The external investigation committee presented a series of technical and managerial failures: in the last 20 years, repeated injuries of the insulating foam in the NASA shuttles were ignored
The head of the investigation committee (left) presents the conclusions, yesterday
At the end of six months of intensive investigation, the external investigation committee that examined the circumstances of the Columbia space shuttle crash determined yesterday that two main factors were behind the disaster. On the technical level, it is about the impact of a piece of insulating foam on the shuttle's wing immediately after launch, and on the administrative level, it is about the "loss of NASA's control systems", according to retired Admiral Harold Gaiman, head of the investigative committee.
The full report, published yesterday in Washington, severely criticizes the management of the American space agency and the manner in which it managed the space program. "The inefficient leadership of the organization failed in fulfilling its commitment to do everything possible to ensure the safety of the staff members," the committee stated. The members of the committee pointed out a series of failures in NASA's conduct, both in the way it handled the malfunction in the "Columbia" shuttle after the damage became clear, both in its ignoring over the years of similar malfunctions that passed peacefully, and in its general policy, which it interpreted as a continuous erosion of flight safety in favor of meeting schedules, while continuously cutting budgets . "We are convinced that the organizational problems are no less important than the issue of the isolation foam," Admiral Gaiman said yesterday.
The space shuttle "Columbia", which was on the scientific mission STS-107, crashed over the US skies on February 1 after completing 16 days in space. The seven astronauts on board were killed in the crash, including the first Israeli astronaut in space, Air Force pilot Ilan Ramon. The committee found that the crew members were killed almost immediately - the crew cabin was destroyed in a process that lasted only 24 seconds and that began a few seconds after the contact with the ground was lost. The cause of death was defined as "severe trauma and loss of oxygen". The committee found that the astronauts did not wear the space suits as required when returning to Earth, but this detail "would not have improved their chances of survival", the report stated.
The committee states, however, that if it had become clear on the seventh day of the mission that there was indeed damage to the shuttle, the astronauts could have been rescued safely by immediately launching the shuttle "Atlantis", transferring the crew members to it and abandoning the "Columbia" in space.
The technical reason for the shuttle crash is clear: the piece of foam that broke off from the fuel tank 81 seconds after the launch, hit the leading edge of the left wing with great force and caused a hole, while returning to the atmosphere allowed hot gas to enter the shuttle's body. The gas caused the wing to fall and the shuttle to disintegrate.
The investigation committee formulated some essential recommendations, before launching the next ferry, to prevent the recurrence of this type of malfunction. She called on NASA to develop a plan to reduce the shedding of pieces of insulation during takeoff, to strengthen the shuttle's body so that it can withstand this type of damage, to require every flight into space to include satellite images that will examine the shuttle's body during flight, and to develop methods for repairing damage and rescuing crew members in the event of damage to the shuttle.
But beyond the one-off malfunction that led to the loss of the "Columbia" and its crew members, the investigative committee gave great weight to the organizational and managerial circumstances at the American space agency. In an analysis of how decisions were made regarding the last "Columbia" space mission, the report notes four cases of poor judgment. The first was dealing with the problem of the insulation foam being damaged and the wrong assessment that it was an insignificant matter that would not cause serious damage. These types of injuries happened on many of the flights and were never handled properly. Another misjudgment was the refusal of the program managers to order satellite images to check the damage to the ferry, even though engineers in the organization urged the management to do so. Another problem was the pressure of the schedule - NASA's management constantly demanded from the professionals to speed up the launch of the shuttle, therefore safety problems and issues that aroused suspicion were not properly addressed. The fourth problem was the lack of a repair and rescue plan, which in the committee's opinion had an effect, if only psychologically, on the way the damage to the ferry was handled. Had such a plan been in place, mission managers might have been more open to discussing the dangers of hitting the foam. The committee determined that no one at NASA took the question of the damage seriously and that even when the calculations were made - which were themselves wrong - none of the managers took responsibility for it.
The investigative committee determined that the culture of ignoring safety issues began twenty years ago and that safety issues were gradually pushed to the sidelines. In the committee's opinion, another accident could occur in the future - "if the technical, organizational and cultural recommendations are not implemented, not much will be achieved to prevent the possibility of another accident happening", the report said.
NASA refuses to accept personal responsibility
The American space agency NASA announced yesterday that it accepts the findings of the investigative committee and its recommendations, but none of the heads of the agency announced their acceptance of personal responsibility. The head of the space agency, Sean O'Keefe, said yesterday that "we have received the findings and we will comply with the recommendations to the best of our ability" and noted that work has already begun on implementing some of the conclusions. He defined the committee's report as a "roadmap" for correcting the deficiencies. The committee did not call for the resignation of NASA managers and even said that this step would not help because the problem is in the culture that has taken root in the agency.
The manager of the shuttle project at NASA at the time of the accident, Ron Ditmore, has already resigned from his position. The other managers still remain in their positions.
NASA's failures: the public now understands that the space program that filled his heart with pride is full of holes
"We want to open a public debate on the issue of sending humans into space," Admiral Harold Gaiman, head of the investigation team into the Columbia shuttle crash, announced yesterday at a press conference in Washington upon the presentation of the report. Over the past six months, the committee has mapped out over 250 pages the double lie that was the basis of the American space program - on the one hand, a nation and government that wants a human space program but is unwilling to meet its budgetary burden, and on the other hand, a space agency that is unwilling to recognize its limitations and prefers to round corners instead of declaring that it cannot to meet her plans. The report calls on the American nation to decide what it wants now and how much it is willing to pay for this ambition and recommends a careful path to a solution - to continue with the plan to send humans into space, but to outline a plan that is within the bounds of what is possible - technologically and financially. The 13 members of the committee, most of whom are not affiliated with NASA, unanimously agreed that the manned space program should continue and that the serious findings revealed by the report do not require abandoning the vision, it just needs to be adapted to reality.
The US will not abandon its space program, but the serious report that was slapped in the face of NASA yesterday requires America to re-examine some myths of the last decades. The American people now understand that the space program that filled their hearts with pride and stuck the US flag on the moon, was a program full of holes. Behind the vision stood the public and politicians who demanded results in an unrealistic schedule and in front of them was a space agency that could not withstand the pressure and launched unsafe shuttles. The public is forced to understand that from now on the space agency carries with it the mark of disgrace established by the committee, according to which it did not live up to its basic obligation to do everything to maintain the safety of the astronauts.
How does the US space agency proceed from here? On the technical level the path is clear. The committee indicated the improvements and repairs that should be introduced in the short and long term, and the agency's engineers have already started working on plans to reduce the fall of fragments, to protect the shuttle's body and to examine the condition of the shuttle while in flight. But at the organizational level it will be more difficult to chart the way forward. The improper management culture pointed to by the investigation committee's report began twenty years ago and is built into the system - the treatment of malfunctions as a routine matter, the ignoring of warning signs and the silencing of anyone who tried to voice a different opinion. The solution will be to increase the supervision of the space program at all levels - within NASA, the committee recommends establishing a separate safety body that will supervise and approve every action, and outside the organization, the administration and Congress will be asked to demonstrate more involvement in what is happening at the space bases. NASA promised to scrupulously adopt the conclusions, but this is what it did even after the "Challenger" crash. Admiral Gaiman remains skeptical: "The committee's fear is that after a year or two, there will be an erosion of this strictness. This has already happened to NASA in the past," he said.
Members of the Ramon family refused to comment on the report
Rona Ramon, the widow of the Israeli astronaut Ilan Ramon who died in the "Columbia" crash on February 1, refused yesterday to comment on the committee's conclusions. Ramon only said that the recommendations, which appear in the report published yesterday in Washington, in which the American space agency is harshly criticized, are familiar to her.
Ramon, along with the other astronauts' families, received the report of the external review committee that investigated the shuttle crash a day before it was released to the general public. Rona Ramon now lives with her four children in Houston, Texas, not far from the NASA space base.
Ilan Ramon's father, Eliezer Wolferman, told "Haaretz" last night: "I am now learning about the findings of the Columbia report through television and the Internet and will only address them in a few days, after I have studied them."
