Columbia Accident Investigation Complete

A transformative force in EHS

CONTACT INFORMATION Campbell Institute national safety council

call (630) 775-2063 this leading-edge knowledge is brought to you by web thecampbellinstitute.org the campbell institute email [email protected] 1012 900001825 ©2012 national safety council 2011 Executive Edge Panel: NASA’s Journey of Cultural Transformation

Presented by: Johnny Stephenson, NASA John Casper, NASA Hal Bell, NASA Wayne Frazier, NASA Moderated by: Bill Williams, Maersk Inc.

Presented by: Johnny Stephenson Deputy Director, Office of Strategic Analysis and Communication Marshall Space Flight Center National Aeronautics and Space Administration

1960 1970 1980 1990 2000 2010 Space Shuttle Program Apollo Program Constellation SLS

Apollo 11 Apollo/Soyuz Spacelab Shuttle/MIR

Skylab ISS first element launch ISS complete

Saturn V STS-1 Ares 1-X first flight

NASA’s culture is characterized 3 by a “can-do” attitude

NASA’s Legacy

1960 1970 1980 1990 2000 2010 Space Shuttle Program Apollo Program Constellation SLS

Apollo 11 Apollo/Soyuz Spacelab Shuttle/MIR

Skylab ISS first element launch ISS complete

Saturn V STS-1 Ares 1-X

Challenger Accident Columbia Accident Apollo I Cabin Fire

STS return to flight STS return to flight

Failure, Self-examination, Recovery. 4

Challenger… a wake-up call

1960 1970 1980 1990 2000 2010 Space Shuttle Program Apollo Program Constellation SLS

Apollo 11 Apollo/Soyuz1986 Spacelab Shuttle/MIR

The Roger’sSkylab Commission ISS first element launch ISS complete • managers propensity to withhold Saturnproblems V STS-1 Ares 1-X

Apollo I Cabin• silent Fire safety program, lackingChallenger Accident Columbia Accident independence STS return to flight STS return to flight

Close calls – Nagging Questions

1960 1970 1980 1990 2000 2010 Space Shuttle Program Apollo Program 1999 Constellation SLS Shuttle Independent Apollo 11 Apollo/Soyuz Spacelab Shuttle/MIR Assessment Team Skylab ISS first element launch ISS complete • ability to manage risk eroded “by the desire Saturn V to reduceSTS- 1costs” Ares 1-X • S&MA was not sufficiently independent Apollo I Cabin Fire Challenger Accident Columbia Accident • conflicting messages due to emphasis on cost and staff STSreductions return to flight STS return to flight • organizational culture deemed “too insular” • need for improved communications

A new generation takes another look

1960 1970 1980 1990 2000 2010 Space Shuttle Program Apollo Program 2002 Constellation SLS One NASA Apollo/Soyuz Shuttle/MIR Apollo 11 • lack of anSpacelab Agency unified goal or shared vision Skylab ISS first element launch ISS complete • operational stovepipes where leaders often placed organizational interests ahead of agency interests Saturn V STS-1 Ares 1-X • unhealthy competition between centers and Apollo I Cabin Fire enterprisesChallenger for Accident limited resources Columbia Accident • the need toSTS add return emphasis to flight to the softer sciencesSTS returnin to flight addition to technical excellence • the need to improve communications and culture

Columbia… Symptoms Remain

1960 1970 1980 1990 2000 2010 Space Shuttle Program Apollo Program 2003 Constellation SLS CAIB Report Apollo/Soyuz Shuttle/MIR Apollo 11 Spacelab• organizational causes Skylab ISS first element launch ISS complete • reliance on past success as a substitute for sound engineering practices (such as testing) Saturn V STS-1 Ares 1-X • organizational barriers that prevented effective Apollo I Cabin Fire Challengercommunication Accident Columbia Accident STS• lack return of to integrated flight management acrossSTS return to flight program elements • reliance on an informal chain of command

Lessons “learned”?

1960 1970 1980 1990 2000 2010 Space Shuttle Program Apollo Program 2004 Constellation SLS Diaz Report Apollo/Soyuz Shuttle/MIR Apollo 11 Spacelab• leadership accountability to establish a culture Skylab that allows for dissentingISS first elementopinions launch ISS complete • “Lessons captured” versus “Lessons learned” Saturn V STS-1 Ares 1-X • inhibitors to the flow of effective Apollo I Cabin Fire Challengercommunication Accident Columbia Accident STS return to flight STS return to flight

People versus Process

1960 1970 1980 1990 2000 2010 Space Shuttle Program Apollo Program 2004 Constellation SLS Culture Surveys Apollo/Soyuz Shuttle/MIR Apollo 11 Spacelab• “Excellence is a treasured value when it Skylab comes to technicalISS first work, element but launch not seen…ISS complete for other aspects of the organization’s Saturn V STS-1 functioning” Ares 1-X Apollo I Cabin Fire Challenger Accident Columbia Accident

STS return to flight STS return to flight

Learning – So What?

Safety culture isn’t created overnight; it’s created over time and difficult to change.

Technical organizations tend toward mechanistic procedures to fix organizational problems. The greatest challenge to communications is often hearing the signal over noise.

At what cost – safety? 13

The National Aeronautics and Space Administration

www.nasa.gov

Space Shuttle Program Return to Flight

Presented by: John Casper Space Shuttle Program Associate Manager, Veteran Space Shuttle Astronaut National Aeronautics and Space Administration

New Views: External Tank Camera

RTF Overview

• CAIB Accident and Investigation

• RTF Implementation Plan

• STS-114 Flight Rationale

• Status of RTF Actions

• External Tank Status

Columbia Impact on Human Space Flight

February 1, 2003

• Shuttle Fleet Grounded

• Space Station Crew Reduced to Two

• Space Station Assembly on Hold

• Dependence on ISS Partnership

Columbia Accident Scenario

• 81 seconds after launch, foam insulation on the Tank strikes the Shuttle’s wing at Mach 2.46

• On re-entry, plasma enters the breached wing

• Plasma flow degrades wing internal structure

• Wing structural failure leads to loss of vehicle control and break-up STS-112 External Tank Bipod Foam Loss

Missing Foam on -Y Bipod Ramp Columbia Accident Investigation Complete

• Report Released August 26, 2003 – Columbia Accident Scenario – 29 Recommendations; 15 Return to Flight (RTF) and 14 Long-Term

• Report Focus: – Culture and Organization – Requirements for safely returning to flight – Technical Excellence

Admiral Hal Gehman Columbia Board Chairman Agency Response to CAIB Report

The NASA Administrator documented his response to the CAIB report in NASA’s Implementation Plan for Space Shuttle RTF and Beyond Sean O’Keefe

• NASA will “accept, embrace, and comply” with the CAIB report and recommendations

• NASA will “Raise the Bar” above the CAIB recommendations

• When fixes are completed, and the Space Shuttle is fit to fly safely, then and only then will NASA return to flight CAIB Recommendations (RTF)

3.2-1 External Tank Thermal Protection System Modifications 3.3-2 Orbiter Hardening and Thermal Protection System Impact Tolerance 6.4-1 Thermal Protection System On-Orbit Inspect and Repair 3.3-1 Reinforced Carbon-Carbon Nondestructive Inspection 3.4-1 Ground-Based Imagery 3.4-2 External Tank Separation Imagery 3.4-3 On-Vehicle Ascent Imagery 6.3-2 National Imagery and Mapping Agency Memorandum of Agreement 4.2-1 Solid Rocket Booster Bolt Catcher 4.2-3 Closeout Inspection 6.2-1 Scheduling 6.3-1 Mission Management Team Improvements 9.1-1 Detailed Plan for Organizational Changes 10.3-1 Digitize Closeout Photographs NASA Implementation Plan for RTF

• Evolving Plan

• Periodically updated

• Defines RTF process

• Documents technical progress for closing CAIB recommendations and Space Shuttle Program “Raising the Bar” initiatives; and RTF budget estimates

• Final Release – May 15, 2007 Published on nasa.gov website

RTF Planning Process

Columbia Accident Investigation Board (CAIB) Recommendations

Space Shuttle Program Proposes Plan

Space Flight Leadership Council Approves Plan

Stafford Covey Task Group (SCTG) Validates Plan

Shuttle Returns to Flight Columbia Debris Recovery Facts

• Columbia broke up at 201,000 ft; 12,400 mph • Debris Landed in East TX and LA • 84,000 Pieces Recovered • 38 % of Columbia Recovered (84,900 Lbs) • 270 Agencies Involved • 25,000 Total People Involved • 2400 NASA People Involved • NASA Initiated the Rapid Response Team during the afternoon of Feb 1. • Recovery Effort February 1 - April 30, 2003 • Columbia Crew Search and Recovery Separate from Debris Recovery • Goal of the Recovery – Public Safety (Local Communities from any Hazard) – Collection and Catalog Debris – Aid in Accident Investigation Public Safety (Protect Local Communities from any Hazard) – Collection and Catalog Debris – Aid in Accident Investigation

External Tank RTF Status

LO2 Feedline Bipod Ramp Fwd & Aft Intertank Flange Closeout PAL Ramps ET Feedline Camera • Camera being installed TPS Verification, Validation Redesigned Bipod Fitting

and Certification Plan • Critical design review • TPS Certification Team presented complete; closeout rationale for removing and replacing sprays in work the ET-120 and 121 forward longeron sections; new closeout spray process being developed

LO2 Feedline Bellows Ice Elimination Intertank Flange / PAL Ramp Improvements • CDR Board concurred • Thrust panel/Intertank flange hand spray closeout with drip lip redesign; validation and verification sprays complete; significant validation CDR Board successfully completed on Sep 29 work remains STS-114 Flight July 2005 • 22 missions were flown after returning to flight • 21Number to the International 1 Priority Space –Station Safe Mission Execution • 1 to refurbish the Hubble Space Telescope • 135 Space Shuttle total missions were flown • 355 total individuals were flown • 180 payloads were deployed, 53 were returned, 10 serviced (HST 5 times) • 3.5 million lbs useable cargo delivered to space; 237,000 lbs returned

54 Shuttle Program Legacy

• Hubble Space Telescope deployment and servicing missions

• Assembly and outfitting of the International Space Station (37 missions flown)

• Developing the world’s premier human spaceflight operations team

Transformation – The Path to Technical Excellence

Technical Authority

Presented by: Hal Bell Deputy Chief Engineer National Aeronautics and Space Administration

How do you know…? (CAIB Report Excerpts) Cultural traits and organizational practices detrimental to safety were allowed to develop, including: • Reliance on past successes as a substitute for sound engineering practices • Organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion • Lack of integrated management across program elements • Evolution of an informal chain of command and decision- making process that operated outside the organization’s rules

Insulating Foam Separates from Bipod Ramp and Impacts Left Wing of Columbia

The Bipod Ramp

Impact Analysis and Testing

Orbiter Leading Edge Full Scale Tests

68 External View of RCC Panel 8 Test Background (CAIB Report Excerpts) • Naval Reactor Success Depends on: – Concise and timely communication of problem using redundant paths – Insistence on airing minority opinions – Formal written reports based on independent peer- reviewed recommendations – Facing facts objectively and with attention to detail – Ability to manage change and deal with obsolescence

Background (Cont) • CAIB R7.5-1 recommended establishing an independent Technical Authority for Shuttle • NASA established independent Technical Authority (iTA) for the Shuttle and made the decision to expanded TA across NASA • The Technical Excellence initiative will expand the Technical Authority concept across NASA – Consistent with NASA governance NPD 1000.0

Technical Authority

Programs/Project Engineering Technical Authority Structure Administrator Deputy Administrator CE Level 3 Authority Associate Administrator

Level1

Mission Directorate Center AA Director Level 2 Authority

Level 2

Program Program CE Manager (Level 2) Center Eng. Director

Integration

Level 3 Project Project CE Direct Report Managers (Level 3) Eng.Tech Authority Program Authority Matrix Report Discipline Engineers 72

Key Attributes of Technical Authority • Organizationally separate from Program and Project • Funded by Headquarters separate from the Program or Project • Technical authorities will be selected based on demonstrated technical competence and leadership

Engineering Technical Authority • Establishes and is responsible for the engineering design processes, standards, specifications, rules, practices, etc., necessary to fulfill programmatic mission performance requirements. • Approving changes to, and waivers of all Engineering TA owned requirements. • Serving as members of program/project control boards, change boards, and internal review boards • In the case of a dispute, resolution is sought at successively higher levels of Programmatic Authority and Engineering TA per the dissenting opinion process • Provide technical consistency across NASA

Wake up call indicators 1. Substitutions are being made for sound physics based engineering practices. 2. Roadblocks to redundant, unfettered paths of communication develop over time. 3. Reduced tolerance for minority opinions with reducing levels of support from stakeholders. Fear of retribution grows. 4. Can do cultures put under the pressures of trying to do too much with too little begins to produce trades that are not in the best interests of the program or organization. 5. Slow evolution of shadow organizations, informal chains of command, and conducting business outside norms of a rules based cultures --all signs for the need of a pause and discovery.

Restoring and Sustaining a Safety Culture Presented by: Wayne Frazier Office of Safety and Mission Assurance National Aeronautics and Space Administration

® © 2011 National Safety Council Where NASA Thought It Was • In the late 90’s and early 2000’s NASA became overconfident regarding safety performance – Agency Safety Initiative (protect the public, our workforce, our valuable assets) – We had flown the world’s most complex space vehicle ~87 missions over 17 years without a loss since Challenger – ISO 9000 agency certification (first federal agency with all locations certified)

Where NASA Thought It Was (cont) – VPP “STAR” rating at half of NASA Centers – One of lowest LTCR and TCR rates in gov’t – Proud and devoted workforce with a “can do” attitude • NASA perennially ranked as one of the best places to work in the gov’t – NASA Safety Reporting System (NSRS) did not highlight any significant concerns

CAIB Concerns with Safety Culture • But CAIB discussed problems in our organizational safety culture as well as programmatic safety – Lack of Shuttle upgrades – Currency of Hazard reports/analysis – “Engineering by viewgraphs” – “Missed opportunities” – Safety Program shortcomings – “Blind spots” in safety culture

NASA Response to Columbia Incident

Organizational Response • 2004 “Diaz” Report • Behavioral Science and Technology, Inc (BST) 2004-2005 • New Governance Model/Core Values • Technical Excellence • Benchmarking • Culture assessments • SMA “Yes if Awards”

2004 “Diaz” Report • Appointed by Administrator to look at CAIB Report’s broader applicability across NASA • Forty actions in 7 specific areas – Leadership – Organizational Structure – Risk Management

2004 – 2005 Behavioral Science and Technology, Inc. • 3 phase program – Initial assessment of safety culture and plan to go forward – Pilot phase tested at three centers – Rollout and training NASA-wide • 2005 effort moved “in house” with a change in Administrator and NASA top management

New Governance Model – “4 legged stool” with 3 Independent Technical Authorities • Program • SMA, Engineering, Health & Medical – Formalized dissenting opinion process in policy – New core values statement

Independent Technical Authority

Technical Success

Program

New NASA Core Values Statement

Safety Excellence

Mission Success

Teamwork Integrity

Mission success requires uncompromising commitment to: Safety, Excellence, Teamwork, and Integrity.

Focus on Technical Excellence • Partially in response Adm Gehman’s quote – “On paper, it looks perfect, but when you bore down, there is…not enough people, money, or engineering expertise to do the job right.” • NASA formed two centers of Technical Excellence – NASA Engineering and Safety Center (NESC) – NASA Safety Center (NSC) • NASA also established more senior career positions for those desiring to stay technical vs. managerial • Established Engineering “Tech Fellows”

Benchmarking Other Agencies/Organizations • For best practices, lessons learned, etc. – Navy “SubSafe” – DoD Safety Centers – INPO – Johnson & Johnson – Ford Motor Co – MUSC – Brookhaven Natl Lab – Bechtel – Alcoa – Dupont

Culture Assessment and Updates • 2007 Agency Culture Survey – Follow up from 2006 NASA Historian’s survey that highlighted employee concerns with management honesty, communication, and organizational support – Prompted a specially designed culture survey • Identified 9 top NASA groups to benchmark • Incorporated best practices and lessons learned into training for supervisors, employees, agency operations, focus groups, and agency policies

Culture Updates (cont) • Goal is a periodic and continuous Safety Culture assessment with a focus on where we want to be and how to get there • Futron assessment based on model used in the Navy – Sucessful beta testing at 2 NASA Centers – However NASA decided to build this expertise in house • Hired safety culture expert • Developed internal survey

“Yes, If…” Award • Vs. “No because…” • Intended to promote positive SMA support to help solve a program challenge • SMA Chief gives award for unique circumstances – e.g. SMA engineer champions path to resolve challenge in time for launch while still meeting intent of requirements – One of the highest SMA recognitions given

NASA “Yes, If…” Coin

Lessons Learned (or relearned) • Cultivate a questioning attitude • Leaders must actively solicit dissenting opinions • Develop stronger safety professional skills and identity • Strive to minimize program waivers • Assure critical decisions are based on more than viewgraphs • Strive to use lessons learned in new efforts • Continually assess safety culture

Examples of Shuttle Program Lessons Learned • Not only answer the question…question the answer • Be proactive to find issues before they become problems • Scrub requirements at regular intervals • Some can become unnecessary and be deleted • Others may require enhancement

Final Thoughts • Leading up to Columbia, NASA overlooked the results of previous tragedies, and assessments weren't taken seriously enough. How do you keep this from happening in your own companies? • Are the communications channels in your companies sufficient at all levels to share information, identify problems, and seek timely solutions before a mishap occurs?

Final Thoughts (cont’d) • Culture can trump all procedures and safeguards. If your company’s culture is solely focused on the mission (operations), you may be headed for your own version of Columbia. • It took an accident to spur these changes • Independent Technical Authority • Technical Excellence • Dissenting opinions process • Governance model implementation • Sustaining Cultural program

Questions & Answers

What’s Next? Tuesday, November 1, Room 126A+B

1:00 – 3:00 p.m. Executive Edge Track Workshop A Creating and Leading Change: a Hands-On Look at NASA’s Journey

3:30 – 5:30 p.m. Executive Edge Track Workshop B Sustaining Change: a Hands-On Look at NASA’s Journey

Pre-Registration Required for Workshops. See Congress Registration Desk for Details.

Please stay with us for an exclusive NASA video!

Made Possible with the Generous Support of:

Government Group

Robert w. Campbel l