WEBVTT

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Professor Sheila Widnall.

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We are really lucky that she is able to come
and talk to us today.

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She has been here at MIT since 1964 as a professor
and then as provost, but she didn't serve

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very long as provost because she was assigned
to go to Washington by the President to be

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the Secretary of the Air Force, which she
did for almost five years, I guess.

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Four years.

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Then came back here.

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And she is now an institute professor which
basically means you can do anything you want,

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right, including come and talk to our class.

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In particular, Professor Widnall was on the
Columbia Accident Investigation Board.

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And that specifically is what she's going
to talk to us about today, along with just

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general comments about how this relates back
to systems engineering, the design, operation

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of the Shuttle, and basically anything else
that you would like to say because it is your

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time.

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So thanks for being with us, Sheila.

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OK.

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Well, thank you, Jeff.

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As I understand the schedule.

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It is two hours.

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And if I don't finish, we still take a break.

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And then we come back and finish, is that
right?

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Generally, the way we've run the classes is
that we encourage students to ask questions

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while you're talking.

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Absolutely.

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That will probably slow me down a little bit.

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Up to you.

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Anyway, two hours, we'll just take it as it
comes.

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OK.

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Well, I am going to focus on the Columbia
Accident Investigation.

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I must say, and I'm sure I will say many times
as I go through it, that it was an incredible

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experience to be a member of that board.

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02:00 I get chills up my back when I see that.

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The reason I show this is for two reasons.

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First of all, I mean it was, in fact, an incredible
event.

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I am sure that all of you can remember where
you were that morning when that happened.

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I also show it because of the expression on
the face of the principal mission controller,

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Leroy Cain, when he realized that the Shuttle
was lost.

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And if the Shuttle doesn't make it to Cape
Kennedy, more or less on schedule, there is

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no engine at that point, you've got a problem.

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And so he was in a windowless box in Houston.

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And so he had no kind of external, although
all the citizens of Texas knew what had happened,

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the guys in the windowless box did not.

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So it was really an incredible emotional experience
for all of NASA as an agency.

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But then what happens after that?

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Well, fortunately the Challenger Commission
had anticipated the need for a method to call

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an accident board into being if there should
be another Shuttle accident.

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And so there were individuals who were more
or less ex-officio by rank or title waiting

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to be called.

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So, the fact of the matter is, that on Saturday,
when this all happened, the Accident Investigation

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Board was pretty much called into being at
that point.

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Now, who were the Accident Investigation Board
at that point?

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Well, they were primarily government employees.

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Not so much NASA employees.

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That clearly would have been unacceptable.

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But they were military.

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Three Air Force generals, the head of Air
Force Safety, a general from Space Command

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and a general from Material Command who had
actually served as an executive staff to the

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Challenger Commission.

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That would be General Barry.

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So, they had some very good experience.

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The board was chaired by Admiral Hal Gehman
who had been the Vice Chief of Naval Operations.

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He had also been the Chairman of the Cole
Investigation.

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I don't remember how many of you remember
the Cole Investigation, but there was a big

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explosion.

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It is in the Middle East.

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I don't remember.

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Where was it?

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Yemen.

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It was probably Yemen killing 19 people.

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And there were other government employees.

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Somebody from the National Transportation
Safety Board.

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Jim Hallock who is across the street here
at the Department of Transportation, the head

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of NASA Ames and the head of Navy Safety,
Admiral Turcotte.

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It was a smaller board than it ultimately
ended up being.

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05:30 And I'm blanking on names because I
am at that sort of age, but we had a Nobel

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Prize physicist from Stanford.

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You have to have a Nobel Prize physicist on
a Shuttle investigation.

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Also, somebody who had been looking into issues
of policy and history with respect to the

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Shuttle Program.

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And I am not getting any of these names right
so I'm not even going to try.

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Pardon?

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The class has met John Logsdon.

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John Logsdon, right.

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Thank you, John Logsdon.

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Doug Osheroff was the Stanford physicist.

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He was kind of a kick because at the beginning
he was very media shy.

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He just wouldn't talk to the media, but then
he really got into it and he went way outside

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the box, which was kind of interesting to
see how that all happened.

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In any case, we were all pulled together and
we were chartered to uncover the facts, as

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well as the actual or probable cause of the
Shuttle mishap and recommend preventative

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and other appropriate actions to preclude
the recurrence of a similar mishap.

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Yes?

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Professor Widnall, before you and Sally Ride
came on there were no females?

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That's right, no women.

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[AUDIENCE QUESTION]

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I'm not sure.

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Maybe a little bit.

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But, actually, the day of the accident, of
course everybody was saying what happened?

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That's not what I was saying.

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I was saying I wonder who is going to be on
the board.

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I actually had a strong sense that I, in fact,
would be on the board.

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Think about it.

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Gene Covert had been on the Challenger.

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I think, like you have to have Nobel Prize
physicist from Stanford, you have to have

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an aeronautical engineer from MIT.

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I think the other thing was, as Secretary
of the Air Force, I was really in charge of

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accident investigation.

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All accident investigations reported to me.

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Well, you guys don't know a lot about accident
investigations in the military.

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But there are two accident investigations
in the military.

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One called a safety investigation, which is
privileged, and you take testimony and you

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seal it.

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And I will talk about that later because we
tried to replicate some of that on the Columbia

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investigation.

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You have that one and then you have the public
investigation which you take testimony, people

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can be court-martialed.

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There is an Accident Investigation procedure
that goes on in the Air Force, and I had really

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been in charge of that.

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In addition to be an aerodynamicist, which
is always good, I was the aerodynamicist on

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the commission, I was a faculty member at
MIT, I had been Secretary of the Air Force,

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I had been in charge of accidents.

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Also, I had spent my last five years really
being interested in space, safety and mission

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assurance in space.

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I mean all these things kind of came together.

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Sally Ride was obvious.

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She was an astronaut.

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And she had been a member of the Challenger
investigation board.

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She brought that historic knowledge.

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I don't think that was the primary thing,
but it is probably good to have a balanced

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group.
See, I actually did come on board pretty much
February 18th.

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That was when I came.

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I think that one of the early issues that
we faced was our relationship with NASA.

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I think at the very beginning NASA had this
image that we would work for them.

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That was one thing.

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And the second thing was that we would find
the widget that failed and then we would leave

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leaving them to carry on.

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Not with this group of people you don't do
that, and not in this situation.

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We very clearly and fairly early established
our independence.

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We removed a number of senior NASA people
from inline responsibility for the investigation

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like Ralph Rowe.

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Again, I'm blanking on these names, but the
people who had been in charge of the program.

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Of course, some of them quit even before we
got there.

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Linda Ham was right in the middle of things.

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And we just said look, we're not questioning
your integrity but you just cannot investigate

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yourself so we need to move you aside.

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Go back to your normal responsibilities and
bring in independent people who had not been

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so deeply involved.

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And they will be the primary interface between
the Accident Investigation Board and NASA

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because we really needed to use NASA.

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I basically had very strong interactions with
the NASA aerodynamics division.

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And you will see the reasons why as we proceed.

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But at the end of my interaction with them,
which occurred at the end of June, and they

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presented their 450 page report to me with
all the calculations and studies and things

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that they had done at my direction, I basically
looked to the group and said well, I think

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I could probably give 22 PhDs at this point
to this group.

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Because we had really pressed the envelope
in terms of improving the methodology that

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we used to analyze some of the details of
kind of what I'm going to talk about.

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But, in any case, the issue of independence
was extremely important.

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And I recall a lot of meetings with a lot
of banging on the table and yelling and screaming

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before we finally got this all straightened
out.

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Admiral Gehman was an incredible leader.

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He really just did such good work.

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He had a sense of where to press and where
to stay on pad and how to interact.

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He really was a marvelous chairman.

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Incidentally, he recently served on the BRAC
Commission so he is somebody who is deeply

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involved in public service.

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And I know, from my conversations with him,
that he is a person who refuses to serve on

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any board of directors that has anything to
do with the Department of Defense because

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he does not want to give the appearance of
a conflict of interest.

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And he is just a man of incredible integrity.

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Obviously, I am a big fan.

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In any case, we proceeded then to wrap our
group together and begin our interactions

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with NASA.

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12:30 And I will show that a couple of times.

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And this happened in about 81 seconds, two
seconds after launch.

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I don't remember the mach number, but I think
it was something like 2, 2.5, something like

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that.

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This is the video.

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And you see the piece coming off and smashing.

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And I will show it again.

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That video was pretty much available the weekend
of the launch.

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There was an understanding among senior program
managers that there could be a problem.

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Now, what did we know about it?

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Well, there were video cameras at the site.

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There was a video camera located here, a video
camera located here.

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A rather shallow angle to try to do any triangulation.

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But, obviously, you use what you have.

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And so, as a result of triangulated these
two video cameras, we were able to make an

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estimate.

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It's probably also worth mentioning that there
were other video cameras but they were out

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of order.

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Right.

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And I was going to talk about that with respect
to our recommendations.

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One of our recommendations was that working
video cameras were an absolute necessity for

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launch.

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In other words, you do not launch if you don't
have a reasonable set of video cameras.

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And, by the way, you don't launch at night
because then, obviously, the video cameras

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would not be any good.

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That was one of our recommendations, what
I would call a near term recommendation, return

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to flight recommendation.

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Yes?

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[AUDIENCE QUESTION]

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I don't know the answer to that.

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Maybe you know the answer to that.

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It is very interesting because I have been
doing a lot of mission assurance and space

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accident stuff.

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You almost always have a picture of a space
accident mostly because they occur on launch.

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So, in the case of the Challenger, we had
excellent video.

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We could see the little hole in the Challenger.

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We could see the stuff coming out.

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In this case, we had reasonable video of potential
impact.

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You can launch with an 8000 foot ceiling.

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In which case we would not have seen the Challenger.

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Yeah, at that point.

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I don't think it's true now.

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And I don't know how they followed up on that,
but there is also a possibility of using aircraft

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if they cannot get the video.

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In any case, it turns out to be an important
issue.

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And we made recommendations.

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What we knew about the impact was we figured
-- Of course you guys all know exactly what

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this is.

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This is the left wing underside.

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This is where the curvature changes, and so
it was kind of right in here some place, what

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we refer to as panel seven, panel eight, panel
nine of the underside of the composite material

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that surrounds the leading edge.

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Now, I don't know if you guys have studied
that composite material.

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It is a truly marvelous material.

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And I may say a little bit more about it.

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So, we sort of knew where the impact had occurred.

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Obviously, we were hampered by the shallow
angle of the video but this was our best estimate.

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The velocity was estimated to be roughly 800
feet per second.

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And that was obtained from several different
methods.

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One was a computational fluid dynamics calculation
of how would the airstream accelerate a piece

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of foam of that particular shape weighing
two pounds and having it hit?

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And the other thing was from the video itself.

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We had pretty good correlation between the
estimates based on the video and the estimates

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based on calculations using computational
fluid dynamics, so we felt pretty comfortable

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about this velocity.

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What did we know?

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When I joined the board what did we know?

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What kind of data did we have?

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Well, this particular vehicle had some telemetry
of some sensors in the wing and in other places.

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At this point in the investigation, we had
not recovered the flight data recorder.

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The other thing that is interesting is that
this is the only vehicle with a flight data

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recorder.

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This is the vehicle that was considered to
be a research and development vehicle.

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All the other vehicles were operational.

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They did not equip them with flight data recorders.

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Now, I will get back to this point when I
talk about the criticisms that we had of the

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agency.

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But we took strong exception to the notion
that the Shuttle had be declared to be operational.

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And, therefore, there was no need to continue
to study it as a research and development

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vehicle.

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It was just like a piper cub or a 747.

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That takeoff was a routine event and was not,
in fact, a major event.

00:18:39.379 --> 00:18:46.379
And even in this system, if a sensor failed
in the flight data recorder it was not replaced.

00:18:47.710 --> 00:18:52.809
So what we had on the Columbia was a wasting
asset, but at least we had an asset.

00:18:52.809 --> 00:18:53.940
We had a flight data recorder.

00:18:53.940 --> 00:18:55.669
At this point we had not found it.

00:18:55.669 --> 00:18:57.340
Where were these sensors located?

00:18:57.340 --> 00:19:00.080
Well, there were a lot of sensors in the wheel
well.

00:19:00.080 --> 00:19:03.139
There were some temperature sensors in this
region of the leading edge.

00:19:03.139 --> 00:19:07.549
There were some temperature sensors back in
here and different places.

00:19:07.549 --> 00:19:13.779
Now, one thing that is significant about this
is that these temperature sensors were connected

00:19:13.779 --> 00:19:15.629
to two different boxes.

00:19:15.629 --> 00:19:22.629
Actually, it looks like three but what I'm
going to focus on are these wires.

00:19:23.570 --> 00:19:28.600
Some of the temperature sensors were connected
to wires that were basically in this region

00:19:28.600 --> 00:19:30.289
and running along the wheel well.

00:19:30.289 --> 00:19:37.289
19:30 That's one of the reasons why that was
important and kind of how we began to hypothesize

00:20:05.350 --> 00:20:06.729
what had gone wrong.

00:20:06.729 --> 00:20:11.289
Now, you see the time was sort of 8:44.

00:20:11.289 --> 00:20:13.720
That is Eastern Standard, I think.

00:20:13.720 --> 00:20:16.059
I was shopping, actually, at the time.

00:20:16.059 --> 00:20:23.059
Between 8:44 and 9:00 is when all of this
took place, so we're talking about 15 minutes

00:20:24.210 --> 00:20:26.229
of problems.

00:20:26.229 --> 00:20:29.739
At 8:44 everything was fine and at 9:00 the
vehicle had crashes.

00:20:29.739 --> 00:20:36.739
20:30 Why did these sensors fail first?

00:21:02.779 --> 00:21:09.779
It was because the wire that controls these
sensors is located here in this sort of critical

00:21:12.049 --> 00:21:15.149
area, so that was the wire cutting.

00:21:15.149 --> 00:21:15.399
Yes?

00:21:15.330 --> 00:21:21.570
You said the other orbiters don't have flight
data recorders.

00:21:21.570 --> 00:21:21.820
Right.

00:21:21.799 --> 00:21:24.649
[AUDIENCE QUESTION]

00:21:24.649 --> 00:21:26.080
Commercial, that's a whole different mindset.

00:21:26.080 --> 00:21:26.409
Yeah.

00:21:26.409 --> 00:21:33.409
I mean those carry people and

00:21:39.960 --> 00:21:46.960
it

00:21:58.979 --> 00:22:01.330
is an FAA regulation.

00:22:01.330 --> 00:22:05.759
21:30 That the wires were being cut.

00:22:05.759 --> 00:22:12.759
And so we could follow the failure of these
sensors right up to the point when the vehicle,

00:22:16.529 --> 00:22:19.499
we had loss of signal which was at about 8:59.

00:22:19.499 --> 00:22:26.249
This whole thing happened fairly rapidly,
of course, and this was the trajectory of

00:22:26.249 --> 00:22:26.950
the vehicle.

00:22:26.950 --> 00:22:33.419
I will show another picture, but the whole
problem sort of started off Hawaii and then

00:22:33.419 --> 00:22:38.989
the vehicle began to break up here in Texas.

00:22:38.989 --> 00:22:42.379
This was kind of what we knew on roughly February
18th.

00:22:42.379 --> 00:22:46.309
In fact, that's all we knew really.

00:22:46.309 --> 00:22:51.960
I mean the temperature increases were not
particularly dramatic, you know, 50 degrees,

00:22:51.960 --> 00:22:53.039
30 degrees.

00:22:53.039 --> 00:22:55.599
That's not really interesting.

00:22:55.599 --> 00:22:58.099
What was interesting is the wires were cut.

00:22:58.099 --> 00:23:01.820
That was more interesting.

00:23:01.820 --> 00:23:04.340
OK.

00:23:04.340 --> 00:23:09.599
We began to look for the debris.

00:23:09.599 --> 00:23:16.599
We had people essentially marching over the
State of Texas about that far apart.

00:23:16.669 --> 00:23:23.669
It was an extremely expensive thing, but we
recovered about 40% of the material that came

00:23:24.570 --> 00:23:25.220
from Columbia.

00:23:25.220 --> 00:23:29.519
And, of course, it is all these little pieces
of stuff that fell on the ground.

00:23:29.519 --> 00:23:32.289
Fortunately, it fell in a fairly rural area.

00:23:32.289 --> 00:23:33.229
Nobody was hurt.

00:23:33.229 --> 00:23:38.489
I don't think there was any damage to structures
or anything like that.

00:23:38.489 --> 00:23:41.460
And we were able to recover a great deal of
it.

00:23:41.460 --> 00:23:47.119
A lot of it, because I actually looked at
the weather radar, was very small particles

00:23:47.119 --> 00:23:49.359
that actually floated into the Gulf of Mexico.

00:23:49.359 --> 00:23:52.749
I mean you could see it on the weather radar,
the NEXRAD system.

00:23:52.749 --> 00:23:54.289
You guys all know what the weather radar is.

00:23:54.289 --> 00:23:59.149
But you could see the particles streaming
into the Gulf of Mexico.

00:23:59.149 --> 00:24:04.139
I think a lot of it was just sort of vaporized.

00:24:04.139 --> 00:24:09.849
And there is a footprint of the debris.

00:24:09.849 --> 00:24:14.229
And we did a lot of searching in that area.

00:24:14.229 --> 00:24:15.700
We tried to search upstream.

00:24:15.700 --> 00:24:21.440
We were really trying to find the earliest
pieces of debris, but these fell down onesies

00:24:21.440 --> 00:24:25.769
and twosies in really strange places like
in mountains in Utah and stuff like that.

00:24:25.769 --> 00:24:30.279
So we were never really successful, although
some of these had been tracked on radar by

00:24:30.279 --> 00:24:32.989
the FAA.

00:24:32.989 --> 00:24:38.279
And there is the debris collection, a hanger
down at Kennedy.

00:24:38.279 --> 00:24:42.460
This is pretty standard stuff for a commercial
aircraft, I think you all know that.

00:24:42.460 --> 00:24:49.460
When you have an accident, what you try to
do is recover the debris and reconstruct the

00:24:49.729 --> 00:24:51.070
vehicle.

00:24:51.070 --> 00:24:53.450
This debris was particularly interesting.

00:24:53.450 --> 00:25:00.009
And I don't know if I have a graph later,
but let me talk a little bit about the temperatures

00:25:00.009 --> 00:25:02.029
involved.

00:25:02.029 --> 00:25:07.940
We're talking about reentry of a damaged vehicle
at mach 25.

00:25:07.940 --> 00:25:13.229
Now, of course, that is the course that I
tried to get out of when I was a graduate

00:25:13.229 --> 00:25:20.229
student, was that high temperature stuff where
the gas begins to ionize and dissociate and,

00:25:20.539 --> 00:25:23.340
you know, all that enthalpy stuff.

00:25:23.340 --> 00:25:27.359
I really tried to avoid that, so I got paid
back.

00:25:27.359 --> 00:25:30.820
Anyway, that is the subject of high-speed
gas dynamics.

00:25:30.820 --> 00:25:32.769
And so I had to take a refresher course.

00:25:32.769 --> 00:25:36.559
And Judd Barren, one of our faculty members,
was extremely helpful.

00:25:36.559 --> 00:25:38.969
I used to go over to his house on Saturdays
and he would give me references.

00:25:38.969 --> 00:25:45.969
But, roughly speaking, if the gas didn't dissociate,
the temperatures on reentry at the leading

00:25:47.129 --> 00:25:52.710
edge of this vehicle would give off 50,000
degrees Fahrenheit, which is really pretty

00:25:52.710 --> 00:25:54.210
hot.

00:25:54.210 --> 00:25:59.830
The fact that the gas does dissociate -- Ionization
at this mach number is not that important.

00:25:59.830 --> 00:26:04.210
It interferes with the radio signals but does
not, in fact, absorb a lot of energy.

00:26:04.210 --> 00:26:10.469
The gas is slightly ionized 1%, something
like that, 2%, but not enough to be a big

00:26:10.469 --> 00:26:11.919
energy issue.

00:26:11.919 --> 00:26:17.659
But the dissociation of oxygen, dissociation
of nitrogen is an extremely important phenomenon.

00:26:17.659 --> 00:26:22.799
And, because of that, the gas temperature
is roughly 10,000 degrees Fahrenheit which

00:26:22.799 --> 00:26:25.440
is a lot better than 50,000 degrees Fahrenheit.

00:26:25.440 --> 00:26:26.570
So that makes a big difference.

00:26:26.570 --> 00:26:31.710
Let's talk about the leading edge material.

00:26:31.710 --> 00:26:36.129
The leading edge material is, in fact, an
incredible material.

00:26:36.129 --> 00:26:39.070
It is a carbon-carbon composite material.

00:26:39.070 --> 00:26:46.070
It is about a quarter of an inch thick and
it can withstand a temperature of 3200 degrees

00:26:46.429 --> 00:26:47.499
Fahrenheit.

00:26:47.499 --> 00:26:54.139
And the Shuttle was conceived in, what are
we talking about here, '70?

00:26:54.139 --> 00:26:58.649
Yeah, '69, '70.

00:26:58.649 --> 00:27:00.919
We don't have much better materials today.

00:27:00.919 --> 00:27:07.239
We might be able to go to 3400 degrees Fahrenheit
instead of 3200 degrees Fahrenheit, so we've

00:27:07.239 --> 00:27:10.539
made some progress, but this is a marvelous
material.

00:27:10.539 --> 00:27:16.190
Now, how in the world, with the gas temperature
of 10,000 degrees Fahrenheit, can you use

00:27:16.190 --> 00:27:19.149
a material of 3200 degrees Fahrenheit?

00:27:19.149 --> 00:27:23.009
Well, that's the other part that I tried to
avoid as a graduate student.

00:27:23.009 --> 00:27:24.629
It is called radiation.

00:27:24.629 --> 00:27:25.879
And what is it?

00:27:25.879 --> 00:27:32.200
The Stefen-Boltzmann Law of Radiation, T to
the fourth.

00:27:32.200 --> 00:27:35.519
And you could write it down on the back of
an envelope and you can calculate it.

00:27:35.519 --> 00:27:42.519
And it turns out that the gas coming in does
heat the leading edge up, but then the leading

00:27:42.589 --> 00:27:47.299
edge radiates out the right amount of energy
to basically have an equilibrium temperature

00:27:47.299 --> 00:27:52.119
of the order of magnitude of, say, 2800 degrees
or maybe 3000 degrees.

00:27:52.119 --> 00:27:59.119
It is comfortable below its maximum temperature,
but this is obviously a very dangerous situation.

00:28:04.719 --> 00:28:10.619
In the early days of the Shuttle Program they
made some tests of this material, its ability

00:28:10.619 --> 00:28:14.149
to withstand impact.

00:28:14.149 --> 00:28:19.669
They shot BBs at it and made quarter inch
holes in it.

00:28:19.669 --> 00:28:21.710
And then I'm a little fuzzy on this part.

00:28:21.710 --> 00:28:27.179
They may have tested those quarter inch holes
in an arc jet to see would they ablate, how

00:28:27.179 --> 00:28:31.409
would they behave and would they grow?

00:28:31.409 --> 00:28:36.249
And I think at that point they felt comfortable
that they could withstand the impact of a

00:28:36.249 --> 00:28:41.549
BB and not be destroyed.

00:28:41.549 --> 00:28:43.029
So that is an important set of issues.

00:28:43.029 --> 00:28:49.759
I guess the other thing I want to point out
is if you have a good solid continuous edge

00:28:49.759 --> 00:28:54.039
you can support a temperature of 3200 degrees
because of radiation.

00:28:54.039 --> 00:28:59.639
But if you get a hole in that leading edge
then the gas that goes into the cavity behind

00:28:59.639 --> 00:29:02.399
the leading edge is your old friend 10,000
degrees.

00:29:02.399 --> 00:29:09.399
But there is no radiation balance to bring
you back down to 3200 degrees so you have

00:29:09.509 --> 00:29:16.509
a 7000 to 10,000 degree arc jet coming through
any major size hole in the leading edge of

00:29:17.989 --> 00:29:18.809
the shuttle.

00:29:18.809 --> 00:29:20.669
And that is, of course, exactly what happened.

00:29:20.669 --> 00:29:25.419
And, to remind people, 10,000 degrees is the
surface temperature of the sun.

00:29:25.419 --> 00:29:26.399
Oh, it's very hot.

00:29:26.399 --> 00:29:27.479
Yes.

00:29:27.479 --> 00:29:31.879
There is no material that will withstand this.

00:29:31.879 --> 00:29:38.499
And this happens routinely in shuttle operations
is that the shuttle reenters at mach 25 and

00:29:38.499 --> 00:29:41.589
the temperatures of the gas surrounding the
shuttle are about 10,000 degrees.

00:29:41.589 --> 00:29:48.589
And we've successfully gone through how many
shuttle flights in total?

00:29:49.259 --> 00:29:53.509
114.

00:29:53.509 --> 00:29:56.409
It's a sporty course.

00:29:56.409 --> 00:30:03.179
Now, I want to talk about something else we
knew before we found the flight data recorder.

00:30:03.179 --> 00:30:08.460
And this was of great interest to me for lots
of different reasons, but one of the things

00:30:08.460 --> 00:30:15.460
we were able to do is infer the aerodynamics
of the damaged vehicle by looking at what

00:30:16.440 --> 00:30:22.460
the Flight Control System had to do in order
to keep the Shuttle perfectly on its pre-assigned

00:30:22.460 --> 00:30:24.639
flight path.

00:30:24.639 --> 00:30:31.639
In other words, until very late in the flight
the Shuttle was doing exactly what it was

00:30:31.979 --> 00:30:32.789
programmed to do.

00:30:32.789 --> 00:30:38.719
But it was working a lot harder and in very
off nominal ways.

00:30:38.719 --> 00:30:42.889
And we had to back this out.

00:30:42.889 --> 00:30:47.029
Now, this is almost like a zero over zero
calculation so it's a little sensitive, a

00:30:47.029 --> 00:30:50.229
little hard to do, but this was something
the aerodynamics group did.

00:30:50.229 --> 00:30:52.200
And I worked really closely with these guys.

00:30:52.200 --> 00:30:54.499
I have great admiration for them.

00:30:54.499 --> 00:31:01.399
They were able to back out the off nominal
roll moments and the off nominal yaw moments

00:31:01.399 --> 00:31:04.339
of the Shuttle during this final reentry.

00:31:04.339 --> 00:31:11.339
And I made this little schematic of kind of
where were they when some of these things

00:31:11.450 --> 00:31:18.450
happened in terms of the Coast of California
and their flight over New Mexico and down

00:31:19.299 --> 00:31:21.209
to loss of control over Texas.

00:31:21.209 --> 00:31:28.209
Before I do that, let me just add to my previous
remark that you almost always have a picture

00:31:28.809 --> 00:31:30.969
of a space accident.

00:31:30.969 --> 00:31:35.179
Now, normally that's because space accidents
occur on launch.

00:31:35.179 --> 00:31:40.149
This is a remarkable photo of a space accident.

00:31:40.149 --> 00:31:47.149
This photo was taken by modestly my guys at
Kirtland Air Force Base.

00:31:47.209 --> 00:31:50.879
And basically they had been working with optics.

00:31:50.879 --> 00:31:52.249
That is basically their business.

00:31:52.249 --> 00:31:59.249
And so Saturday morning IBM personal computer,
fooling around with some little telescope

00:31:59.739 --> 00:32:02.589
that they had been developing for tracking
things.

00:32:02.589 --> 00:32:09.589
32:00 Yeah, this is interesting.

00:32:31.649 --> 00:32:38.649
This is a bulge at the leading edge showing
some distortion of the shock shape due to

00:32:40.330 --> 00:32:41.859
vehicle damage.

00:32:41.859 --> 00:32:46.979
And I obviously consider this photo to be
extremely probative.

00:32:46.979 --> 00:32:53.979
And also there is a small amount of debris
that has got some optical signature to it

00:32:54.690 --> 00:33:01.690
that is sort of streaming out of that general
area indicating -- I mean there are all sorts

00:33:02.209 --> 00:33:05.889
of things going on in this vehicle, but one
of the things that was going on was the melting

00:33:05.889 --> 00:33:11.429
of aluminum, the vaporization of aluminum
and the combustion of aluminum because aluminum

00:33:11.429 --> 00:33:13.009
will burn.

00:33:13.009 --> 00:33:17.309
I don't know how many of you know it but aluminum
is something you add to rocket engines in

00:33:17.309 --> 00:33:19.309
order to get higher temperatures.

00:33:19.309 --> 00:33:21.269
It burns when it gets hot enough.

00:33:21.269 --> 00:33:23.309
It can be a very dangerous material.

00:33:23.309 --> 00:33:28.669
In any case, we suspect there was a lot of
aluminum combustion going on while this thing

00:33:28.669 --> 00:33:29.089
was happening.

00:33:29.089 --> 00:33:33.339
Had there been, for reference, any similar
photographs?

00:33:33.339 --> 00:33:33.879
No.

00:33:33.879 --> 00:33:37.599
So we didn't have a nominal baseline.

00:33:37.599 --> 00:33:39.099
No, as far as I know.

00:33:39.099 --> 00:33:41.169
I actually don't know the answer to that question.

00:33:41.169 --> 00:33:48.169
I know, because I know the guys who took the
photo and I know their boss, that they were

00:33:48.570 --> 00:33:52.639
doing it for a very specific reason that had
nothing to do with anything they had done

00:33:52.639 --> 00:33:53.369
in the past.

00:33:53.369 --> 00:33:57.909
They were trying to develop a little telescope
to track things because that's what they do

00:33:57.909 --> 00:34:01.479
at Kirtland, is they work with optics.

00:34:01.479 --> 00:34:04.299
But I don't know whether anybody has tried
to do it.

00:34:04.299 --> 00:34:10.899
I suspect their level of precision is a little
greater than the average citizen trying to

00:34:10.899 --> 00:34:14.820
take a picture of the Shuttle coming in.

00:34:14.820 --> 00:34:17.030
But this was not a really high powered telescope.

00:34:17.030 --> 00:34:19.320
I mean they had some really high powered telescope
at Kirtland.

00:34:19.320 --> 00:34:22.418
This was just a small one.

00:34:22.418 --> 00:34:26.829
Anyway, I don't know the answer to that.

00:34:26.829 --> 00:34:32.909
Well, I think what we're looking at here is
the glowing of this 10,000 degree envelope

00:34:32.909 --> 00:34:34.129
that surrounds the Shuttle.

00:34:34.129 --> 00:34:40.819
That is what we're looking at, is we're looking
at the radiation, basically, from the gas

00:34:40.819 --> 00:34:41.760
surrounding the Shuttle.

00:34:41.760 --> 00:34:43.839
It was normal.

00:34:43.839 --> 00:34:50.839
But, of course, this was 8:50 in the morning
Boston time.

00:34:53.069 --> 00:34:57.519
This is February so it probably was dark in
New Mexico.

00:34:57.519 --> 00:35:02.500
That is kind of the picture that we go, which
I think is really neat.

00:35:02.500 --> 00:35:08.670
This is the trajectory, but this is the backing
out of the off nominal moments.

00:35:08.670 --> 00:35:13.079
Now, let me talk about the yaw moments just
to give you a feeling for what does all this

00:35:13.079 --> 00:35:15.299
mean.

00:35:15.299 --> 00:35:22.299
I contend that off nominal aerodynamic forces
are an indication of external damage to the

00:35:22.589 --> 00:35:22.839
vehicle.
That is basically what it is.

00:35:25.250 --> 00:35:31.160
The vehicle was flying because its reaction
jets were moving and doing all sorts of things.

00:35:31.160 --> 00:35:36.760
The aerodynamic surfaces were virtually useless
at these dynamic pressures.

00:35:36.760 --> 00:35:41.950
This was a reaction jet controlled vehicle,
but we knew how much force the reaction jets

00:35:41.950 --> 00:35:45.630
were putting out so we could do the vehicle
aerodynamics.

00:35:45.630 --> 00:35:47.500
Let me talk about the yaw moment.

00:35:47.500 --> 00:35:53.869
What we have here is that as the accident
began the yaw moment became negative, kind

00:35:53.869 --> 00:35:57.720
of flattened out for a little while and then
became very strongly negative.

00:35:57.720 --> 00:35:58.500
What is yaw moment?

00:35:58.500 --> 00:36:02.910
Yaw moment is the force turning the vehicle
this way.

00:36:02.910 --> 00:36:08.869
If I have a damaged left wing, what is my
yaw moment going to be and why?

00:36:08.869 --> 00:36:14.390
Well, I'm going to have increased drag on
this wing because I've got a big chunk out

00:36:14.390 --> 00:36:20.130
of the leading edge, I've got a disturbed
shock, I've got all sorts of stagnation pressure

00:36:20.130 --> 00:36:25.069
in this region where in normal circumstances
it would be smoothly flowing.

00:36:25.069 --> 00:36:29.279
I've got increased drag on this wing, and
so that's going to drive me this way which

00:36:29.279 --> 00:36:30.319
is exactly what you see.

00:36:30.319 --> 00:36:32.839
That is off nominal yaw moment.

00:36:32.839 --> 00:36:39.230
Roll moment is a little stranger.

00:36:39.230 --> 00:36:46.230
Basically, as the drag increases, and you
probably lose lift so your roll moment begins

00:36:46.710 --> 00:36:51.760
to go like that, you have decreasing roll
moment.

00:36:51.760 --> 00:36:58.760
This was a bit of a mystery because basically
what it said is you lose roll moment, but

00:37:01.450 --> 00:37:05.420
then all of a sudden your roll moment increases.

00:37:05.420 --> 00:37:09.130
That is a problem that only an aeroelastician
could solve.

00:37:09.130 --> 00:37:12.640
I happened to be an aeroelastician.

00:37:12.640 --> 00:37:15.349
Do you know what I'm talking about?

00:37:15.349 --> 00:37:22.349
If you stick your hand out of the car window
and you turn it slightly what happens?

00:37:24.000 --> 00:37:24.960
It goes up.

00:37:24.960 --> 00:37:27.250
And it may also turn some more.

00:37:27.250 --> 00:37:34.250
In other words, if you lose the leading edge
spar of a wing, you lose its resistance to

00:37:35.819 --> 00:37:38.150
torsion.

00:37:38.150 --> 00:37:44.799
Now, we don't have all the data we need to
prove that that's what was going on.

00:37:44.799 --> 00:37:51.329
But I believe a strong hypothesis that we
lost the strength in the leading edge spar

00:37:51.329 --> 00:37:55.319
and the leading edge spar tipped up.

00:37:55.319 --> 00:37:58.789
And obviously the lift would increase because
the angle-of-attack was increasing.

00:37:58.789 --> 00:38:03.369
But this was a very, very puzzling and very
interesting phenomenon.

00:38:03.369 --> 00:38:08.579
But, in any case, what happened is that both
the roll moments and the yaw moments got too

00:38:08.579 --> 00:38:15.069
strong for the control system of the vehicle
which, again, was just the reaction control

00:38:15.069 --> 00:38:19.019
jets that are on the area around the vertical
tail.

00:38:19.019 --> 00:38:25.160
Then, ultimately, the thing went into a spin,
lost control and then, of course, the vehicle

00:38:25.160 --> 00:38:28.730
was lost, began to break apart.

00:38:28.730 --> 00:38:31.670
This was a very interesting set of data.

00:38:31.670 --> 00:38:37.029
And, as I say, when we started, this was pretty
much all we had.

00:38:37.029 --> 00:38:41.769
There was a pivotal moment, and it occurred
sort of at the end of March, about March 27th.

00:38:41.769 --> 00:38:45.160
Remember, the accident occurred February 1st.

00:38:45.160 --> 00:38:46.599
We found the flight data recorder.

00:38:46.599 --> 00:38:53.579
And we found it by these guys walking across
the field looking for stuff.

00:38:53.579 --> 00:38:56.190
And the flight data recorder was found.

00:38:56.190 --> 00:39:03.190
And it was in pretty good condition considering
it had done a reentry at mach 25.

00:39:05.200 --> 00:39:08.710
We were able to recover the data from the
flight data recorder.

00:39:08.710 --> 00:39:10.670
I think we pretty much got it all.

00:39:10.670 --> 00:39:17.390
At that point we had hundreds and hundreds
of data points.

00:39:17.390 --> 00:39:24.390
And I would say, at this point, NASA's attitude
changed.

00:39:25.089 --> 00:39:31.589
I think up until this point there had been
a certain level of denial about the accident,

00:39:31.589 --> 00:39:33.980
about what caused it.

00:39:33.980 --> 00:39:36.109
Maybe it was a micro meteorite.

00:39:36.109 --> 00:39:42.049
Maybe it was some unexplained system failure.

00:39:42.049 --> 00:39:48.109
They were not really sure that we were pursuing
the right road until the flight data recorder

00:39:48.109 --> 00:39:49.299
was found.

00:39:49.299 --> 00:39:51.039
And I think maybe that's to NASA's credit.

00:39:51.039 --> 00:39:53.420
NASA is data driven.

00:39:53.420 --> 00:39:57.400
And when they began to see the data and they
began to see how well the data correlated

00:39:57.400 --> 00:40:03.650
with the hypothesis and the models then they
hopped right onboard and did a tremendous

00:40:03.650 --> 00:40:10.650
amount of work to try to help us unscramble
all of this and come to a hypothesis.

00:40:11.920 --> 00:40:13.519
What kind of data did we have?

00:40:13.519 --> 00:40:19.130
Well, this is a picture of the leading edge
spar, this big thing here.

00:40:19.130 --> 00:40:26.130
And this is a picture of the hypothesis sort
of about a piece of foam taking out a fairly

00:40:27.259 --> 00:40:34.259
large piece of this carbon-carbon fiber and
allowing hot gas to enter into the region

00:40:35.369 --> 00:40:37.650
behind the leading edge.

00:40:37.650 --> 00:40:41.460
This leading edge region is, as you can see
by the picture, sort of hollow.

00:40:41.460 --> 00:40:42.920
There isn't anything back there.

00:40:42.920 --> 00:40:49.920
There is a layer of insulation covering this,
but that is because of the radiation.

00:40:50.019 --> 00:40:54.519
In other words, because this, in fact, is
3200 degrees.

00:40:54.519 --> 00:40:56.039
It radiates in both directions.

00:40:56.039 --> 00:40:59.970
And so there is a layer of insulation here
to protect against radiation.

00:40:59.970 --> 00:41:05.240
But that insulation will not protect against
the equivalent of an arc jet.

00:41:05.240 --> 00:41:10.930
That is just, again, burrowing and blasting
it.

00:41:10.930 --> 00:41:17.930
It was fairly quickly that this gas just blew
a hole through the leading edge spar.

00:41:22.690 --> 00:41:24.339
How did we know that?

00:41:24.339 --> 00:41:25.480
Well, it's kind of interesting.

00:41:25.480 --> 00:41:26.730
Let's look at one of these.

00:41:26.730 --> 00:41:30.490
We had all these wires back here.

00:41:30.490 --> 00:41:32.400
And we had these temperature sensors.

00:41:32.400 --> 00:41:33.869
Let's just pick one temperature sensor.

00:41:33.869 --> 00:41:36.480
I didn't even know where it was located, but
it was not located in this region.

00:41:36.480 --> 00:41:39.940
It was located back someplace else.

00:41:39.940 --> 00:41:45.359
So we looked at the temperature sensor and
compared it with earlier flights where the

00:41:45.359 --> 00:41:49.259
earlier flights would show this behavior and
this temperature sensor kind of did this.

00:41:49.259 --> 00:41:55.150
It began to go up and then all of a sudden
we lost it.

00:41:55.150 --> 00:41:55.500
What happened?

00:41:55.500 --> 00:42:02.500
42:00 The
picture begins to emerge of wire bundles being
cut, of gas entering here, of this wire bundle

00:43:03.369 --> 00:43:10.029
being cut to the sensor of this, in fact,
entire region beginning to sort of fill up

00:43:10.029 --> 00:43:17.029
with extremely hot gas, 7000 degrees roughly,
eventually entering the wheel well, although,

00:43:17.519 --> 00:43:20.230
that was later in the flight.

00:43:20.230 --> 00:43:26.190
We did have some indication of the gas in
the wheel well because of the temperatures

00:43:26.190 --> 00:43:30.940
and the loss of sensors.

00:43:30.940 --> 00:43:37.940
Because of this the focus turned to the question
of this what we call RCC, which is this composite

00:43:38.660 --> 00:43:41.140
material that surrounds the leading edge.

00:43:41.140 --> 00:43:43.039
And where did we find it?

00:43:43.039 --> 00:43:44.269
And we found a lot of it.

00:43:44.269 --> 00:43:49.190
I mean we found it all along in Texas.

00:43:49.190 --> 00:43:54.799
The other thing we were able to look at, with
respect to the RCC, is its pattern of erosion.

00:43:54.799 --> 00:43:59.809
I mean this RCC was kind of flopping out in
the breeze here at roughly 7000 to 10,000

00:43:59.809 --> 00:44:01.019
degrees.

00:44:01.019 --> 00:44:05.950
And so it was a material that was being effectively
subject to an arc jet.

00:44:05.950 --> 00:44:09.440
And, if you took a material like that and
stuck it in an arc jet, it probably would

00:44:09.440 --> 00:44:16.440
ablate and it would maybe sharpen up and you'd
have maybe little pointy edges where it had

00:44:16.829 --> 00:44:18.579
ablated.

00:44:18.579 --> 00:44:21.769
And so we looked at the part that was particularly
eroded.

00:44:21.769 --> 00:44:23.210
And that would be the yellow stuff.

00:44:23.210 --> 00:44:30.210
And we found that upstream of the stuff that
was more put together, the rest of the RCC

00:44:33.220 --> 00:44:33.849
from the wing.

00:44:33.849 --> 00:44:39.430
And, from the right wing, we found the right
wing downstream of the left wing which means

00:44:39.430 --> 00:44:42.089
that the left wing came off first.

00:44:42.089 --> 00:44:49.089
Now, the image that emerges from this is hole
in the leading edge, material coming off,

00:44:50.200 --> 00:44:56.960
but gas flow going down this what some people
called the "chunnel." I never liked that term,

00:44:56.960 --> 00:45:00.980
but it's a big open cavity.

00:45:00.980 --> 00:45:06.299
Gas flowing down this open cavity and simply
destroying all the fittings that held the

00:45:06.299 --> 00:45:07.690
RCC onto the wing.

00:45:07.690 --> 00:45:10.990
I mean the screws and the brackets and all
of that.

00:45:10.990 --> 00:45:13.890
And, again, gas is coming in.

00:45:13.890 --> 00:45:15.920
And the wing just unzips.

00:45:15.920 --> 00:45:18.559
All this stuff just kind of unzips and falls
off.

00:45:18.559 --> 00:45:23.309
And, of course, that is where we find it,
just lying on the ground.

00:45:23.309 --> 00:45:28.339
It all unzipped and fell off.

00:45:28.339 --> 00:45:29.480
What did we actually find?

00:45:29.480 --> 00:45:36.480
45:30 What we had to do, however, is to construct
analysis using a whole lot of different disciplines.

00:46:14.069 --> 00:46:21.069
And we had to be able to analyze, according
to the rules of that discipline, and line

00:46:21.309 --> 00:46:24.049
them all up for consistency.

00:46:24.049 --> 00:46:31.049
And I would say that we never found a theoretical
or experimental result that was in conflict

00:46:32.299 --> 00:46:34.839
with our basic hypothesis.

00:46:34.839 --> 00:46:37.440
And that everything sort of lined up.

00:46:37.440 --> 00:46:44.440
I was more or less in charge of the aerodynamic
analysis, as well as my favorite subject thermodynamic

00:46:45.930 --> 00:46:46.759
analysis.

00:46:46.759 --> 00:46:51.799
I never liked that part either, but the whole
question of heat transfer and how fast these

00:46:51.799 --> 00:46:54.900
materials would melt, I was pretty much involved
in that.

00:46:54.900 --> 00:47:01.099
I may have another picture later, but let
me just show you some pictures that we had.

00:47:01.099 --> 00:47:04.099
There is a hypersonic wind tunnel down at
Langley.

00:47:04.099 --> 00:47:07.539
And we did a lot of tests in that wind tunnel.

00:47:07.539 --> 00:47:11.890
One of the things we did was we had a score
of wind tunnel models.

00:47:11.890 --> 00:47:14.599
They were about this big.

00:47:14.599 --> 00:47:17.250
But we took chunks out of their leading edge.

00:47:17.250 --> 00:47:19.450
We have our wind tunnel model which was the
nominal shuttle.

00:47:19.450 --> 00:47:23.849
And then we'd have a nominal shuttle with
panel six missing and then a nominal shuttle

00:47:23.849 --> 00:47:27.920
with panel seven missing and a nominal shuttle
with panel eight missing.

00:47:27.920 --> 00:47:34.920
47:30 And then you see the green.

00:48:01.549 --> 00:48:03.660
That is probably a little intermediate temperature.

00:48:03.660 --> 00:48:05.170
And then you see the blue.

00:48:05.170 --> 00:48:06.420
That is probably lower.

00:48:06.420 --> 00:48:11.349
But, if you look at this, being an aerodynamicist,
I can tell you where that vehicle gets hot.

00:48:11.349 --> 00:48:15.240
It gets hot near stagnation points and near
leading edges.

00:48:15.240 --> 00:48:18.559
And especially at the stagnation point on
the vehicle.

00:48:18.559 --> 00:48:22.910
You can put a wind tunnel model like that
in a hypersonic tunnel painted with this special

00:48:22.910 --> 00:48:26.589
paint, and you can take pictures of it and
you can get that temperature distribution.

00:48:26.589 --> 00:48:32.920
Here is my little figure of aerodynamic forces.

00:48:32.920 --> 00:48:39.339
We had all sorts of data from both the flight
data recorder and the telemetry that gave

00:48:39.339 --> 00:48:42.170
us a pretty good indication of the timeline.

00:48:42.170 --> 00:48:46.640
If any of you ever want to come into my office,
I have this enormous poster.

00:48:46.640 --> 00:48:53.640
It's like ten feet long which basically shows
the timeline of the Shuttle reentry with all

00:48:54.099 --> 00:49:00.559
kinds of the individual data bits, the temperature
distributions and all the things that kind

00:49:00.559 --> 00:49:02.589
of we could fit on this enormous poster.

00:49:02.589 --> 00:49:05.369
That is kind of what we were trying to do.

00:49:05.369 --> 00:49:06.829
We looked at the debris.

00:49:06.829 --> 00:49:09.890
We looked at forensic analysis of the debris.

00:49:09.890 --> 00:49:10.910
Where was it ablated?

00:49:10.910 --> 00:49:13.749
What was its chemical composition?

00:49:13.749 --> 00:49:16.499
Did we see melted Incanol?

00:49:16.499 --> 00:49:21.049
I mean we saw all these things and were able
to figure it out.

00:49:21.049 --> 00:49:24.359
Well, we knew what temperature Incanol melts
at so, therefore, the temperature on this

00:49:24.359 --> 00:49:28.529
particular piece was, I don't know what the
temperature of Incanol is, but let me say

00:49:28.529 --> 00:49:29.789
1200 degrees.

00:49:29.789 --> 00:49:36.789
It would be that kind of
material.

00:49:44.619 --> 00:49:51.619
49:30 And you don't replace this material.

00:50:00.029 --> 00:50:03.460
This material is the same material that was
used on the original shuttles.

00:50:03.460 --> 00:50:09.049
Every time it flies it loses a little bit
of stuff through vaporization.

00:50:09.049 --> 00:50:15.019
And so then they kind of tried to paint it
again, but I think our hypothesis is it just

00:50:15.019 --> 00:50:19.240
gets weaker and weaker as it is being used.

00:50:19.240 --> 00:50:22.009
And the problem is it is hardly being made
anymore.

00:50:22.009 --> 00:50:25.259
It is material that was all made at the beginning
of the program.

00:50:25.259 --> 00:50:26.740
It is not being made anymore.

00:50:26.740 --> 00:50:28.029
It is very expensive.

00:50:28.029 --> 00:50:34.319
It is not a material that is easy to get.

00:50:34.319 --> 00:50:37.579
And, in fact, that became an issue for us
because one of the things I will show is we

00:50:37.579 --> 00:50:43.049
wanted to do a full scale mockup of the leading
edge and we wanted to test it with a piece

00:50:43.049 --> 00:50:45.259
of foam going 800 feet per second.

00:50:45.259 --> 00:50:46.480
Now, why would we want to do that?

00:50:46.480 --> 00:50:50.930
Well, that is exactly the test conditions
that we wanted to simulate.

00:50:50.930 --> 00:50:57.930
Well, that is not only expensive but this
material just doesn't exist.

00:50:58.170 --> 00:50:59.710
I don't remember where we got the material.

00:50:59.710 --> 00:51:02.740
We probably took it off of Endeavor or something
like that.

00:51:02.740 --> 00:51:09.740
But, I mean, this was a big deal that we should
run this test because the material is very

00:51:10.150 --> 00:51:11.390
precious.

00:51:11.390 --> 00:51:15.269
But, anyway, we banged on the table and said
that we were going to do this and that they

00:51:15.269 --> 00:51:16.809
had to support us.

00:51:16.809 --> 00:51:18.180
We did the wind tunnel test.

00:51:18.180 --> 00:51:25.180
I have a question about that test.

00:51:27.589 --> 00:51:28.480
Yes?

00:51:28.480 --> 00:51:35.480
My reaction, as an outsider, when they published
the pictures of the holes on that test was

00:51:50.650 --> 00:51:52.839
wow.

00:51:52.839 --> 00:51:55.029
Wow.

00:51:55.029 --> 00:51:57.999
That was my reaction, too.

00:51:57.999 --> 00:52:00.779
Yeah, my reaction was wow.

00:52:00.779 --> 00:52:07.779
51:30 Anyway, we did the tests and we studied
timelines, we conducted arc jet tests, we

00:52:07.880 --> 00:52:12.190
did forensic analysis of debris, both chemical
and sort of physical.

00:52:12.190 --> 00:52:15.499
We did a lot of different in-depth analysis.

00:52:15.499 --> 00:52:22.499
The test itself, in addition to being expensive
and working with material that was really

00:52:23.460 --> 00:52:28.970
hard to pull together enough of this material
to run the test was also emotional.

00:52:28.970 --> 00:52:35.970
It was also an emotional event for the people
involved.

00:52:37.119 --> 00:52:44.119
And just very late in the game NASA said we
are prepared to accept that the foam put a

00:52:45.779 --> 00:52:49.619
hole in the leading edge so don't run the
test.

00:52:49.619 --> 00:52:56.039
And we said well, you may be prepared to accept
his but somewhere down in your organization

00:52:56.039 --> 00:53:01.140
is someone who doesn't believe that, and this
test is for him.

00:53:01.140 --> 00:53:02.170
I actually met that guy.

00:53:02.170 --> 00:53:05.640
I mean there are people in NASA who do not
believe this.

00:53:05.640 --> 00:53:12.640
So maybe what makes sense is let me show the
movies and then we will have our break.

00:53:14.180 --> 00:53:20.690
Here is the wow.

00:53:20.690 --> 00:53:24.519
Can I hear it from the class?

00:53:24.519 --> 00:53:24.900
Wow.

00:53:24.900 --> 00:53:26.049
And this really was.

00:53:26.049 --> 00:53:29.829
I mean the guy who developed this material,
and, as I say, I have great respect for that

00:53:29.829 --> 00:53:30.410
material.

00:53:30.410 --> 00:53:37.410
53:30 Let me go inside.

00:54:08.299 --> 00:54:10.049
This is inside.

00:54:10.049 --> 00:54:11.240
They had a camera mounted inside.

00:54:11.240 --> 00:54:18.240
That is kind of gee whiz thing because you
can see the deformation before it breaks.

00:54:25.799 --> 00:54:27.329
Was this done in the wind tunnel?

00:54:27.329 --> 00:54:31.089
No, this was a full scale mockup that was
done at Southwest Research Institute.

00:54:31.089 --> 00:54:34.019
We had a big mockup of the vehicle.

00:54:34.019 --> 00:54:35.200
It was done outside.

00:54:35.200 --> 00:54:38.049
Southwest Research has been involved in the
Shuttle Program for quite a while.

00:54:38.049 --> 00:54:45.049
They have a foam gun that they have used to
shoot foam primarily at the underbody tiles.

00:54:46.240 --> 00:54:49.989
The concern has always been on the strength
of the tiles.

00:54:49.989 --> 00:54:51.130
Do you guys know what the tiles are?

00:54:51.130 --> 00:54:54.559
The sort of foam stuff that is underneath
the vehicle.

00:54:54.559 --> 00:54:56.150
They have done a lot of tests on foam.

00:54:56.150 --> 00:54:59.849
Not big pieces of foam but sort of small pieces
of foam.

00:54:59.849 --> 00:55:05.670
Never tested the leading edge because it is
damn expensive to test this leading edge material.

00:55:05.670 --> 00:55:12.670
And the only tests I am aware of were these
BBs that were shot.

00:55:12.700 --> 00:55:19.700
This was really the first time this test was
done.

00:55:26.210 --> 00:55:29.299
Now, let me make a profound comment about
space systems.

00:55:29.299 --> 00:55:36.299
There is a fundamental principle in the development
of space systems, test-as-you-fly.

00:55:36.849 --> 00:55:38.809
You all know that.

00:55:38.809 --> 00:55:41.539
I hope you all know that.

00:55:41.539 --> 00:55:46.579
This test should have been done at the beginning
of the Shuttle Program.

00:55:46.579 --> 00:55:50.269
It was not done.

00:55:50.269 --> 00:55:53.900
And the reason it wasn't done is because there
was a requirement in the Shuttle Program that

00:55:53.900 --> 00:55:57.950
foam shouldn't come off the orbiter or off,
whatever that thing is, the tank.

00:55:57.950 --> 00:56:04.549
It was a requirement that foam shouldn't come
off the tank so, therefore, why do the test

00:56:04.549 --> 00:56:07.380
if it's a requirement that foam not come off?

00:56:07.380 --> 00:56:11.029
Well, the fact of the matter is foam has come
off on every single shuttle flight, as far

00:56:11.029 --> 00:56:13.140
as we know.

00:56:13.140 --> 00:56:17.999
So this was a violation of the test-as-you-fly
principle.

00:56:17.999 --> 00:56:22.950
That is, I would say, the number one principle
in the development of space systems is test-as-you-fly.

00:56:22.950 --> 00:56:24.930
It is the most important thing.

00:56:24.930 --> 00:56:27.059
Anyway, we can take our break now.

00:56:27.059 --> 00:56:33.930
And remember JR Thompson's remarks about testing
to failure, which they did on the main engine,

00:56:33.930 --> 00:56:39.009
didn't do on the SRBs, and they clearly didn't
do here.

00:56:39.009 --> 00:56:46.009
OK, a quick two minute, you know the drill.

00:57:30.309 --> 00:57:34.420
What you see is sort of an aluminum frame.

00:57:34.420 --> 00:57:37.089
I mean what you have here is really what would
be called a full scale mockup.

00:57:37.089 --> 00:57:44.089
It is an aluminum frame that holds the tile
in the right position.

00:57:46.079 --> 00:57:50.559
And I suppose holds it with fittings of the
right strength.

00:57:50.559 --> 00:57:54.509
In other words, what you're trying to do is
replicate with what would be called a full

00:57:54.509 --> 00:57:59.980
scale mockup the structural conditions of
the leading edge.

00:57:59.980 --> 00:58:05.160
You would have fittings holding the panels
and then you would have it angled properly

00:58:05.160 --> 00:58:11.509
to the foam gun, which is over here some place,
and then you fire the foam at 800 feet per

00:58:11.509 --> 00:58:11.950
second.

00:58:11.950 --> 00:58:13.730
So that's basically the test.

00:58:13.730 --> 00:58:15.450
And, as I say, it was done outdoors.

00:58:15.450 --> 00:58:18.160
It was quite spectacular.

00:58:18.160 --> 00:58:22.309
A big audience, you know, there was the media
and NASA.

00:58:22.309 --> 00:58:23.430
A big audience.

00:58:23.430 --> 00:58:30.430
It was quite an event.

00:58:35.049 --> 00:58:42.049
As a result of this, the committee felt pretty
confident that we had identified the technical

00:58:42.769 --> 00:58:44.239
cause of the accident.

00:58:44.239 --> 00:58:50.960
When we started this, we didn't know how sure
we would be so we had all these words like

00:58:50.960 --> 00:58:56.059
probably, more likely than not, conceivably.

00:58:56.059 --> 00:59:03.059
Because we needed to think about describing
our certainty whether we knew, in fact, what

00:59:04.499 --> 00:59:05.150
had happened.

00:59:05.150 --> 00:59:12.109
But by the time we finished all of this, because
everything had lined up so well, we felt pretty

00:59:12.109 --> 00:59:14.509
confident that we knew, in fact, what had
happened.

00:59:14.509 --> 00:59:19.029
And so we all sat down around the table and
argued about these words.

00:59:19.029 --> 00:59:20.730
This was a committee consensus.

00:59:20.730 --> 00:59:22.809
We voted on every word.

00:59:22.809 --> 00:59:23.690
Well, not every word.

00:59:23.690 --> 00:59:24.710
Some of the words are obvious.

00:59:24.710 --> 00:59:31.710
But we basically came to consensus on every
single important word in this statement of

00:59:37.849 --> 00:59:38.730
technical cause.

00:59:38.730 --> 00:59:43.710
I will just sort of let you read it because
it took us a long time to write.

00:59:43.710 --> 00:59:48.329
I should mention that one of the things.

00:59:48.329 --> 00:59:53.210
And I think this was from the flight data
recorder.

00:59:53.210 --> 00:59:57.549
I really have not given you as much data about
the flight data recorder.

00:59:57.549 --> 01:00:03.230
But one of the things we had from the flight
data recorder is an indication of conditions

01:00:03.230 --> 01:00:08.940
on assent relative to earlier flights.

01:00:08.940 --> 01:00:13.480
And if you look at the conditions on assent,
you can make a pretty good case that there

01:00:13.480 --> 01:00:19.049
was a hole in the leading edge on assent after
the foam had hit.

01:00:19.049 --> 01:00:24.839
Because you see increased temperatures on
the sensor right behind that region of the

01:00:24.839 --> 01:00:25.839
leading edge.

01:00:25.839 --> 01:00:31.739
And so you can make a pretty good case that
the hole was there on assent after mach 2.5

01:00:31.739 --> 01:00:33.849
or whatever the mach number was.

01:00:33.849 --> 01:00:35.400
But that was data from the data recorder?

01:00:35.400 --> 01:00:38.180
I believe it was from the flight data recorder.

01:00:38.180 --> 01:00:38.880
They didn't get that on telemetry?

01:00:38.880 --> 01:00:40.779
They did not have that from telemetry.

01:00:40.779 --> 01:00:45.829
I'm pretty sure about that but I'm not absolutely
sure.

01:00:45.829 --> 01:00:46.079
Yes?

01:00:46.019 --> 01:00:49.299
[AUDIENCE QUESTION]

01:00:49.299 --> 01:00:52.940
Oh, they knew that weekend.

01:00:52.940 --> 01:00:57.880
Oh, in fact, I'm going to talk about that
because that's part of the organizational

01:00:57.880 --> 01:01:00.579
and cultural issues.

01:01:00.579 --> 01:01:07.579
Finishing the technical cause, this was our
final statement about the cause of the accident.

01:01:07.589 --> 01:01:08.789
But we didn't stop there.

01:01:08.789 --> 01:01:11.759
Not this group of people.

01:01:11.759 --> 01:01:12.009
Yes?
I was going to ask how soon did you arrive
at the hypothesis that the hole led to the

01:01:23.509 --> 01:01:25.329
gases that led to the [OVERLAPPING VOICES]?

01:01:25.329 --> 01:01:26.259
I think pretty quickly?

01:01:26.259 --> 01:01:28.960
Yeah, I would say it was pretty quickly.

01:01:28.960 --> 01:01:32.079
Now, there was a little pushback from NASA
on that.

01:01:32.079 --> 01:01:38.859
But I described my appearance on February
18th on the board and the fact that we had

01:01:38.859 --> 01:01:45.859
the wire cutting sensor information, that
we had the video of the foam hitting the Shuttle

01:01:46.440 --> 01:01:47.319
and exploding.

01:01:47.319 --> 01:01:49.589
In other words, there was a shattering of
the foam.

01:01:49.589 --> 01:01:56.220
And we had the aerodynamic forces which indicated
damage to the vehicle which were consistent

01:01:56.220 --> 01:01:57.819
with the wing leading edge.

01:01:57.819 --> 01:02:04.819
We have a picture from Kirtland of some bulging
around the wing leading edge.

01:02:06.849 --> 01:02:12.410
I would think by sort of the third week in
February that's where we were headed.

01:02:12.410 --> 01:02:14.450
Now, you don't want to get blindsided.

01:02:14.450 --> 01:02:21.450
Sure, we don't want to get blindsided.

01:02:24.538 --> 01:02:27.799
We got lots of inputs from the public, as
well as from the scientific community.

01:02:27.799 --> 01:02:31.720
And there was an input we felt we had to take
seriously.

01:02:31.720 --> 01:02:33.089
And I can sort of say what it was.

01:02:33.089 --> 01:02:40.089
We got an input from sort of solar physicists
who said that on that day there was a violent

01:02:41.729 --> 01:02:48.729
sun episode that would have sent a shower
of solar radiation to the earth on that particular

01:02:50.440 --> 01:02:50.989
day.

01:02:50.989 --> 01:02:56.670
And that it was possible that this could have
created some kind of shockwave in the vicinity

01:02:56.670 --> 01:02:59.779
of the Shuttle and done some damage.

01:02:59.779 --> 01:03:01.869
I mean it was a credible hypothesis.

01:03:01.869 --> 01:03:05.288
I called the Air Force.

01:03:05.288 --> 01:03:12.288
Out at Hanscom we have these guys who do basically
radiation physics, radiation weather, space

01:03:13.089 --> 01:03:13.869
weather.

01:03:13.869 --> 01:03:20.869
And Jim Hallock from DOT kind of shepherded
that part of the project, but Jim is a physicist.

01:03:21.660 --> 01:03:24.609
He has a PhD from MIT and works at the Department
of Transportation.

01:03:24.609 --> 01:03:27.819
And so the two of us go together and said
we have to take this seriously.

01:03:27.819 --> 01:03:32.369
We have to put an expert team together and
completely examine this hypothesis.

01:03:32.369 --> 01:03:34.788
So we did that.

01:03:34.788 --> 01:03:40.479
And we had data from all over the world of
this radiation coming in, and so it was very

01:03:40.479 --> 01:03:41.109
exhaustive.

01:03:41.109 --> 01:03:48.109
It turned out that this radiation didn't reach
the earth until 3:00 PM on that day, but we

01:03:49.130 --> 01:03:49.920
took it seriously.

01:03:49.920 --> 01:03:54.309
I think that was probably one of the most
credible things.

01:03:54.309 --> 01:03:59.190
We obviously got a lot of junk stuff that
it was an Israeli plot or something like that.

01:03:59.190 --> 01:04:04.960
I cannot even remember those things.

01:04:04.960 --> 01:04:11.549
And then I think there was always this suggestion
that it was just a micro meteorite, but I

01:04:11.549 --> 01:04:18.380
think because of the magnitude of the damage
and the fact that, I think this is general

01:04:18.380 --> 01:04:20.849
knowledge, the Air Force watches space junk.

01:04:20.849 --> 01:04:24.930
They have a catalog of everything that is
lying up there, and there wasn't really a

01:04:24.930 --> 01:04:30.769
piece up there large enough to do that kind
of damage so that was eliminated.

01:04:30.769 --> 01:04:34.559
There were a number of hypotheses.

01:04:34.559 --> 01:04:39.519
But, again, when we did the data, we didn't
go in with a hypothesis.

01:04:39.519 --> 01:04:45.150
We went in to see what the data told us.

01:04:45.150 --> 01:04:49.479
That was a bit of independence with respect
to the data and the analysis.

01:04:49.479 --> 01:04:49.729
Yes?

01:04:49.630 --> 01:04:56.630
[AUDIENCE QUESTION]

01:05:02.890 --> 01:05:09.890
No, it
is melting.

01:05:21.029 --> 01:05:27.450
No,
the temperatures.

01:05:27.450 --> 01:05:30.630
See, it's aluminum.

01:05:30.630 --> 01:05:32.749
[AUDIENCE QUESTION]

01:05:32.749 --> 01:05:33.819
Eventually.

01:05:33.819 --> 01:05:36.160
Well, I think heat was the main culprit.

01:05:36.160 --> 01:05:43.160
The dynamic pressures, and I am sorry I didn't
bring the graph, in this regime were not that

01:05:46.210 --> 01:05:46.589
large.

01:05:46.589 --> 01:05:51.999
I am thinking they were less than 100 pounds
per square foot because you're really up at

01:05:51.999 --> 01:05:53.279
very high altitude.

01:05:53.279 --> 01:05:57.220
And, even though you're going very fast, the
dynamic pressures are not that high.

01:05:57.220 --> 01:05:59.670
I actually have a graph of dynamic pressures.

01:05:59.670 --> 01:06:06.079
In fact, come into my office and you will
see the dynamic pressure as a function.

01:06:06.079 --> 01:06:10.400
I would think the way to think about it is
that the important parts melted.

01:06:10.400 --> 01:06:15.769
See, we know from observations, and I didn't
show all of these, but people were recording,

01:06:15.769 --> 01:06:20.788
I don't remember what we called them, but
big pieces of the Shuttle were coming off.

01:06:20.788 --> 01:06:25.200
You saw the video with all these pieces flying
in, but we have pieces coming off as early

01:06:25.200 --> 01:06:27.910
as California.

01:06:27.910 --> 01:06:32.079
And I think we hypothesized at one point that
the upper wing came off.

01:06:32.079 --> 01:06:36.349
In other words, the upper surface of the wing
just lifted off.

01:06:36.349 --> 01:06:40.729
And the reason it did is not so much from
pressure is that all this gas is in there.

01:06:40.729 --> 01:06:46.130
Aluminum melts at 700 degrees Fahrenheit or
some ridiculously low number.

01:06:46.130 --> 01:06:53.130
We're talking 7000 degrees Fahrenheit so we're
talking about destruction primarily by arc

01:06:53.930 --> 01:06:54.180
jet.
You have to think of the atmosphere as a big
arc jet.

01:06:57.109 --> 01:07:04.109
And eventually the vehicle became uncontrollable,
unflyable because the aerodynamics were so

01:07:04.309 --> 01:07:07.059
off nominal and the vehicle couldn't be controlled.

01:07:07.059 --> 01:07:13.099
But, again, I think the dynamic pressures
didn't get larger than 200 pounds per square

01:07:13.099 --> 01:07:13.349
foot.

01:07:13.249 --> 01:07:14.720
I don't think.

01:07:14.720 --> 01:07:16.950
Which is about what I am doing right here.

01:07:16.950 --> 01:07:21.529
That is about 200 pounds per square foot.

01:07:21.529 --> 01:07:22.269
Yes?

01:07:22.269 --> 01:07:25.009
What happened to the crew?

01:07:25.009 --> 01:07:25.609
[AUDIENCE QUESTION]

01:07:25.609 --> 01:07:27.420
I probably don't want to talk about that.

01:07:27.420 --> 01:07:31.799
We have some information.

01:07:31.799 --> 01:07:35.950
Well, let me say what I can say.

01:07:35.950 --> 01:07:42.950
The vehicle itself stayed intact through a
large part of the reentry and got into what

01:07:44.450 --> 01:07:51.359
would be called the fighter pilot's regime,
you know, 50,000 feet.

01:07:51.359 --> 01:07:56.489
The actual cause of the death of the crew
was what any fighter pilot would experience

01:07:56.489 --> 01:07:59.269
if he lost his vehicle at 50,000 feet.

01:07:59.269 --> 01:08:00.339
It's blunt force trauma.

01:08:00.339 --> 01:08:02.089
That is what it was.

01:08:02.089 --> 01:08:08.920
And we found a lot of the cockpit.

01:08:08.920 --> 01:08:10.069
Reentry is really interesting.

01:08:10.069 --> 01:08:11.410
There is something called ballistic coefficient.

01:08:11.410 --> 01:08:13.269
Do you know about ballistic coefficient?

01:08:13.269 --> 01:08:17.520
We found briefcases, pillows.

01:08:17.520 --> 01:08:24.520
Ballistic coefficient, people talk about it
in two different ways, and one is the reciprocal

01:08:26.799 --> 01:08:27.259
of the other.

01:08:27.259 --> 01:08:28.540
I always get confused about that.

01:08:28.540 --> 01:08:35.540
But if you have a low ballistic coefficient
and you drop a pillow at mach 25 at 400,000

01:08:36.210 --> 01:08:41.750
feet, it would probably make it to the earth
because it will slow down and then it will

01:08:41.750 --> 01:08:45.250
just gradually float down to earth.

01:08:45.250 --> 01:08:52.210
We found a lot of the crew compartment, a
lot of pillows, chairs, all the stuff that

01:08:52.210 --> 01:08:59.170
was really light just reentered without burning
up because of ballistic coefficient.

01:08:59.170 --> 01:08:59.859
There was a lot there.

01:08:59.859 --> 01:09:06.859
69:00 And

01:09:36.690 --> 01:09:41.790
so that gets into some of your questions having
to do with when did they know.

01:09:41.790 --> 01:09:45.809
And, of course, the big why question.

01:09:45.809 --> 01:09:46.920
Let me go to that.

01:09:46.920 --> 01:09:51.359
Now I'm going to go off into the second part
of our investigation.

01:09:51.359 --> 01:09:58.359
And we consider this to be as important, if
not more important than our technical investigation.

01:09:58.849 --> 01:10:05.719
We talked a little bit about the history of
the Shuttle Program.

01:10:05.719 --> 01:10:12.719
And I am sure that is something that you have
been through in terms of the budgets, the

01:10:13.040 --> 01:10:20.040
margins, what we believe is a mischaracterization
of the vehicle as a mature operational system.

01:10:23.840 --> 01:10:29.510
And we think that there is a story here to
be told, and so we looked into this.

01:10:29.510 --> 01:10:35.500
Now, I have to say that I was not as much
a part of this as some other members because

01:10:35.500 --> 01:10:37.480
I was busy on the aerodynamics part of it.

01:10:37.480 --> 01:10:44.480
But you had John Logsdon, we had quite a number
of the Air Force people, and Admiral Gehman

01:10:45.010 --> 01:10:49.780
were more deeply involved in pulling together
the sort of history of how this happened,

01:10:49.780 --> 01:10:51.969
the cultural issues.

01:10:51.969 --> 01:10:57.420
I am sort of reporting on behalf of my fellow
board members what our conclusions were and

01:10:57.420 --> 01:11:02.199
the data that we gathered together to put
this together.

01:11:02.199 --> 01:11:06.530
The things that were pointed out are that
there was this fundamental uncertainty in

01:11:06.530 --> 01:11:13.500
the Shuttle Program and that led to a sort
of fluctuating attitude towards investing

01:11:13.500 --> 01:11:16.330
in upgrades and infrastructure.

01:11:16.330 --> 01:11:20.219
The nation didn't really know where it was
going.

01:11:20.219 --> 01:11:21.830
And I hope you won't take offense at this.

01:11:21.830 --> 01:11:22.909
I worked for NASA.

01:11:22.909 --> 01:11:23.719
You worked for NASA.

01:11:23.719 --> 01:11:29.159
We found them to be an extremely insular organization.

01:11:29.159 --> 01:11:31.580
And I think, actually, they still are.

01:11:31.580 --> 01:11:33.770
They don't take advice from the outside.

01:11:33.770 --> 01:11:40.250
And I will be prepared to admit that they
are the only organization that does human

01:11:40.250 --> 01:11:45.119
spaceflight, at least in our nation, but they
are not the only organization that handles

01:11:45.119 --> 01:11:47.050
risky technologies.

01:11:47.050 --> 01:11:51.330
And they have a lot to learn from other organizations.

01:11:51.330 --> 01:11:58.300
And they have not been a part of that conversation
with the type of people like the nuclear navy

01:11:58.300 --> 01:12:02.349
and some of the commercial industries that
use extremely risky technologies.

01:12:02.349 --> 01:12:05.020
They have not been a part of that dialogue.

01:12:05.020 --> 01:12:10.020
And that is where we have criticized them.

01:12:10.020 --> 01:12:11.040
As I say, they are insular.

01:12:11.040 --> 01:12:15.960
They think that they cannot learn anything
from anybody else.

01:12:15.960 --> 01:12:22.290
That they know how to do all these things
and that they don't need to accept any external

01:12:22.290 --> 01:12:22.849
suggestions.

01:12:22.849 --> 01:12:29.849
That is a very dangerous line of reasoning
for an organization, really, no matter how

01:12:30.270 --> 01:12:33.230
good you are.

01:12:33.230 --> 01:12:39.849
So we felt that the people at NASA, that leadership
clearly believed these things and the people

01:12:39.849 --> 01:12:44.010
in the engineering workforce were under tremendous
pressure to go along, in some sense, with

01:12:44.010 --> 01:12:47.540
these basic attitudes.

01:12:47.540 --> 01:12:54.540
And we saw that in our investigation of kind
of the what went on during the flight.

01:12:54.929 --> 01:12:59.239
I mentioned before that there is this history
of foam.

01:12:59.239 --> 01:13:00.690
And let me introduce the word anomaly.

01:13:00.690 --> 01:13:03.929
Have you talked about anomaly?

01:13:03.929 --> 01:13:04.480
Not directly.

01:13:04.480 --> 01:13:04.770
OK.

01:13:04.770 --> 01:13:11.770
Anomaly is one of the most important words
in space systems.

01:13:12.360 --> 01:13:16.820
Anomaly means that something happened that
shouldn't happen.

01:13:16.820 --> 01:13:23.820
Anomaly should bring your organization to
a standstill while you figure out what happened

01:13:24.000 --> 01:13:25.000
and why it happened.

01:13:25.000 --> 01:13:27.790
Anomaly is a violation of requirements.

01:13:27.790 --> 01:13:32.429
Sometimes I think it's a euphemism for failure.

01:13:32.429 --> 01:13:32.679
Well, yeah.

01:13:32.650 --> 01:13:35.469
Hopefully you catch it before failure.

01:13:35.469 --> 01:13:42.020
Anomaly is a clue that something may even
worse happen down the road.

01:13:42.020 --> 01:13:47.460
It is something to be taken extremely seriously.

01:13:47.460 --> 01:13:49.880
Foam shedding off the tank was an anomaly.

01:13:49.880 --> 01:13:54.989
It didn't destroy the vehicle but it is a
violation of requirements.

01:13:54.989 --> 01:14:01.080
And, in the early days, it was really put
on a list of problems to be worked.

01:14:01.080 --> 01:14:06.900
I mean NASA didn't completely ignore it, but
they put it on a list of the other 5000 problems

01:14:06.900 --> 01:14:10.179
that needed to be worked.

01:14:10.179 --> 01:14:17.179
And they just kept flying until foam shedding
really became a normal expectation that all

01:14:21.030 --> 01:14:26.719
the flights would have foam shedding and that
nothing serious would ever happen.

01:14:26.719 --> 01:14:30.690
It was treated as a maintenance turnaround
problem, you know, when the vehicle gets back

01:14:30.690 --> 01:14:31.540
we can fix it.

01:14:31.540 --> 01:14:32.949
And that was true in this case, too.

01:14:32.949 --> 01:14:38.030
They said something like well, if foam hits
the Shuttle, we'll fix it when it gets back.

01:14:38.030 --> 01:14:40.230
I mean that was the stance.

01:14:40.230 --> 01:14:47.230
Now, I think what's interesting about this,
if you think about this, is that the anomaly

01:14:48.630 --> 01:14:53.949
of foam shedding without hurting the Shuttle
was treated as if it were a planned engineering

01:14:53.949 --> 01:14:56.320
test.

01:14:56.320 --> 01:15:03.320
In other words, it was a test that was planned
to see if foam could hurt the Shuttle.

01:15:03.369 --> 01:15:08.159
And the fact that foam didn't hurt the Shuttle
was treated as confirmation that foam couldn't

01:15:08.159 --> 01:15:10.730
hurt the Shuttle.

01:15:10.730 --> 01:15:12.210
Now, I think that's kind of a fundamental.

01:15:12.210 --> 01:15:15.630
I like that particular phrase.

01:15:15.630 --> 01:15:18.510
There was enormous schedule pressure on NASA.

01:15:18.510 --> 01:15:25.510
They had already slipped a couple of times
because of other what I would call strong

01:15:26.770 --> 01:15:27.020
signals.

01:15:26.860 --> 01:15:28.760
We use the word strong signals.

01:15:28.760 --> 01:15:35.760
When something really dramatic is identified
NASA shuts down.

01:15:36.070 --> 01:15:37.760
And I don't remember the issues.

01:15:37.760 --> 01:15:43.199
There was something about a connector that
didn't seem to work properly and it just grounded

01:15:43.199 --> 01:15:45.369
the Shuttle fleet for three months or something.

01:15:45.369 --> 01:15:49.880
And there was some other problem that was
a strong signal and they simply shut it down.

01:15:49.880 --> 01:15:52.330
The foam we put in the category of a weak
signal.

01:15:52.330 --> 01:15:59.159
It is something that while you're fighting
all the strong signals it is hard to justify

01:15:59.159 --> 01:16:02.150
shutting the organization down for what you
perceive as a weak signal.

01:16:02.150 --> 01:16:07.230
So they had used up almost all of their margin
to complete the Space Station.

01:16:07.230 --> 01:16:08.800
And they were under tremendous pressure.

01:16:08.800 --> 01:16:14.909
Sean O'Keefe was obviously sent to NASA to
put the house in order, put the schedule and

01:16:14.909 --> 01:16:20.570
the budget in shape and get this Space Station
finished by February 19th.

01:16:20.570 --> 01:16:22.199
Ooh, we've already passed that one.

01:16:22.199 --> 01:16:29.199
We will talk a little bit about what happened
on the ground while the vehicle was in the

01:16:31.469 --> 01:16:32.920
air.

01:16:32.920 --> 01:16:37.630
I mentioned before that in the military we
do two investigations.

01:16:37.630 --> 01:16:43.989
We do a safety investigation where the testimony
is privileged and we do an investigation which

01:16:43.989 --> 01:16:44.440
is public.

01:16:44.440 --> 01:16:48.469
And our group was kind of doing both.

01:16:48.469 --> 01:16:51.050
In other words, we were obviously doing a
public investigation.

01:16:51.050 --> 01:16:54.340
We had press conferences every week and the
media would come and we'd share everything

01:16:54.340 --> 01:16:55.679
with them.

01:16:55.679 --> 01:17:02.550
But, because we did have so many military
people who understood the importance of accident

01:17:02.550 --> 01:17:09.550
investigation, we also had, I don't know,
an annex, I guess you'd call it, a way to

01:17:10.030 --> 01:17:11.739
take testimony and keep it privileged.

01:17:11.739 --> 01:17:12.489
And we did that.

01:17:12.489 --> 01:17:15.050
We took testimony from individual people at
NASA.

01:17:15.050 --> 01:17:16.469
It was privileged testimony.

01:17:16.469 --> 01:17:23.199
And they felt free to share with us their
participation and what happened and who said

01:17:23.199 --> 01:17:25.090
what when and all of that.

01:17:25.090 --> 01:17:27.739
And we had the damnedest trouble keeping this
from Congress.

01:17:27.739 --> 01:17:29.150
I mean it really was.

01:17:29.150 --> 01:17:32.760
And anything that's written down is accessible
to Congress, at least that's the way they

01:17:32.760 --> 01:17:38.360
look at it, but we really held very firm and
we would not allow this privileged testimony

01:17:38.360 --> 01:17:41.770
to be accessed.

01:17:41.770 --> 01:17:47.830
And I think the compromise we made was that
a staffer could come over to where we were

01:17:47.830 --> 01:17:50.900
located, he could read the testimony and take
no notes.

01:17:50.900 --> 01:17:56.580
Well, they soon tired of that so the fact
of the matter is they didn't come.

01:17:56.580 --> 01:18:02.360
But we had a lot of privileged testimony that
allowed us to put this picture together with

01:18:02.360 --> 01:18:08.989
employees not being too concerned about the
implications of sharing with us.

01:18:08.989 --> 01:18:14.360
So, the weekend that the flight went up, NASA
knew that there was a potential problem.

01:18:14.360 --> 01:18:18.659
And they put in place something called the
"debris assessment team" which is supposed

01:18:18.659 --> 01:18:25.659
to look at all the data that they had and
decide whether or not there was a problem.

01:18:26.530 --> 01:18:32.099
Now, I've chaired a lot of committees, not
only here at MIT but other places.

01:18:32.099 --> 01:18:36.880
And I understand how important it is for a
committee to have a clear charter and a clear

01:18:36.880 --> 01:18:43.750
line of reporting and to have a certain level
of independence from their home organization.

01:18:43.750 --> 01:18:47.909
For example, if I were chairing a committee
here at MIT on an important research issue

01:18:47.909 --> 01:18:52.150
or important policy issue and members of my
committee were getting pressure from their

01:18:52.150 --> 01:18:54.980
department heads, I would blow the whistle.

01:18:54.980 --> 01:18:58.420
I would say that is not the way a committee
works.

01:18:58.420 --> 01:18:59.630
A committee has a charter.

01:18:59.630 --> 01:19:00.949
It has independence.

01:19:00.949 --> 01:19:07.239
It is not subject to outside influence from
the people to whom these people report in

01:19:07.239 --> 01:19:09.030
their normal way of life.

01:19:09.030 --> 01:19:12.610
So, with respect to the debris assessment
team, I would make two comments.

01:19:12.610 --> 01:19:14.690
First of all, they had a very unclear charter.

01:19:14.690 --> 01:19:18.139
It wasn't clear kind of who they reported
to or what their authority was.

01:19:18.139 --> 01:19:24.290
And they, as individuals, were getting pressure
from their home organization, both NASA and

01:19:24.290 --> 01:19:29.760
the companies, the USA, Lockheed, Boeing,
because those guys were getting pressure from

01:19:29.760 --> 01:19:30.849
NASA.

01:19:30.849 --> 01:19:35.020
It was just an enormous amount of pressure
being applied to various people in what I

01:19:35.020 --> 01:19:37.619
considered to be a totally inappropriate way.

01:19:37.619 --> 01:19:40.780
In any case, this team, I admire them.

01:19:40.780 --> 01:19:42.929
I mean I think they were doing a good job.

01:19:42.929 --> 01:19:49.929
They wanted to get on-orbit pictures to see
whether or not using national assets we could

01:19:52.780 --> 01:19:56.800
take pictures of the Shuttle.

01:19:56.800 --> 01:19:59.580
And so, who do you contact when you want something
like that?

01:19:59.580 --> 01:20:01.590
You talk to the Air Force.

01:20:01.590 --> 01:20:08.260
And the Air Force is, of course, like a great
collie dog just waiting to show what they

01:20:08.260 --> 01:20:09.219
can do.

01:20:09.219 --> 01:20:09.469
You know?

01:20:09.449 --> 01:20:13.550
I mean oh, great, we've got this wonderful
opportunity to take these pictures.

01:20:13.550 --> 01:20:14.469
It's really going to be fun.

01:20:14.469 --> 01:20:16.340
We're going to show what we can do.

01:20:16.340 --> 01:20:23.340
They are very enthusiastic about responding
to that kind of request, but NASA didn't want

01:20:23.889 --> 01:20:24.809
the pictures.

01:20:24.809 --> 01:20:27.280
I mean the senior managers of NASA didn't
want the pictures.

01:20:27.280 --> 01:20:29.829
The debris assessment team did want the pictures.

01:20:29.829 --> 01:20:34.500
And they tried to make these requests of different
parts of the organization.

01:20:34.500 --> 01:20:41.500
And every time they would make a request it
would get slapped down by senior managers.

01:20:41.730 --> 01:20:43.130
Well, I guess we have it.

01:20:43.130 --> 01:20:47.869
This is a highly classified area, but let
me just say there were eight separate opportunities

01:20:47.869 --> 01:20:52.320
where we could have gotten some significant
information about the state of the Shuttle

01:20:52.320 --> 01:20:57.880
and we didn't do it.

01:20:57.880 --> 01:21:04.880
We didn't do it because every time there was
a flurry of activity around there NASA said

01:21:06.219 --> 01:21:06.920
they didn't need it.

01:21:06.920 --> 01:21:08.619
They'd fix the Shuttle when it got back.

01:21:08.619 --> 01:21:15.090
If the damage had been discovered what do
you think would have been done?

01:21:15.090 --> 01:21:16.510
Well, I can talk to that issue.

01:21:16.510 --> 01:21:18.349
I mean this is as good a time as any.

01:21:18.349 --> 01:21:25.340
We actually asked NASA to do some studies
about what could have been done.

01:21:25.340 --> 01:21:32.340
This is a nation that will save a whale that
is trapped in the Arctic or Baby Jessica in

01:21:32.840 --> 01:21:33.400
the well.

01:21:33.400 --> 01:21:37.929
I mean if we find that there is a crisis we
will mobilize.

01:21:37.929 --> 01:21:39.630
There is no question about it.

01:21:39.630 --> 01:21:43.610
It would be a very chancy situation.

01:21:43.610 --> 01:21:46.300
We know the vehicle is destroyed.

01:21:46.300 --> 01:21:47.219
The vehicle is lost.

01:21:47.219 --> 01:21:51.929
There is no question about that the vehicle
cannot reenter safely with the people.

01:21:51.929 --> 01:21:55.840
So what was the best option?

01:21:55.840 --> 01:22:01.199
I mean we looked at the possibility of stuffing
the hole with things, you know, old sleeping

01:22:01.199 --> 01:22:02.989
bags and suitcases and stuff.

01:22:02.989 --> 01:22:08.219
There wasn't anything onboard that could have
withstood the temperatures.

01:22:08.219 --> 01:22:11.610
And, of course, one of our recommendations
was that there should be some capability for

01:22:11.610 --> 01:22:12.719
in-flight repair.

01:22:12.719 --> 01:22:15.469
That has been a big issue.

01:22:15.469 --> 01:22:22.469
But the only other thing you could do is to
sort of go into life support mode.

01:22:27.760 --> 01:22:28.530
Stop doing the science.

01:22:28.530 --> 01:22:34.139
Jettison the module, I guess, which would
make the vehicle lighter and then maybe the

01:22:34.139 --> 01:22:35.520
reentry would be a little more successful.

01:22:35.520 --> 01:22:37.309
Conserve electricity.

01:22:37.309 --> 01:22:37.800
Conserve water.

01:22:37.800 --> 01:22:39.690
Conserve food.

01:22:39.690 --> 01:22:44.420
Try to stay in orbit for an additional, I
don't remember the number, 15, 16 days, something

01:22:44.420 --> 01:22:47.670
like that so that you could send up a second
shuttle.

01:22:47.670 --> 01:22:50.510
I think it was Atlantis.

01:22:50.510 --> 01:22:52.849
They could get Atlantis ready and send it
up.

01:22:52.849 --> 01:22:59.849
It was sort of by chance, but it just happened
that in this mission they did have the possibility

01:22:59.969 --> 01:23:01.449
of doing a rescue.

01:23:01.449 --> 01:23:02.389
Right.

01:23:02.389 --> 01:23:09.389
It's a gutsy move, but I have a feeling that
if we actually had that information that we

01:23:09.710 --> 01:23:10.860
could have put that together.

01:23:10.860 --> 01:23:17.119
It is interesting that when you read some
of the stuff that is being talked about, like

01:23:17.119 --> 01:23:23.059
the Hubble and things like that, we did not
recommend that a second shuttle be standing

01:23:23.059 --> 01:23:24.099
by.

01:23:24.099 --> 01:23:29.369
But that seems to have been internalized at
NASA as a potential safety measure.

01:23:29.369 --> 01:23:34.780
That they will always want to have a second
shuttle standing by if they send the shuttle

01:23:34.780 --> 01:23:35.030
up.

01:23:35.000 --> 01:23:39.389
The problem with that is it's a bit of a "going
out of business" strategy because there aren't

01:23:39.389 --> 01:23:41.449
that many left.

01:23:41.449 --> 01:23:41.699
Yes?

01:23:41.639 --> 01:23:45.429
[AUDIENCE QUESTION]

01:23:45.429 --> 01:23:46.920
We never looked at that option.

01:23:46.920 --> 01:23:48.090
We simply didn't.

01:23:48.090 --> 01:23:53.170
This particular vehicle was not in an orbit
that could have reached the Space Station.

01:23:53.170 --> 01:23:58.880
And that is another big issue, is whether
you want to have the Space Station available

01:23:58.880 --> 01:24:02.639
for a safe house if you have an accident.

01:24:02.639 --> 01:24:06.110
In this particular case, this vehicle could
not have reached the Space Station.

01:24:06.110 --> 01:24:11.760
Soyuz could not have reached this because
Soyuz launches from 51 degrees.

01:24:11.760 --> 01:24:13.610
This was in 28 degrees.

01:24:13.610 --> 01:24:19.130
Also remember there were seven people aboard
so you would have needed three Soyuzs.

01:24:19.130 --> 01:24:20.889
The Russians just don't have them available.

01:24:20.889 --> 01:24:24.070
It was either Atlantis or nothing.

01:24:24.070 --> 01:24:26.250
Larry, you had a question.

01:24:26.250 --> 01:24:27.510
Yeah, going back to the on-orbit photo.

01:24:27.510 --> 01:24:32.570
It was alleged at the time that the NASA management
thought that the quality of the photos was

01:24:32.570 --> 01:24:35.369
what it had been several years earlier and,
therefore, would not have helped them.

01:24:35.369 --> 01:24:40.090
Let me speak to that because I was going to
mention that.

01:24:40.090 --> 01:24:45.679
In the early days of the Shuttle Program there
was, in fact, a good interaction between NASA

01:24:45.679 --> 01:24:49.550
and the national security apparatus that does
this sort of work.

01:24:49.550 --> 01:24:56.550
And people at NASA were cleared, to an appropriate
level, to have this interaction.

01:24:59.050 --> 01:25:00.610
That has atrophied.

01:25:00.610 --> 01:25:06.780
The current people at NASA basically have
no experience with that world, are not cleared

01:25:06.780 --> 01:25:12.960
to an appropriate level, have just not had
an interaction and see it as a bigger deal

01:25:12.960 --> 01:25:14.090
than it really is.

01:25:14.090 --> 01:25:16.030
It is not a big deal.

01:25:16.030 --> 01:25:20.489
We do it all the time with my collie dog friend.

01:25:20.489 --> 01:25:24.110
I mean it's just not a big deal.

01:25:24.110 --> 01:25:28.550
So our recommendation was that there should
be a better interaction between NASA and the

01:25:28.550 --> 01:25:30.260
national security apparatus.

01:25:30.260 --> 01:25:35.380
And that the senior people at NASA should
be cleared to an appropriate level to have

01:25:35.380 --> 01:25:36.110
that interaction.

01:25:36.110 --> 01:25:42.400
And that this should be, in fact, routine
that you always take pictures when the shuttle

01:25:42.400 --> 01:25:43.630
is in orbit.

01:25:43.630 --> 01:25:46.530
And so I think that was basically one of our
recommendations.

01:25:46.530 --> 01:25:53.530
In any case, we were not pleased with the
decision or the failure to take photos onboard.

01:26:00.050 --> 01:26:07.050
86:00 It was called the "crater model".

01:26:30.800 --> 01:26:37.800
Its fundamental purpose was to figure out
whether foam would hurt the tiles.

01:26:39.420 --> 01:26:43.940
It was developed as a result of the experiments
done at Southwest Research Institute of shooting

01:26:43.940 --> 01:26:47.309
small pieces of foam at the tiles.

01:26:47.309 --> 01:26:52.040
Not the leading edge but the tiles.

01:26:52.040 --> 01:26:58.579
And it was sort of all things kind of rolling
together.

01:26:58.579 --> 01:27:03.429
The people who developed this model were in
Huntington Beach, California when they transferred

01:27:03.429 --> 01:27:06.960
the operation to the Cape or to Houston, I
don't remember.

01:27:06.960 --> 01:27:11.260
The senior people in that group refused to
move so they turned the tool over to junior

01:27:11.260 --> 01:27:12.429
people.

01:27:12.429 --> 01:27:18.530
There was a loss of corporate memory, a loss
of understanding, and so it just got worse

01:27:18.530 --> 01:27:19.400
and worse and worse.

01:27:19.400 --> 01:27:23.389
And so finally the people who were applying
these tools were not the same people who were

01:27:23.389 --> 01:27:28.230
in the development of the tool and really
lacked understanding of what this tool was

01:27:28.230 --> 01:27:32.199
all about.

01:27:32.199 --> 01:27:36.770
The tool predicted that you had a serious
problem.

01:27:36.770 --> 01:27:41.630
But they said, oh, well, the tool always over-predicts.

01:27:41.630 --> 01:27:44.179
They ignored it and said there was no problem.

01:27:44.179 --> 01:27:51.179
I mean it was just cascading of kind of bad
things happening.

01:27:51.389 --> 01:27:54.679
We talked a little bit about the organization
of NASA.

01:27:54.679 --> 01:27:58.280
And I don't know whether you talked to Aaron,
but this would be a good question to ask Aaron

01:27:58.280 --> 01:27:58.650
Cohen.

01:27:58.650 --> 01:28:02.420
I am setting him up here.

01:28:02.420 --> 01:28:05.489
About an independent safety organization at
NASA.

01:28:05.489 --> 01:28:05.739
Yes?

01:28:05.679 --> 01:28:10.389
[AUDIENCE QUESTION]

01:28:10.389 --> 01:28:17.389
As far as we can tell nothing until about
one or two minutes before.

01:28:18.199 --> 01:28:25.199
Actually, Mission Control had arranged for
a press conference with the crew in orbit.

01:28:27.159 --> 01:28:27.590
Right.

01:28:27.590 --> 01:28:28.659
Are you going to mention that?

01:28:28.659 --> 01:28:28.949
I will talk about that.

01:28:28.949 --> 01:28:34.909
Because the crew new that some foam had come
off, but they were told that it was no problem.

01:28:34.909 --> 01:28:36.880
Yeah, but that's different than the crew knowing.

01:28:36.880 --> 01:28:37.739
Right.

01:28:37.739 --> 01:28:39.429
No, I think that is true.

01:28:39.429 --> 01:28:45.020
That the crew was notified that there had
been an incident on liftoff but there was

01:28:45.020 --> 01:28:45.809
no problem.

01:28:45.809 --> 01:28:49.730
And the only reason they told them was because
somebody from the press might ask them.

01:28:49.730 --> 01:28:50.030
Yeah.

01:28:50.030 --> 01:28:54.270
And I have had media training so I know exactly
what they were thinking about.

01:28:54.270 --> 01:28:59.929
The Shuttle lands, the astronauts get out,
the microphone gets into the mouth and they

01:28:59.929 --> 01:29:02.119
say do you know?

01:29:02.119 --> 01:29:06.650
And the astronauts would say of course, we
knew, and we understood it was no problem.

01:29:06.650 --> 01:29:13.650
I mean it was a pre-media sort of skull session
for the astronauts, as opposed to a more responsible

01:29:15.340 --> 01:29:16.409
concern.

01:29:16.409 --> 01:29:21.559
What we do know about the astronauts is we
have the voice recording and stuff, and I

01:29:21.559 --> 01:29:26.219
think there was something from Mission Control
to the astronauts saying we see a temperature

01:29:26.219 --> 01:29:27.929
anomaly in your wheel well.

01:29:27.929 --> 01:29:32.159
The temperature was 50 degrees higher than
would have normally been.

01:29:32.159 --> 01:29:37.690
And this was literally just like I don't think
any more than five minutes before the vehicle

01:29:37.690 --> 01:29:38.290
lost control.

01:29:38.290 --> 01:29:39.630
Maybe even less than that.

01:29:39.630 --> 01:29:44.219
I mean it's all in the timeline.

01:29:44.219 --> 01:29:45.909
And that is probably all I want to say about
it.

01:29:45.909 --> 01:29:50.559
I think the evidence we have seems to indicate
that the astronauts knew.

01:29:50.559 --> 01:29:55.270
Obviously, when the vehicle went out of control
they knew there was a problem, when it began

01:29:55.270 --> 01:29:56.889
spinning and stuff like that.

01:29:56.889 --> 01:30:00.389
But, as far as we know, there was no indication
prior to that.

01:30:00.389 --> 01:30:01.929
Everything else was sort of nominal.

01:30:01.929 --> 01:30:02.179
Yes?

01:30:02.110 --> 01:30:09.110
After both shuttle accidents, you have investigation
boards, but what happened after Apollo 1,

01:30:10.969 --> 01:30:12.239
for example?

01:30:12.239 --> 01:30:13.510
[AUDIENCE QUESTION]

01:30:13.510 --> 01:30:14.909
I don't know the answer to that.

01:30:14.909 --> 01:30:18.829
Well, actually, that's what Aaron did talk
about, safety organization with respect to

01:30:18.829 --> 01:30:24.860
that and Apollo 13 and the fact that when
it was set up, they did start out with a very

01:30:24.860 --> 01:30:29.070
strong independent safety organization which
did not exist before Apollo 1.

01:30:29.070 --> 01:30:36.070
90:30 Now, why did we say that?

01:31:01.139 --> 01:31:05.820
Well, you're all engineers.

01:31:05.820 --> 01:31:10.389
The idea behind an independent safety organization
is that you should have engineers fighting.

01:31:10.389 --> 01:31:14.750
How do engineers fight, in an ideal world?

01:31:14.750 --> 01:31:21.340
They fight with data and analysis and hypothesis
and testing.

01:31:21.340 --> 01:31:27.380
In other words, if the program wants to waive
a requirement, change a requirement then they

01:31:27.380 --> 01:31:30.440
have to present a case.

01:31:30.440 --> 01:31:36.510
And if the safety organization feels that
there is crossing the line then they present

01:31:36.510 --> 01:31:36.989
a case.

01:31:36.989 --> 01:31:43.619
And the two organizations basically try to
bring together the best analytical and experimental

01:31:43.619 --> 01:31:47.599
framework they can in order to determine what
should be done.

01:31:47.599 --> 01:31:50.250
And so that's the notion of an independent
safety organization.

01:31:50.250 --> 01:31:55.590
I guess the thing that I was somewhat gratified
by, we will see how it all works out, is that

01:31:55.590 --> 01:32:00.639
we recommended, as a return to flight thing,
that NASA present a plan for an independent

01:32:00.639 --> 01:32:06.750
safety organization with the idea that in
the midterm they would actually begin such

01:32:06.750 --> 01:32:07.559
an organization.

01:32:07.559 --> 01:32:14.559
Sean O'Keefe took the bit in his teeth, I
guess is the way to say it, and he moved out

01:32:16.909 --> 01:32:21.440
much more strongly on that than I would have
anticipated.

01:32:21.440 --> 01:32:24.360
We met with him last December.

01:32:24.360 --> 01:32:25.530
I guess it was December.

01:32:25.530 --> 01:32:27.050
These years go by very quickly.

01:32:27.050 --> 01:32:34.050
But he had actually put in place a structure,
to get ready for the flight, that had outside

01:32:37.710 --> 01:32:44.710
experts from within NASA to sort of come together
as an independent safety board to look at

01:32:45.679 --> 01:32:46.880
anomaly resolution.

01:32:46.880 --> 01:32:49.130
I guess they didn't do too good on the foam.

01:32:49.130 --> 01:32:55.590
But, in any case, as far as the structure
goes, it was a stronger safety structure than

01:32:55.590 --> 01:32:57.800
had existed before.

01:32:57.800 --> 01:33:01.800
That was something that we recommended.

01:33:01.800 --> 01:33:08.210
It was very important that there be an independence
in the safety organization and that this is,

01:33:08.210 --> 01:33:13.420
in fact, a characteristic of an organization
that effectively manages high-risk.

01:33:13.420 --> 01:33:19.420
And we would claim that there are several
such organizations in our country.

01:33:19.420 --> 01:33:24.659
And there is a lot to be learned and a lot
to be shared.

01:33:24.659 --> 01:33:31.540
We also looked at the comparisons between
this accident and the Challenger accident.

01:33:31.540 --> 01:33:38.030
And, in fact, found more similarity than you
might have expected given that Challenger

01:33:38.030 --> 01:33:45.030
occurred on liftoff and this occurred, well,
in reentry, but did occur on liftoff.

01:33:45.969 --> 01:33:52.710
In terms of the role of engineers and technical
managers, this notion of normalizing deviance.

01:33:52.710 --> 01:33:54.300
Deviance is an anomaly.

01:33:54.300 --> 01:33:59.290
It is a departure from the requirements.

01:33:59.290 --> 01:34:02.909
And, if you normalize it, it means you accept
it.

01:34:02.909 --> 01:34:09.909
You accept it and, in fact, you try to profit
from it by saying that it's proven that there

01:34:10.429 --> 01:34:12.309
is no danger.

01:34:12.309 --> 01:34:17.030
So this phrase normalization of deviance is
an important sort of technical phrase that

01:34:17.030 --> 01:34:20.770
our group used.

01:34:20.770 --> 01:34:27.770
We had with us, actually, a faculty member
from Boston College who had written a book

01:34:28.820 --> 01:34:30.730
on the Challenger investigation.

01:34:30.730 --> 01:34:37.010
She is a social scientist, and she worked
very closely with us to try to put, what I

01:34:37.010 --> 01:34:40.219
would call, the social science and organizational
effects together.

01:34:40.219 --> 01:34:41.270
That is Diane Vaughn.

01:34:41.270 --> 01:34:43.110
You might bring her over some time.

01:34:43.110 --> 01:34:46.449
She is a fascinating speaker.

01:34:46.449 --> 01:34:53.449
But the thing that was interesting about Diane,
not only was she a great colleague, she published

01:34:54.590 --> 01:34:58.960
her first book on the Challenger accident,
is there's an in-depth analysis of the cultural

01:34:58.960 --> 01:35:03.110
flaws in the organization that led to the
Challenger accident.

01:35:03.110 --> 01:35:03.989
She published this book.

01:35:03.989 --> 01:35:09.540
And she said well, you know, I got a lot of
reaction from the book.

01:35:09.540 --> 01:35:16.540
She said the Navy called, my old boyfriend
called, the various industries called to have

01:35:17.579 --> 01:35:20.469
her come and talk about safety culture.

01:35:20.469 --> 01:35:23.070
NASA never called.

01:35:23.070 --> 01:35:30.070
NASA never indicated any interest in her analysis
of the cultural flaws within the organization

01:35:30.880 --> 01:35:37.880
that led to the Challenger accident, which
I think is another indication of the insularity.

01:35:38.219 --> 01:35:45.219
That was, I think, an important input to our
look at the organizational issues.

01:35:48.150 --> 01:35:54.989
We got together as a result of all of this.

01:35:54.989 --> 01:36:00.889
And, as I said, I wasn't deeply involved in,
say, some of the privileged interviews having

01:36:00.889 --> 01:36:02.710
to do with the individuals.

01:36:02.710 --> 01:36:09.710
But certainly as a board, we came to this
organizational cause which we considered to

01:36:09.800 --> 01:36:15.520
be as important as the technical cause.

01:36:15.520 --> 01:36:20.099
And the various words rooted in the Space
Shuttle Program.

01:36:20.099 --> 01:36:21.579
History and culture.

01:36:21.579 --> 01:36:25.760
Original compromises that were required to
gain approval.

01:36:25.760 --> 01:36:27.829
The years of resource constraints.

01:36:27.829 --> 01:36:29.219
The fluctuating priorities.

01:36:29.219 --> 01:36:31.119
The scheduled pressures.

01:36:31.119 --> 01:36:35.349
This mischaracterization of the Shuttle as
operational rather than developmental.

01:36:35.349 --> 01:36:40.099
Lack of agreed national vision for human space
flight.

01:36:40.099 --> 01:36:44.219
The cultural traits and organizational practices
that were detrimental to safety that we're

01:36:44.219 --> 01:36:51.219
allowed to develop including reliance on past
success as a substitute for sound engineering

01:36:51.760 --> 01:36:58.489
practices such as testing to understand why
systems were not performing in accordance

01:36:58.489 --> 01:37:00.389
with requirements.

01:37:00.389 --> 01:37:06.309
Organizational barriers that prevented effective
communication of safety information and stifled

01:37:06.309 --> 01:37:08.349
professional differences of opinion.

01:37:08.349 --> 01:37:13.270
Lack of integrated management across program
elements and the evolution of an informal

01:37:13.270 --> 01:37:19.300
chain of command and decision-making process
that operated outside the organization rules.

01:37:19.300 --> 01:37:22.790
A bit of an old-boy network in some sense.

01:37:22.790 --> 01:37:29.790
And we should mention the lack of an agreed
national vision for human space flight has

01:37:31.320 --> 01:37:36.199
been the jumping off point for everything
that has happened since with the new vision,

01:37:36.199 --> 01:37:41.230
which is presumably going to determine what
we do in the next ten years, so I think it

01:37:41.230 --> 01:37:44.619
is great that all of you called attention
to that.

01:37:44.619 --> 01:37:47.840
Let me talk about our recommendations.

01:37:47.840 --> 01:37:51.170
We made recommendations in basically three
piles.

01:37:51.170 --> 01:37:55.889
One of them are the near term recommendations
which are the return to flight recommendations.

01:37:55.889 --> 01:37:59.510
And these were monitored by a committee of
28 people.

01:37:59.510 --> 01:38:02.400
It was enormous.

01:38:02.400 --> 01:38:06.849
In any case, we asked them to present a plan
for an independent safety organization.

01:38:06.849 --> 01:38:09.329
I think they went a little further.

01:38:09.329 --> 01:38:15.829
We asked that they develop a method to do
onboard repair.

01:38:15.829 --> 01:38:18.969
Now, there was a big discussion about onboard
repair.

01:38:18.969 --> 01:38:24.530
It is very clear that it is much easier to
do onboard repair for all sorts of different

01:38:24.530 --> 01:38:31.440
reasons, including crew safety if you are
going to the Space Station.

01:38:31.440 --> 01:38:36.270
Because then you've got a safe house and all
sorts of supplies.

01:38:36.270 --> 01:38:38.260
It is like your recreation room.

01:38:38.260 --> 01:38:43.860
If you're not going to the Space Station,
it is considerably more dangerous, and that

01:38:43.860 --> 01:38:46.559
is the fundamental issue with respect to a
Hubble mission.

01:38:46.559 --> 01:38:49.480
Because a Hubble mission is incompatible with
going to the Space Station.

01:38:49.480 --> 01:38:54.790
If you take this recommendation seriously,
you either have to develop an autonomous onboard

01:38:54.790 --> 01:38:58.800
repair, which is much more difficult than
a Space Station onboard repair, or you cannot

01:38:58.800 --> 01:39:00.380
have any Hubble mission.

01:39:00.380 --> 01:39:07.380
So, this is a bit of turmoil in the political
issues surrounding missions.

01:39:09.719 --> 01:39:15.040
The other impacts, as I mentioned, not our
recommendation, but this notion of having

01:39:15.040 --> 01:39:18.409
a second shuttle standing by seems to have
been internalized.

01:39:18.409 --> 01:39:19.969
There were a number of other recommendations.

01:39:19.969 --> 01:39:21.250
Our report is on the Web.

01:39:21.250 --> 01:39:23.429
I mean more video cameras.

01:39:23.429 --> 01:39:29.400
More onboard video that gets telemetered to
the ground during the flight so you don't

01:39:29.400 --> 01:39:33.880
have to wait until the vehicle gets back to
see the video.

01:39:33.880 --> 01:39:36.500
External video cameras launched during day.

01:39:36.500 --> 01:39:38.750
Keep your sensors up to date.

01:39:38.750 --> 01:39:44.550
I mean there was just a whole lot of I think
25 recommendations of a return to flight.

01:39:44.550 --> 01:39:48.900
And the Return to Flight Committee was in
charge of monitoring all of those.

01:39:48.900 --> 01:39:50.960
And they have recently issued a report.

01:39:50.960 --> 01:39:56.559
Incidentally, I got a copy of the Return to
Flight report and donated it to the AeroLibrary.

01:39:56.559 --> 01:39:58.829
It should be in the AeroLibrary.

01:39:58.829 --> 01:40:03.690
And there was a very interesting minority
report that was submitted by like about five

01:40:03.690 --> 01:40:10.690
people which was just damming with respect
to their observations about how NASA works

01:40:12.860 --> 01:40:16.290
the safety issues.

01:40:16.290 --> 01:40:20.469
Take it as the opinion of these five people
who were on the Return to Flight Committee.

01:40:20.469 --> 01:40:23.540
It makes good reading.

01:40:23.540 --> 01:40:24.750
But that is all in the AeroLibrary.

01:40:24.750 --> 01:40:31.750
Our midterm recommendations.

01:40:34.199 --> 01:40:38.429
In some sense, we made these recommendations
assuming the Shuttle Program would continue.

01:40:38.429 --> 01:40:43.570
And I think we had this recommendation for
an independent safety organization.

01:40:43.570 --> 01:40:50.570
And what I thought was one of our most important
recommendations was that if you intend to

01:40:52.800 --> 01:40:55.860
fly the Shuttle past 2010, you should recertify
it.

01:40:55.860 --> 01:41:02.860
Now, certification is a very technical process
where you have to go through every piece of

01:41:03.010 --> 01:41:08.179
equipment and, in some sense, revalidate that
it will satisfy the requirements.

01:41:08.179 --> 01:41:15.179
101:05 What better project for the Shuttle
Program Office and the Independent Safety

01:41:37.150 --> 01:41:39.510
Organization than to recertify the Shuttle?

01:41:39.510 --> 01:41:42.480
At least that was my vision.

01:41:42.480 --> 01:41:48.139
That would really be an extremely useful thing
to do, to work together, to recertify the

01:41:48.139 --> 01:41:48.389
Shuttle.

01:41:48.219 --> 01:41:54.809
Now, unfortunately, evidently the Shuttle
is not going to operate past 2010 so we will

01:41:54.809 --> 01:41:55.090
see.

01:41:55.090 --> 01:41:56.610
I mean they won't recertify it.

01:41:56.610 --> 01:42:01.290
Now, I think what's going to happen is they're
going to get up to 2009 and are going to say

01:42:01.290 --> 01:42:04.849
oh, my gosh, we don't have any way to get
to space.

01:42:04.849 --> 01:42:11.849
There is going to be enormous pressure to
keep the Shuttle operating past 2010.

01:42:12.449 --> 01:42:16.369
And, of course, they will be late to need
in terms of recertifying.

01:42:16.369 --> 01:42:20.599
It is going to be a bit of a jump-all at that
point.

01:42:20.599 --> 01:42:23.280
It should be very interesting to watch.

01:42:23.280 --> 01:42:28.869
Now, the long-term recommendation, of course,
we made was that we need an agreed upon vision

01:42:28.869 --> 01:42:31.250
for further manned space flight.

01:42:31.250 --> 01:42:37.989
And so, from my point of view, we skip the
midterm and we went immediately to the long-term

01:42:37.989 --> 01:42:42.489
because with the President's new program that
we have basically set this vision.

01:42:42.489 --> 01:42:47.380
And, unfortunately, we have skipped some of
the intermediate steps that would have strengthened

01:42:47.380 --> 01:42:52.869
NASA as an organization and its ability to
carry out a new mission.

01:42:52.869 --> 01:42:59.869
I stand back watching, as all of this develops,
having had this incredible background of being

01:43:00.469 --> 01:43:02.329
a member of this Accident Investigation Board.

01:43:02.329 --> 01:43:06.510
It looks like I landed the plane right on
time.

01:43:06.510 --> 01:43:06.760
Yes.

01:43:06.679 --> 01:43:12.429
Incidentally, I brought this Halloween candy.

01:43:12.429 --> 01:43:18.290
And I would really appreciate it if you guys
would come and take it because it's not something

01:43:18.290 --> 01:43:20.139
that my husband and I need.

01:43:20.139 --> 01:43:24.829
And if it doesn't get eaten, would somebody
please take it down and put it with the graduate

01:43:24.829 --> 01:43:25.329
students downstairs?

01:43:25.329 --> 01:43:25.579
Good.

01:43:25.579 --> 01:43:26.840
Anyway, you had a question.

01:43:26.840 --> 01:43:29.550
I am wondering if you think there might have
been any effect on that if it was explicitly

01:43:29.550 --> 01:43:35.449
stated that this is why we want the recertification
to happen.

01:43:35.449 --> 01:43:35.809
I don't know.

01:43:35.809 --> 01:43:42.119
You know, it is hard to micromanage a big
organization.

01:43:42.119 --> 01:43:46.260
I personally was disappointed because I believed
very strongly in this.

01:43:46.260 --> 01:43:52.800
And I felt that it would be a way to bring
the organization together around this set

01:43:52.800 --> 01:43:53.800
of ideas.

01:43:53.800 --> 01:43:55.099
So, that won't happen.

01:43:55.099 --> 01:44:02.099
And we will see how they work with this "independent
safety board" that they have put in place.

01:44:02.889 --> 01:44:05.760
All of what we're doing is self-education.

01:44:05.760 --> 01:44:08.010
It is organizational education.

01:44:08.010 --> 01:44:08.900
It is self-education.

01:44:08.900 --> 01:44:10.010
It is process education.

01:44:10.010 --> 01:44:13.969
So, we will see how they will bring all that
together.

01:44:13.969 --> 01:44:18.670
The reason I asked that was because actually,
in terms of reading this recommendation, I

01:44:18.670 --> 01:44:20.050
read it a little differently.

01:44:20.050 --> 01:44:27.010
I thought it was kind of a push to move past
the Shuttle to say that recertification is

01:44:27.010 --> 01:44:30.300
going to be too complicated.

01:44:30.300 --> 01:44:32.960
Well, there might have been a little bit of
that.

01:44:32.960 --> 01:44:39.960
I mean it really was up to NASA to decide
whether a process that was so resource-intensive

01:44:41.230 --> 01:44:45.650
was worth doing, I mean given the fact that
the Shuttle is in the sort of sunset of its

01:44:45.650 --> 01:44:47.550
career.

01:44:47.550 --> 01:44:53.730
I guess I felt that we should leave that to
them but that they could not continue to operate

01:44:53.730 --> 01:44:54.790
the way they were operating.

01:44:54.790 --> 01:44:56.550
I think that was really the message.

01:44:56.550 --> 01:44:57.579
They had to make a decision.

01:44:57.579 --> 01:45:04.579
Sheila, the board's recommendation of the
number of 2010 has had enormous impact.

01:45:05.349 --> 01:45:06.040
I know.

01:45:06.040 --> 01:45:08.840
Of course it has.

01:45:08.840 --> 01:45:13.719
Very negative from my point of view.

01:45:13.719 --> 01:45:17.090
Say something about how you picked that number
and how flexible it is?

01:45:17.090 --> 01:45:21.619
Well, recall we did this in 2004.

01:45:21.619 --> 01:45:27.130
We wanted to give NASA enough time to get
back to flying.

01:45:27.130 --> 01:45:33.199
And, of course, the whole definition of what
recertification means is a bit unclear.

01:45:33.199 --> 01:45:36.880
In other words, I would think that NASA could
have gone in.

01:45:36.880 --> 01:45:43.250
I think what we saw was we needed to get a
couple of flights under our belt, but we needed

01:45:43.250 --> 01:45:43.980
to go back.

01:45:43.980 --> 01:45:48.130
I think what we meant by recertification is
a relook at the whole mission.

01:45:48.130 --> 01:45:48.869
What is that thing called?

01:45:48.869 --> 01:45:51.869
Mission rules?

01:45:51.869 --> 01:45:52.670
No, not mission rules.

01:45:52.670 --> 01:45:54.940
When they get together and decide whether
they are going to fly.

01:45:54.940 --> 01:45:58.070
Mission readiness review.

01:45:58.070 --> 01:45:59.099
Flight readiness review.

01:45:59.099 --> 01:46:05.309
We felt that the flight readiness review was
broken and that part of the reason it was

01:46:05.309 --> 01:46:11.900
broken is that there were too many requirements
that were silly like the Shuttle had only

01:46:11.900 --> 01:46:16.739
two wings instead of four because you'd need
redundancy.

01:46:16.739 --> 01:46:20.030
Wings are important, and if you really thought
they were important you would have four instead

01:46:20.030 --> 01:46:20.659
of two.

01:46:20.659 --> 01:46:24.190
And every time they did a flight readiness
review you would have to go through these,

01:46:24.190 --> 01:46:27.000
what I would call silly requirements.

01:46:27.000 --> 01:46:33.849
One issue about recertification was to try
to narrow down to what were the key systems

01:46:33.849 --> 01:46:40.210
that needed reexamination in the light of
technology and what we know about the Shuttle?

01:46:40.210 --> 01:46:44.260
That, in and of itself, would have been a
very useful process that would have helped

01:46:44.260 --> 01:46:44.739
this.

01:46:44.739 --> 01:46:50.460
And so, I think what we saw is that there
is a set of processes that need to be carried

01:46:50.460 --> 01:46:56.050
out after a couple of successful flights that
would really position the organization to

01:46:56.050 --> 01:46:56.750
do its job.

01:46:56.750 --> 01:47:01.020
107:00 They wasted a lot of time.

01:47:01.020 --> 01:47:08.020
But suppose someone had come back to you,
or members of the board and said well, life

01:47:21.710 --> 01:47:28.710
would be easier for us if we called it 2013?

01:47:41.429 --> 01:47:45.380
Well, I would think if you're going to do
that, that NASA should come forward with a

01:47:45.380 --> 01:47:52.380
plan at the minimum of how they're going to
operate the Shuttle safely through 2013.

01:47:53.219 --> 01:47:56.030
They have not even thought about doing that.

01:47:56.030 --> 01:48:00.290
They are carrying on with "business as usual".

01:48:00.290 --> 01:48:01.300
Flight, flight, flight.

01:48:01.300 --> 01:48:06.300
And they are not thinking about this more
fundamental issue which would, I think, be

01:48:06.300 --> 01:48:11.710
very useful for them as an organization of
what are the critical issues if we wanted

01:48:11.710 --> 01:48:14.900
to operate the Shuttle to 2013?

01:48:14.900 --> 01:48:18.909
They just kind of got off the hook by saying
2010, we can do that.

01:48:18.909 --> 01:48:20.219
You know, pretty shallow.

01:48:20.219 --> 01:48:20.570
Yes?

01:48:20.570 --> 01:48:24.770
And this is going to have to be the last question,
unfortunately.

01:48:24.770 --> 01:48:29.790
Anyway, you're all invited to my office to
see my big poster on the flight.

01:48:29.790 --> 01:48:36.790
Your recommendation for not flying unless
you have a safe house in orbit.

01:48:38.469 --> 01:48:40.300
No, we didn't recommend that.

01:48:40.300 --> 01:48:41.349
Oh, safe house in orbit.

01:48:41.349 --> 01:48:41.599
OK.

01:48:41.559 --> 01:48:48.559
If you would have said that at the beginning
of the Shuttle Program, that would have cut

01:48:49.489 --> 01:48:50.900
out dozens of flights.

01:48:50.900 --> 01:48:51.250
Sure.

01:48:51.250 --> 01:48:58.250
But, you see, at the beginning of the program,
NASA was committed to a system that met its

01:49:01.770 --> 01:49:04.750
requirements.

01:49:04.750 --> 01:49:09.960
Once they backed off of a system that met
it requirements, they left itself open to

01:49:09.960 --> 01:49:12.770
operating a risky system.

01:49:12.770 --> 01:49:18.030
And so then you come in, after having two
accidents, and say OK, how can we operate

01:49:18.030 --> 01:49:19.780
this system safety?

01:49:19.780 --> 01:49:24.989
You've already demonstrated that you're willing
to back off on requirements so how can we

01:49:24.989 --> 01:49:31.989
identify what some key issues are so that
you get back to operating safely?

01:49:35.989 --> 01:49:40.809
What we fundamentally recommended was that
you should develop onboard repair capability.

01:49:40.809 --> 01:49:42.090
And that's really all we said.

01:49:42.090 --> 01:49:49.090
And we sort of left open how they would do
that.

01:49:49.969 --> 01:49:56.389
And so they investigated a lot of things and
decided that it would be a heck of a lot easier

01:49:56.389 --> 01:49:59.070
if they could use the Space Station for a
repair.

01:49:59.070 --> 01:50:03.469
And so they themselves said OK, Space Station
only.

01:50:03.469 --> 01:50:05.340
That really was not our recommendation.

01:50:05.340 --> 01:50:09.559
Although, we understood that it would be a
lot easier to do Space Station repair.

01:50:09.559 --> 01:50:10.039
OK.

01:50:10.039 --> 01:50:11.980
Thank you very much.

01:50:11.980 --> 01:50:12.460
[APPLAUSE]