February 10, 2003, Pg. A01

Cultural Divide Plagues NASA; Gap Persists Between Engineers, Managers

By Shankar Vedantam

HOUSTON, Feb. 9 -- After the space shuttle Challenger exploded in 1986, Nobel Prize-winning physicist Richard P. Feynman asked NASA officials what risk of failure each mission carried. NASA engineers said about 1 in every 100 flights was likely to experience a catastrophe. NASA managers put the risk closer to 1 in 100,000.

As accident investigators pore through mountains of data to determine why the shuttle Columbia disintegrated over Texas on Feb. 1, the most difficult questions may lie not in telemetric data, risk analyses and high-temperature physics.

Rather, they may lie in the agency's discordant internal cultures, and in asking whether gaps in communication and perception might have caused the shuttle's demise.

Feynman suggested that the managers' role in selling space exploration to Congress, the White House and the public might have clouded their own perceptions about how risky the technology was. "For a successful technology, reality must take precedence over public relations, for nature cannot be fooled," he wrote in a report to President Ronald Reagan.

The gap between engineering and managerial perceptions persists today.

Technical people tend to assess risk based on individual components, which can behave unpredictably in the hostile environment of shuttle launches and reentry. Engineers know that solutions to problems often create other problems. Managers tend to look at the big picture, and base their assessments of safety partly on the previous number of safe flights flown.

In the Columbia investigation, managers say they discounted the damage done by a piece of foam to the underside of Columbia's wing during liftoff because such damage had happened many times before -- and those shuttles had all come back safely.

"Each time it ran a risk and succeeded, the institution learned the wrong lesson," said Charles Bosk, a sociologist at the University of Pennsylvania who studies why organizations fail. "Instead of saying, 'I was lucky,' you say, 'Maybe that wasn't so risky after all.' "

Today, the space agency continues to maintain an uneasy balance between its mission as a science program, which learns the most by sending robots into space, and public expectations that NASA "go where no one has gone before" -- exploring the space frontier with an astronaut program.

Budget cuts and expensive programs still vie against each other, and the competing pressures to fly safely and fly often influence daily decision-making. Moreover, NASA is a coordinating agency that monitors a vast number of private contractors, who build components, design new systems and even train the astronauts.

Coordinating far-flung groups and disparate goals -- under pressure of a tightening budget -- makes it difficult on a day-to-day basis to judge whether safety is being compromised.

Last October, to save money, astronaut commander Eileen Collins was asked whether she could reduce the number of practice hours her team was flying each week. Collins, like other astronauts, was eager to do whatever she could to help the space program, and if keeping costs down would help, she was all for it.

"We decided we could save money," said Collins, a three-time astronaut who was to command the March 1 mission on the shuttle Atlantis. "We cut a couple of sorties a week to save the fuel."

Though Collins doesn't believe safety was compromised, the example illustrates the extent to which the space agency has battled costs -- and the difficulty of judging whether small, day-to-day cuts influence safety.

In the Challenger explosion, private contractors were under tremendous pressures to maintain launch schedules -- NASA had promised supporters on Capitol Hill that the shuttles would fly 100 missions each in 10 years. The Challenger launch had been delayed before, and officials decided to go ahead with the fatal launch despite the concerns of some engineers that it was too risky.

Investigators into Columbia's demise have said their inquiry will be comprehensive, and include reviews of NASA's internal culture and the willingness of managers to encourage dissent. Top officials have said that employees can use an anonymous internal reporting system to voice concerns, but a week after one of NASA's biggest disasters, no one has apparently used the system.

At the same time, managers have been reluctant to make engineers and other officials available for interviews with the media. Public affairs staff have monitored reporters' conversations with astronauts. And Administrator Sean O'Keefe lambasted the media last week for not relying on official briefings from top management.

"The administrators have their own priorities that are different than the technical people," said William Evan, co-author of a book called "Minding the Machines: Preventing Technological Disasters." "Technical people are concerned with technology and safety . . . as opposed to the starry-eyed administrators, who are very confident that systems are going to work and that NASA will succeed because they want to brag to Congress and the White House."

Ironically, NASA's success in the 17 years since the Challenger disaster bolstered a public belief that shuttle launches are essentially routine. Collins, who was the first female commander of a shuttle, pointed out that most people probably did not even know that Columbia was completing a mission on Feb. 1. Such confidence, based on past success and touted by NASA leadership, Congress and the White House, came even as engineers were as cautious as ever.

This caution has a long history. Well-designed shuttle components have frequently developed complications, and small changes have created dramatic problems. On Columbia's second mission, in November 1981, a fuel cell became contaminated and stopped working. The particle causing the problem was tiny, but it forced three days to be cut from the five-day mission.

As soon as the shuttle landed, NASA engineers started working on a fix. They devised a filter to keep out contaminants and, as a safety measure, put in a second filter as well. There were no contaminants on the next mission, but hydrogen gas collected between the filters and seeped into a tank. A single spark would have caused an explosion aboard the shuttle.

Another time, William Schneider, a former NASA engineer, recalled that the agency had to move a shuttle from California to Cape Canaveral to meet certain launch deadlines.

The shuttle is normally ferried on an airplane. In this instance, Schneider said, about 600 of the protective insulation tiles had not yet been put on. Concerned about damage to the shuttle during the flight, Schneider and the other engineers came up with what they thought was a simple solution. They would pack the untiled areas with foam and then finish the tile work once the shuttle was in Florida.

They thought they had considered all the risks. But when they took the shuttle up, bits of foam came loose and smashed against the tiles already installed.

"It was a nice smooth surface, and the foam smashed into other tiles and damaged the real tiles and made it much worse," recalled Schneider, now a professor at Texas A&M University. "It was very good [to start with] and we tried to make it better and we damaged the tiles."

Hundreds of experiences such as these have infused Mission Control engineers here with an extreme caution when it comes to altering a complex and unpredictable system. And it has created a demonic sense of caution in making wholesale changes or redesigns.

"It always looks nice with a clean sheet of paper because everything is ideal," said Thomas Moser, a former NASA engineer, who is an aerospace consultant. "It's not to say we shouldn't look at ways to improve, but there have been improvements that have caused more harm than good."

Such caution, combined with managerial and public misperceptions about risk and cost pressures to stick to launch schedules collectively led the agency to avoid a major redesign that could have prevented the Challenger accident, said Diane Vaughan, a Boston College sociologist who wrote about NASA's internal cultures in her book, "The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA."

"There are eerie parallels with what is unfolding right now," said Vaughan, who wrote about how NASA had dismissed the danger of leaking rubber O-rings in Challenger's rockets. Managers assumed leaks in the ring were routine and acceptable risks, and engineers didn't want to redesign the ring afresh because the replacement might be even worse.

"They kept fixing it, but they never stopped to redesign it altogether because they didn't think it was serious enough to cause a catastrophic disaster," she said in an interview. "They became desensitized to the possibility of failure."

In the end, critics and supporters say NASA must find ways to balance the caution and the hype, the scientific benefits of an unmanned program and the romance of sending astronauts into space, as well as the managerial and engineering perceptions of risk.

"You don't want the hubris of imagining we can overcome everything," Bosk said, "but without that hubris, you can't create the enterprise. How do you instill a spirit of adventure, and at the same time have the humility to recognize all the things that could go wrong? One doesn't go very well with the other."

§ § §