The Gun Is Always Loaded

From: Thomas Buckner (
Date: Fri Feb 18 2005 - 05:09:02 MST

Eliezer keeps saying it, and it keeps being true.
The gun is always loaded, and there's no such
thing as too careful. Here, an essay by James
Oberg on 'not taking it seriously' at NASA. Note
the last para.

Tom Buckner


What does a sick “space safety culture” smell
by James Oberg
Monday, February 7, 2005

In the months following the Columbia shuttle
disaster two years ago, the independent Columbia
Accident Investigation Board (CAIB) sought both
the immediate cause of the accident and the
cultural context that had allowed it to happen.
They pinpointed a “flawed safety culture”, and
admitted that 90% of their critique could have
been discovered and written before the astronauts
had been killed—but NASA officials hadn’t

The challenge to NASA workers in the future is to
learn to recognize this condition and react to
it, not to “go along” to be team players who
don’t rock the boat. NASA has supposedly spent
the last two years training its work force to
“know better” in the future, and this is the
greatest challenge it has had to face. It’s
harder than the engineering problems, harder than
the budget problems, harder than the political
problems—and in fact might just be too hard.

>From personal experience, perhaps I can offer a
case study to help in this would-be cultural
Fixing NASA’s “flawed safety culture” will be
harder than the engineering problems, harder than
the budget problems, harder than the political
problems—and in fact might just be too hard.

I remember what a flawed safety culture smelled
like—I was there once. It was mid-1985, and the
space shuttle program was a headlong juggernaut
with the distinct sense among the “working
troops” that things were coming apart. My job was
at Mission Control, earlier as a specialist in
formation flying and then as a technical analyst
of how the flight design and flight control teams

Very deliberately, I’ve tried to insure that this
memory wasn’t an edited version, with impressions
added after the loss of the Challenger and its
crew the following January. No, I recall the hall
conversations and the wide-eyed anxiety of my
fellow workers at the Johnson Space Center in
Houston. Something didn’t smell right, and it
frightened us, even at the time—but we felt
helpless, because we knew we had no control over
the course of the program.

In June there had been a particularly
embarrassing screw-up at Mission Control. On STS
51-G, the shuttle was supposed to turn itself so
that a special UV-transparent window faced a test
laser in Maui, allowing atmospheric transmission
characteristics to be measured for a US Air Force

Instead, the shuttle rolled the window to face
high into space, ruining the experiment. When it
happened, some people in the control room
actually laughed, but the flight director—a
veteran of the Apollo program—sternly lectured
them on their easy acceptance of a major human
error. Privately, many of the younger workers
later laughed at him some more.

The error was caused by smugness, lack of
communications, assumptions of goodness, and no
fear of consequences of errors. All of these
traits were almost immediately obvious. Nothing
changed afterwards, until seven people died. And
then, for a while only, things did change, only
to tragically change back until another seven
lives were lost.

The following description of the event ventures
into technical areas and terminology, but I’m
doing my best to keep it “real world” because the
process was so analogous to the more serious
errors that would, at other times, kill people.
It was a portent—one of many—that NASA’s
leadership failed to heed.
Then, as with the ancestry of many, many
engineering errors, somebody had a good idea to
improve the system.

The plan had been to use a feature of the
shuttle’s computerized autopilot that could point
any desired “body vector” (a line coming out of
the shuttle’s midpoint) toward any of a variety
of targets in space. You could select a celestial
object, the center of the Earth, or even another
orbiting satellite. Or, you could select a point
on Earth’s surface.

That point would be specified by latitude,
longitude, and elevation. The units for the first
two parameters were degrees, of course, but for
some odd reason—pilot-astronaut preference,
apparently—the elevation value was in nautical

This was no problem at first, when only two
digits were allowed on the computer screen for
the value. Clearly the maximum altitude wasn’t 99
feet, so operators who were puzzled could look up
the display in a special on-board dictionary and
see what was really required.

Then, as with the ancestry of many, many
engineering errors, somebody had a good idea to
improve the system.

Because the pan-tilt pointing system of the
shuttle’s high-gain dish antenna was considered
unreliable, NASA approved a backup plan for
orienting the antenna directly towards a relay
satellite. The antenna would be manually locked
into a “straight-up” position, and the shuttle
would use the pointing autopilot to aim that body
axis at an earth-centered point: the
“mountaintop” 22,000 miles above the equator
where the relay satellite was in stationary

It was a clever usage of one software package to
an unanticipated application. All that was
required was that the allowable input for
altitude (in nautical miles) be increased from
two digits to five. It seemed simple and safe, as
long as all operators read the user’s manual.
“If it can go wrong in space, it will”

The backup control plan was never needed, since
the antenna pointing motors proved perfectly
reliable. In addition, the ground-site pointing
option was rarely used, so Mission Control got
rusty in its quirks.

Then came the Air Force request to point a
shuttle window at a real mountaintop. Simple
enough, it seemed, and the responsible operator
developed the appropriate numbers and tested them
at his desktop computer, then entered them in the
mission’s flight plan.

The altitude of the Air Force site was 9,994
feet. That’s 1.65 nautical miles—but that number
never showed up in the flight plan.

Instead, because the pointing experts used a
desktop program they had written that required
feet be entered (they weren’t pilots, after all),
they had tested and verified the shuttle’s
performance when the number “9994” was entered.
So that’s what they submitted for the crew’s

As the hour approached for the test, one clue
showed up at Mission Control that something was
amiss. The pointing experts had used longitude
units as degrees east, ranging from 0 to 360, and
had entered “203.74” for the longitude. Aboard
the shuttle, the autopilot rejected that number
as “out of range”.

A quick check of the user’s manual showed that
the autopilot was expecting longitude in degrees
with a range of plus or minus 0 to 180. The
correct figure, “–156.26”, was quickly computed
and entered, with an “oops” and a shoulder shrug
from the pointing officer. He did not ask
himself—and nobody else asked him—that if one
parameter had used improper units and range, was
it worth the 30 seconds it would take to verify
the other parameters as well? No, it was assumed,
since the other values were “accepted” by the
autopilot, they must be correct.

So as ordered, when the time came, the shuttle
obediently turned its instrument window to face a
point in space 9,994 nautical miles directly over
Hawaii. The astronauts in space and the flight
controllers on Earth were at first alarmed by the
apparent malfunction that ruined the experiment.
But then came the explanation, which most thought
funny. After all, nobody had been hurt. The alarm
The breadth of the stink

A young engineer from a contract team that
supported the pointing experts later showed me
the memo he had written, months earlier,
correctly identifying the errors in the two
parameters that had been written down in the crew
checklist. They were inconsistent with the user’s
manual, he had pointed out, and wouldn’t work—and
he also showed the computer simulation program
that verified it. The memo was never answered,
and the engineer’s manager didn’t want to pester
the pointing experts further because his group
was up for contract renewal and didn’t want any
black marks for making trouble.
Other friends of mine in other disciplines
confided in me their growing desperation of
encountering a more and more sloppy approach to
spaceflight, as repeated successes showed that
“routine” was becoming real and that carelessness
was turning out to have no negative consequences.

Nor was the space press all that interested in
drawing alarming conclusions from this and other
“straws in the space wind” that were becoming
widely known. NASA had announced its program for
sending a journalist into space. The classic
penchant of big bureaucracies to adore press
praise and resent press criticism was well known,
and NASA wasn’t immune to this urge, as space
reporters well knew. So it was safer for their
own chances to fly in space if they just passed
over this negative angle.

Other friends of mine in other disciplines—in the
robot arm, in electrical power budgeting, in life
science experiments—confided in me their growing
desperation of encountering a more and more
sloppy approach to spaceflight, as repeated
successes showed that “routine” was becoming real
and that carelessness was turning out to have no
negative consequences. People all around them,
they lamented, had lost their fear of failure,
and had lost respect for the strict discipline
that forbade convenient, comfortable “assumptions
of goodness” unless they were backed up by solid
testing and analysis.

It was precisely this sort of thinking that led
to the management decision flaws that would lose
Challenger (that specific flaw was at Cape
Canaveral, but it reflected a NASA-wide cultural
malaise), and a generation later, lose Columbia
(the flaws then were squarely in the Houston
space team and at the Alabama center that built
the fuel tank whose falling insulation mortally
wounded the spaceship’s wing).

It is that sort of thinking that space workers,
and workers in any activity where misjudgment can
have grievous impact, must vigorously learn to
smell out. This time, too, they must know that
they must act, and not “go along”, or else it’s
only a matter of time that the real world finds
another technical path that leads to a new

James Oberg ( is a 22-year
veteran of NASA mission control. He is now a
writer and consultant in Houston.

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