NASA's own bureaucracy was as much to blame for the space shuttle Columbia disaster as a dislodged piece of foam insulation that punctured the orbiter's wing on takeoff, the board investigating the Feb. 1 accident said in its final report, released yesterday.
"The first cause was the foam that came off and struck the reinforced carbon-carbon material. The second was the loss within NASA of its checks and balances," Harold W. Gehman Jr., chairman of the Columbia Accident Investigation Board, said at a news conference.
In a blistering 248-page document, the 13-member board said bad management within the National Aeronautics and Space Administration and a flawed safety culture helped doom Columbia and its seven-member crew.
The board issued 29 recommendations for the space agency, 15 of which must be completed before the next launch. But, in often-harsh terms, the panel said that both striking changes and heightened oversight are needed to ensure that the remaining three shuttles fly safely.
"Based on NASA's history of ignoring external recommendations, or making improvements that atrophy with time, the board has no confidence that the space shuttle can be safely operated for more than a few years based solely on renewed post-accident vigilance," the report said.
The board also urged Congress and the White House to require long-term changes in the way NASA conducts itself to prevent the recommendations from becoming the "second report on the shelf to be followed by a third report."
"I don't believe we should just trust NASA to do things," Gehman said.
Board members recommended that NASA:
Take high-resolution pictures of the external fuel tank after it separates from the shuttle and make them available soon after launch.
Determine the structural integrity of the heat-shielding material known as reinforced carbon-carbon, which was damaged by the foam strike, before shuttles fly again.
Get in-flight images of the shuttles from spy satellites and other sources.
Use the international space station as an orbiting repair and inspection shop for damaged shuttles.
Upgrade its imaging system to get at least three "useful views" of the shuttle starting at liftoff and continuing at least until the solid rocket boosters separate during ascent.
Board members said some of those urgent fixes will prove simple - for example, obtaining satellite photos of the shuttle orbiting Earth, allowing a long-distance damage inspection.
By far, board members and outside experts said, the toughest immediate challenge NASA faces will be developing an untested system to allow spacewalkers to inspect and fix damage to the thermal protection tiles and the reinforced carbon-carbon, or RCC, that protects the wing edge.
'The biggest challenge'
"I think we're all in agreement that the RCC repair will be the biggest challenge," said board member Sheila E. Widnall, a professor of aeronautics and astronautics at MIT. "It will be an engineering exercise that will wring out the organization."
NASA is already working on ways to patch a hole such as the one that doomed Columbia. The repair would involve spacewalkers inserting an umbrella-like locking device into the hole, which would be screwed down and caulked with heat-resistant material to seal the patch.
Yesterday's report confirmed what investigators had earlier concluded - that the Columbia disaster was caused by a 1.67-pound chunk of insulating foam that flew off the external tank nearly 82 seconds after takeoff and struck the shuttle's left wing. The impact created a hole large enough to allow super-hot gases to penetrate and destroy the wing during re-entry.
"The foam did it," said board member G. Scott Hubbard, director of NASA's Ames Research Center.
Launched Jan. 16, Columbia was racing toward a Florida landing early Feb. 1 when the ship broke apart about 200,000 feet over Texas, killing all seven astronauts on board.
In its report, the board outlined a disaster scenario of budget cuts, downsizing and prolonged use of the shuttle fleet beyond its original replacement schedule.
Board member John M. Logsdon, a George Washington University professor, said a 40 percent cut in NASA's budget and subsequent reduction of its work force over the past decade contributed to Columbia's failure: "It was operating too close to too many margins."
Adm. Stephen A. Turcotte chided NASA for not updating its inspection and maintenance procedures as the shuttle fleet aged: "As aircraft ages, the maintenance changes, the inspection changes. We found that lacking."
Turcotte described the shuttle program as "frozen in time."
The board questioned how the continual problem of "foam-shedding and other debris" striking the orbiter became a routine maintenance issue rather than a serious safety concern.
"It seems that shuttle managers had become conditioned over time to not regard foam loss or debris as a safety-of-flight concern," the report concluded. "This rationale is seriously flawed."
The board also criticized NASA for trying to do too much too fast to meet a Feb. 19, 2004, deadline to deliver a section of the space station. An aggressive launch schedule of 10 flights in less than 16 months left little time or attention to the shuttle program's mounting safety problems, the board concluded.
"When a program agrees to spend less money or accelerate a schedule beyond what the engineers and program managers think is reasonable, a small amount of overall risk is added," the report said. "These little pieces of risk add up until managers are no longer aware of the total program risk, and are, in fact, gambling."
In recommending changes within NASA that would eliminate future shuttle disasters, the board called upon the leadership of the space agency, Congress and the White House to place safety ahead of meeting schedules and cutting costs.
"National leadership needs to recognize that NASA must fly only when it is ready. As the White House, Congress and NASA Headquarters plan the future of human space flight, the goals and the resources required to achieve them safely must be aligned," the report said.
At a news conference after the report's release, NASA Administrator Sean O'Keefe pledged to follow the "blueprint" of the board's recommendations. He said one of the board's recommendations - the creation of an independent NASA Engineering and Safety Center - should be in place within the next 30 days.
O'Keefe also quoted Gene Kranz, who was Mission Control flight director when a fire aboard Apollo 1 killed three astronauts on Jan. 27, 1967.
Spoken two days after that tragedy, Kranz's words would echo within the pages of the Columbia accident report.
"Whatever it was, we should have caught it. We were too gung-ho about the schedule. We locked out all the problems we saw each day in our work. Every element of the program was in trouble, and so were we," Kranz said. "We are the cause."
Robyn Suriano and Sean Mussenden of The Orlando Sentinel's staff contributed to this article. The Sentinel is a Tribune Publishing newspaper.