Wednesday, August 27, 2003
More NASA data
More response to the Columbia report: this time from someone currently engaged in the private side of the effort and who has studied NASA methodology extensively. Thank you for writing, and for allowing me to share it. [Responses may be be left in the comments section and will be passed on to the author.]1) Principally this is a management failure/cultural failure at NASA. NASA has had an organizational culture adrift from peer organizations in government and industry for 20 years and like many closed societies has drifted into dysfunction and mysticism. (Gehman stated most of this report could have been written prior to the loss of Columbia). 2) Technical cause of the accident was a piece of foam shed from the Shuttle Tank striking the wing and damaging the Carbon heat protective tiles. While factual, this particular failure is almost irrelevant. Dozens of near-misses in other failed systems in recent years have had equal potential to cause loss of crew and vehicles. The management system that has allowed this to occur is the principle problem. (Other near misses include flawed wiring, hydrogen gas buildup, failure of bolt catchers in flight, fires in APU's) 3) A far more grave issue is the inability to design and build space craft that are capable of fault tolerance, grave degradation and incremental growth in understanding and technology. Aircraft have been designed with 100 years of slow gradual steady improvements from Wilbur and Orville wright to the F-22, 777 and SR-71. Orbital space launchers have only increased in size while using design philosophies based upon the V-2 missile and not upon sensible transportation systems. 4) NASA has developed a cultural problem where proper scientific and engineering analysis are not performed. Argument is preferred over analysis. PowerPoint analysis is preferred over scientific method. Ground tests are preferred over flight tests. Prior to the loss of Columbia, inadequate testing or analysis was performed over numerous flight systems leading to over 300 waivers of critical issues. Wishing away trouble has replaced proper operational discipline. -- This problem can be seen in that the External tank has never been flown in a fully instrumented manner. Test data must validate models, a concept lost on NASA. -- No basic lab tests were conducted of Foam behaviour until Osheroff conducted his experiments in his kitchen. Prior to that senior NASA managers had scoffed at Foamology and disputed that foam was of any consideration in the loss of Columbia. 5) NASA built hundreds of billions of dollars of systems (ISS, Hubble, Compton, Spacelab, SpaceHab) on a highly experimental and provably unreliable launch system (STS). While it is a reasonable federal activity to engage in both scientific research and aircraft design and test, these experiments should not be tied together. Science platforms should be divorced from experimental launch vehicles. The X-15 flew the occasional science experiment but these were always tertiary to the primary mission of research flight test. There is something fundamentally wrong when the X-15 flew 199 times as a research rocket plane, while the Shuttle flew 4 times and was declared operational. 6) A gross disconnect exists between NASA's ground side view of spacecraft and the operational roles and needs on orbit. At KSC it is almost religious that no loose items strike the shuttle. Jewelry is removed, loose items on clothing are taped down, visitors are confined to limited spaces, but when foam flakes off of the ET in flight, this is treated as a minor maintenance issue. ISS flight hardware is processed by ground crews in sterile gowns, booties and masks, but when on orbit, astronauts float around inside in their underwear, eating and playing inside the modules. 7) Aversion to data collection and monitoring: Modern large aircraft are built with Black box recorders to collect condition information to support crash investigation. By luck, Columbia had a data collection system which was vital to this investigation. None of this data is analyzed in flight. Little of this data is analyzed between flights. 1/3 of the Columbia flight sensors had failed at the time of the loss. Proper scientific organizations collect data and utilize it for trend information. NASA dumps most of this information. 8) Inability to institute accountability for improper actions: No NASA managers have ever lost their jobs over gross failures. Challenger, Hubble and Columbia have only resulted in a reshuffling of name-plates. Military officers who lose seven men during a training operation can be sure their careers will be terminated, and they may even face court-martial. Two USAF pilots bombed five Canadian Special forces soldiers during the Afghan War. They were pulled before a Board of Inquiry: their careers were ruined. A USAF captain failed to identify a helicopter containing UN/US Army officials in Iraq during the air patrol in the late 1990's. This failure lead to the shootdown of the helicopter, and a subsequent court-martial of the officer. It is unfortunate we hold Juniour officers to a higher standard of responsibility than a NASA administrator. 9) Obsolescence/failure to grow and adapt: NASA has maintained aging systems and approaches from the 1970's instead of adapting to modern 21st century approaches. -Analog test equipment instead of digital testers. -Paper drawings instead of CAD based systems. -Complex information management instead of digital documentation control systems. -Failure to update drawings to reflect current conditions. These are all symptoms of an organization out of control. 10) Failure to conform to FAA flight safety practice and military range safety practice on re-entry or launch: NASA has always felt immune from practices of lesser bodies. 11) Failure to conform to industrial practices: ASTM, AIAA, ASME. NASA has never had professional engineers in key positions, or used industry guidelines in design practices. SRB design violates ASME design rules. Orbiter bolts have been placed in violation of recommended guidelines. While one can continue on about technical issues, the single biggest problem is that NASA has serious cultural and organizational problems. Policy changes to move NASA away from operating systems and buying flights are needed.
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