On February 1, 2003
, the space shuttle Columbia disintegrated as it reentered Earth’s atmosphere, killing the seven astronauts aboard. The cause was soon revealed; during take-off 16 days earlier, a piece of insulating foam about the size of a carry-on suitcase broke off the huge external fuel tank. Although the foam chunk weighed less than two pounds, the shuttle was moving at twice the spend of sound, and the chunk struck the leading edge of the left wing with such force, it created a hole about 16 inches across. During re-entry, air heated to almost 3,000 degrees ripped through the hole, destroying the wing’s internal structure. Once the wing disintegrated, the shuttle spun out of control and broke up in the skies over Texas.
The investigation that followed found the foam strike was known to ground control officials the day after launch. Flight engineers viewing videos of the take-off noticed the foam striking the wing. The loss of foam from the fuel tank was not unusual; almost all take-offs experienced some “foam shedding” as it was called, and none caused serious damage. Over the next few days, engineering staff and management reviewed the videos and discussed their options. Eventually, they decided the foam strike wasn’t dangerous, and even if it was, there was little they could do; the shuttle carried no repair materials capable of plugging a large hole in the wing. The shuttle wasn’t designed so the pilots could see the wings from the cabin, and managers decided a dangerous spacewalk to check for damage was not worth the risk.
Soon after the accident, NASA created a special commission to investigate its cause and the sequence of events that led up to it. Significantly, the chair was retired
Admiral Harold W. Gehman, Jr
. Admiral Gehman had an impressive record at sea and in the fleet’s hierarchy. During the Vietnam War, he commanded a squadron of river patrol boats. Following the war, he earned a series of promotions and increasingly important commands. Surprisingly, despite chairing a committee investigating a spacecraft accident, he had no flight experience of any kind. But he did have a reputation as a skilled administrator and policy expert. NASA’s administrators wanted someone with no preconceived notions about designs and safety policies.
Impressively, the
investigation board produced its report in a little more than six months, releasing its findings in late August 2003
. Besides confirming foam shedding as the cause of the accident, the report provided a detailed overview of the poor decision-making and lack of initiative that led to the disaster. In Gehman’s words, NASA created a “culture of complacency” that allowed the foam strike to go uninvestigated following the launch. Since foam strikes had not caused damage in previous flights, managers took no action to prevent them in future launches. That complacency drove decision-making after the strike on Columbia’s left wing. NASA could have requested the Air Force to change the orientation of one of its spy satellites to take a picture of Columbia’s wing. But managers decided it wasn’t worth the cost or change to the satellite’s or Columbia’s orbit to align for an photo. Other than a reassuring message to Columbia’s crew, no action to assess the damage or plan a possible rescue mission using shuttle Atlantis was taken.
The Board also found a program with priorities driven by PR and politics instead of safety and science. The flight had already been delayed several times, and mission control staff were under increasing pressure to launch for the PR value of maintaining a regular schedule of flights to the International Space Station. The demand for launch could have led to rushed safety checks, one of which may have found and corrected the loose foam attachment.
We can take the lessons from the Columbia investigation and apply them to the failure of Los Angeles’ homelessness programs. A “culture of complacency” is probably the best description of how homelessness programs are managed in LA.
A court-ordered assessment
found that the City and LAHSA paid service providers with little or no proof of outcomes, and allowed providers to define their own performance measures.
During testimony in federal court
, LAHSA’s former CIO said data reports were intentionally modified to make the city’s programs as good as possible, meaning any report coming from LAHSA and City is questionable at best, and politically-driven fiction at worst. In other words, the same culture of complacency that infected NASA is the current environment in the City and LAHSA. It is a lax, politically driven system based on ideology instead of effectiveness.
The hearings in federal court are nearing a critical point, with Judge David O. Carter soon to make a decision on appointing a receiver to oversee LA’s broken homelessness system. Despite its systemic failures, NASA’s leadership had the moral integrity to appoint an impartial and unbiased chairman to its lead its investigation board, and it adopted the reforms that board recommended. LA’s homeless program leaders have no such fortitude. Even though they pay lip service to reform, reality shows how unserious they are.
As I described in a recent CityWatch article
, the Leadership Table for the board overseeing Measure A is a who’s who of champions for maintaining the status quo. Mayor Bass continues to insist Inside Safe is a success despite huge costs and little progress. She and other leaders also claim homelessness has decreased, despite
indications LAHSA’s leadership intentionally ignored hundreds–if not thousands–of unhoused people
in recent PIT counts. LA’s homelessness programs are steeped in complacency, political posturing, financial waste and ideological blindness that place more value on appearance than on results.
The lesson the Columbia disaster has for us is that systems don’t reform themselves. It took the deaths of seven astronauts and Admiral Gehman’s commitment to the truth to make changes in the shuttle program. LA’s homeless population endures the equivalent of a Columbia disaster every night, and yet leaders tell us the system is working. There could be no stronger argument for a court-appointed receiver than the ever-increasing toll of lost lives on our streets.
Tim Campbell is a resident of Westchester who spent a career in the public service and managed a municipal performance audit program.