Many accident investigations do not go far enough. They identify the technical cause of the accident, and then connect it to a variant of "operator error" --- the line worker who forgot to insert the bolt, the engineer who miscalculated the stress, or the manager who made the wrong decision. But this is sel-dom the entire issue. When the determinations of the causal chain are limited to the technical flaw and individual failure, typically the actions taken to prevent a similar event in the fu-ture are also limited: fix the technical problem and replace or retrain the individual responsible. Putting these corrections in place leads to another mistake --- the belief that the problem is solved. The Board did not want to make these errors.

Attempting to manage high-risk technologies while mini-mizing failures is an extraordinary challenge. By their nature, these complex technologies are intricate, with many interrelated parts. Standing alone, the components may be well understood and have failure modes that can be antici-pated. Yet when these components are integrated into a larg-er system, unanticipated interactions can occur that lead to catastrophic outcomes. The risk of these complex systems is increased when they are produced and operated by complex organizations that also break down in unanticipated ways.

In our view, the NASA organizational culture had as much to do with this accident as the foam. Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of an institution. At the most ba-sic level, organizational culture defines the assumptions that employees make as they carry out their work. It is a powerful force that can persist through reorganizations and the change of key personnel. It can be a positive or a negative force.

In a report dealing with nuclear wastes, the National Re-search Council quoted Alvin Weinbergs classic statement about the "Faustian bargain" that nuclear scientists made with society. "The price that we demand of society for this magical energy source is both a vigilance and a longevity of our social institutions that we are quite unaccustomed to." This is also true of the space program. At NASAs urging, the nation committed to building an amazing, if compromised, vehicle called the Space Shuttle. When the agency did this, it accepted the bargain to operate and maintain the vehicle in the safest possible way. The Board is not convinced that NASA has completely lived up to the bargain, or that Con-gress and the Administration has provided the funding and support necessary for NASA to do so. This situation needs to be addressed --- if the nation intends to keep conducting hu-man space flight, it needs to live up to its part of the bargain.

Part Two of this report examines NASAs organizational, historical, and cultural factors, as well as how these factors contributed to the accident. As in Part One, this part begins with history. Chapter 5 examines the post-Challenger his-tory of NASA and its Human Space Flight Program. This includes reviewing the budget as well as organizational and management history, such as shifting management systems and locations. Chapter 6 documents management perfor-mance related to Columbia to establish events analyzed in later chapters. The chapter reviews the foam strikes, intense schedule pressure driven by an artificial requirement to de-liver Node 2 to the International Space Station by a certain date, and NASA managements handling of concerns regard-ing Columbia during the STS-107 mission.

In Chapter 7, the Board presents its views of how high-risk activities should be managed, and lists the characteristics of institutions that emphasize high-reliability results over economic efficiency or strict adherence to a schedule. This chapter measures the Space Shuttle Programs organizational and management practices against these principles and finds them wanting. Chapter 7 defines the organizational cause and offers recommendations. Chapter 8 draws from the previous chapters on history, budgets, culture, organization, and safety practices, and analyzes how all these factors contributed to this accident. This chapter captures the Boards views of the need to adjust management to enhance safety margins in Shuttle operations, and reaffirms the Boards position that without these changes, we have no confidence that other "corrective actions" will improve the safety of Shuttle opera-tions. The changes we recommend will be difficult to accom-plish --- and will be internally resisted.