Déjà vu all over again: NASA and the question of riskby Roger Handberg
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| The threat grows out of the erratic pattern of funding NASA has encountered over the past decade and likely will continue to confront going forward. |
The Board’s concern reflects their fear is that such budgetary events may trigger the same organizational response as before; that is, NASA pushing to meet some externally imposed or perceived schedule so that potential or actual hazards are minimized or ignored in the rush. NASA continually confronts criticism that it is too slow or bureaucratic or risk averse or, in the worst case, all three. All are true at different points in time, but the reality is that the agency correctly perceives its current situation to be as fragile as it has encountered in the past. Congress demands progress regardless of its sporadic budgetary actions and contradictory goals imposed on the agency. Presidential transitions further ratchet up the pressure on the agency especially in the current period of partisan strife that has generated considerable hostility toward the current administration. Plans may unravel, which further increases the pressure on the agency to perform as it picks up the pieces.
This pressure is not subtle when congressional members, at committee hearings, demand achievements that justify the expenditures. Presidents normally respond to this pressure by ratcheting up the pressure, implicitly or explicitly, on the agency to “do something.” Even more debilitating is the agency’s belief that it must continually produce “spectaculars” in order to sustain public interest and support for its programs.
Public opinion data suggests that the degree of public support and awareness assumed by NASA does not exist. NASA and its programs are part of the noise within the public sphere, rising to prominence only on occasions such as the New Horizons Pluto flyby in 2015. Unfortunately, those episodes have too often involved mishaps and disasters. Triumphs occur but recede quickly into the background. When asked for national priorities, space is not ranked a major priority by the public.
Presidents and Congress reflect that public attitude. NASA and its programs can be raised to public prominence by a president but cannot be kept there. For presidents, space activities as embodied in NASA are only one in a multitude of presidential priorities and concerns. President George W. Bush in 2004 announced what became the Constellation program and then abandoned it to its fate in Congress and the public. Subsequent funding by Congress reflected that presidential priority, enough to keep the program alive but not progressing quickly.
| NASA, regardless of the specific mission it is charged with accomplishing, is often left implementing a program that likely will not retain its political viability, especially when a new administration enters office. |
His successor, Barack Obama, announced in 2010 the new path forward would be “flexible” rather than specific location driven as with Apollo earlier. The flexible path would not take the US to the Moon and only to Mars after a series of intermediate steps, including visiting an asteroid. The immediate purpose is to establish and test capabilities that later allow missions to Mars. The Moon option was rejected in part because the US has been there and done that. Many find that insufficient and postulate that going back to the lunar surface will provide long duration experience and allow for further exploration of the Moon itself. Regardless, the point is not the specifics but instead recognition of the reality that has been pointed out repeatedly: the space program cannot depend on presidential leadership beyond the symbolic statements and gestures while the president moves to other more critical priorities, such as war and peace.
The result is that NASA, regardless of the specific mission it is charged with accomplishing, is often left implementing a program that likely will not retain its political viability, especially when a new administration enters office. How many times one can go back to the drawing boards is unclear, but it’s likely a finite number. So, the pressure is on and the schedule (real and imagined) becomes the driver, with mistakes or, more likely, oversights occurring that have disastrous long-term consequences. That is the pattern that the Aerospace Safety Advisory Panel is concerned with, seeking to stop its possible reappearance as much as outsiders can impact a bureaucratic organization.
Pressure to press forward has appeared at several points in the US human spaceflight program. One must remember NASA was born in the midst of the first space race beginning in the late 1950s. Thus, deep in the folkways (the bureaucratic equivalent of organizational DNA) of the agency, there operates the premise that visible progress must be sustained and even accelerated if possible. Unfortunately, mistakes occur even though recognition of their existence may not come to public attention until a disaster occurs.
The first major human spaceflight accident did not even occur during flight but in the run up to the first Apollo flight. Apollo 1 was being readied for launch in January 1967 when, during a launch simulation activity, a fire occurred. The cause was frayed wires within the capsule which ignited a pure oxygen environment with a great deal of flammable materials inside the capsule. The Apollo 1 pad fire was essentially investigated by the agency itself, reflecting politicians’ confidence in the agency. The investigation found a number of decisions and practices that led up to the fatal accident, including much more flammable materials inside the capsule than was understood. In addition, the crew had little hope of exiting the capsule due to the extreme difficulty in unlatching and opening the hatch. All three men perished mere feet from safety.
The Space Shuttle Challenger accident in January 1986 came after a contentious developmental process during the 1970s, coupled with disappointing results in terms of flight rate and an inability to maintain a schedule. The earlier projections of 60 missions a year prior to operations had evaporated in the reality of a launch vehicle requiring extensive flight preparations along with lengthy delays prior to actual flight while sitting on the pad.
The cause of the accident was an O-ring failure on a solid rocket booster, and the failure was attributed to cold weather prior to launch. This allowed burn through, igniting the external fuel tank leading to catastrophic failure. The post-accident review found that the O-ring issue had been identified on earlier launches but, over time, the problem had been absorbed into the routine of preflight review, the so-called “normalization of risk.” Information from lower level engineers regarding the possible hazard were pushed aside and the flight went forward. The Rogers Commission investigation came in a political atmosphere of great skepticism regarding the agency’s capacity to fix its problems. After reworking procedures and fixing the problems found with the solid state boosters, the space shuttles returned to flight in September 1988 with the launch of Discovery.
| The Aerospace Safety Advisory Panel, looking forward but conscious of the past, is signaling the agency to be cognizant of the potential hazards of being tunnel vision focused only on mission completion. |
On February 1, 2003, the Space Shuttle Columbia broke up during reentry. The cause of the accident was a hole in the left wing’s leading edge. The damage had occurred when suitcase-sized foam debris fell off the super cold external fuel tank. Such foam debris striking the shuttle during liftoff had occurred during every flight. Over time, that reality became effectively an acceptable risk. What occurred during Columbia’s liftoff was that the debris was larger and struck at an angle and velocity that caused damage to the leading edge to left wing. Engineers analyzing image from the liftoff identified the danger but were unable to convince their superiors to pursue the issue. A request to have a national security satellite take images of the shuttle was cancelled. So, during reentry, the agency and crew were unaware of the danger. The more tragic aspect was that knowledge would not have saved the crew. The Columbia lacked the capability to reach the International Space Station as a safe haven. The time necessary to ready a second shuttle was too long to affect a rescue. The crew, unbeknownst to all, was doomed.
Again, in a manner similar to Challenger, the foam debris hazard was identified by NASA engineers but over time, the specific risk had been incorporated into agency standard operation procedures (http://www.nasa.gov/columbia/home/CAIB_Vol1.html). Repairing the wing was not really possible, although post-accident scenarios were constructed that implied that a temporary wing repair might have been possible for an attempted safe landing or at least descent under controlled conditions so that the crew might have abandoned the vehicle.
The Aerospace Safety Advisory Panel, looking forward but conscious of the past, is signaling the agency to be cognizant of the potential hazards of being tunnel vision focused only on mission completion. Agency budgets remain works in progress dependent on shifting political tides while the pressures to push forward grow in intensity. The cancelation of the Constellation program and its Ares launch vehicle puts additional pressure on the agency to push harder before the next change in political currents. Delays in launching the SLS and Orion while the private sector progresses toward human spaceflight adds to these pressures.
The concern being raised is that the agency may again push past hazards, incorporating their risks into the normal operations of the program. This will not be deliberate but part of the normal processes of organizations. Pressure on NASA comes both externally and internally. Externally, Congress, the president, and the public exert pressure simply by their presence, but members of Congress are the most prominent since constituency interests and ideological desires drive members to demand something they desire happen. The agency lacks the political protection necessary to put off those pressures, especially when, according to the congressional critics, “nothing is happening.”
The agency works in an environment when nothing to the public appears to happen while missions run and then there comes an intense period of activity. Witness the recent mission to Pluto and beyond: years of nothing in terms of the public and then a sharp burst of activity during the flyby itself. Landing Curiosity on the surface of Mars led to a raucous celebration but now to Congress and the public, the Mars rovers are just a series of pictures and speculation about water and life, along with talk of how long the rovers have survived and remained operational. That is extremely interesting to scientists and a few others, but for most individuals the events slip back into the humdrum of daily life.
Internally, however, NASA defines human spaceflight as its prime directive, effectively translating into a constant demand for immediate results. Results are essential, obviously, but can lead to shortcuts or understandings that incorporate hazards in order to accomplish the mission. What is more deceptive is that the hazard may appear more benign than it proves to be in time. Apollo 1, Challenger, and Columbia were victims of the routinization of risk with terrible consequences. As the saying goes, “the road to hell is paved with good intentions.” Likewise, the road to a space tragedy is paved with good exceptions. One could argue that such tragedies are part of the cost of exploration, which is true in the abstract. However, what occurs is somewhat similar events, a catastrophic failure leading to loss of the crew and then a period of reflection and recrimination along with a return to normal: a new normal, but a normal within the parameters of perceived risk.
The first accident occurred in January 1967, with Challenger in January 1986 followed by Columbia in February 2003. There is no argument here about weather conditions, but one might suggest a more prosaic and mundane explanation: the time intervals between the accidents—an average of 18 years—are sufficiently long that a generational change occurs within the organization, especially among leadership responsible for conducting human spaceflight operations. This interval is sufficiently long that the collective memory of the earlier event becomes muted and partially forgotten. Sufficient time elapses so that shortcuts become more attractive and the taboos against taking those actions fades in intensity.
There is no conspiracy theory here, but instead the responses of individuals placed in positions where pressures to succeed both real and imagined take hold. It is embarrassing for an action-driven organization to fall behind schedule and/or not meet the expectations of others. This is especially pressing for NASA, whose future depends on the goodwill of others. The workarounds and approvals (of what ultimately prove to be problematic choices) lead one to the brink of disaster when arguments to the contrary are ignored or rejected; see Challenger and Columbia for that organizational process in operation.
| Politics started the US human spaceflight program over a half century ago and drove NASA to its greatest triumph, the Moon landings, but such involvement becomes a two-edged sword. |
It was suggested after the Columbia accident that NASA look into the Navy nuclear power program for some guidance as to how to sustain the necessary caution for safe flight operations. This analogy, while interesting, suffers from one fundamental flaw: the Navy personnel operating nuclear propulsion systems do not endure intense public scrutiny and criticism in a manner equivalent to NASA human spaceflight leadership. That reality means that criticism may occur but does so within the parameters of the service and its associated support groups; Congress, for example, is rarely involved directly. The shuttle program was declared to be still in test flight mode after Columbia, reflecting recognition that the agency had pushed the shuttle forward too quickly because the US needed (in their judgment) to get back into space. The space shuttles were declared operational after four test flights (ironically, that was the Columbia.) With that, the future was set in place. It took time for flight failures to occur, but that such accidents occurred was, in fact, not unexpected for a test vehicle.
Politics started the US human spaceflight program over a half century ago and drove NASA to its greatest triumph, the Moon landings, but such involvement becomes a two-edged sword. Demanding continuous visible success regardless of the operational realities confronting the agency can be a harbinger of great success or tragedy. The previous accidents were at least partially products of that pressure; one can only hope the Aerospace Safety Advisory Panel’s warnings do not land on deaf ears.
