Deadly space lessons go unheeded

Grim memorial
A graphic example of this "aversion of eyes" can be found in the Challenger memorial services of the past, and the historical summaries now widely published. The heart of the matter is the clash between “73” and “207”.

For a few subsequent anniversaries to the 1986 catastrophe, on the appropriate day and at the appropriate hour, NASA workers were invited to gather for a period of silence. In Houston where I worked, it was at the center’s main flagpole.

According to the official NASA description of the ceremony, this was to last 73 seconds, “the duration of Challenger’s flight”. That’s what press accounts said, too -- look it up on the Internet, where references almost always say something like “The space shuttle Challenger explodes 73 seconds after launch, killing all seven astronauts aboard”.

But we were engineers and operators, not managers and media flacks, and we knew better. Challenger had been in flight for 73 seconds when it broke apart, and the cabin -- with its crew still alive but presumably (and mercifully) soon unconscious from anoxia -- continued its upwards, then downwards arc for another 134 seconds. This was more than two whole minutes of additional flight before the cabin hit the water, killing the astronauts.

This is the reality that was all too easy for most people to turn away from. After the 73 seconds of silence, as other space workers shuffled back to their desks, their duties to the dead ostensibly done, I and a few friends would continue to stand in silence for the true flight duration, the true last seconds of the astronauts’ lives, 207 seconds in all. We had had enough of comfortable make-believe. And so these days, whenever some space official who ought to know (and say) better uses the phrase “73 seconds”, you have one more unintentionally self-confessed averter of eyes.

Early in the 1990s, some NASA managers in Houston began planning a visible memorial to the Challenger disaster, and to Apollo 1 as well. It was to be a set of displays -- including actual wreckage from both spacecraft, that people could run their fingers over -- on a wide landing in the stairwell leading up to the main Flight Control Room in the Mission Control Center. Nothing ever came of it, alas -- those involved proved out of step with the new Dan Goldin regime and were shuffled off into retirement. The debris from the disasters remained safely hidden away, comfortably out of sight and -- as experience would show -- tragically out of mind.

Learning wrong lessons
In space as on Earth, bitter experience teaches that a good "safety culture" decays from a variety of causes. There is the lulling of anxiety through repeated success, or the loss of respect (or fear) for past experience. And sometimes it’s from the elevation of other measures of goodness higher than safety.

The NASA of the mid-1990s was an agency where political satisfaction of top management -- all the way up to the White House -- became the ultimate goal. This was seen in the approach to safety during the initial stages of the partnership with Russia aboard their Mir space station.

When asked about the hazards of dangerous fires aboard Mir, based on reports of a bad incident in late 1995 and a long series of earlier anecdotal incidents, NASA space station official James Nise replied in writing: “NASA is satisfied with the safety and reliability of Russian [on-board fire suppression] hardware.”

Little more than a year later, a fire nearly killed six men aboard the station (including one American), and the official in charge denied knowing about any of the earlier events: “Nobody ever told me about earlier fires on Mir,” astronaut Frank Culbertson, manager of the Shuttle-Mir Program, told a television news crew. Yet a subsequent internal NASA investigation found numerous documents in which engineers had expressed alarm over the fire hazard but had been rebuffed by their managers. “These issues are better raised before, not after a life-threatening event,” the report concluded ominously -- but nothing changed.

After the near-fatal fire, NASA again decided that it was diplomatically desirable to believe that Mir was safe. Prior to the next visit, its official conclusion was that “no new risks have been identified, and no problems are foreseen.” An official in Moscow told reporters, “It looks like we’ve gone through the darkest part and we’re headed toward the light,” and a headquarters official concurred: “We are very confident we are operating in a safe manner.” The man being sent to Mir, astronaut Michael Foale, believed it: “I’m not worried,” he told reporters. “The safety is perfectly assured.”

Then, when Foale and his spaceshipmates were very nearly killed by an air leak caused by a supply ship collision, the same officials agreed that the accident was a "good thing" because it taught them lessons about space safety. But what it seems to have taught them was that one could in fact screw up safety assessments again and again, and by dumb luck still not kill anybody. It seems to have taught NASA that they didn’t need to worry quite so much -- even when the worst happened, there was always some way out.

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