- (KRT) - Sarah McGregor is what she had dreamed of being
since seventh grade: a space-shuttle engineer.
Watching her climb scaffolding recently to inspect the heat shielding
on a shuttle's belly may have brought to an onlooker's mind NASA's glory
years, when moon landings made adrenaline flow in legions of young
McGregor, 23, looks forward to the day she sees a shuttle, her
assigned shuttle, Atlantis, leap free of its launchpad at Kennedy Space
"I'm trying not to think about it too much," she said. "That will be
But McGregor's passion notwithstanding, these aren't the Apollo
years. The agency isn't racing for the moon and extending
manned-spaceflight technology. Atlantis first flew when McGregor was
almost 5 - and critics say keeping it flying is a waste of money and
Worse, the board that investigated the Feb. 1 shuttle Columbia
accident castigated the National Aeronautics and Space Administration
for having a failed culture of safety that wasted lives. And a member of
that board, Brig. Gen. Duane Deal, singled out Kennedy Space Center for
"dysfunctional" safety operations. He found "cause for alarm" that NASA
inspectors are no longer given the opportunity or the authority to be an
effective voice in shuttle safety.
KSC Director Jim Kennedy acknowledged in a recent interview that
safety attitudes "need to be changed." But NASA is proud of its
practices and suspicious that changes will trigger more problems. Its
approach to safety reform has been tedious and in the hands of multiple
As a result, 11 months after the Columbia accident, NASA has yet to
reveal to KSC workers any specific changes that will bridge the expanse
among enthusiastic workers such as McGregor, the Columbia board's
criticisms and Deal's concerns.
"As far as new policies and procedures - zero," said a line manager
for shuttle servicing.
Long before the Columbia accident, flying and maintaining a fleet of
shuttles built with 1970s technology had been a challenge for NASA.
For the past decade, Congress and the White House imposed tight
budgets on the agency, even as costs of the international space station
spiraled out of control. NASA's response was to delay shuttle upgrades,
cut 7,000 jobs, aggressively privatize shuttle maintenance - and insist
that launches go off on time for construction of the space station.
The Columbia accident, which killed seven astronauts, exposed some of
the consequences of those decisions. NASA, the accident board found, had
routinely ignored potential hazards in order to maintain its launch
schedule. Breakaway pieces of insulating foam, like the one that struck
a fatal blow to Columbia's left wing, had been observed many times
before. But NASA never found a solution - other than to keep flying.
The board also found several other hazards it said should not have
been tolerated. It concluded that NASA's "safety culture no longer asks
enough hard questions about risk."
So besides coping with tight budgets, a stressed work force and aging
orbiters, KSC now is under orders to rehabilitate its safety culture -
to manage better, listen to employees better and perhaps hire more
The stakes are high. The loss of another orbiter could mean the end
of the shuttle program, which is essential for construction and upkeep
of the $100 billion space station. That is why, officials said, they're
moving slowly and carefully.
For now, KSC is simply trying to understand its safety culture.
Management recently gave copies of the Columbia board's final report to
nearly 13,000 center workers - from schedulers who rarely see the
shuttles to night-shift technicians who have their hands on the orbiter
most of the time. They were instructed to look for parallels between the
flawed decisions that led to the disaster and what occurs in their
It was a move suggested by the report's chapter on safety culture:
"People who are marginal and powerless in organizations may have useful
information or opinions."
Deal, one of 13 members of the Columbia accident board and commander
of the 21st Space Wing in Colorado
Springs, Colo., was assigned by the board to focus on safety
operations. What he found, after talking to more than 80 KSC workers,
"Not one of them said safety is where it ought to be," said Deal,
whose conclusions were echoed by nearly two dozen KSC workers
interviewed by the Orlando Sentinel.
In particular, the Air Force general was alarmed by what he learned
about the 100-plus NASA shuttle inspectors at KSC.
These inspectors once roamed hangar floors to catch worker errors and
stamp them with a "hex" - a black-ink outline of a stop sign that
signified a problem had to be fixed, reinspected and tracked with a new
paper trail. NASA inspectors were the final assurance that the thousands
of steps in shuttle servicing were done right.
But by the time Columbia disintegrated over Texas, Deal said,
inspectors had come to be regarded as bogging down shuttle operations
and were essentially shoved aside. Use of the hex stamps virtually
stopped, the Columbia accident report found, even as the number of
mandatory inspections for each servicing of a shuttle was cut by NASA
from about 40,000 to fewer than 10,000.
Deal said inspectors were discouraged - even threatened - by NASA
managers at KSC from making surprise or random checks of repair work.
The accident report said inspectors were "told to cooperate with
contractors to fix problems rather than rejecting the work."
Sidelining the NASA inspectors, Deal said, left most of the "eyes-on,
hands-on" inspections to employees of United Space Alliance, the company
that does most shuttle servicing and stands to earn or lose millions of
dollars by meeting NASA's launch schedule.
If anything, he said, the trend should have been in the opposite
direction, given that the aging shuttles were riskier to fly, launch
schedules were more demanding and NASA was on cost-cutting binges.
Deal put all of his concerns together in a nine-page "supplement" to
the board's report, to provide broader detail about how NASA undermined
its inspection process and what needed to be fixed at KSC.
He found that inspectors weren't paid well enough, lacked sufficient
training and didn't have enough clout. And there aren't enough of them.
Three years ago, NASA acknowledged its ranks of inspectors had shrunk
to an alarmingly low number and hired 35 more. But since then,
retirements and other departures have resulted in the number of
inspectors dropping to about 110 - about the same number that NASA found
alarmingly low three years ago.
As their numbers and role diminished, Deal said, so did their voice.
Despite their expertise, they simply weren't being listened to by
"That sets up animosity and distrust," he said.
Deal, 49, speaks with authority.
Earlier in his career, he flew an SR-71 Blackbird spy plane, the
world's fastest jet. He has managed two aircraft-safety programs and
regularly investigates crashes.
Now his command includes the Cheyenne Mountain fortress near Colorado
Springs. The installation, originally built to survive and respond to a
nuclear attack, monitors spacecraft and space debris. Its sensors
recorded the fiery end of Columbia and a crew that included commander
Rick Husband, a friend and Air Force colleague of Deal's.
The Air Force has learned hard lessons from aircraft crashes and lost
many high-ranking officers. "There are a lot of (Air Force) bases named
after dead guys," said Deal, who hopes NASA comes away from its hard
lessons with a stronger approach to safety.
The NASA official most responsible for formulating the KSC response
is Kennedy, who took the post in August.
He is a career manager for NASA; people who have worked with him say
he is "hard-nosed" about engineering excellence. Yet Kennedy, 54, is
also spoken of as having strong "people" skills - potentially useful for
probing and repairing safety culture.
"Nothing will be ignored," Kennedy said. "The report is going to make
He defined the culture of safety as the "natural behavior" of workers
when they don't have specific orders to follow. At KSC, he said, that
behavior is "90 percent good."
Several reviews are under way to determine whether inspectors have
enough authority and independence, whether the number of mandatory
inspections should be changed, and whether inspectors are able to have
their concerns heard by management, he said. Kennedy added that, when
Deal released his supplement, he was told by NASA Administrator Sean
O'Keefe to learn the concerns of shuttle inspectors.
"He said to me to personally go out and talk with every one of the
quality (inspector) people," Kennedy said. "I'm going to give them
answers to every one of their questions."
To a layman, it's difficult to see how safety practices can be
improved at KSC, where shuttles launch, land and are serviced.
The simplest tasks are done meticulously. For example, there is a
rule that workers "tether up" - wrap security tape around wristwatches
and otherwise secure personal items - so that foreign objects don't fall
into a shuttle.
More complex procedures require multiple sets of eyes. A task such as
installing a shuttle computer requires technicians, engineers and
inspectors for the physical labor, while more engineers and inspectors
orchestrate the procedure from a distant control room via headset radios
and video images.
The pampering given a shuttle is apparent from a look at Atlantis, on
track to be the first orbiter to return to flight. Catwalks, vent ducts,
power cabling and test tools engulf the orbiter. As many as 150 "worker
bees" swarm over it.
The 90-ton spacecraft is enormous - but their work often involves
minute adjustments with thumb and forefinger grasping an instrument,
while the pinky juts outward.
On a recent afternoon, USA mechanic Billy Witt attached metal
brackets called spanner beams to the back side of a U-shaped,
reinforced-carbon-carbon panel that costs nearly $1 million and is part
of the leading edge of Atlantis' left wing.
The nuts and bolts at the attachment points of spanner beams must not
be too tight, to allow for flexing during the jolts of a launch or
landing. So Witt, wearing a jeweler's magnifying glasses, used thin
strips of metal - feeler gauges - to check the attachment points for
tolerances that are thinner than a sheet of paper. The task looked like
flossing teeth, only with much more repetition.
"There's a lot of precision work," said Witt, a 13-year veteran.
Precision takes time; attaching spanner beams to a panel requires
more than four hours - and there are 44 panels.
The two shuttle disasters that have occurred so far, Columbia last
year and Challenger in 1986, were triggered by design flaws that were
widely known but ignored by the space agency.
What worries Deal and others, though, are the one-time glitches -
such as wiring damaged by workers, tools inadvertently left onboard an
orbiter and other mistakes - that can sneak through the process.
Bob Sieck, a retired NASA engineer who lives in Titusville, Fla.,
said he learned early in his career just how easy it is to overlook
glitches waiting to cause serious problems.
He was a troubleshooting engineer in 1970 when Apollo 13 flirted with
disaster. He subsequently turned his knowledge of the event into a
lecture about safety.
During a ground test of the Apollo 13 rocket, engineers were unable
to drain liquid oxygen from a tank that had been slightly damaged by
handling. Their solution was to turn on a heater, warming the
super-chilled liquid into a gas that then escaped through a vent. It was
a tricky operation, with no sensors to monitor rising temperatures.
Sieck remembers how Johnson Space Center told everybody not to worry,
asserting that a thermostat inside the tank would prevent overheating.
But the engineers overlooked the fact that the thermostat was certified
for 28 volts from the rocket's electrical system - not for the 65 volts
provided by a ground supply.
Nobody realized it, but the thermostat was fried - and temperatures
inside the tank got hot enough to char insulation on electrical wiring.
The damaged tank was launched with Apollo 13. Two days later, the wires
sparked an explosion - and only luck and heroics got the crew home.
"It was preventable," Sieck said, who went on to direct 52 shuttle
launches. "On a day-to-day basis, you've got to be looking out for clues
and signs of breakdowns."
To Deal, one such breakdown occurred when a part that wasn't
flight-certified - tested to withstand the rigors of spaceflight - was
bolted onto an Atlantis engine a few years ago and launched into space.
It was a metal plate - about 2 inches wide and 4 inches long - used
to cover an inspection hole. It had been certified for use only during
engine test firings.
Deal said NASA downplayed the incident, declaring there wasn't
significant risk of catastrophe. But that didn't matter, he said,
because NASA's certifications for flight hardware are the backbone of
"How many of those things do you accept?" Deal said. "Zero should be
Nearly three years ago, NASA inspectors began to push hard for a
better way to look for signs of breakdowns in critical hardware. They
wanted to inspect engines just before they were installed in shuttles.
At that point, the 14-foot-tall engines are in a horizontal position,
and inspectors can stand nearby while the engine is rotated much like a
chicken on a rotisserie. Components, such as the plumbing for a powerful
pump that spins at nearly 40,000 rpm and could fill a swimming pool with
liquid hydrogen in about a minute, are in plain sight.
Once the engine is installed, inspectors must squeeze into a cramped
compartment, deal with obstructed views and risk damaging critical
NASA has rejected the request several times, saying that its study of
mandatory-inspection points hadn't found such an inspection necessary.
But Columbia accident investigators also learned that NASA wouldn't
budge because there weren't enough inspectors to do the additional
That, said Deal in his supplement, is a "poor excuse."
Deal said he isn't certain why NASA has gone to such great lengths to
silence its inspectors. But a widely shared perception among workers is
that NASA, shackled by tight budgets and schedules, does not want to
interfere with shuttle servicing by USA.
Another common belief is that USA has been blinded by the formulas
that determine its paycheck, which is about $1.5 billion a year. The
company, owned by The Boeing Co. and Lockheed Martin, is paid for its
costs, such as payroll, and earns profits by meeting a variety of
standards that include quality, deadlines and cutting costs.
USA officials have said that safety is their first priority, which is
reinforced by the compensation formula. But the Columbia accident board
warned that NASA's method of payment to the company "sends a message
that money, not technical excellence, is the important objective."
Nearly two dozen KSC workers interviewed for this story did not want
to be identified for fear of retribution from their employer.
"They would whack me in a heartbeat," said a longtime shuttle
technician who works for USA.
The new KSC director may be well-suited for the task of sorting
through workers' perceptions and worries about safety practices.
Kennedy has brought regular-guy credentials to the space center,
where the uniform in the three shuttle hangars is often blue jeans and a
T-shirt imprinted with the logos of NASCAR, Mosquito Lagoon or Bike
His red pickup, parked in a prominent spot in front of KSC
headquarters, has a Ron Jon Surf Shop license plate - he grew up nine
blocks from the Cocoa Beach business and bought surfboards there - and a
Harley-Davidson sticker (though he now rides a BMW).
He is said to find it easy to talk to nearly anybody and to have a
photographic memory for faces.
"The one issue that means the most to me and has all the cultural
implications wrapped up in it is, do we have this feeling of openness
and honesty with all employees where everybody's voice is valued?"
Kennedy said. "I think that's the biggest cultural issue we are facing."
One worker, hearing that statement later, agreed, saying, "A big part
of the culture is, 'I'm an engineer, and you're not, so shut up.'"
One thing that Kennedy and other shuttle managers agree on is the
commitment of KSC's workers.
"The people who actually work on the shuttle know what they are doing
and how to do it," a USA scheduling specialist said. "I think they put
their heart and soul into it."
Because they are so committed to their jobs, many workers said, there
has been no crisis of personal confidence because of the Columbia
Scott Thurston, the NASA vehicle manager for Atlantis, and Roberta
Wyrick, the USA manager for Atlantis maintenance, agreed in an interview
that it's hard to detect a change in behavior since Columbia.
There's a sense of loss, they said, but no guilt or additional
"They know everything they are doing is critical," Wyrick said.
Deal is quick to agree that the KSC work force performs at a high
level. Yet, he cautions, "worker bees can do only so much" and said many
would like to have their tasks reviewed by the "extra set of eyeballs"
provided by NASA inspectors.
The general said he is concerned that the space center still hasn't
revealed any proposals to restore the opportunity and authority for NASA
inspectors to do that.
"Congress has asked us to come back in a year" for a follow-up
investigation, Deal said. "If they are looking to get a passing grade,
they ought to make sure our concerns are met."