Jinn of Quality and Risk

Over and over, a projector at one end of a long, pale-blue conference room in Building 13 of the Johnson Space Center showed a piece of whitish foam breaking away from the space shuttle Columbia's fuel tank and bursting like fireworks as it struck the left wing.

In twos and threes, engineers at the other end of the cluttered room drifted away from their meeting and watched the repetitive, almost hypnotic images with deep puzzlement: because of the camera angle, no one could tell exactly where the foam had hit.

It was Tuesday, Jan. 21, five days after the foam had broken loose during liftoff, and some 30 engineers from the National Aeronautics and Space Administration and its aerospace contractors were having the first formal meeting to assess potential damage when it struck the wing.

Virtually every one of the participants ... agreed that the space agency should immediately get images of the impact area, perhaps by requesting them from American spy satellites or powerful telescopes on the ground.

They elected one of their number, a soft-spoken NASA engineer, Rodney Rocha, to convey the idea to the shuttle mission managers.

Mr. Rocha said he tried at least half a dozen times to get the space agency to make the requests. There were two similar efforts by other engineers. All were turned aside. ...

The Columbia's flight director, LeRoy Cain, wrote a curt e-mail message that concluded, I consider it to be a dead issue. [What a poor choice of words. Issues can be analyzed, resolved, shelved, ignored, categorized as risk, but they don't die. People die, especially when managers don't know how to deal with risk. —Ed.]

New interviews and newly revealed e-mail sent during the fatal Columbia mission show that the engineers' desire for outside help in getting a look at the shuttle's wing was more intense and widespread than what was described in the Aug. 26 final report of the board investigating the Feb. 1 accident...

The new information makes it clear that the failure to follow up on the request for outside imagery, the first step in discovering the damage and perhaps mounting a rescue effort, did not simply fall through bureaucratic cracks but was actively, even hotly resisted by mission managers. [NYT]