing a breach that allowed superheated gas to invade the ship on re-entry and led to its disintegration over Texas.
"NASA's organizational culture and structure had as much to do with this accident as the external tank foam," the board said.
After seven months of work at a cost of about US$20 million, the 248-page report recommended wholesale changes in how the NASA does business, including the creation of a Technical Engineering Authority funded directly from NASA headquarters to monitor safety outside the constraints of individual program pressures.
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