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Columbia's Last Flight(P4)


Some of the shuttle's contents survived intact. For instance, a vacuum cleaner still worked, as did some computers and printers and a Medtronic Tono-Pen, used to measure ocular pressure. A group of worms from one of the science experiments not only survived but continued to multiply. Most of the debris, however, was a twisted mess. The recovered pieces were meticulously plotted and tagged, and transported to a hangar at the Kennedy Space Center, where the wing remnants were laid out in correct position on the floor, and what had been found of the left wing's reinforced carbon-carbon (RCC) leading edge was reconstructed in a transparent Plexiglas mold—though with large gaps where pieces were missing. The hangar was a quiet, poignant, intensely focused place, with many of the same NASA technicians who had prepared the Columbia for flight now involved in the sad task of handling its ruins. The assembly and analysis went on through the spring. One of the principal caib agents there was an affable Air Force pilot named Patrick Goodman, an experienced accident investigator who had made both friends and enemies at NASA for the directness of his approach. When I first met him, outside the hangar on a typically warm and sunny Florida day, he explained some of the details that I had just seen on the inside—heat-eroded tiles, burned skin and structure, and aluminum slag that had emerged in molten form from inside the left wing, and had been deposited onto the aft rocket pods. The evidence was complicated because it resulted from combinations of heat, physical forces, and wildly varying airflows that had occurred before, during, and after the main-body breakup, but for Goodman it was beginning to read like a map. He had faith. He said, "We know what we have on the ground. It's the truth. The debris is the truth, if we can only figure out what it's saying. It's not a theoretical model. It exists." Equally important was the debris that did not exist, most significantly large parts of the left wing, including the lower part of a section of the RCC leading edge, a point known as Panel Eight, which was approximately where the launch cameras showed that the foam had hit. Goodman said, "We look at what we don't have. What we do have. What's on what we have. We start from there, and try to work backwards up the timeline, always trying to see the previous significant event." He called this "looking uphill." It was like a movie run in reverse, with the found pieces springing off the ground and flying upward to a point of reassembly above Dallas, and then the Columbia, looking nearly whole, flying tail-first toward California, picking up the Littlefield tile as it goes, and then higher again, through entry interface over the Pacific, through orbits flown in reverse, inverted but nose first, and then back down toward Earth, picking up the external tank and the solid rocket boosters during the descent, and settling tail-first with rockets roaring, until just before a vertical touchdown a spray of pulverized foam appears below, pulls together at the left-wing leading edge, and rises to lodge itself firmly on the side of the external tank.

The foam did it.

There was plenty of other evidence, too. After the accident the Air Force dug up routine radar surveillance tapes that upon close inspection showed a small object floating alongside the Columbia on the second day of its mission. The object slowly drifted away and disappeared from view. Subsequent testing of radar profiles and ballistic coefficients for a multitude of objects found a match for only one—a fragment of RCC panel of at least 140 square inches. The match never quite passed muster as proof, but investigators presumed that the object was a piece of the leading edge, that it had been shoved into the inside of the wing by the impact of the foam, and that during maneuvering in orbit it had floated free. The picture by now was rapidly filling in.

But the best evidence was numerical. It so happened that because the Columbia was the first of the operational shuttles, it was equipped with hundreds of additional engineering sensors that fed into an onboard data-collection device, a box known as a modular auxiliary data system, or mads recorder, that was normally used for postflight analysis of the vehicle's performance. During the initial debris search this box was not found, but such was its potential importance that after careful calculation of its likely ballistic path, another search was mounted, and on March 19 it was discovered—lying in full view on ground that had been gone over before. The really surprising thing was its condition. Though the recorder was not designed to be crash-proof, and used Mylar tape that was vulnerable to heat, it had survived the breakup and fall completely intact, as had the data that it contained, the most interesting of which pertained to heat rises and sequential sensor failures inside the left wing. When combined with the telemetric data that already existed, and with calculations of the size and location of the sort of hole that might have been punched through the leading edge by the foam, the new data allowed for a good fit with computational models of the theoretical airflow and heat propagation inside the left wing, and it steered the investigation to an inevitable conclusion that the breach must have been in the RCC at Panel Eight.

By early summer the picture was clear. Though strictly speaking the case was circumstantial, the evidence against the foam was so persuasive that there remained no reasonable doubt about the physical cause of the accident. As a result, Gehman gave serious consideration to NASA's request to call off a planned test of the launch incident, during which a piece of foam would be carefully fired at a fully rigged RCC Panel Eight. NASA's argument against the test had some merit: the leading-edge panels (forty-four per shuttle) are custom-made, $700,000 components, each one different from the others, and the testing would require the use of the last spare Panel Eight in the entire fleet. NASA said that it couldn't afford the waste, and Gehman was inclined to agree, precisely because he felt that breaking the panel would prove nothing that hadn't already been amply proved. By a twist of fate it was the sole NASA member of the caib, the quiet, cerebral, earnestly scientific Scott Hubbard, who insisted that the test proceed. Hubbard was one of the original seven board members. At the time of the accident he had just become the director of NASA's Ames Research Center, in California. Months later now, in the wake of Gehman's rebellion, and with the caib aggressively moving beyond the physical causes and into the organizational ones, he found himself in the tricky position of collaborating with a group that many of his own people at NASA saw as the enemy. Hubbard, however, had an almost childlike belief in doing the right thing, and having been given this unfortunate job, he was determined to see it through correctly. Owing to the closeness of his ties to NASA, he understood an aspect of the situation that others might have overlooked: despite overwhelming evidence to the contrary, many people at NASA continued stubbornly to believe that the foam strike on launch could not have caused the Columbia's destruction. Hubbard argued that if NASA was to have any chance of self-reform, these people would have to be confronted with reality, not in abstraction but in the most tangible way possible. Gehman found the argument convincing, and so the foam shot proceeded.

The work was done in San Antonio, using a compressed-nitrogen gun with a thirty-five-foot barrel, normally used to fire dead chickens—real and artificial—against aircraft structures in bird-strike certification tests. NASA approached the test kicking and screaming all the way, insisting, for instance, that the shot be used primarily to validate an earlier debris-strike model (the so-called Crater model of strikes against the underside tiles) that had been used for decision-making during the flight, and was now known to be irrelevant. Indeed, it was because of NASA obstructionism—and specifically the illogical insistence by some of the NASA rocket engineers that the chunk of foam that had hit the wing was significantly smaller (and therefore lighter) than the video and film record showed it to be—that the caib and Scott Hubbard finally took direct control of the testing. There was in fact a series of foam shots, increasingly realistic according to the evolving analysis of the actual strike, that raised the stakes from a glancing blow against the underside tiles to steeper-angle hits directly against leading-edge panels. The second to last shot was a 22-degree hit against the bottom of Panel Six: it produced some cracks and other damage deemed too small to explain the shuttle's loss. Afterward there was some smugness at NASA, and even Sean O'Keefe, who again was badly advised, weighed in on the matter, belittling the damage. But the shot against Panel Six was not yet the real thing. That was saved for the precious Panel Eight, in a test that was painstakingly designed to duplicate (conservatively) the actual impact against the Columbia's left wing, assuming a rotational "clocking angle" 30 degrees off vertical for the piece of foam. Among the engineers who gathered to watch were many of those still living in denial. The gun fired, and the foam hit the panel at a 25-degree relative angle at about 500 mph. Immediately afterward an audible gasp went through the crowd. The foam had knocked a hole in the RCC large enough to allow people to put their heads through. Hubbard told me that some of the NASA people were close to tears. Gehman had stayed away in order to avoid the appearance of gloating. He could not keep the satisfaction out of his voice, however, when later he said to me, "Their whole house of cards came falling down."

NASA's house was by then what this investigation was really all about. The caib discovered that on the morning of January 17, the day after the launch, the low-level engineers at the Kennedy Space Center whose job was to review the launch videos and film were immediately concerned by the size and speed of the foam that had struck the shuttle. As expected of them, they compiled the imagery and disseminated it by e-mail to various shuttle engineers and managers—most significantly those in charge of the shuttle program at the Johnson Space Center. Realizing that their blurred or otherwise inadequate pictures showed nothing of the damage that might have been inflicted, and anticipating the need for such information by others, the engineers at Kennedy then went outside normal channels and on their own initiative approached the Department of Defense with a request that secret military satellites or ground-based high-resolution cameras be used to photograph the shuttle in orbit. After a delay of several days for the back-channel request to get through, the Air Force proved glad to oblige, and made the first moves to honor the request. Such images would probably have shown a large hole in the left wing—but they were never taken.

When news of the foam strike arrived in Houston, it did not seem to be crucially important. Though foam was not supposed to shed from the external tank, and the shuttle was not designed to withstand its impacts, falling foam had plagued the shuttle from the start, and indeed had caused damage on most missions. The falling foam was usually popcorn sized, too small to cause more than superficial dents in the thermal protection tiles. The caib, however, discovered a history of more-serious cases. For example, in 1988 the shuttle Atlantis took a heavy hit, seen by the launch cameras eighty-five seconds into the climb, nearly the same point at which the Columbia strike occurred. On the second day of the Atlantis flight Houston asked the crew to inspect the vehicle's underside with a video camera on a robotic arm (which the Columbia did not have). The commander, Robert "Hoot" Gibson, told the caib that the belly looked as if it had been blasted with shotgun fire. The Atlantis returned safely anyway, but afterward was found to have lost an entire tile, exposing its bare metal belly to the re-entry heat. It was lucky that the damage had happened in a place where a heavy aluminum plate covered the skin, Gibson said, because otherwise the belly might have been burned through.

Nonetheless, over the years foam strikes had come to be seen within NASA as an "in-family" problem, so familiar that even the most serious episodes seemed unthreatening and mundane. Douglas Osheroff, a normally good-humored Stanford physicist and Nobel laureate who joined the caib late, went around for months in a state of incredulity and dismay at what he was learning about NASA's operational logic. He told me that the shuttle managers acted as if they thought the frequency of the foam strikes had somehow reduced the danger that the impacts posed. His point was not that the managers really believed this but that after more than a hundred successful flights they had come blithely to accept the risk. He said, "The excitement that only exists when there is danger was kind of gone—even though the danger was not gone." And frankly, organizational and bureaucratic concerns weighed more heavily on the managers' minds. The most pressing of those concerns were the new performance goals imposed by Sean O'Keefe, and a tight sequence of flights leading up to a drop-dead date of February 19, 2004, for the completion of the International Space Station's "core." O'Keefe had made it clear that meeting this deadline was a test, and that the very future of NASA's human space-flight program was on the line.

From Osheroff's scientific perspective, deadlines based on completion of the International Space Station were inherently absurd. To me he said, "And what would the next goal be after that? Maybe we should bring our pets up there! 'I wonder how a Saint Bernard urinates in zero gravity!' NASA sold the International Space Station to Congress as a great science center—but most scientists just don't agree with that. We're thirty years from being able to go to Mars. Meanwhile, the only reason to have man in space is to study man in space. You can do that stuff—okay—and there are also some biology experiments that are kind of fun. I think we are learning things. But I would question any statement that you can come up with better drugs in orbit than you can on the ground, or that sort of thing. The truth is, the International Space Station has become a huge liability for NASA"—expensive to build, expensive to fly, expensive to resupply. "Now members of Congress are talking about letting its orbit decay—just letting it fall into the ocean. And it does turn out that orbital decay is a very good thing, because it means that near space is a self-cleaning place. I mean, garbage does not stay up there forever."

In other words, completion of the Space Station could provide a measure of NASA's performance only in the most immediate and superficial manner, and it was therefore an inherently poor reason for shuttle managers to be ignoring the foam strikes and proceeding at full speed. It was here that you could see the limitations of leadership without vision, and the consequences of putting an executive like O'Keefe in charge of an organization that needed more than mere discipline. This, however, was hardly an argument that the managers could use, or even in private allow themselves to articulate. If the Space Station was unimportant —and perhaps even a mistake—then one had to question the reason for the shuttle's existence in the first place. Like O'Keefe and the astronauts and NASA itself, the managers were trapped by a circular space policy thirty years in the making, and they had no choice but to strive to meet the timelines directly ahead. As a result, after the most recent Atlantis launch, in October of 2002, during which a chunk of foam from a particularly troublesome part of the external tank, known as the "bipod ramp," had dented one of the solid rocket boosters, shuttle managers formally decided during the post-flight review not to classify the incident as an "in-flight anomaly." This was the first time that a serious bipod-ramp incident had escaped such a classification. The decision allowed the following two launches to proceed on schedule. The second of those launches was the Columbia's, on January 16.

The videos of the foam strike reached Houston the next day, January 17. They made it clear that again the offending material had come from the area of the bipod ramp, that this time the foam was larger than ever before, that the impact had occurred later in the climb (meaning at higher speed), and that the wing had been hit, though exactly where was not clear. The astronauts were happily in orbit now, and had apparently not felt the impact, or been able to distinguish it from the heavy vibrations of the solid rocket boosters. In other words, they were unaware of any trouble. Responsibility for disposing of the incident lay with engineers on the ground, and specifically with the Mission Management Team, or MMT, whose purpose was to make decisions about the problems and unscripted events that inevitably arose during any flight. The MMT was a high-level group. In the Houston hierarchy it operated above the flight controllers in the Mission Control room, and just below the shuttle program manager, Ron Dittemore. Dittemore was traveling at the time, and has since retired. The MMT meetings were chaired by his protégé, the once rising Linda Ham, who has come to embody NASA's arrogance and insularity in many observers' minds. Ham is the same hard-charging manager who, with a colleague, later had to be forcefully separated from the caib's investigation. Within the strangely neutered engineering world of the Johnson Space Center, she was an intimidating figure, a youngish, attractive woman given to wearing revealing clothes, yet also known for a tough and domineering management style. Among the lower ranks she had a reputation for brooking no nonsense and being a little hard to talk to. She was not smooth. She was a woman struggling upward in a man's world. She was said to have a difficult personality.

As the head of the MMT, Ham responded to news of the foam strike as if it were just another item to be efficiently handled and then checked off the list: a water leak in the science lab, a radio communication failure, a foam strike on the left wing, okay, no safety-of-flight issues here—right? What's next? There was a trace of vanity in the way she ran her shows. She seemed to revel in her own briskness, in her knowledge of the shuttle systems, in her use of acronyms and the strange, stilted syntax of aerospace engineers. She was decisive, and very sure of her sense for what was important and what was not. Her style got the best of her on day six of the mission, January 21, when at a recorded MMT meeting she spoke just a few words too many, much to her later regret.

It was at the end of a report given by a mid-ranking engineer named Don McCormack, who summarized the progress of an ad hoc engineering group, called the Debris Assessment Team, that had been formed at a still lower level to analyze the foam strike. The analysis was being done primarily by Boeing engineers, who had dusted off the soon to be notorious Crater model, primarily to predict damage to the underwing tile. McCormack reported that little was yet resolved, that the quality of the Crater as a predictor was being judged against the known damage on earlier flights, and that some work was being done to explore the options should the analysis conclude that the Columbia had been badly wounded. After a brief exchange Ham cut him short, saying, "And I'm really ... I don't think there is much we can do, so it's not really a factor during the flight, since there is not much we can do about it." She was making assumptions, of course, and they were later proved to be completely wrong, but primarily she was just being efficient, and moving the meeting along. After the accident, when the transcript and audiotapes emerged, those words were taken out of context, and used to portray Ham as a villainous and almost inhumanly callous person, which she certainly was not. In fact, she was married to an astronaut, and was as concerned as anyone about the safety of the shuttle crews. This was a dangerous business, and she knew it all too well. But like her boss, Ron Dittemore, with whom she discussed the Columbia foam strike several times, she was so immersed in the closed world of shuttle management that she simply did not elevate the event—this "in-family" thing—to the level of concerns requiring action. She was intellectually arrogant, perhaps, and as a manager she failed abysmally. But neither she nor the others of her rank had the slightest suspicion that the Columbia might actually go down.

The frustration is that some people on lower levels were actively worried about that possibility, and they understood clearly that not enough was known about the effects of the foam strike on the wing, but they expressed their concerns mostly to one another, and for good reason, because on the few occasions when they tried to alert the decision-makers, NASA's management system overwhelmed them and allowed none of them to be heard. The question now, of course, is why.

The caib's search for answers began long before the technical details were resolved, and it ultimately involved hundreds of interviews and 50,000 pages of transcripts. The manner in which those interviews were conducted became a contentious issue, and it was arguably Gehman's biggest mistake. As a military man, advised by military men on the board, he decided to conduct the interviews according to a military model of safety probes, in which individual fault is not formally assigned, and the interviews themselves are "privileged," meaning forever sealed off from public view. It was understood that identities and deeds would not be protected from view, only individual testimonies to the caib, but serious critics cried foul nonetheless, and pointed out correctly that Gehman was using loopholes to escape sunshine laws that otherwise would have applied. Gehman believed that treating the testimony as privileged was necessary to encourage witnesses to talk, and to get to the bottom of the story, but the long-term effect of the investigation will be diminished as a result (for instance, by lack of access to the raw material by outside analysts), and there was widespread consensus among the experienced (largely civilian) investigators actually conducting the interviews that the promise of privacy was having little effect on what people were willing to say. These were not criminals they were talking to, or careful lawyers. For the most part they were sincere engineering types who were concerned about what had gone wrong, and would have been willing even without privacy to speak their minds. The truth, in other words, would have come out even in the brightest of sunshine.

The story that emerged was a sad and unnecessary one, involving arrogance, insularity, and bad luck allowed to run unchecked. On the seventh day of the flight, January 22, just as the Air Force began to move on the Kennedy engineers' back-channel request for photographs, Linda Ham heard to her surprise that this approach (which according to front-channel procedures would have required her approval) had been made. She immediately telephoned other high-level managers in Houston to see if any of them wanted to issue a formal "requirement" for imagery, and when they informed her that they did not, rather than exploring the question with the Kennedy engineers she simply terminated their request with the Department of Defense. This appears to have been a purely bureaucratic reaction. A NASA liaison officer then e-mailed an apology to Air Force personnel, assuring them that the shuttle was in "excellent shape," and explaining that a foam strike was "something that has happened before and is not considered to be a major problem." The officer continued, "The one problem that this has identified is the need for some additional coordination within NASA to assure that when a request is made it is done through the official channels." Months later one of the caib investigators who had followed this trail was still seething with anger at what had occurred. He said, "Because the problem was not identified in the traditional way—'Houston, we have a problem!'—well, then, 'Houston, we don't have a problem!' Because Houston didn't identify the problem."

But another part of Houston was doing just that. Unbeknownst to Ham and the shuttle management, the low-level engineers of the Debris Assessment Team had concluded that the launch films were not clear enough to indicate where the foam had hit, and particularly whether it had hit the underside tile or a leading-edge RCC panel. Rather than trying to run their calculations in the blind, they had decided that they should do the simple thing and have someone take a look for damage. They had already e-mailed one query to the engineering department, about the possibility of getting the astronauts themselves to take a short spacewalk and inspect the wing. It later turned out that this would have been safe and easy to do. That e-mail, however, was never answered. This time the Debris Assessment engineers decided on a still simpler solution—to ask the Department of Defense to take some high-resolution pictures. Ignorant of the fact that the Kennedy group had already made such a request, and that it had just been peevishly canceled, they sent out two requests of their own, directed, appropriately, to Ron Dittemore and Linda Ham, but through channels that were a little off-center, and happened to fail. Those channels were ones they had used in their regular work as engineers, outside the formal shuttle-management structure. By unfortunate circumstance, the request that came closest to getting through was intercepted by a mid-level employee (the assistant to an intended recipient, who was on vacation) who responded by informing the Debris Assessment engineers, more or less correctly, that Linda Ham had decided against Air Force imagery.

The confusion was now total, yet also nearly invisible—and within the suppressive culture of the human space-flight program, it had very little chance of making itself known. At the top of the tangle, neither Ron Dittemore nor Linda Ham ever learned that the Debris Assessment Team wanted pictures; at the bottom, the Debris Assessment engineers heard the "no" without suspecting that it was not an answer to their request. They were told to go back to the Crater model and numerical analysis, and as earnest, hardworking engineers (hardly rebels, these), they dutifully complied, all the while regretting the blind assumptions that they would have to make. Given the obvious potential for a catastrophe, one might expect that they would have gone directly to Linda Ham, on foot if necessary, to make the argument in person for a spacewalk or high-resolution photos. However, such were the constraints within the Johnson Space Center that they never dared. They later said that had they made a fuss about the shuttle, they might have been singled out for ridicule. They feared for their standing, and their careers.

The caib investigator who asked the engineers what conclusion they had drawn at the time from management's refusal later said to me, "They all thought, 'Well, none of us have a security clearance high enough to view any of this imagery.' They talked about this openly among themselves, and they figured one of three things:

"'One: The "no" means that management's already got photos, and the damage isn't too bad. They can't show us the photos, because we don't have the security clearance, and they can't tell us they have the photos, or tell us the damage isn't bad, because that tells us how accurate the photos are—and we don't have the security clearance. But wait a minute, if that's the case, then what're we doing here? Why are we doing the analysis? So no, that can't be right.

"'Okay, then, two: They already took the photos, and the damage is so severe that there's no hope for recovery. Well ... that can't be right either, because in that case, why are we doing the analysis?

"'Okay, then, three: They took the photos. They can't tell us they took the photos, and the photos don't give us clear definition. So we need to do the analysis. That's gotta be it!'"

What the Debris Assessment engineers could not imagine is that no photos had been taken, or ever would be—and essentially for lack of curiosity by NASA's imperious, self-convinced managers. What those managers in turn could not imagine was that people in their own house might really be concerned. The communication gap had nothing to do with security clearances, and it was complete.

Gehman explained the underlying realities to me. He said, "They claim that the culture in Houston is a 'badgeless society,' meaning it doesn't matter what you have on your badge—you're concerned about shuttle safety together. Well, that's all nice, but the truth is that it does matter what badge you're wearing. Look, if you really do have an organization that has free communication and open doors and all that kind of stuff, it takes a special kind of management to make it work. And we just don't see that management here. Oh, they say all the right things. 'We have open doors and e-mails, and anybody who sees a problem can raise his hand, blow a whistle, and stop the whole process.' But then when you look at how it really works, it's an incestuous, hierarchical system, with invisible rankings and a very strict informal chain of command. They all know that. So even though they've got all the trappings of communication, you don't actually find communication. It's very complex. But if a person brings an issue up, what caste he's in makes all the difference. Now, again, NASA will deny this, but if you talk to people, if you really listen to people, all the time you hear 'Well, I was afraid to speak up.' Boy, it comes across loud and clear. You listen to the meetings: 'Anybody got anything to say?' There are thirty people in the room, and slam! There's nothing. We have plenty of witness statements saying, 'If I had spoken up, it would have been at the cost of my job.' And if you're in the engineering department, you're a nobody."

One of the caib investigators told me that he asked Linda Ham, "As a manager, how do you seek out dissenting opinions?"

According to him, she answered, "Well, when I hear about them ..."

He interrupted. "Linda, by their very nature you may not hear about them."

"Well, when somebody comes forward and tells me about them."

"But Linda, what techniques do you use to get them?"

He told me she had no answer.

This was certainly not the sort of risk-versus-risk decision-making that Michael Bloomfield had in mind when he described the thinking behind his own shuttle flights.


Columbias Last Flight(P4) - 科学松鼠会 - 科学松鼠会

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