Inadequate Systems Play Role in Columbia Disaster, Report Finds

WASHINGTON -- Spaceflight is an inherently risky business, but the National Aeronautics and Space Administration's reliance on e-mail and a flimsy spreadsheet application helped turn risk into disaster.

That's one of the main conclusions of last week's long-awaited final report by the Columbia Accident Investigation Board (CAIB). The board concluded that "deficiencies in communication ... were a foundation for the Columbia accident."

The CAIB, chaired by retired Navy Adm. Hal Gehman, painted a picture of a massive bureaucracy that relied on informal e-mail communications to manage the in-flight analysis of the damage to Columbia's left wing by a piece of insulating foam that broke loose during takeoff.

This led to a series of discussions that took place in a vacuum, with little or no cross-organizational communications and often no feedback from senior managers contacted by low-level engineers with concerns about the shuttle's safety, the report said.

In its attempt to answer why a seemingly IT-savvy agency would rely on little more than e-mail to communicate critical analyses, the CAIB discovered that there were deficiencies in problem- and waiver-tracking systems, and that the exchange of communications across NASA hierarchy was limited.

A major element in NASA's management and decision-making failures was its inability to integrate critical safety information and analysis, the report said. "The agency's lack of a centralized clearinghouse for integration and safety further hindered safe operations," it said.

And while NASA does have an automated system in place to track so-called critical items related to safety, "the information systems supporting the shuttle -- intended to be tools for decision-making -- are extremely cumbersome and difficult to use at any level," the report said.

"The Lessons Learned Information System database is a much simpler system to use, and it can assist with hazard identification and risk assessment," the board concluded. "However, personnel familiar with the Lessons Learned Information System indicate that design engineers and mission assurance personnel use it only on an ad hoc basis, thereby limiting its utility."

The CAIB report also slammed NASA for its reliance on a modeling and simulation tool called Crater that was, in the board's opinion, "inadequate" to evaluate the damage caused to Columbia by the foam impact.

In fact, Crater is nothing more than a spreadsheet that matches the size of debris strikes with damage to protective heat tiles based on tests and observations from previous shuttle flights.

NASA Administrator Sean O'Keefe said the agency plans within the next 30 days to establish a NASA Engineering and Safety Center to act as the central clearinghouse for all safety data integration and collaboration as recommended in the report.

In addition, he said, engineers will be researching ways to communicate more data from shuttle sensors to ground control centers to give officials more accurate real-time data. They will also work on improving the digitization of shuttle engineering drawings to expedite safety investigations, O'Keefe said.