ORLANDO, Fla. - During the 17 years between space shuttle accidents, a succession of advisory groups sounded the alarm that NASA's safety systems and communications were eroding.
NASA often did little to heed the repeated warnings.
That point was driven home this week when the Columbia Accident Investigation Board blamed many of those same, continuing problems for creating "blind spots" that helped doom the shuttle Columbia and its seven-member crew.
In 1990, a General Accounting Office report warned that the safety offices at NASA field centers were not independent enough from the programs they were supposed to monitor.
Ten years later, the Shuttle Independent Assessment Team report, headed by then-Ames Research Center Director Henry McDonald, repeated that. It also warned that workers were afraid to speak up and that NASA managers had been lulled into a false sense of security by years of successful shuttle flights.
All the while, the Aerospace Safety Advisory Panel - which issues an annual report on the agency's human spaceflight programs - worried about budget cuts and their effect on safety.
Yet in its 248-page report on the Feb. 1 accident, the Columbia board said all of those problems, and many more cited in reports, still exist.
"They lost their ability to accept criticism, leading them to reject the recommendations of many boards and blue-ribbon panels," the board's report says.
A supplement to the report, written by board member Duane Deal, an Air Force brigadier general, is even more blunt: "History reveals NASA has repeatedly demonstrated a lack of regard for outside studies and their findings."
For example, numerous reviews found that NASA didn't effectively recognize risk or spot dangerous trends. If a surprise cropped up but didn't cause a problem, it became part of the accepted landscape instead of a red flag. It happened with the O-rings on Challenger and again with the insulating foam on the shuttle's external tank, the physical trigger that brought down Columbia.
On the advice of the McDonald task force, NASA worked on better methods to track trends, gather data and analyze risk. But the Columbia accident investigators found the system - and NASA's risk-taking attitude - still very troubling, calling the databases used to analyze problems "dysfunctional" and "marginally effective decision tools."
The Columbia report called the Aerospace Safety Advisory Panel, chartered after the 1967 Apollo 1 launch pad fire killed three astronauts, "independent, but often not very influential."
McDonald, a professor at the University of Tennessee-Chattanooga, said the findings of the Columbia investigators brought back dispiriting memories of his experience with NASA.
"It's the same finding we found - and when we tried to shake them up, we found the same reluctance to change that is now being evidenced," he said. "I'm not at all surprised at what they're finding. Disappointed, unhappy, but not surprised."
In their report, the Columbia investigators reached back to the recommendations of the so-called Rogers Commission, which played a similar role after the 1986 Challenger accident. The Columbia panel found that many of the same communications and safety issues discovered by the Rogers Commission are just as problematic now.
"There have been safety panels out the gazoo. But NASA just tells them to go talk in their hat," said Robert Hotz, a member of the Rogers Commission. "It's a deep part of the NASA culture. They won't listen to anyone else."
NASA was cooperative just after the Challenger accident, just as agency chief Sean O'Keefe is now promising to convert all of the Columbia board's recommendations into major changes.
"But they wore off," Hotz said. "That's what's frightening to me. NASA is back where it was 17 years ago."
Tom Young, a former head of Martin Marietta and a longtime member of the NASA Advisory Council, attributes the problems to the mindset within the human spaceflight program itself.
"They're the experts on human spaceflight and, as a result, my observation is they're very difficult to help - and what I mean by that is when you're insular, even if you're very good, things pass you by," he said. "They're not a lot interested in what other people have to say and have a lot of confidence in their own abilities."
This time, O'Keefe has vowed to follow the Columbia board's recommendations to the letter.
"That is our commitment," O'Keefe has said. "We intend to do that without reservation."
Already, the agency has moved to create an independent safety and engineering office, to be based at Langley Research Center in Virginia. That new group, which will report to the Office of Safety and Mission Assurance at NASA headquarters, is aimed at making the workers responsible for safety and technical issues completely independent of the shuttle program, to ensure that any concerns are fully aired.
NASA also has named a 27-member task force to advise the agency on how to turn those recommendations into major changes. Led by Apollo-era astronaut Thomas Stafford and Richard Covey, who flew on the first mission after the Challenger accident, the group is supposed to issue a report to O'Keefe about a month before the next launch.
But McDonald and others wonder whether that will be enough because the Stafford-Covey panel is only chartered for two years.
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