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Dear Subscriber:

Where were you last Saturday morning when the space shuttle Columbia disintegrated in flames against a cloudless sky 40 miles over Texas?

A friend in Coppell, Texas, near the Dallas-Fort Worth Airport, heard a loud bang and thought a bird had smashed a back porch window, or a garden tool had crashed on his wife's car in the garage.

He had no idea a space shuttle was screaming overhead at 12,500 m.p.h., 16 minutes from a scheduled landing in Florida.

He wasn't alone. Typically, most Americans reacted to the Columbia catastrophe saying, "I didn't even know they were up there."

Or as President Bush said, "It has become easy to overlook the dangers of travel by rocket."

These national calamities carry special resonance with safety and health professionals, who work every day to make sure dangers are not overlooked and workers return home safe each night. "The crew of the shuttle Columbia did not return safely to Earth. Yet we can pray that all are safely home," the President said.


In the hours and days after the stunning on-the-job deaths of the seven Columbia astronauts, a cycle of emotions, rhetoric and searching began to be played out. In this edition of ISHN's e-newsletter, we examine seven stages of human reaction to disaster. Many of you can personally relate.



Disbelief is the first reaction. The risky becomes the routine, and we forget to pay attention. After 113 shuttle flights, we overlook that these missions amount to "riding a stick of dynamite into space" as a Massachusetts Institute of Technology physicist described to a reporter.

Who wants to think of the worst? Astronauts are no different than miners, ironworkers, firefighters, or maintenance workers.

Last month, a 29-year-old overnight maintenance worker was crushed to death by a machine that resets bowling pins at a Wichita, Kansas, bowling alley. Imagine the shock when employees arriving at work about 8 a.m. found the man still pinned inside the machine.

What are the odds of that happening?

The 16-day Columbia mission had gone off without a hitch. A Philadelphia newspaper's Saturday morning edition devoted all of two sentences to its expected blue sky landing on page four. After wrapping up more than two weeks of scientific research in orbit, Columbia aimed for homecoming under heavy security at Cape Canaveral, due to an Israeli astronaut on board, the paper reported.

A far different story, of course, appeared beneath the inch-and-a-half "COLUMBIA LOST" banner headline a day later.



Next come the investigations. "We're trying to understand what this problem is," said the deputy associate administrator for the space shuttle program. "We're going to find the problem. We're going to fix it," said the manager of the program.

But he admitted, "It's a mystery to us, and we seem to have conflicting information."

Cascading failures, complex events, conflicting reports, missing evidence, assumptions, false findings -safety investigators of all stripes know the struggle.

They also know someone is always looking over their shoulder - reporters, regulators, lawmakers. Outsiders. Sen. John McCain, the Arizona Republican who chairs the committee that oversees NASA, said the first hearing would convene next week.



A culprit, a root cause, must be found to settle the matter and get the operation back on track. Always, there are timetables to meet; budgets and trust at stake; political and public relations pressures. And in the case of the shuttle program, three astronauts in the orbiting International Space Station scheduled to run out of supplies this summer. (If the shuttles remain grounded, a Russian escape vehicle attached to the station, or a Russian shuttle sent from Earth, could bring the crew back).

NASA declares that there will be no rush to judgment, no shortcuts, no scapegoating. But no one wants a dragged-out investigation, either, like the one 17 years ago following the Challenger explosion that kept the shuttle fleet grounded for almost three years.

NASA takes just about all questions head on, like a crisis manager would advise. There are two press briefings a day early on. The major networks are allowed to set up inside the Johnson and Kennedy Space Centers. Interviews are granted with relatives of astronauts.

NASA's space shuttle program manager speaks with candor. "I'm the accountable individual," he tells reporters.

"We want to know if we made any erroneous assumptions. We want to know if we made any mistakes."

Hurry up and find out what happened, but you better be thorough. . .



It never takes long for echoes of dusty reports and forgotten advisory committees to emerge.

Second-guessing comes quickly. A San Diego professor holds a press conference after Columbia is lost to assert that he had long ago raised alarms about the fragility of the 20,000 heat-resistant ceramic tiles hand laid on the shuttle's nose and underside.

Three days after Columbia's fiery end, The New York Times reported: "As early as 1997, a senior NASA engineer warned that hardened foam popping off the external fuel tank on the Columbia shuttle had caused significant damage to the ceramic tiles." NASA, though, decided the problem did not threaten the survival of the spacecraft.

Old red flags are raised again: Six outside consultants on a safety panel were fired in March, 2001, the press reports, after warning that the shuttle program needed more money and newer equipment or risk rising safety dangers.

"I have never been as concerned for space shuttle safety as I am right now," the safety panel's chairman told Congress in April, 2002.



"Somebody should have done more," said a former quality assurance chief at the Kennedy Space Center. Alarms should have sounded across the agency, around the world, he said.

But. . . but. . . the best and brightest engineers, quality, safety, tile and tank experts and mission managers had agreed: a safe landing was not compromised by the damage to tiles cause by liftoff debris. Officials a few days ago announced the investigation was going in another direction.

After calmly explaining the technical details of the investigation to reporters, the shuttle program manager described how he coped with his personal anguish: "I can stay pretty well focused on what I need to do, as long as I'm at work. The hardest thing that I've had to do over the past two days was drive home in my car Saturday afternoon alone with my own thoughts."

"You can only imagine how it felt when someone comes up to you to tell you that you've lost the vehicle and the crew," he told reporters, his eyes reddening. "It's not something I would want you to go through."



Said a Texas Congressman: "Given that the basic technology is 30 years old, why not build a new fleet? "

That's after Congress presided over a 40 percent decline in NASA's budget in the last decade. After reports of "long-delayed safety improvements to the space shuttle" and "safety losing out in the battle for scarce NASA funds."

The title of NASA's 2004 budget proposal from the President underscored the White House's thinking before Columbia went down: "Setting Priorities and Bringing Costs Under Control." Did spending constraints put astronauts at risk? "That should be part of the investigation," said Senator McCain.

A newspaper headline days after the accident: "Several Chief Lawmakers Vow a Rapid Push for Money to Improve the Shuttle's Safety".



"The investigation we have just launched will find the cause, we'll fix it, and we'll move on," said NASA's space flight chief.

That's always the objective: learned the lessons and get back to business.

In 1986, NASA vowed to put safety first, ahead of budget constraints and political pressures, after the Challenger space shuttle exploded on live TV.

But priorities shift. Cost pressures mount and public support fades. NASA tried to wring longer life out of old equipment, just like in industry. Columbia was considered for retirement in 2001. Improvements to reduce risk were deferred or eliminated, according to reports. Retrofitting Columbia with an emergency escaped system was deemed too costly. The number of quality assurance inspectors for each shuttle was reduced.

And few people know. A Philadelphia teenage could speak for many when she told a reporter: "The space program isn't anything I can relate to, it's so far out of my league. Space travel happens every day. You don't die unless you're an astronaut."

It won't happen to me. I can't relate. Safety pros know the tune. And then the cycle repeats.


Dave Johnson is the ISHN E-News editor. He can be reached at djsafe@bellatlantic.net, (610) 666-0261; fax (610) 666-1906.


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Are you a safety and health pro or a manufacturer or provider of occupational safety and health products or services who enjoys writing?

Shakespeare need not apply, but ISHN is looking for authors to publish short articles (1,000 words) in our monthly issues.

Topics include: safety success stories, close calls and personal experiences, training tips, use of software, engineering controls (machine guards, lockout-tagout), gas detection and air monitoring, confined space safety, personal protective equipment, and OSHA compliance issues.

If any of these topics interest you - or if you have other ideas - e-mail editor Dave Johnson at djsafe@bellatlantic.net

We will also consider articles you've already written but not submitted to any safety magazine.