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Top Ten: Questions and Answers About the Columbia Board Report
By Jim Banke
Senior Producer,
posted: 07:00 am ET
07 July 2003

5. The danger signals seem obvious now. So what was NASA thinking?

The Columbia Accident Investigation Board has taken great pains to avoid falling into the trap of having 20/20 hindsight because what seems clear now wasn't before the tragedy.

The 1967 Apollo 1 fire is a great example: Pump pressurized pure oxygen into a capsule, lock three guys inside for a day and hope there are no problems with the miles of wiring.

In the case of the Columbia tragedy, no one saw the big picture. The clues were there, but no one realized there was a puzzle to solve in the first place.

First, the external tank was designed with a layer of insulation foam that isn't supposed to shed during launch. It was designed to stick to the tank, so if it's not sticking then something isn't working the way it's supposed to be.

Second, the shuttle's heatshield of tiles, RCC panels and thermal blankets were not designed to be damaged in any way for any reason. That's why the orbiter isn't allowed to fly through rain, stay outside when it hails or risk having workers drop tools on it. The tiles are especially fragile.

But for some reason, when foam fell off at launch and damaged tiles, NASA managers didn't seem alarmed. When the shuttle came back and there wasn't significant damage, managers convinced themselves there was no safety of flight issue. After 112 flights in which foam shed 70 times and tiles came back damaged every time, shuttle officials got used to it.

Some call it "gambler's dilemma." The roulette wheel had come up red 112 times in a row, so there was no reason to believe it wouldn't come up red again. Author Diane Vaughan, writing about Challenger, called it the "normalization of deviance."

We call this stupid. But then again, having covered the space program for some two decades, we never connected the dots either and we had the same information.

The board is going to tell NASA to set up a safety group that will step back and be extra sensitive to listen to what the hardware is saying when it doesn't work as designed -- a group that is going to go looking for the "unknown unknowns."

Next page: Safety first.

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