NASA's Dependence on Contractors is Faulted by Columbia Accident Investigators NASA’s dependence on contractors for most space shuttle operations is “a mistake,” a member of the Columbia Accident Investigation Board said as the board released its report on the disaster that killed seven astronauts. The report placed no blame for the accident on the prime contractor, United Space Alliance LLC, a company co-owned by Boeing and Lockheed Martin. But the board ripped NASA for lax oversight of USA’s work and for flawed communications between government and contractor personnel. “The Board believes that deficiencies in communications…were a foundation for the Columbia accident,” the report said. The board named two causes of the accident: a 1.7 pound piece of foam insulation that fell off the orbiter’s external fuel tank and punched a hole in Columbia’s left wing; and the culture of NASA’s manned space program, a “can-do” attitude that was unfriendly to anyone who said “can’t do.” “In the Board’s view, NASA’s organizational culture and structure had as much to do with this accident as the External Tank foam,” the report said. United Space Alliance’s 10,000 employees and its subcontractors handle shuttle operations ranging from maintenance and repair of the spacecraft to training of NASA’s astronauts and Mission Control personnel. NASA awarded the Space Flight Operations Contract to USA on a sole-source basis in 1995. It consolidated dozens of separate contracts for various shuttle operations. USA has since been paid $12.8 billion. The contract comes up for option next year. But the board said the decision to outsource was based on a mistaken idea, expressed in a 1995 report by the legendary NASA flight director Christopher Kraft: “The Shuttle has become a mature and reliable system…about as safe as today’s technology will provide.” The board said that conclusion was “at odds with the realities of the Shuttle Program.” Kraft recommended choosing a single contractor to run the operations. That was done over the objection of NASA’s independent, but largely toothless, Aerospace Safety Advisory Panel, the investigating board said. “We believe that was a mistake,” said board member John Logsdon, a space historian at George Washington University, at an Aug. 26 news briefing in Washington. However, the report says, “The Board found no evidence that the transition from many Space Shuttle contractors to a partial consolidation of contracts under a single firm has by itself introduced additional technical risk into the Space Shuttle Program. The transfer of responsibilities that has accompanied the Space Flight Operations Contract has, however, complicated an already complex Program structure and created barriers to effective communication.” The board said the contract “involved substantial transfers of safety responsibility from the government to the private sector; rollback of tens of thousands of Government Mandated Inspection Points; and vast reductions in NASA’s in-house safety-related technical expertise.” As NASA drastically reduced its workforce in the 1990s, it became ever more dependent on contractors, the report found. About 85% of the agency’s budget now goes to contractors. Contractor employees working on the shuttle program outnumber NASA personnel by 10-to-1. The USA contract is performance-based. The board noted that USA is required to “meet a series of safety ‘gates’” to earn performance fees, but also receives a bonus for each mission that is completed on schedule. The contract contains a powerful cost-cutting incentive: USA keeps 35 cents of every dollar it saves. “There is a potential for conflict between contractual and programmatic goals,” the board added. Although NASA projected the Space Flight Operations Contract would save $500 million to $1 billion a year, the board said the savings “have not materialized.” It cited estimates that the contract had produce total savings of $1 billion in its first six years. One board member heaped praise on workers on “the shop floor” where shuttle maintenance and flight preparation is done at the Kennedy Space Center in Florida. Rear Adm. Stephen Turcotte, a Navy pilot, said, “Those are good people…They’re working their hearts out.” But he added that many of the technologies and practices they use don’t measure up to the standards of such high-risk programs as military aircraft, submarines and nuclear reactors. Much of NASA’s testing equipment “is 22 years old,” he said. “It’s frozen in time.” To analyze the effect of the foam hitting Columbia’s wing, the board said, Boeing engineers used a computer model called Crater that was designed to predict the effect of small pieces of debris; the foam that struck Columbia was 400 times as large as anything that had previously been analyzed by that model. In addition, the report said, Boeing had recently transferred responsibility for the Crater program to its Houston office from Huntington Beach, CA. The Columbia flight marked the first time Houston had taken full responsibility for the Crater analysis; the engineer who conducted the tests had used the program only twice before. The board said NASA personnel lacked the expertise to question the Boeing analysis. NASA and Boeing said they are developing a new program to analyze debris hits. The fatal flaw in NASA’s response to the debris hit on Columbia was the shuttle managers’ strongly held conviction that the lightweight foam could not seriously damage the spacecraft, the board found. Even though pieces of foam had fallen off on many flights, NASA managers did not consider that a danger signal because the foam had never caused significant damage. Managers running the flight saw the foam only as a maintenance problem, not a safety issue. The board said, “With no engineering analysis, shuttle managers used past success as a justification for future flights.” “The machine was talking, but why was nobody listening?” asked board member Steven Wallace, the Federal Aviation Administration’s chief accident investigator. Even after Columbia disintegrated Feb. 1, the board said, shuttle managers were still “in denial,” not believing that the foam could have caused the disaster. The board found NASA managers missed at least eight opportunities to learn more about possible foam damage during Columbia’s flight. Management rebuffed requests by several engineers for spy satellite imagery to examine the wing, and the engineers did not push the issue. Even the head of NASA’s safety office declined to pursue the matter. In reconstructing the events during Columbia’s flight, the board noted many chilling “echoes” of the 1986 Challenger explosion, which also killed seven crew members. Just as in 1986, engineers working for both NASA and contractors were raising a safety issue, but their concerns never reached top mission management. The board said NASA had never created an independent safety office, as the Challenger investigating commission recommended. The report also cited the impact of budget and personnel cuts on the space agency. “The past decisions of national leaders — the White House, Congress, and NASA Headquarters — set the Columbia accident in motion by creating resource and schedule strains that compromised the principles of a high-risk technology organization,” the reports says. “The measure of NASA’s success became how much costs were reduced and how efficiently the schedule was met. But the space shuttle is not now, nor has it ever been, an operational vehicle. We cannot explore space on a fixed-cost basis.” It said Daniel Goldin, NASA administrator from 1992 to 2001, created “continuous turmoil” in the agency with his mandate to do things “faster, better, cheaper.” The board issued 29 recommendations, and said more than half of them should be accomplished before the shuttle fleet flies again. Unless NASA changes its organization and culture, the board warned, “the scene is set for another accident.” But the chairman of the investigating panel, retired Adm. Harold Gehman, acknowledged, “NASA has been told this 10 times.” President Bush and NASA Administrator Sean O’Keefe both promised that the shuttles will fly again. “We have accepted the findings and will comply with the recommendations to the best of our ability,” O’Keefe said. But the Washington Post reported that administration officials say there will be no significant increase in NASA’s budget. NASA has been hoping to resume flights next spring. United Space Alliance had no immediate comment on the report. The report is available at www.caib.us.