A recent tour of Titanic Belfast with my son, Dave, and pondering the responsibilities of engineers with respect to Big Constructs, like defending a city against floods, or advising on the ramifications of deploying geoengineering, and worrying about the tendency of scientists and many engineers to self-censor, led me to think about Space Shuttle’s Challenger and Columbia, again. As always, the definitive work is the comprehensive report by the Columbia Accident Investigation Board (CAIB). Related, and very good, is the talk given by Professor Sheila Widnall of and at MIT regarding the CAIB and the accidents, included below.
But the best single write-up, before Professor Widnall’s summary, is by William Langewiesche in The Atlantic. An excerpt:
But Gehman was in some ways also naive, formed as he had been by investigative experience within the military, in which much of the work proceeds behind closed doors, and conflict of interest is not a big concern. The Columbia investigation, he discovered, was going to be a very different thing. Attacks against the caib began on the second day, and by midweek, as the board moved from Shreveport to Houston to set up shop, they showed no signs of easing. Congress in particular was thundering that Gehman was a captive investigator, that his report would be a whitewash, and that the White House should replace the caib with a Challenger-style presidential commission. This came as a surprise to Gehman, who had assumed that he could just go about his business but who now realized that he would have to accommodate these concerns if the final report was to have any credibility at all. Later he said to me, “I didn’t go in thinking about it, but as I began to hear the independence thing’You can’t have a panel appointed by NASA investigating itself!’ I realized I’d better deal with Congress.” He did this at first mainly by listening on the phone. “They told me what I had to do to build my credibility. I didn’t invent itthey told me. They also said, ‘We hate NASA. We don’t trust them. Their culture is no good. And their cost accounting is no good.’ And I said, ‘Okay.'” …
By the end of the second week, as Gehman established an independent relationship with Congress and began to break through the boundaries initially drawn by NASA, it became clear that O’Keefe was losing control. He maintained a brave front of wanting a thorough inquiry, but it was said that privately he was angry. The tensions came to the surface toward the end of February, at about the same time that Gehman insisted, over O’Keefe’s resistance, that the full report ultimately be made available to the public. The caib was expanding to a staff of about 120 people, many of them professional accident investigators and technical experts who could support the core board members. They were working seven days a week out of temporary office space in the sprawling wasteland of South Houston, just off the property of the Johnson Space Center. One morning several of the board members came in to see Gehman, and warned him that the caib was headed for a “shipwreck.” …
At the caib, Gehman, who was not unsympathetic to NASA, watched these reactions with growing skepticism and a sense of déjà vu. Over his years in the Navy, and as a result of the Cole inquiry, he had become something of a student of large organizations under stress. To me he said, “It has been scorched into my mind that bureaucracies will do anything to defend themselves. It’s not evil—it’s just a natural reaction of bureaucracies, and since NASA is a bureaucracy, I expect the same out of them. As we go through the investigation, I’ve been looking for signs where the system is trying to defend itself.” Of those signs the most obvious was this display of blind faith by an organization dependent on its engineering cool; NASA, in its absolute certainty, was unintentionally signaling the very problem that it had. Gehman had seen such certainty proved wrong too many times, and he told me that he was not about to get “rolled by the system,” as he had been rolled before. He said, “Now when I hear NASA telling me things like ‘Gotta be true!’ or ‘We know this to be true!’ all my alarm bells go off … Without hurting anybody’s feelings, or squashing people’s egos, we’re having to say, ‘We’re sorry, but we’re not accepting that answer.'”
Now, I don’t want to minimize how hard it is to be an engineer some times, particularly when you know something’s not right, and it needs a decision. Often, bad news is dampened, and the approach to a problem may involve cultural clash.
In the case of Columbia, NASA and the United States got lucky: Columbia was an R&D vehicle. The other Shuttles had been declared “operational”, and, so, they did not even have flight data recorders on them, victims of the Agency’s overly aggressive declaration of success.