“This is a dangerous precedent,” says Jim Hall, former Safety Board chairman
By appointing the team to investigate the fatal Feb. 1 crash of the space shuttle Columbia, the action of the National Aeronautics and Space Administration (NASA) is analogous to an airline appointing the panel to investigate the crash of one of its airplanes. As such, the investigation has come under sharp criticism for not being truly independent.
According to sources, the National Transportation Safety Board (NTSB) has the authority to conduct the Columbia investigation. A 1974 NTSB letter clearly outlines the pitfalls of NASA’s preferred course.
Indeed, constituting the Columbia probe under the aegis of NASA sets a precedent that could undo years of effort by which airline accidents are investigated by an independent body. The track record established by an NTSB created nearly 30 years ago speaks for itself, according to former NTSB Chairman Jim Hall. “Commercial aviation has shown that the independent process can provide a very safe system,” he declared.
Hall’s views have been seconded by other experts, including former NTSB chairman James Burnett, who served in the 1980s, the decade prior to Hall’s tenure. It should be pointed out that the NTSB is currently short two of its five appointed board members, one of which is the chairman’s position (see ASW, Feb. 3). In this respect, the board is not in the best position to assume responsibility for the Columbia investigation. However, Burnett pointed to some of the larger issues involved.
“This is not just a political issue” of whether NASA or an outside agency like the NTSB should be responsible for the Columbia investigation, he said. “It’s hard on the personnel to investigate a situation in which they’re emotionally involved,” he said. “This was the case in the Challenger investigation, and we ought not go down that road a second time.”
Moreover, Burnett added, “Having our staff members sit on the investigation can compromise the reputation of the NTSB.” As in the Challenger accident investigation, NTSB investigators have been detailed to participate in the Columbia inquiry. Hall pointed out, “There is no agreement for any cost reimbursement or a written guarantee of independence.”
The appearance that NASA is essentially in the position of investigating itself has created a furor, especially in light of the Feb. 28 decision by NASA Administrator Sean O’Keefe to not reassign shuttle officials participating in the investigation. Adm. Harold Gehman, head of the Columbia Accident Investigation Board, had earlier requested that they be reassigned. O’Keefe’s rejection of Gehman’s request prompted Rep. Bart Gordon (D-Tenn.), ranking member of the aeronautics and space subcommittee, to exclaim, “I’m just astonished that Mr. O’Keefe doesn’t understand the fundamental concept that you can’t investigate yourself.”
At the end of last week, notwithstanding his somewhat testy letter to Gehman, O’Keefe evidently changed his mind, agreeing to remove senior shuttle managers from the investigation while leaving some mid-level NASA experts in place. At a March 4 press conference, Gehman said, “Color me as satisfied that this is not an issue any more.”
The degree of independence is a matter of debate that has its roots in the charter by which Gehman’s investigation was constituted. That charter, and whether it mandates a truly independent body, is the springboard from which the exchange between Gehman and O’Keefe played out. It is apparent from the details of the correspondence that the issue of independence also was raised by NASA’s Inspector General.
Hall maintained that even the appearance of a conflict of interest could compromise the credibility of an accident investigation, irrespective of the personal integrity of the members. “Can a government agency sit in active judgment of an activity in which it participates? This is a dangerous precedent,” Hall said.
There seems no question that the NTSB is empowered to investigate the shuttle Columbia disaster, based on the 1974 legislation which created the NTSB. The NTSB was formed to independently investigate civil aircraft accidents, to include “public use” aircraft, a category in which the shuttle as a government vehicle fits. Furthermore, the NTSB is empowered to establish special boards of inquiry (analogous to the Gehman investigation for NASA), and the legislation takes special note of the need of such special inquiries to avoid conflicts of interest.
The current concern stems from the road not taken in 1994, Hall recalled. Following the NTSB’s participation in the shuttle Challenger accident postmortem, Hall proposed to NASA that the NTSB take the lead in conducting investigations of any future shuttle mishaps or accidents.
“In 1994 after the Challenger investigation, NASA was presented with two paths. One was an independent investigation,” Hall said. “NASA chose to provide management and oversight of its own investigation.”
Hall maintained that the need for a truly independent inquiry is particularly important given that the Columbia disaster took place in an environment involving even more contractor support than was the case when Challenger blew up in 1986. “Now the whole operation is even more dependent on contractors which NASA selected and supervised,” Hall said.
Had the NTSB assumed the primary investigative role at the outset, NASA officials like Shuttle program manager Ron Dittemore would not have been theorizing on national television the day after Columbia’s loss about the likely “root cause” of the disaster. American Airlines [AMR] executives were sharply rebuked by the NTSB for engaging in such public speculation the day after the crash of American Flight 1420 June 1, 1999, at Little Rock, Ark. (see ASW, June 21, 1999)
According to the legislation governing the NTSB’s activities, only the board member managing the early phase of an investigation may publicly discuss particulars, and those are limited to “factual developments.” In other words, freelance hypothesizing is strictly against NTSB operating protocols.
Indeed, the selective release of e-mails between NASA officials during Columbia’s mission simply would not occur under NTSB practices (see ASW, Feb. 17). The e-mails likely would become a part of the documentary database, which would eventually become a matter of public record, but only in the context of the complete body of correspondence, telephone calls, related documents, and so forth. The e-mails that have been released thus far cover mission discussions which fit into one or another of NASA’s scenarios. The Gehman probe may take quite a different direction.
A secondary issue involves the makeup of the team of experts supporting the Gehman probe. Two NTSB investigators on the roster of 22 persons are outnumbered three to one by six individuals with backgrounds in nuclear submarine operations. There are two ways to look at this apparently high proportion of submariners. One is that submarines operating at hazardous sea depths (“inner space” to some) may be analogous to space ships in “outer space,” exposing their operators to a comparable attention to detail and disciplined execution of standard operating procedures. On the other hand, the submariners now participating in the Columbia investigation do not bring to the table the safety and investigation expertise of the other 16 members, including the two NTSB detailees, the Air Force chief of aviation safety and the U.S. Navy‘s chief of aircraft mishap investigations. But the submariners do bring a perspective from outside the aerospace industry, which may prove to be uniquely valuable as the investigation proceeds. >> Hall, e-mail [email protected]; Burnett, tel. 501/745-2480 <<
Authorized to Investigate
United States Code, Title 49, Transportation, US dollars 1132. Civil aircraft accident investigations:
The National Transportation Safety Board shall investigate … each accident involving civil aircraft.
US dollars 2101. The term “accident” includes damage to or destruction of vehicles … regardless of whether the initiating event is accidental or otherwise.
United States Code, Title 49, Transportation, US dollars 1112. Special boards of inquiry on air transportation safety:
(a) The NTSB may establish a special board of inquiry composed of … one member of the Board acting as chairman, and … two members representing the public, appointed by the President on notification of the establishment of the special board of inquiry.
(b) Qualifications and conflicts of interest. The public members of a special board of inquiry must be qualified by training and experience to participate … and may not have a pecuniary interest in an aviation enterprise involved in the accident to be investigated.
A Question of Independence
The NASA Board Charter (extracts)
“In the case of a high-visibility, mission-related Shuttle mishap, the NASA Administrator may activate an … Investigation Board.
“The Board should consist of at least seven members, and be supported by the Office of Space Flight Headquarters and technical consultants as the Board deems appropriate.
“The Independent Board will … use the established NASA support structure of working groups, NASA Field Center support, and supporting facilities … The Board may use non- NASA support as it deems appropriate.”
NASA Administrator Sean O’Keefe to Admiral Harold Gehman, Feb. 18, 2003 (extracts):
“I am … in receipt of a copy of a letter addressed to you from NASA’s Inspector General … asking you to acknowledge your independence in certain respects.
“[The] charter provisions … clearly demonstrate that your Board can and must act independently … It is within your charter to determine causes, including whether NASA budget or management … created an environment which caused or contributed to the cause of this accident.”
Columbia Accident Investigation Board Chairman Adm. Gehman Feb. 25 letter to O’Keefe (extracts):
“Now that the initial recovery operations and response actions are behind us … the Board requests that you reassign the top level Space Shuttle Program management personnel who were involved in … the flight of STS 107 back to their duties and remove them from directly managing or supporting the investigation.”
O’Keefe response to Gehman of Feb. 28 (extracts):
“I am convinced this course of action will be viewed as prejudging the facts before the investigation is complete. Despite your assurances that no conclusions have been made arising from the facts of the investigation at this time, simply reassigning personnel will not accomplish your stated goal. Moreover, new personnel could be subjected to the same appearance of conflict in the future and I will not submit anyone to this treatment.”
Sources: Board charter, http://www.caib.us/board_charter/index.html; letters, see http://www.caib.us/news/press_releases/okeefe_letter.pdf
The Road Not Taken
Safety Board Aug. 29, 1994, offer to National Aeronautics and Space Administration (extracts)
“Thank you for the opportunity to comment on your plan to establish a NASA Space Shuttle Mishap Independent Review Board and the consideration of NTSB participation as Chairman and members on that Board. I commend you for the desire to have a contingency investigation plan in place before an accident … I also commend you on recognizing the critical importance of establishing an investigative body to function independently of the NASA structure charged with the responsibility for shuttle operations.
“Safety Board staff participated significantly in the 1986 … Challenger accident investigation, and have participated in or led investigations concerning the 1986 Air Force Titan 34D explosion and the recent commercial Pegasus air launch anomaly. We currently employ twelve investigators … who either have space launch accident investigation experience, have taken formal NASA familiarization courses in space launch safety, or both. Most importantly, we also possess extensive experience in quickly and efficiently organizing and overseeing an investigation of the magnitude you probably envision.
“Given this background, I believe that successful space shuttle accident or incident investigations should be accomplished under the sole direction of the Safety Board, with participation of essential parties, such as NASA and space vehicle manufacturers and contractors.
“The value of having the Safety Board, or a similar, completely independent and unbiased organization, direct an investigation is very important from a public perception standpoint. No matter how successfully NASA attempts full independence during an investigation, a NASA Space Shuttle Mishap Independent Review Board will always be a NASA Review Board in the eyes of Congress and the public.
“Congress passed the independent Safety Board Act of 1974 because it … believed that one unbiased, truly independent body should be in charge of transportation accident investigations … I do not believe, given this statutory charge, that I could commit the Chairmanship or other Board Members to serve on an investigative panel such as you propose.
“Although our preference is as reflected above … I would be willing to furnish senior NTSB investigators, technically qualified … to assist investigative groups made up of NASA and other experts … similar to our role in the Challenger investigation. However, I would urge … serious consideration to a fully independent, NTSB-led investigation.” Source: Acting NTSB Chairman Jim Hall to Jeremiah Pearson, III, associate NASA administrator for space flight, Aug. 29, 1994