The New York Times, August 14, 2003


Shuttle Inquiry Uncovers Flaws in Communication


As the Columbia Accident Investigation Board writes its report on the shuttle disaster, it will have to explore the critical breakdown in communication that left the leader of the mission management team without any knowledge of three requests for spy satellite images of the damaged shuttle.

A flurry of e-mail messages disclosed under the Freedom of Information Act showed that several NASA engineers around the country wanted the images. One made an informal request that NASA officially withdrew, and a top official at the agency's headquarters actually turned down an offer of help from an Air Force surveillance agency.

The information now in the public record does not establish precisely why the agency did not take the issue of debris more seriously and follow through on the first impulse of some of its engineers to get pictures of the shuttle in orbit. The public will have to wait for that explanation in the release of the report by the Columbia Accident Investigation Board.

But some things stand out already.

For example, the leader of the mission management team at Johnson Space Center, Linda Ham, said she never learned of the requests for images. In fact, Ms. Ham told reporters at a briefing on July 22 that because she had heard that someone wanted to make such a request, she spent much of Jan. 22, in the middle of the mission, asking about it, but learned nothing.

She said she asked who wanted the images at the Mission Evaluation Room, where a cluster of middle managers troubleshoot engineering issues during flights. Working in that room was the chief engineer of the shuttle's structural engineering division at the Johnson Space Center, Alan R. Rocha, known as Rodney. In an interview with ABC television after the crash, Mr. Rocha said he regretted not having spoken up at the mission management team meeting, at which Ms. Ham presided.

If the accounts of both managers are accurate, Mr. Rocha not only did not volunteer his desire for the images at that meeting, but his wishes were not conveyed after Ms. Ham asked questions at the office where he worked.

''It never, never came up,'' Ms. Ham said.

The flow of information, or the lack of it, displays another characteristic about the National Aeronautics and Space Administration that the board may analyze: the agency's approach to peer review and accountability. Ms. Ham said in her meeting with reporters last month that she had considered whether debris shed on liftoff, now believed to be the fatal flaw, could have damaged the orbiter. But she said she had relied on an analysis by Boeing that indicated no threat to the mission from the impact of the foam.

''We must rely on our contractor work force who had the systems expertise to go off and do that analysis,'' she told reporters last month. ''We don't have the tools to do that. We don't have the knowledge to do that or the background or expertise to do that kind of thing.''

That explanation does not satisfy one member of the shuttle team, who attended some of the meetings in question and spoke only on the condition of anonymity.

''Part of the problem is that everybody assumed that someone else would do it, and the old axiom of business is no one ever wanted to be first,'' the engineer said.

This unwillingness to be first to discuss a problem is well known among contractors that work with NASA, says Joseph Grenny, an organizational consultant who has worked with agency contractors. The companies call that phenomenon ''NASA Chicken.''

Mr. Grenny, a co-author of the book ''Crucial Conversation: Tools for Talking When the Stakes Are High,'' says people are reluctant to raise any flags that can slow a project and carry political or economic risks. Instead, they say, ''I will wait, bide my time and hope others speak up first,'' he said.

The NASA engineer explained, ''The NASA culture does not accept being wrong.'' Instead of a culture in which ''there's no such thing as a stupid question,'' within the agency ''the humiliation factor always runs high,'' he said.

On Friday, NASA officials did not respond to requests for further comment from Ms. Ham.

Testimony and documents that the agency has released do not show that anyone reviewed the Boeing analysis skeptically. Transcripts of the meeting of the mission management team in which the Boeing report was briefly discussed show a presentation that dealt lightly with the degree of uncertainty and risk in the report. Ms. Ham cut off that presentation with assertions that the analysis showed no serious risk to the shuttle or its crew.

Edward R. Tufte, a professor emeritus at Yale University and an expert in the visual presentation of evidence, has expressed his dismay at the content of the transcripts from the Jan. 23 meeting. In March, Professor Tufte published a blistering critique of the Boeing studies used by NASA. He has since included the material in a course he teaches on presenting data and information, and in a booklet. He calls the crucial slide about the foam strike a ''PowerPoint festival of bureaucratic hyper-rationalism'' because, he said, it conceals far more than it reveals.

The optimistic conclusion that the foam probably did no harm is undercut by the data in the presentation -- including the fact that the piece of foam that hit the orbiter was 640 times as large as anything that NASA had tested.

Still, a careful reading of the slides would show the great uncertainty in the research, Professor Tufte said.

''It's very clear that all they were getting were in effect the executive summaries of the Boeing reports, even a filtered executive summary,'' he said. ''It was like a double filtering.''

The summary lines on the slide were ''way more sanguine about the Columbia than the actual report,'' he said. ''The summary lines don't reflect a lot of the doubts and uncertainties and error possibilities in the report itself.''

The Boeing report, if read carefully, ''raises real uncertainties and poses rather threatening issues'' about whether the impact was on tile or on reinforced carbon carbon, he said. Anybody looking at the figures describing the size of the foam chunk should have known the problem was beyond any test data, he added.

''In a sense, the real fault of upper management is they didn't look beneath the optimistic surface of the reports of their subordinates,'' he said.

Ms. Ham's assertion at the briefing for reporters that she did not have the tools to perform a more thorough analysis is absurd, Professor Tufte said. ''I'm from out of town, and I can see all the stuff on that slide.'' An administrator should have seen much more, he said, and dug deeper.

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