Lessons from accidents forgotten, experts say

America's most spectacular spaceflight successes were born of reforms spurred by catastrophic accidents - from the fatal Apollo fire that paved the way for the first moon landing to the Mars Observer mishap that fostered efforts to explore the red planet.

Time and again, it took the shock of disaster or death to galvanize the National Aeronautics and Space Administration's senior managers and an engineering bureaucracy blinded by belief in its own infallibility, historians and sociologists said.


"Periodically, NASA gets vaccinated with an accident," said space policy analyst John Pike, who operates the national security Web site

The causes of the fatal Columbia accident, however, so closely mirror the management flaws and engineering miscalculations that killed the seven crew members aboard Challenger 17 years ago that many analysts are skeptical of NASA's capacity today for reform and self-renewal.


Despite persistent efforts to mend its ways, the space agency is still afflicted with the curse of the "Can Do" attitude, they said. NASA is afraid to admit failure, all but incapable of accepting independent criticism and unwilling to trim its space-faring ambitions to match its resources.

The world's only reusable spacecraft and its crew foundered not on the unexplored reefs of space, but on familiar shoals of bureaucratic incompetence, imprudent cost-cutting, management pressures and political expediency.

"Some of the issues facing NASA now are at least as old as the Apollo fire," said Duke University historian Alex Roland.

Public revulsion at the serious safety problems uncovered after the Apollo fire in 1967, which killed three astronauts during a launch pad test, provided the impetus to revolutionize the management of human spaceflight, said American University historian Howard McCurdy.

Errant aerospace contractors were brought to heel; design flaws were reworked; policy dictates were abandoned and key managers were replaced. NASA itself was forced to adopt a more thorough method of spaceflight operations called systems management, pioneered by U.S. Air Force project leaders in their development of intercontinental ballistic missiles.

"The result was that we went to the moon without losing any astronauts," McCurdy said, even though the agency had anticipated that almost one-third of the Apollo astronauts might die in the effort.

While the hard-won management lessons of the Apollo fire helped NASA secure victory in a race to the moon with the Soviet Union, they were forgotten as the space shuttle program took form in the early 1970s.

To secure funding approval, NASA officials seduced the taxpaying public with breezy promises of routine access to space, 52 shuttle flights a year, orbital industries and a tenfold reduction in launch costs, historians said.


But the people in charge of the shuttle program ran afoul of fierce schedule pressures and the engineering reality of running the most complex flying machine ever built. Danger signals were overlooked or, worse, taken as reassuring evidence that systems could survive safely outside their operating margins.

It took an accident in 1986 - and the death of the seven Challenger crew members - to bring the agency to its senses.

In a harsh assessment of NASA and its shuttle managers, the presidential commission that investigated the 1986 disaster insisted that the agency strengthen the safety organization that oversees the shuttle, reduce its flight rates, redesign its solid rocket boosters and improve communications so that safety concerns could be more clearly heard within the organization.

For a time, the reforms ensured the safety of human spaceflight.

"NASA responded to the Rogers Commission in just the right way," Roland said. "Over time, their resolve simply eroded. The Columbia accident is a repeat of the Challenger accident. It is the same systemic failure."

With engineers afraid to speak out and mission managers avoiding bad news, the program's complex rules and reporting procedures became a parody of safety and quality assurance operations, analysts said.


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