The destruction of space shuttle Columbia and the death of its seven astronauts were caused by a culture of "systemic flaws" at the US National Aeronautics and Space Administration, according to a damning invesstigators' report published today..
The Columbia Accident Investigation Board, in a wide-ranging analysis of decades of Nasa history, said the space agency's attitude toward safety is little improved since the 1986 Challenger disaster, which also killed seven, and that without fundamental changes more tragedies will occur.
"The board strongly believes that if these persistent, systemic flaws are not resolved, the scene is set for another accident," the report said.
In events leading up to the loss of Columbia, the report said, NASA mission managers fell into the habit of accepting as normal some flaws in the shuttle system and tended to ignore or not recognize that these problems could foreshadow catastrophe. This is an "echo" of some root causes of the Challenger accident, the board said.
"These repeating patterns mean that flawed practices embedded in NASA's organizational system continued for 20 years and made substantial contributions to both accidents," the 248-page report said.
During Columbia's last mission, NASA managers missed opportunities to evaluate possible damage to the craft's heat shield from a strike on the left wing by flying foam insulation. Such insulation strikes had occurred on previous missions and the report said NASA managers had come to view them as an acceptable abnormality that posed no safety risk.
This attitude also contributed to the lack of interest in getting spy satellite photos of Columbia, images that might have identified the extent of damage on the shuttle and came to incorrect conclusions.
But most of all, the report noted, there was "ineffective leadership" that "failed to fulfill the implicit contract to do whatever is possible to ensure the safety of the crew."
The 13-member investigation board was announced by Nasa within hours of the accident. Led by retired Navy Adm. Harold Gehman Jr., the board members spent almost seven months reviewing evidence, talking to engineers and conducting experiments that proved fast-flying foam could damage the heat shield on the wing of a space shuttle.