Five Nines | Maybe IT is Rocket Science

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The conclusions of the Space Shuttle Columbia Accident Investigation Board, headed by retired Admiral Harold W. Gehman Jr. were published in August. The board placed ultimate blame for the spacecraft's horrific destruction on NASA's corporate culture and on politicians who mandated the Shuttle's purpose and milestones. It teaches us how any massive, critical, new-technology project - including a healthcare information and image management system - can come awry.

"The organizational causes of this accident are rooted in the Space Shuttle Program's history and culture," states the Gehman Report. "Including the original compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fluctuating priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed national vision."


The Shuttle Program was conceived during the closing Apollo moon missions. It was presented to Congressional leaders and the Nixon administration as a small, supporting part of a grander, expensive scheme to launch interplanetary missions from a permanent Space Station.

However, the Shuttle was approved, providing the spacecraft could be modified to launch commercial satellites, carry scientific payloads, conduct military missions, as well as fulfilling its original concept as the vanpool-vehicle for low-orbit space workers. NASA went along with the confused mandate because the Shuttle was the agency's only opportunity to stay in the manned spaceflight game, and NASA administrators knew Congress wouldn't throw really big money at a simpler, unmanned spacecraft, no matter how efficient or safe it might be.

"To satisfy the Administration's requirement that the system be economically justifiable, the vehicle had to capture essentially all space launch business, and to do that, it had to meet wide-ranging requirements," explains the well-written Columbia Accident Investigation Board report.

The Board concluded the Program "has never met any of its original requirements for reliability, cost, ease of turnaround, maintainability or, regrettably, safety."


In January, shuttle mission STS-107 thunderously ascended into the sky. Lift-off vibrations shook a large chunk of insulating foam off the external fuel tank. The foam struck a reinforced carbon-carbon (RCC) panel on the leading edge of the left wing. That strike was spotted the next day during routine launch tapes reviews, but in NASA's overconfident and budget-constrained culture, any suggestion that the foam strike threatened the crew's lives was pooh-poohed. Instead, the concern was about productivity, that the damage created a maintenance headache threatening turnaround time at the Cape.

"Tapes of STS-107 Mission Management Team sessions reveal a noticeable 'rush' by the meeting's leader to the preconceived bottom line that there was 'no safety-of-flight' issue," said the Gehman Report.

"Imagine the difference if any Shuttle manager had simply asked, 'Prove to me that Columbia has not been harmed."

As the spacecraft re-entered the Earth's atmosphere on Feb. 1, the breach in the RCC allowed superheated air to penetrate. The left wing's core melted and stress tore the rest of the spacecraft and its crew of seven to bits. Wrote the Board, "NASA's organizational culture had as much to do with this accident as foam did."


The Board chastised NASA for its "reliance on past success as a substitute for sound engineering practices." It also blames the overconfidence imbued by years of "Right Stuff" praise.

"NASA was blinded by its 'Can-Do' attitude," the Gehman Report accuses. "Engineers and program planners were also affected by 'Can-Do' which, when taken too far, can create a reluctance to say that something can't be done."

Large, critical engineering efforts require a gadfly: the human reality-check who asks difficult questions, demands answers based on technical facts instead of optimistic beliefs and blows the whistle when a project strays from its intended design. Not just a nay-sayer, this inspired technical manager becomes the adhesive holding the system together as project management faces political demands, the most sinister of which is budget pressure.


The report cites the success of Aerospace Corp., created in 1960 to verify the readiness of U.S. Air Force launch systems.

"This 'concept-to-orbit' process begins in the design requirements phase, continues through the formal verification to countdown and launch, and concludes with a post-flight evaluation of events with findings for subsequent missions." It is independent of schedule and cost pressures. The result, "The Air Force has a 2.9 percent 'probability-of-failure' rate for expendable launch vehicles, compared to 14.6 percent in the commercial sector."

The Columbia Accident Investigation Board recommends establishing "an independent Technical Engineering Authority that is responsible for technical requirements and all waivers to them."

They want integrated program management that spans NASA's far-flung interests and vendors. Most important, the Gehman Board commands, "National leadership needs to recognize that NASA must fly only when it is ready."

The same command must be directed to our healthcare system administrators: Recognize that a reliable, safe and secure information and image management system - one that serves caregivers and doesn't put patients at risk - can only fly when it's ready.

Bob Larkin is senior technology planner for the international architecture firm of NBBJ Design in Columbus, Ohio. He has almost 25 years' experience as a healthcare project gadfly. In case you're wondering, "Five Nines" refers to 99.999% uptime.