Deadly space lessons go unheeded

Real lessons
Looking back on the actual fatal disasters, clear patterns emerge. The common thread was a willingness to make comfortable assumptions in the known absence of hard data.

For the Apollo-1 disaster, the not unreasonable use of pure oxygen in the cabin at low pressure had been compounded by simply overpressurizing with oxygen at sea level pressure for the pre-launch test. Components and fire-fighting systems that would have been tolerable at the design pressures had never been tested at the higher pressures they were subject to.

As for actual fires, the design had demanded that no sparks occur -- not that sparks that DID occur be containable. And having a hatch that required ten minutes to open was based on the same convenient assumption that since nobody could think of ways a bad fire could start and spread, then mother Nature couldn’t either.

For the Challenger disaster, numerous "scrubs" had led to schedule pressure and news media mockery. Two upcoming planet missions had irrevocable launch dates, and could not slip. Meanwhile, NASA’s new administrator was on Capitol Hill meeting with congressmen that day.

When engineers said that weather was colder than ever tested and trended "away from goodness," and that the brittle booster seals had never been tested under those conditions, their managers were ordered them to "take off their engineering hats and put on management hats." The engineers were challenged to prove it was NOT safe to launch, and they had no data to do so.

Columbia pattern a familiar one
The sequence of events and decisions that doomed Columbia two years ago is a familiar litany. Foam shedding from the fuel tank during launch had become familiar, and had gouged the silica wing tiles but this had never led to dangerous levels of damage during fiery reentries. As for the entirely different materials that lined the most severely heated regions such as the wing leading edges and the nose, they had never been tested against foam impact -- it was just assumed they were even tougher than the silica tiles.

INTERACTIVE What went wrong Anatomy of a disaster

After Columbia blasted off and the tracking camera tapes showed the debris impact -- the largest ever, and one that seemed to hit an area that might well have included the wing leading edge -- all interest in making sure there hadn’t been damage was squelched. It was easier to ask for proof there HAD been damage, and lacking any, the easy assumption of goodness carried the day -- and denied the crew any chance of an emergency repair or rescue option.

Some technological endeavors seem to maintain an effective safety culture, even over decades, and NASA needs become more like them. It must evolve beyond its "exceptionalism," the idea that it’s the smartest team on the planet with nothing to learn from outsiders.

A good place to start is with the words of Admiral Hyman Rickover, father of the nuclear navy and founder of a safety culture with a remarkable record.

“Quality must be considered as embracing all factors which contribute to reliable and safe operation,” he wrote. “What is needed is an atmosphere, a subtle attitude, an uncompromising insistence on excellence, as well as a healthy pessimism in technical matters, a pessimism which offsets the normal human tendency to expect that everything will come out right and that no accident can be foreseen -- and forestalled -- before it happens.”

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