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Tuesday, July 22, 2003

Shuttle loss: NASA/Navy study


Imbed safety in system

A NASA study of the Navy's super-safe nuclear submarine program identifies reforms that might have saved the space shuttle Columbia. The joint NASA/Navy study, begun last year, isn't finished, but its progress report released last week found stark management differences, and suggests NASA could benefit from copying some Navy safety strategies.

NASA needs to adopt major institutional changes. After the Feb. 1 Columbia disaster, investigators found shuttle damage from shedding foam had been a long-time subject of internal debate, and NASA engineers' concerns after Columbia's launch did not reach the agency's highest levels.

The Navy reactors program depends on a "closed loop" safety system that lets no problem slide or escape correction, no matter how "minor." A "flat" management structure not only allows Navy personnel and contractors "freedom to dissent" but actively seeks out alternative opinions. The Navy has long used "robust independent audits" to make sure its people and outside contractors comply with the highest safety standards. The Navy nuclear sub program has no separate safety office. It makes safety a primary responsibility of everyone linked to the program.

Much of that individual responsibility for keeping nuclear subs super-safe and disaster-free dates from the 34-year leadership of Admiral Hyman Rickover, who founded the program in 1948. Rickover's demands for reliability bordered on fanatical, but it has paid off for decades. Another nuclear Navy rule of thumb is that "silver bullet thinking is dangerous." The Navy insists on assuring all elements are in compliance, not just those singled out as critical.

The study doesn't gloss over NASA's comparatively few years of experience with shuttle flights and the unique challenges in space. But the agency needs to re-evaluate if its safety philosophy should differ so sharply from the Navy's, which sets strict, achievable requirements, while NASA sets broad "requirement goals," which often are unachievable and must be waived. NASA needs to overhaul more than launch preparations or mission goals. It should build "safety first" systems into all its programs and management processes if it expects to lower the odds of another space flight catastrophe.




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