Willam Langewiesche, Columbia's Last Flight
Source: Atlantic Monthly; Nov2003, Vol. 292 Issue 4, p58, 26p, 3c
[ I gave up on the coverage of Columbia early on, too depressing. But Langewiesche does a great job in this article. The really sad thing is that it's almost a total replay of the Challenger disaster, engineers versus managers, and the engineers lose, along with the astronauts. This isn't available online yet at the Atlantic, so I will restrict myself to a few extended excerpts. Then there's the story of the head of the investigation board. After reading this, I sort of wish Gehman had been put in charge of a more prominent investigation, but that's another story. ]
Nonetheless, that morning in his car Gehman realized that even with a lukewarm White House endorsement, the position that NASA was offering, if handled correctly, would allow for a significant inquiry into the accident. Gregory made it clear that Gehman would have the full support of NASA's engineers and technical resources in unraveling the physical mysteries of the accident — what actually had happened to the Columbia out there in its sheath of fire at 200,000 feet. Moreover, Gehman was confident that if the investigation had to go further, into why this accident had occurred, he had the experience necessary to sort through the human complexities of NASA and emerge with useful answers that might result in reform. This may have been overconfident of him, and to some extent Utopian, but it was not entirely blind: he had been through big investigations before, most recently two years earlier, just after leaving the Navy, when he and a retired Army general named William Crouch had led an inquiry into the loss of seventeen sailors aboard the USS Cole, the destroyer that was attacked and nearly sunk by suicide terrorists in Yemen in October of 2000. Their report found fundamental errors in the functioning of the military command structure, and issued recommendations (largely classified) that are in effect today. The success of the Cole investigation was one of the arguments that Gregory used on him now. Gehman did not disagree, but he wanted to be very clear. He said, "I know you've got a piece of paper in front of you. Does it say that I'm not an aviator?" . . .
Gehman told me that he had never asked for the full story behind his selection on the morning of the accident- maybe because it would have been impossible to know the unvarnished truth. Certainly, though, O'Keefe had had little opportunity to contemplate his choice. By quick view Gehman was a steady hand and a good establishment man who could lend the gravitas of his four stars to this occasion; he was also, of course, one of the men behind the Cole investigation. O'Keefe later told me that he had read the Cole report during his stint as a professor, but that he remembered it best as the subject of a case study presented by one of his academic colleagues as an example of a narrowly focused investigation that, correctly, had not widened beyond its original mandate. This was true, but a poor predictor of Gehman as a man. His Cole investigation had not widened (for instance, into assigning individual blame) for the simple reason that other investigations, by the Navy and the FBI, were already covering that ground. Instead, Gehman and Crouch had gone deep, and relentlessly so. The result was a document that bluntly questioned current American dogma, identified arrogance in the command structure, and critiqued U.S. military assumptions about the terrorist threat. The tone was frank. For example, while expressing understanding of the diplomatic utility of labeling terrorists as "criminals," the report warned against buying into that language, or into the parallel idea that these terrorists were "cowards." When, later, I expressed my surprise at his freedom of expression, Gehman did not deny that people have recently been decried as traitors for less. But freedom of expression was clearly his habit: he spoke to me just as openly about the failures of his cherished Navy, of Congress, and increasingly of NASA.
When I mentioned this character trait to one of the new board members, Sheila Widnall, she laughed and said she'd seen it before inside the Pentagon, and that people just didn't understand the highest level of the U.S. military. These officers are indeed the establishment, she said, but they are so convinced of the greatness of the American construct that they will willingly tear at its components in the belief that its failures can be squarely addressed. Almost all of the current generation of senior leaders have also been through the soul-searching that followed the defeat in Vietnam. . . .
By early summer the picture was clear. Though strictly speaking the case was circumstantial, the evidence against the foam was so persuasive that there remained no reasonable doubt about the physical cause of the accident. As a result, Gehman gave serious consideration to NASA's request to call off a planned test of the launch incident, during which a piece of foam would be carefully fired at a fully rigged RCC Panel Eight. NASA's argument against the test had some merit: the leading-edge panels (forty-four per shuttle) are custom-made, $700,000 components, each one different from the others, and the testing would require the use of the last spare Panel Eight in the entire fleet. NASA said that it couldn't afford the waste, and Gehman was inclined to agree, precisely because he felt that breaking the panel would prove nothing that hadn't already been amply proved. By a twist of fate it was the sole NASA member of the CAIB, the quiet, cerebral, earnestly scientific Scott Hubbard, who insisted that the test proceed. Hubbard was one of the original seven board members. At the time of the accident he had just become the director of NASA's Ames Research Center, in California. Months later now, in the wake of Gehman's rebellion, and with the CAIB aggressively moving beyond the physical causes and into the organizational ones, he found himself in the tricky position of collaborating with a group that many of his own people at NASA saw as the enemy. Hubbard, however, had an almost childlike belief in doing the right thing, and having been given this unfortunate job, he was determined to see it through correctly. Owing to the closeness of his ties to NASA, he understood an aspect of the situation that others might have overlooked: despite overwhelming evidence to the contrary, many people at NASA continued stubbornly to believe that the foam strike on launch could not have caused the Columbia's destruction. Hubbard argued that if NASA was to have any chance of self-reform, these people would have to be confronted with reality, not in abstraction but in the most tangible way possible. Gehman found the argument convincing, and so the foam shot proceeded.
The work was done in San Antonio, using a compressed-nitrogen gun with a thirty-five-foot barrel, normally used to fire dead chickens — real and artificial — against aircraft structures in bird-strike certification tests. NASA approached the test kicking and screaming all the way, insisting, for instance, that the shot be used primarily to validate an earlier debris-strike model (the so-called Crater model of strikes against the underside tiles) that had been used for decisionmaking during the flight, and was now known to be irrelevant. Indeed, it was because of NASA obstructionism — and specifically the illogical insistence by some of the NASA rocket engineers that the chunk of foam that had hit the wing was significantly smaller (and therefore lighter) than the video and film record showed it to be — that the CAIB and Scott Hubbard finally took direct control of the testing. There was in fact a series of foam shots, increasingly realistic according to the evolving analysis of the actual strike, that raised the stakes from a glancing blow against the underside tiles to steeper-angle hits directly against leading-edge panels. The second to last shot was a 22-degree hit against the bottom of Panel Six: it produced some cracks and other damage deemed too small to explain the shuttle's loss. Afterward there was some smugness at NASA, and even Sean O'Keefe, who again was badly advised, weighed in on the matter, belittling the damage. But the shot against Panel Six was not yet the real thing. That was saved for the precious Panel Eight, in a test that was painstakingly designed to duplicate (conservatively) the actual impact against the Columbia's left wing, assuming a rotational "clocking angle" 30 degrees off vertical for the piece of foam. Among the engineers who gathered to watch were many of those still living in denial. The gun fired, and the foam hit the panel at a 25-degree relative angle at about 500 mph. Immediately afterward an audible gasp went through the crowd. The foam had knocked a hole in the RCC large enough to allow people to put their heads through. Hubbard told me that some of the NASA people were close to tears. Gehman had stayed away in order to avoid the appearance of gloating. He could not keep the satisfaction out of his voice, however, when later he said to me, "Their whole house of cards came falling down." . . .
The story that emerged was a sad and unnecessary one, involving arrogance, insularity, and bad luck allowed to run unchecked. On the seventh day of the flight, January 22, just as the Air Force began to move on the Kennedy engineers' back-channel request for photographs, Linda Ham heard to her surprise that this approach (which according to front-channel procedures would have required her approval) had been made. She immediately telephoned other high-level managers in Houston to see if any of them wanted to issue a formal "requirement" for imagery, and when they informed her that they did not, rather than exploring the question with the Kennedy engineers she simply terminated their request with the Department of Defense. This appears to have been a purely bureaucratic reaction. A NASA liaison officer then e-mailed an apology to Air Force personnel, assuring them that the shuttle was in "excellent shape," and explaining that a foam strike was "something that has happened before and is not considered to be a major problem." The officer continued, "The one problem that this has identified is the need for some additional coordination within NASA to assure that when a request is made it is done through the official channels." Months later one of the CAIB investigators who had followed this trail was still seething with anger at what had occurred. He said, "Because the problem was not identified in the traditional way — 'Houston, we have a problem!' — well, then, 'Houston, we don't have a problem!' Because Houston didn't identify the problem."
But another part of Houston was doing just that. Unbeknownst to Ham and the shuttle management, the low-level engineers of the Debris Assessment Team had concluded that the launch films were not clear enough to indicate where the foam had hit, and particularly whether it had hit the underside tile or a leading-edge RCC panel. Rather than trying to run their calculations in the blind, they had decided that they should do the simple thing and have someone take a look for damage. They had already e-mailed one query to the engineering department, about the possibility of getting the astronauts themselves to take a short spacewalk and inspect the wing. It later turned out that this would have been safe and easy to do. That e-mail, however, was never answered. This time the Debris Assessment engineers decided on a still simpler solution — to ask the Department of Defense to take some high-resolution pictures. Ignorant of the fact that the Kennedy group had already made such a request, and that it had just been peevishly canceled, they sent out two requests of their own, directed, appropriately, to Ron Dittcmore and Linda Ham, but through channels that were a little off-center, and happened to fail. Those channels were ones they had used in their regular work as engineers, outside the formal shuttle-management structure. By unfortunate circumstance, the request that came closest to getting through was intercepted by a mid-level employee (the assistant to an intended recipient, who was on vacation) who responded by informing the Debris Assessment engineers, more or less correctly, that Linda Ham had decided against Air Force imagery.
The confusion was now total, yet also nearly invisible — and within the suppressive culture of the human spaceflight program, it had very little chance of making itself known. At the top of the tangle, neither Ron Dittemore nor Linda Ham ever learned that the Debris Assessment Team wanted pictures; at the bottom, the Debris Assessment engineers heard the "no" without suspecting that it was not an answer to their request. They were told to go back to the Crater model and numerical analysis, and as earnest, hardworking engineers (hardly rebels, these), they dutifully complied, all the while regretting the blind assumptions that they would have to make. Given the obvious potential for a catastrophe, one might expect that they would have gone directly to Linda Ham, on foot if necessary, to make the argument in person for a spacewalk or high-resolution photos. However, such were the constraints within the Johnson Space Center that they never dared. They later said that had they made a fuss about the shuttle, they might have been singled out for ridicule. They feared for their standing, and their careers.
The CAIB investigator who asked the engineers what conclusion they had drawn at the time from management's refusal later said to me, "They all thought, 'Well, none of us have a security clearance high enough to view any of this imagery.' They talked about this openly among themselves, and they figured one of three things:
'"One: The "no" means that management's already got photos, and the damage isn't too bad. They can't show us the photos, because we don't have the security clearance, and they can't tell us they have the photos, or tell us the damage isn't bad, because that tells us how accurate the photos are — and we don't have the security clearance. But wait a minute, if that's the case, then what're we doing here? Why are we doing the analysis? So no, that can't be right.
'"Okay, then, two: They already took the photos, and the damage is so severe that there's no hope for recovery. Well ... that can't be right either, because in that case, why are we doing the analysis?
"'Okay, then, three: They took the photos. They can't tell us they took the photos, and the photos don't give us clear definition. So we need to do the analysis. That's gotta be it!'"
What the Debris Assessment engineers could not imagine is that no photos had been taken, or ever would be — and essentially for lack of curiosity by NASA's imperious, self-convinced managers. What those managers in turn could not imagine was that people in their own house might really be concerned. The communication gap had nothing to do with security clearances, and it was complete.
Gehman explained the underlying realities to me. He said, "They claim that the culture in Houston is a 'badgeless society,' meaning it doesn't matter what you have on your badge — you're concerned about shuttle safety together. Well, that's all nice, but the truth is that it does matter what badge you're wearing. Look, if you really do have an organization that has free communication and open doors and all that kind of stuff, it takes a special kind of management to make it work. And we just don't see that management here. Oh, they say all the right things. 'We have open doors and e-mails, and anybody who sees a problem can raise his hand, blow a whistle, and stop the whole process.' But then when you look at how it really works, it's an incestuous, hierarchical system, with invisible rankings and a very strict informal chain of command. They all know that. So even though they've got all the trappings of communication, you don't actually find communication. It's very complex. But if a person brings an issue up, what caste he's in makes all the difference. Now, again, NASA will deny this, but if you talk to people, if you really listen to people, all the time you hear 'Well, I was afraid to speak up.' Boy, it comes across loud and clear. You listen to the meetings: 'Anybody got anything to say?' There are thirty people in the room, and slam! There's nothing. We have plenty of witness statements saying, 'If I had spoken up, it would have been at the cost of my job.' And if you're in the engineering department, you're a nobody." |
