are sick themselves. this would be a good use of sample is a's money. on a basis where you're actually following these and measuring the outcome, ascertaining what kind of decrees you have in hospitalization, jailing, et. cetera, i think it should be the way we should be going. recovery specifically does not include half the people who are not aware of their illness. recovery by definition and -- which is fine for the half that are aware. for the people that are not aware it's ill relevant. >> thank you. >> congressman, i want to throw down something. i appreciate your framing what we're talking about.

i think there is more we should be throwing down here as long as we're talking about newtown. professional experience has taught me that the three most important symptoms are paranoia, hopelessness, and masculine identification with destruction. there's a a reason why heterosexual males are the overwhelming majority of people carrying out mass killings. if we completely limit our consideration just as it is with guns, the idea of psychiatric illness we're recognizing some of the quality. ly also add that while medications are very effective for paranoia, we're also dealing with a population that beyond those who fall in to the cracks, many and perhaps most mass killers, because it's not an impulsive decision, it's a

decision which one deliberates and becomes determined. once they become determined they'll do it. they crawl in to the cracks. they keep themselves from being appreciated for the risk they represent to others. the people that we've heard about today did not have the broad resentment of society to lash out. they killed themselves, they were violent within the family, and research demonstrates that the -- when a person lashes out at general community dc a different individual with different pathology inspect is why beyond this, we can never, never with all good intention, all application and example of federal law and all well meaning states that pick it up, he will never resolve the issue of mass killings in the united states in particular with good mental health care until we deal with the cultural forces of

entertainment violence and video game detachment that the other rend influencing vulnerable people to identify with destruction at the time when they are finding themselves as . >> are they preventable. can we prevent treatment of the identification treatment prevent some of the mass killings? >> the key thing is -- i think dr. torrey brought up an important point. if you appreciate mass killers involve such a high concentration of folks who crawl to the cracks, you can build a best facility in the world and have the best staff. they're not going to come. so you to go to them and so you to engage them at the level and an dialogue that they're willing to have with you whether you're informal, whether they don't appreciate you as a psychiatrist and caseworker. this is why the assertive community model has such promise for folks who either are in denial because a lack of insight or invested in destruction and have to be defused by the mental

health seals that are specially capable as a hostage negotiator would be. >> do you want to comment too? >> yeah, i think the one thing i would add goes back to your come, doctor cassidy, these are treatable in the a sense that we know that the robert griffin iii -- risk of violation goes down 15-fold with treatment. doesn't solve all the problems. but that part of the problem is entirely treatable. it's getting them in to treatment which is you're suggesting is the trouble is. -- struggle is. it's not a new conversation. we have been talking about how do you find the right balance between individual rights and safety for five decades. after big events like this, we went true the same thing with virginia tech. we rebalanced where we want to be. at the end of the day it's a state by state decision. what i hope we can do is bring better and better science to

that question. i think there are real opportunities through other research agencies to try to understand what has worked best and what hasn't worked well. we need to be careful about making policy decisions in the wake of rare effect like -- effort like this. as we rains rebalance this we don't want to go too far in one direction or the other. it has to be a careful conversation. >> would you -- are you the counter point to from earley's, again, speaking for persuasively in the book the folks would say incompetent adult, not speaking majortively but technically, incompetent adult by nature of the illness should not have a right to make a decision saying no to a program therapy. i think mr. earley brielgds against that from his personal experience. someone mentally incompetent

saying no, i don't want the therapy. do you think they should have the right? >> it's -- i don't think it's going to be a black or white call. you have -- you want to look at the unintended consequences. >> i accept that. at some point public law is a little bit moot. >> it is. >> currently as i understand, and again there's a wall street jowrntd -- "the wall street journal" article are where a man kills his mother. and the family was never informed. it was a commitment issue because he was coached on how to get out of commitment and hipaa issue. i guess my question for you, doctor, is would you say no, that is the appropriate level of the law or -- i don't know where you're coming down. >> what i'm saying i think it's the exact conversation to have. i'm not going give you a direct answer because i don't think there is a direct answer. i think in every state there this is the conversation we're trying to encourage. >> if we can't answer it on a federal. the answer is public policy

makers then we are got to despair. >> i think this is a conversation, dr. cassidy to have. as dr. torrey said it does play out in every state. your first question is not all the groups who weigh in on this, as tom said, are here today. there is a robust dialogue going on. my concern is we focus on virginia tech and focus on some of the newtown tragedy, and what have you. smaller versions happen every day in this country. and it happens when people who have untreated have no insight to the illness and the families can't get access to the system. we need to have the dialogue, and tom is right. after every one of the tragedies we have a dialogue. it's an opportunity to i think, rethink, revision how we do this and how we get people in to treatment before they die under a bridge in the winter. before, you know, something happens within a family this

tragic. i'm sorry [inaudible] >> i want to bring to the argument of the discussion too. >> thank you very much, mr. chairman, i do want to thank you for your outstanding leadership in cob convene -- convening these hearings. that's a good segue. i would like to focus on what is working out there? what you can highlight that we need do more of because we have got to be as efficient and effective as possible with the scarce resources that we have. but first, i'd like to thank the parents on the panel who have shown great bravery in coming forward and telling their personal stories. you represent thousands, maybe millions of other physically abuse who have -- family members who have struggled with similar challenges. i'm curious before we get to highlighting what is working and what question do better.

when did -- when can d you notice the mental illness man manifesting itself? what it identified by others? a teacher in a classroom or someone on the little league team or the scout troop? maybe i'll add mrs. long is still available, i can ask her first. did you notice it or was it someone else like a teacher? >> it's kind of a complicated process. my son is not my only child. i have three other children who do not suffer from mental disorders. i didn't notice little things such as behaviors that were a little different with this child compared to other children. we knew by kindergarten. we a clear the room face the order -- which, you know, seems like, yeah, that's what we're going do. we worked with a variety of psychiatrists, therapists, diagnoses across the board,

everything from oppositional disorder -- explosive disorder, right now we're looking at autism factor and adhd, possibly bipolar. we struggled for a long time. things became exacerbated when he went to middle school. he's actually in a pull out program with children who suffer from emotional and behavioral issues. so he's not be able to main streamed with other children at this time in school. we noticed early and it's progressed. >> thank you. >> yes, i'm probably get it wrong. my wife will correct me. it was in the early teens as matthew was addhd. we started having problems with that. but it just gradually got worse, and no matter, like i said, he was treated by one of the top psychiatrists? new orleans for many years different medication. go back to the main issue of matthew, if he took the

medication. okay. when he was in trouble, and he took the medication, he was fine. so then it needs to be a mechanism that if patients aren't taking their medication, what does a parent do? you can't make a 21-year-old man who is living in your home take his medication. you can't got doctor, he won't talk to you. you just have no mechanism to fix the problem. when you know the medication helps. >> the obvious mechanism what we call assisted outpatient treatment. louisiana has it but use it is rarely. 44 of the 50 states. six states don't have it. basically what it is, i used it in the hospital for eight years. the district of columbia has it. i would go to the the court and say this individual has been in the hospital 19 times. he has no awareness of the illness. i brought his mother and sister to explain whales -- what happens when we let him go. he never takes the medicine. we have seen him throw it away

on the way out of the hospital. the judge put on assistanted vote partial treatment you have to get the injection, you don't we have a right to bring you back to the hospital. that's assisted outpatient treatment it. there are six studies showing it decreasing hospitalization, studies showing that decreasing homelessness, decreasing victimization, deceases arrests, decreases violent behavior. studies in new york and north carolina specifically show the decrease in violent behavior by severely mentally ill individuals and staves money. the study in california saved $1.81 for every dollar invested. north carolina found that people on it longer than six months the cost savings were 40%. we know it's not used except in new york states where it's not used as widely as it should be for kendra's law. there's been great resistance to

using any kind of treatment that involves involuntary medication, which this does but you're dealing with people who have brain injury that impairs their ability to make those kinds of decisions. in answer to mr. cassidy's question, yes, some of the people need to be treated involuntarily. >> can i ask you what -- to identify the early stages when you? >> my son was 22, he was a college student and all the sudden he started complaining that food didn't taste good. i rushed up to see him after several months and he couldn't eat. we thought something was wrong. we took him to the psychiatrist, i'll never forget the psychiatrist said if you're lucky your son is using drugs. if you're unluckily he has a mental illness. he gave my son medication. my son quit taking us. i thought it's likes aspirin, you have a headache it goes

away. a year later he was psychotic, like i explained. we looked back, you have to be careful because it's easy to look back -- there were no signs. >> i note that the chairman wants to move on and come back to what works well. but i have to say what i'm hearing from families at home and educators and from doctors the last briefing was that the pruning of the brain early -- the identification of changes in behavior and activity we have got to figure out how to give educators and mental health professionals and families the tools as early as possible to identify and to treat. it does very well in defense of sampsa. they put outstanding tools in the hands of professionals at home, but i'm worried about

disconnect now with the resources that aren't available through schools at home. especially, and then for you all who had health care coverage, you seem to be able to access greater treatment and there is a large segment now that are unensured that is going to change. how can we best impact the growing number of insured to make it meningful. >> -- meaningful. >> do you do you want to comment? >> i would. thank you. i want to speak to the problem of lack of insurance or coverage for mental health. in my own case, my son racked up possibly the world's most expensive library fine. i asked him to return over due library books. he completely went to a rage, threatened to kill me and himself. pulled a knife i was able to get the police involved. they had to transport by balance blanks to emergency room.

we didn't have coverage that covered mental health at the time. he was declared stable and sent home with the bill. >> thank you. doctor you want to comment too? >> this is actually in reference to what works. i would go back to dr. torrey's statement about the importance of thinking about options of assisted outpatient treatment. as he said, the sciences says to work to reduce violation. i think both of us and the other psychiatrist at the table would say that's a low bar. that's really not where we want to end up. important to do. but the real question is what do we have in place and what can we deploy to make sure that people finish their education. get jobs, have families, contribute in some important way. there's an entire package of interventions that help in that respect. they help people to work. and they help people to get back

involved. you heard it from mr. earley about some of the things that made a difference for his son. they're not available in many places and integrated in a package of care you would expect. duo this pretty well for diabetes now. you know, we know -- a really good diet, supers, you need an exercise plan, and take your insulin. there's a realm of people to make it happen. in this area, not so much. >> i think there's also -- [inaudible conversations] yeah, just to make a couple of quick comments. first of all, i think this issue that we're hearing about now is compliance. i think there are two aspects. one is getting someone to comply to go on a medicine. the other is to get them to stay on. with involuntary treatment, you can get someone to take medicine for a certain amount of time, sooner or later you have to, as they say meet jesus. you have to get to a place where

the person csh -- you're going have to bring somebody to taking that medicine they don't want to take. what i found is a clinician, which is much more difficult for younger people than it is for an older dependent, you must find your leverage within the relationship. for some people, that leverage is, hey, i know you don't believe that you're ill. you don't believe you need this, if you don't take your medicine, you're going lose your child because of certain complaints and issues that come up. for others, hey, i know you think it's everybody else at the workplace, if you want to keep your job, you may want to consider taking this medicine that may actually make you more relaxed. and going back to dr. torrey's example i know you think i'm skits schizophrenic -- and for others the criminal justice system works. a judge can say, you know, look,

you don't have to be locked up. if you're not compliant, that's what is going happen. it's certainly what manifests in the insanity system that if people violate order and conditions they go back to a custodial environment. finally, for those who are of age, who are adults, there is a perspective of homelessness. say, look, you're in your 30s, i'm supporting you. i don't have to support you. so you to consider whether this lifestyle that you have where you are comfortable is something that is entitled to if you don't take your medicine. you have responsibilities in this just as i love you. so that's something that each family finds on their own. i can tell you not only from professional experience as treatment, i have had chronic mental illness in my family. i buried a siblings with

illness. if you learn your leverage and use it right in a sensitive, loving relationship you get enduring compliance. that's the holy grail here. >> you want to comment? >> quickly. thank you, mr. chairman. early identification and intervention in schools and primary care offices. families and children are i think is something we need explore. it's a norm is dr. insel said. there are a package of services and treatments available out there. if you can make them available and virtually all communities, it would make a difference and include sort of treatment teams, crisis stablization programs, supported housing, support employment programs for children certainly cognitive behavioral therapy. as he talked about earlier behavioral therapy and other interventions. absolutely make a difference. the challenge we have we saw it

in the 2009 the states report, hit or miss. you can go from one county to the next. one county the services exist. , the next county they don't. the recession comes and wipes out services, long waiting list. taking families sometimes years and years and years to find the services we need. we know what works now. we are not there, e don't have the cure but we know can -- we no what the road to recovery is for most of the people with serious mental illness. there are those with the lack of insight. that's another different conversation. >> to answer what works. there is a project impressive. one is the massachusetts child access project. you have pee -- proceed trisheses who get -- who problem. they are able to get telephonic consultation within that day as

to how to help. it becomes a safety net not only for the patient but the peed pediatrician they understand what kind of interventions they do and know when they should reach for something more comprehensive like a hospitalization or a psychiatric consultation. models like that developed, by the way, during governor romney's term and ron sign gaddafi who blank are effective. they take resources and say we can make the people there better than they are better. because we give them more knowledge and take care. they the first line attack. peed pediatricians could become better at eaching the warning signs. that's who parents turn first. >> go north carolina who is also a nurse.

>> to thank this panel and this is a very, very powerful discussion that we're having here. and i want go back to the issue of hipaa, that is something at the federal level that we can intervene. i think one of the points or clarifications i want to make, mr. chairman, you have mentioned that hhs in some instances uses hipaa as -- i'm going to say an excuse or relies on misinformation that is related -- is that correct? that was one of the things that we were talking about when we were talking about in relation to mental health is that -- because i know we talked about doctors who, unfortunately, many times, you know, rely back on hipaa and say, i'm sorry, it's because of hipaa i cannot do this. i would like to say there that i

think a lot of times it is the fear of legal action against a physician, and because hipaa is difficult to understand, i think that it's something that may be an easy out, so to speak. i know, it doesn't seem reasonably especially in the seriousness of these issues. unfortunately, i think that is sometimes what happens. in north carolina, we need more mental health benefits. there's no doubt about it. i have visited emergency room after emergency room where they are treating mental illness patients who are dangerous to others and themselves in the emergency room where they had to make accommodation, these are not individuals, the health care professionals there are not qualified to take care of them as mental health patients. they do not have psychiatric

background. they are doing the best job they can in the circumstance. i also want to be very help informal that area. but, mr. ma loan, i want to go wack to one point. you talked about having private health care insurance. one of the main point is medication, maybe being admitted and treated for five days, sometimes it takes five weeks for medication to actually start taking effect. in your experience, and the experience you had with your son, what could you have seen done better or as far as insurance coverage? was there a cutoff of days of treatment? was there something that could have been done better there? i think there's another place we might be able to help. >> yeah. these are going to be strong words. one of my major problems, i

consider the medical community and the health care community to almost be in a collusion conspiracy at the adverse for the patient. and my son's situation, there was always, well, the insurance companies is going approve five days. somehow my son was always well by five days. even when i told them my son was seeing invisible policeman wearing rain coyotes. they let him go. there's no doubt in my mind, there is, it may be what we have to live with. certainly the doctors looked and send the medical record, the day he got in there, he says clearly we're charting him for discharge from day one. he wasn't ready. one other thing i mentioned is the joint accreditation and the committee only tracks suicide for two dais. after people are released.

i just don't say we track what we're doing. i don't -- my son -- they all knew my son wasn't going take his medication. he told them it's in the the medical records. i don't know what we can be doing better. there had to be a mechanism where bi, i mentioned my father-in-law is an attorney. it's simple, most of them are in trouble with the law. we can make it part of the bond. it wouldn't be on the government. it would be part of your bond. you're out, you have to take a trust test two days and you taking your medicine. i believe california as law like that, that after -- every two days you have check in and take your medicine. we need to do something proactive to make sure that first that even if he doesn't want to take his medicine that he takes his medicine. >> thank you. i really appreciate this, mr. chairman, having this particular discussion. again, very, very powerful.

>> thank you. i want to ask a question here to the panel in some ways. it's continued to follow are from her comments and some of her family's. but a couple of weeks ago we a meeting doctor burgess brought up a question. interestingly enough last week they published an article saying they found connection between five different severe mental illnesses, depression, autism, attend deficit disorder. -- there are four places on genome 33,000 psychiatric patients. as we're going true this, i'm back to the purpose of why we are here. we are trying to identify people early on to prevent the tragedy. dr. insel. >> that's our study. i'm proud that we got this far. i need to make sure you understand that is still at the

very beginning of trying to provide the genetic are techture for any disorder. and in some ways the glass is half empty. the other part of that was it didn't provide a biomarker for any disorder. they crossed over all the disorderrers people were looking for. your general point is right on the mark. that in the rest of medicine where we had the most progress is with early detention, interintervention. we don't wait for the heart attack before we treat beam hart disease. we try to make sure people don't have the heart attack. in the case of brain disorder behavioral change is a late event. it's always a late event. ..

so that while it may be may be still have them date back between the genetics and between narrow imaging and a whole bunch of different ways we can look at the grain, we can get to the point where we can start to identify young adults before.

>> thank you. i'm going to ask each person here to give a closing one minute statement. i want to start with.or burgess and as we are wrapping up here. >> and want to use my time for a closing closing statement to ask one follow up statement. and i appreciate everyone spent a lot of time and this is then great. you outline three things where you said these are cardinal signs sine qua non-of someone is going to be in real trouble or cause real trouble to society and i've got a list here and it's by no means exhaustive and notes the three most know tory is mass killings of recently but going back 15 years, there are 25 and they seem to have a common thread in the common thread is treatment with some type of antidepressant. i don't raise this to say there is a nexus here that what it does strike me is that every one of these individuals has access

to our mental health system and receiving therapy. whether or not it was the right therapy or whether it was enougs we will have to struggle with but it doesn't look like there's a lack of identification of these individuals and in fact they have all been in front of a psychologist or psychiatrist or school mirrors and received prescription medicines for their condition. since we know you're critical indicators, after coming to someone in the system how do we improve that? >> i will give you a minute to answer but i will answer fast. i would be interested to know what what he says about what i'm about to say and i think for a time this cycle pharmacologic approach to an adolescent who is struggling is a lot harder to

untangle the puzzle of what's going on in adolescence. illnesses are just starting and they are going through changes. are we seeing depression or psychosis or oppositional defiance? a lot of prescribing practices for people who are struggling for a long time relied presumptively on antidepressants because they were diminishing anxiety ,-com,-com ma because they would diminish agitation. now of course if you give someone a medicine that can cause them agitation at a time when they are turbulent enough to have violent urges, that's a pretty lethal cocktail. so are you speaking of -- is that history reflective of prescribing practices or is it a diagnosis itself? is that reflective of the side

effect of a medication for someone as behavior problems that the mental health professional -- bier obliges mental health doctor to say let me presume it's something tradable so you have a number of different forces in place describing practices as well as what happens if you give something that can be agitating and it agitates the wrong person at the wrong time? >> i appreciate it but the broader point is individuals who have come before our mental health -- >> let me just state my point that people are crawling into the cracks. not all of them but taylor in pittsburgh and crumbly in new york and these are people i have met that i have interviewed and i have been conserved about them. they have had concerned families who even came by your office.

these were people who didn't necessarily fall through the cracks and this gets back to the a.c.t. discussion we have before it doesn't mean that some of them don't encounter ineffectual assistance but -- >> dr. burgess beer is an issue here and first of all diagnosis and psychiatry is a clinical diagnosis. you are having chest pain and it's radiating down your left arm. we presume you're having a heart attack but we can do blood tests and we can do an ekg. we don't have that and psychiatry so he can be done in seven minutes. it takes a while. it takes most people a diagnostic if i was in several hours. you need to hear from the parents and you have to hear from the school and the report and you want to see a change of behavior. the other big issue we have found is that many times you'll prescribed medication in the medication isn't taken an effect we hear today from parents who may have even gotten the right diagnosis and the right pill and

a patient just is not going to take it. as far as ssri's go, ssri's came out and the overwhelming majority who were giving it were not psychiatrists and the reason is we finally had an antidepressant i didn't kill people so if you took elavil and you had -- people were petrified of those in kids accidentally took their mother's antidepressant in the medicine chest and i got cardiac side effects. so in the beginning it was and remembered only came in one size of 20 milligrams but the important issue is you shouldn't take out -- -- throughout the baby with the bathwater. in white males went down by 18% in wednesday but the warning label on in primary care physicians got nervous about the suicide rate went back up by 8% and that's dangerous group of white males that are most successfully at killing themselves than anybody else.

i think diagnosis is complicated and it takes time it takes training and b the fact that almost all kids teenagers and young adults don't want to take pills so it's an ongoing conversation. >> i just think that in terms of where we are ending up here i don't think your statement should go unchallenged. i'm not sure anybody has very good evidence that all of the mass shootings or many the violent events we are talking about are linked together by ssri use. if that's the case i haven't seen the data. it's a little bit like what we are talking about a four with respect to the commitment laws. there are people on both sides of this and clearly in the case of treatment. there are many people in this community who are against any medication use at all and in a polarized argument like that, it's probably safest to find herself in the middle somewhere. >> only point is these are people who are at the front of your profession.

>> you talk talked about this last time. most of the people who you found were in the most danger were the people who were taking medicine and stop the people who stop their treatment. it was this group of people with psychosis. they were very ill and stop taking their medicine and that is -- am i quoting you correctly? >> i think that's farringer basic point dr. burgess i wouldn't disagree with that there's an issue that many of these people -- what you will hear is the real problem of stigma. the reality is many these people have been assessed and many of them have been prescribed or been evaluated and referred for additional treatment. that is true for suicide and homicide. so we do have an issue with respect to the effectiveness of what we are doing. >> we are talking about the mass killings in the data suggests 50% are associated with

untreated severe mental thomas. dr. welner was referring to the broader group also who don't necessarily have a severe mental illness and of those with a severe mental thomas is quite clear in retrospect that they were identified. the question that i think is most important is why were they not referred for treatment and i referred to joe and virginia and to adam -- loughner. loughner was diagnosed with schizophrenia and i would say the same thing about james homes in aurora. it has to do with a lot of things including the fear of being sued including the fact that the state laws did not allow it but the fact is if we don't address the critical issue we are going to be back here in six months or six weeks because these will continue to happen unless we get people who are potentially dangerous and identifiable to get treatment. they are not -- most are not writing under the radar. most of them are very clear and they look like goodyear blimps

saying i need treatment but we e are not getting them treatments. >> in closing i would like to thank you mr. chairman for organizing this outstanding hearing and in addition to the early diagnosis and treatment i do think that all of the evidence suggests that we have got to continue to advance in brain research and the example you gave dr. subon this fabulous news of curing aids and an infant, that is only come about because of a sustained commitment through rye and white and our communities and researchers and the congress in providing the resources to get to that point. i think it's obvious now that we need to do more brain research weather is alzheimer's because of the growing baby boom population and the outrageous statistics of suicide and mental illness.

i think it's a call to action and i'm glad the obama district appears to be considering this but i think congress can do a great deal of work together in a bipartisan wind pushing that. >> thank you. i would like to see if you would like to make a closing minute of statements now. >> thank you so much chairman for having this public forum. i feel like i've learned so much today and i'm really grateful for you for opening up this dialog because it's dialogues like this that will reduce the stigma and increase access to treatment for millions of american children and their families. i was struck by dr. and so's repeated reference to diabetes. i feel like if we can learn to diagnose mental illness early and then manage it bleed will hear lots more stories like this and i think that's think that's what area for a parent wants for his or her son or daughter, that they can live happy productive lives and be happy and fulfilled

members of society. thank you. >> thank you very much. >> i would like to continue -- first of all think you and i told you before you are my hero. there may be more psychologists in congress but you bring something that is essential and i think it's an essential national conversation. it's not just one hearing or two hearings. it's the fact that every family in some way and america has been touched and as time to speak up for kids. 75% of the most serious illness occurs before 24 been 15% before 14 then we have to consider annual men's health check-ups. the only way you can do that as pediatricians have to get better at understanding the warning signs. i think we also have to do a better job in educating new teachers and teachers who are currently teaching that they don't avoid the weird, the quiet, the socially isolated kid

and hope that they go way but feel there is some tool to identify them and gold to the school guidance counselor or psychologist to get help before this kind of violence. the message should be that these are israel and is common and treatable and they deserve the same kind of scientific rigor which means more investment pediatric science and brain science and it deserves the same kind of compassion we get when we see someone in a wheelchair and difficult illnesses like aids and cancer. >> mr. fitzpatrick. >> thank you mr. chairman and these are very important hearings and i look forward to the future on the hearings the committee will conduct. absolutely we need more brain research and i think we are on the verge of a very exciting discovery and we are not where we need to be.

these need to be community conversations. but change happens at the local community and we need to engage as we have another illnesses and other problems of this country and and have these larger committee conversations. this hearing for me is all about access. any access to treatment, diagnosed treatment and support for people with serious mental illness and their families and i think they're a number of issues we need to look at in terms of the laws particularly the state laws that block access. better and tighter systems. where people don't get lost. only 40% of the people in this country with serious red zone is on a given day have access to treatment. that is stunning. that's appalling. we don't have a single coordinated system. i think the affordable care act gives us an opportunity. one of the final parity regulations by hhs will give us a single on the impacted affordable care act on serious

mental illness. the parity language is written all through the affordable care act. i meant what i said before the effective treatment does exist but it's in pockets around the country and we need to spread bad treatment and what really is effective across the country. again back to my notion of community dialogue. and then lastly it's really about early intervention. early, getting in their early and not having years and years of policy that sometimes isn't very welcoming and we need to take a look at that. thank you mr. chairman. >> thank you. mr. earley for closing comments. >> thank you for having these hearings. because of newtown i think we are finally reaching a tipping point. everybody wants to do something and we have to take action. i would urge you to be very thoughtful and careful about what actions we take in virginia after the virginia tech shooting there were a flurry of bills.

virginie now is one of the the leading states about reporting anyone with a mental illness to various federal agencies. even people who have shown no danger and people who've shown up and said gee i need help, i need help in the hospital. we talked about stigma. when you make lists like this you are creating stigma. you're saying these people are different. they are dangerous. we have lists of them. you have to be very careful about that. i read that 40% of the first responders after 9/11 suffered from some form of ptsd. what about the officer who is getting a divorce who wants to see a psychiatrist because he is having trouble dealing with that? are you going to say to him he is different and we need to put them on a list and start banning him? yes after a member we are your druthers and your sisters. we are patrick kennedy. we are terry bradshaw. we are not the enemy. >> thank you mr. earley.

>> thank you mr. chairman for having these meetings. my wife debbie and i appreciate the opportunity opportunity to speak before then lastly i would just say a final thought for me, my son was a fun-loving young man, looks fabulous if you saw him earlier. i lay awake at night every night thinking what more could a parent do and i appreciate this committee trying to work towards what more can we do? the horrors that my son had to go through and to worry about people coming to get him from outer space and things like that, that's got to be an awful way to live and i thank you for this opportunity. >> i would pick up on the model of hard disease to say that culture matters. we now have a national imperative against obesity and

we have understood being habits has an impact on actual physical illness. i will tell you our fascination and her indoctrination of the culture of young people with violence through entertainment media that are polluting the culture of this united states has to be dealt with in the same way we dealt with tobacco or the convergence of this poison, and it is a poison, on developing minds with vulnerability is the last thing a paranoid individual who is alienated and isolated needs. culture matters and mental on this just as a matter's with physical on this and i do believe the culture has to be part of the solution here. >> mr. chair and we are obligated to you for this and we appreciate it very much. the future begin -- the long stew dr. caib and dr. insel is the best imh doctormacdoctormac k we have had in the first one

to focus on severe mental illness. in the meantime we have a large number of severely mentally ill individuals out there in the community who are asking for help and we are not doing a good job of getting them to treatment either voluntarily or involuntarily and as long as we are failing at this we will continue to see the aurora and continue to see the tucson's and continued to see the newtown's and until something changes absolutely it's going to continue. >> dr. insel. >> let me finish by thanking the parents, mr. milam and mr. earley and miss long for joining us and sharing with us. i know it's difficult and it's incredibly important for us all to hear the message you have to send. i think if i were going to summarize we have heard a lot about the need for access and changing access and changing policies and some about the need for better science which i certainly would support but i

think most of all, i think the unspoken message here is the need for leadership in this area you started off mr. chairman by saying we had lined landers on and i couldn't help but think of the message president kennedy gave to congress 50 years ago last month in which he said this neglect has gone on too long. and here we are 50 years later still with blinders on so let me thank you for beginning this process. let's hope that this is a journey and we would like to continue with you as you show your leadership in this area and certainly it's greatly needed. everything that we can do to help you as you make us take our blinders off we will be there to serve. >> thank you dr. insel and i want to thank all the panelists for your stories and your very moving compassion. sadly they were true and i thank the members and my colleagues

who were here also. this was a very valuable discussion and we wanted it to be in a different direction to start off with other hearings more targeted toward what we can be doing as congress moving forward. and i think it is helpful for members to understand and put a face on mental illness and the fears, the worries of love and frustration. we need an impact we must, it's our obligation to have elected officials continue to pursue this public health and public safety issue. it is within the realm. i think of looking at general welfare of our country. it is also important to note for those who are here and those who are watching over the years we have developed effective evidence-based treatments in the mental health industry is not where was 100 years ago or even 50 years ago. a lot of changes taken place since president kennedy made those remarks. we have had major changes in the

value prescription medication but we still have a long way to go in terms of being able to target that towards individuals. we obviously have to go further with reviewing federal law and state laws, which impair actions we can take and we will have to look at those. and we certainly have a long way to go with our research and i hope we continue in those areas. i want to say that and thanks several staff who've been behind the scenes working with this and we will continue to work with them on this but it's because we all know we are committed to this and we know it has to be continuous, unwavering and thoughtful in our approach. i want to make sure we are not doing knee-jerk actions and to think we did something we did the right thing. the worst thing we can do is to say we took care of mental thomas and we are done for the next decade. i don't think any of us can identify with that at all. to the parents, thank you. have hope and don't give up.

we hear you and we will be with you. thank you very much. [applause] [inaudible conversations]

george washington enjoyed a long long -- from from the time alexander was founded in 1749 when he was 17 until he died in 1799 at the age of 67. he participated in the political life of the city. he was a trustee of alexandria and he was a -- of fairfax county. he represented alexandra and never judge a legislature and even when he was president he made sure this area would be the new site of the nation's capital and alexandria was included in the original district of columbia.

we are in right now -- the tavern. george washington loved to dance and all the ladies wanted to dance with him. dancing with the first president of the united states was a big thrill. he died in 1799. they have the every year since then but they didn't have one in 1800 they didn't have them in world war ii. today alexandria's main street is named after washington the memorial towers over the city. they have the largest george washington parade in the nation. alexandra like to say it's george washington's hometown.

speonk ever a first, 2003 the space shuttle columbia disintegrated upon re-entry into the ers atmosphere killing all seven crew members. friday the george washington university hosted an all-day conference on the accident. next a panel on the establishestablish ment of the columbia accident investigation board and the interaction of its members with nasa officials after the shuttle tragedy. this is an hour. >> i would like to welcome everybody back from their lunch break. thank you very much for convening. we will try to stay on time here. the next panel is a discussion of we talked about the immediate response after the accident on

the previous panel and now we are going to cover nasa and the columbia investigation and the interaction between the board and nasa and we have two people who are expert in that discussion. one is doug cooke a nasa technical adviser to the case and then we have doctored john logsdon who was with us in the space policy institute and he was a member of the columbia accident investigation board he came into the board membership afterwards as it was realized other organizations and institutional issues needed to be looked at in the course of the investigation. without further ado, doc or logsdon. thanks, scott. i'm not really the best person to describe day by day operations because that's scott said i joined a month after it started operations and since most of the work i was doing had

to do with what was going on in washington, i based my investigations here rather than hanging out with the people in houston as they went about their technical work. but i heard enough about what went on and some of them i will talk about, not all. so, what do i push here? okay. in one of the slides this morning there was a point made that one of the things that happened after challenger was the development of contingency plans should there be another accident and those contingency plans took effect on february 1 of 2003 when it was clear that columbia was not coming back and part of the plan called for a seven person investigation board where the people were pre-designated by their positio.

with the nasa administrator naming the chair of that board which he did that day contacting admiral gehman. admiral gehman rand investigation of the terrorist attack on the destroyer in yemen and had the experience of running a rather elaborate investigation. i think sean o'keefe was in the navy corps and would not have asked for a non-navy person to take over. the board quickly assembled by the afternoon of february 2 and held their first meeting. there were pictures and scots video of that first meeting at barksdale air force base in louisiana. and quickly decided that they needed to be near nasa in houston so moved to louisiana to houston and a couple of days and

then when the investigation was done the court being moved here where we did most of the report writing. remarkable experience and the people that did it from day one with a report released on august 26 at 2003 were working at least six the days a week if not seven and certainly more than eight hours a day. the first thing the board did was to figure out that the way the plan had been set up, there was not provision for adequate independence and so there were three iterations with a revision of the charter to the board to guarantee that it could carry out a totally independent investigation with its own budget, its own staff, a staff that nasa maintaining independent records.

this wasn't going to be about the kind of committee because it was constant meetings but from the start with the exception of as admiral gehman noted this morning information about the crew provisions and the ability to take privilege to witness statements on a confidential basis. this was a very public and very open kind of undertaking and the new charger included the possibility of new members beyond the now eight person board. originally the senior people in the shuttle program were involved in the investigation. the board.that was not too good of an idea. i should add historically by comparison after the apollo 1 fire in 1967 jim webb was able to convince the president to let

nasa run the investigation so there were very three different models of how the investigation would go forward that were in play here. i'm trying to think what is on the next slide. in his first few weeks the board decided to go beyond the traditional technical accident investigation. first of all nasa as an organization, how it operated and what its culture was and how its communication channels were and the next step in broadening was to place the long-term historical context of the shuttle program. that request to not just focus on the focus but have said on

the broader contest of what it said about the future space program and that kind of input came from outside and i should say from the white house wanted very little to do with this and gehman sat with white house people but at the staff level at the executive office they were under orders because they were afraid somehow the white house and his associates would get blamed for the accident. so my meetings with the colleagues here at starbucks on the corner, not in the executive office. here is the board just to remind you of who was there. admiral gehman, major general barry, burkett aired general deal, dr. jim hallock, all of

them are original members. scott hubbard planned the plan called for naming a senior nasa official to be a member of the board and scott at that point director got the honor. i was able to join in early march after the decision that the board was going to look at the history of the budgets in the and the political history of the shuttle program. doug osheroff was added at the same time mainly i think because the board needed a nobel prize winner and we got doug. osheroff won his nobel and cold temperature physics and was pretty clear by then that shedding from the external tank was part of the --

and sally ride was fêted at the same time because she was sally ride, very smart woman and because she had it on the challenger investigation and because she still had a lot of good contacts internal with nasa she was nasa's eye i in terms of what was really going on. earlier roger petro, an ace engineer and a week later she loved widnall a highly qualified engineer added to the board and then steve turcotte and wallace were original members. 13 members incident late ,-com,-com ma not by plan the same numbers the challenger investigation board. it was an elaborate process, kind of a marching army. we were embedded as a board and its own staff in a lot of relationships with nasa and its investigation activities.

that is what doug is going to talk about. doug were you part of the accident investigation team? >> i was actually signed to -- >> okay so you were part of us for having part of them. >> as an advisor. >> right, but we worked in parallel with nasa and doing a lot of work to understand the accident so you get a sense from this block diagram. and the board itself organized itself into four groups. you see the names of the group is and the board members assigned to each group. we were allowed to higher our own staff. the two generals and the crowd and the admiral brought along their commanders and captains in their majors and lieutenant's so

there was a slightly uniform look to the people working on the investigation. and some of those people were very good. one of the lead investigators pat goodman is here and there were a total of 13 board member. investigators were the senior staff working with the board members on investigations and at times they became interchangeable and then there was as was mentioned in the comments this morning and independent analysis running are checksumming analyses that they were giving us. there were people connected, probably about 160. a lot of people anyway. i miss counted by the way. 30 investigators and a

significant support staff ford administration, public affairs and documentation, photography, government relations, budget, travel. there've been a lot of complements over the years about the quality of the report itself and i think from the start there was an intent to make this a high-quality not literature but writing clear, well illustrated, really telling the story. we had a professional writing team to do that but the first draft of all the chapters were written by the board members and maybe a few of the very senior staff. this was extensive and expensive as 17 million-dollar undertaking and a fair amount of change for a six-month effort. we wanted to get it right so we took every provision to make sure we did.

here here's the charter of the four teams, just to see the range of things that were looked at. this was the team i lead, the organization was sally ride and scott hubbard involved and in a sense everybody got involved with this because became i think to the conclusion that the specific technical accident was really embedded in a lot of history and in both political and programmatic organizational history. here were some of the people that were involved in team for. a couple of them will look for belliard to you here in washington.

the state department and space missile office, harry lambrick of syracuse and american university. dennis jenkins who we brought in and admiral gehman quickly procured to be his kind of person that really knew every and bolt on the shuttle. dennis had written an extensive book on the technical development of the shuttle. roger from the air and space museum, duane dey is here. who was a ph.d. by that time from gw now working on the space that is bored and who was the master's candidate at the space policy institute who is probably our most successful graduate and runs a brewery and the virgin islands. [laughter] better than being deputy at nasa. to me, out of the whole report,

this is the single most damning paragraph. nasa and indeed the country keeps its part of the bargain to operate a complicated fragile system to the maximum of its potential for safety. we were rather careful not to point fingers at individuals. we certainly pointed fingers at almost everybody that was involved in the program. and as i said we were asked not only to look at the accident but to place the accent and they have broader context of now what? here are some quotes from chapter 9 of the report. and you can read them.

what is interesting to me is that almost everyone of these is being said at the situation today. there was an attempt to change things and the bush administration read our report, agreed with these kinds of conclusions. president bush set forward a vision for space exploration in january of 2004 but for reasons that i probably don't want to go into here, that was not sustained. that is to say wasn't sustainable but it was not sustained and we are in a situation today where there is a continued failure in my view of national leadership to set out directions for the u.s. in space. and that is all i have to say for my formal remarks. doug.

>> i'm going to go down here so i can watch you. >> you may want to help. >> is that going to work? why don't i go ahead and start. so this afternoon i want to give my perspectives, actually a

perspective that is based on my years at nasa and programs i worked on and my experience with this and so going back on the shuttle program i was in the shuttle program from, starting in 1973 right after it came a program and worked on it through its development so i have experience for about 11 years working, actually leading flight test on aerodynamics for the shuttle. i worked on enterprise, columbia and challenger. we had instrumentation and we did light work. and then after the challenger accident i was asked to work in the program office in and ended up working in the program office during the return to flight activities with the challenger. and so that was my early experience.

i volunteered to work on this. i remember calling brian o'connor right after i learned about the accident and asked him if he needed any help. he said the yeah why do why do you come to barksdale as soon as you can get there and they did and ended up living through the entire experience. what i want to talk about are my views based on my memory which may not be completely consistent with everybody's memory in the last 10 years but i think it's pretty close. i'm going to use charts most of which came from documents and some of which i did at the time but we will talk about some of the technical aspects and some of the things that stood out in my mind. another aspect in my perspective is that i ended up before i left nasa as i did leave nasa i was in exploration at nasa headquarters which included the

programs that came out of the cade experience in the accident these were the programs that follow to be the next programs in the human spaceflight. for seated me as well as a couple of others but i was the last one. and so i have the constellation program. i have been the space launch system and orion and human research program and some technology efforts. so that is my experience and so all of this experience then does relate to where we are today and i want to talk just a bit about that. i want to play a film, a short film. scott showed a little bit of that earlier. this is miraculous and there were a lot of things that were miraculous including all the people involved. but this piece of film as i remember was found lying on the ground by itself, not in the

camera, just the film itself. >> don't forget about the -- >> we are checking that. >> columbia houston. we will take item 27 please. >> up code shoot. >> it looks good. >> i went back to audio. thanks for that houston. >> i didn't know that. we had a problem, rick. >> that might be --

they're not firing right now. we see it out the front. spevak. [inaudible] c. let's do that. go ahead and make sure you check >> all right. >> i will leave it there. at this point in time, the plasma was actually burning into the wing as they were commenting on it. so, the next memory of columbia is the debris from the accident and that is what we worked with during this. math. and it sobering even today to think about the human tragedy as well as the aftermath.

this indicates what can happen. when you have a technical problem, when there are things that you don't know about the vehicle that you are flying. when there can be a lapse in requirements. that i will talk a little bit about where you don't absolutely have to requirements right and so you are not expecting problems but it has to do some with us trying to understand the vehicle is very complicated. in this case the shuttle we learned about the shuttle until the day it was decommissioned. so this is a kfc hangar. you have seen pictures of it previously. as the pieces started to come in from the incredible job done by the recovery crew, david and scott talked about, we saw a briefing in the cave reefing

room where arrow space s. 1 came in and investigated every breakup of anything coming into the atmosphere ever since they they started happening and they said you only get 10% back as david alluded to earlier and it probably broke up 100000 feet. you only get 10% back to it's made of aluminum and aluminum will burn up. we ended up getting as dave said between 40 and 45% of vehicle by weight. a lot of that has to do with the fact that it had hyle on a lot of the aluminum and it survives because of that. we learned an incredible amount by studying this evidence. early in the process all of the requests for data and all of the action was happening through the shuttle control board so we would go over and sit with the shuttle guys and you would see a picture or two a day of something and everybody would

try to solve the accident by that one piece. actually everything was funneled through the shuttle program at that point in terms of program office. this really wasn't working. admiral gehman aboard said we have to have a different model because we need answers faster and we need to get data faster. so that was arranged on an earlier chart that john showed. frank buzzard had a team that was set up to interact with caib and answer requests for data and bring in data and studies that were determined. and so that began to work better. at about the same time we also realized that just seeing a piece a day and a picture on the screen wasn't going to get us where we needed to go in understanding the debris data. so pat goodman is here somewhere. right back here.

he was my partner. we spent a lot of time at the caib going through all of the debris and trying to understand not just the pieces that were probably in the area where the whole occurred, but looking at it in the context of every bit of debris on the vehicle. so that was very enlightening in terms of understanding how this all unfolded. so also the first day we got there we talked to the ntsb guys and they said well we generally wait until we have all the debris that before we start trying to piece it together. we knew that the shuttle program was wanting to get on with the program and we said well that's not going to work. we decided we were going to spend a lot of time down there and look at the data and the debris as it came in. we spent an incredible amount of time. you saw earlier versions of this.

it was a miraculous effort to get all the debris. one important aspect of the debris was they knew what each piece was found. that was incredibly important to understanding the accident. so they had coordinates on every piece of debris. even though it's a rod footprint, that was incredible information for us. this is the stripe as you saw there. and it was a piece of foam. the other picture shows the ramp that was a good piece of foam at the foot of the bipod, the bipod being a structure that attaches to the shuttle in front of the orbiter to the tank, the external tank. this is a piece of foam on the tank and an incredible amount of work was done to understand this trajectory. because that was important from the sense that we needed to know

the relative velocity. at the time of the accident it was thought that the phone couldn't possibly do this kind of damage because it's just a light piece of foam and yet when you calculate the velocity of it, it actually created quite a force. and so as time went on, these models got better. they didn't initially necessarily show it getting light but in fact it did hit panel 8. panel 8 being on the leading edge of the wing. the rcc panel, the gray looks like fiberglass initially so it looks tough but basically we learned over time, we didn't know it early on but it did hit panel 8. i did something wrong.

here we go. another piece of data or set of data was actually the light data that we have the came back from the flight. and what you're seeing here is you're saying a departure. you see the dashed line where this is a rolling moments moment so what happened was during the entry you are seeing dado where the aerodynamics don't make sense and so the orbiter starts departing. all the rcs jets and trolls are saturated and it shouldn't do that. there is another sts-109 trace that it should be kind of what it looks like. we had various data like this and so the team at the nasa and caib everybody was interested in trying to make sense of all the data and there was an incredible number of studies that were done

and tested all kinds of analysis to understand what happens. so one of the things that we realized early on is you have to integrate all this stuff. you can just look at the debris. you have to look at the flight data and where things were on the ground in put that together and integrated and try to figure out what happened. this is interesting in the fact that this is the ground track that shows where rcc, the pieces of the leading edge hit the ground and basically we had left-wing, left-wing a row did rcc and right-wing. the red wing and the left-wing, if you put it down into centroids of those areas basically a a is the middle of the area where the left-wing hit b is the centroid area where the tail hit and c is the area where

the right-wing hit the ground. so from this, and looking at the debris, we determined -- we got a good idea of how the vehicle came apart that also helps us understand what was going on here. so this is a debris map. all these charts pretty much our tape charts and i have dated this one based on the latest model for the final debris of model that we had. it shows where we had pieces of the bottom of the shuttle and basically the shuttle courses flying nose first. as soon as the left-wing departs, we figured out that if you look at the center of gravity in the center of pressure where the basically the outline of the shuttle is, it's going to change direction and so we saw evidence of this actually on the right ring where we stopped puddling of the ceramic

on the tiles going sideways. which was in a direction consistent with the shuttle going sideways. the left side into the wind after the left-wing came off. and then, and then after the right-wing came off there was actually puddling on the back of the flap that showed it was going -- so we were beginning to piece all of us together. we knew where things were knew where things were on the ground the wheels i had a number of scenarios, scenarios being dwelleth could've hit in front of the wheel well or it could have hit the wheel well itself and that was a big -- that was a big point that people thought the wheel well door came off. we also have a scenario where maybe the aerodynamics were caused by the left wheel coming down early. and so, pat and i spent a lot of

time at the caib trying to eliminate these possibilities. this one just shows the pieces that we had in front of the wheel well. the circle on the right shows some of that hardware on the floor and basically we ruled out anything coming in in front of the wheel well. they said well, and there was a team looking at it. the wheel came down and that is what caused it. when we looked at it, the front side if it had come down the front side still had chrome on it which would not have happened. it would would have been burnedf and actually the underside was burned up pretty well which is the picture on the right. and that would indicate it was where was supposed to be during entry so we ruled that out.

one of the scenarios that we thought late in the game, we felt like well maybe it's the carrier panel. their interior panels behind the leading edge that come off with tile on them. the ones on the top half quarter-inch bolts and the ones on the bottom had to, one quarter-inch bolts and we thought well maybe it wasn't the leading edge that had the hole and maybe it was one of the panels that got hit. so we gradually got the interior panels on the underside of the left-wing. the last one that came in was panel 8, and so right up to that point we thought it maybe was the carrier panel but that eliminated that possibility. ..

and they basically would duplicate the damage we are seeing here. basically where we were at this point in time, we're pretty sure it was panel 8 that had been hit, but we couldn't prove it conclusively. then the magic recorder came in, which is shown here. i don't remember a picture, i couldn't find it -- i don't remember a picture showing it sitting there on the ground all by itself. everybody was concerned about the condition of the tape when

they opened it it was perfect. we got data from that. basically between the dpa that itself it showed pressures in temperatures and the left-wing, and the fact that amaze measurements would go offline. they would go offline because the wires are being burned through inspect is the closeout picture of the orbiter with the wires are routed. we knew where they were to which censers and separated by this much and you see them going off one by one. with that data, there's a picture at the bottom of the edge with this information we knew the hole was about that big with an area about that much. and the leading edge. the data actually was the data that cemented our understanding

of what happened. another occurred that occurred, we saw data in the natch showed spikes in heating. well, there's a picture here of tiles from that, it made sense the plasma is burning through the leading edge of the wing, at some point exits. because the flow on the orbiter is going to flow up and hit the spot. when you look at the oms pod piece it had aluminum in it. and exotic terribles out of the leading edge. early on we had part of the vertical tail, it was lying on one side on the floor, but when we learned about -- when we figured this part out, we realized, well, on the side on the floor, there should be -- we were walking by it every day, and so at this point when we thought about the scenario, we said, let's turn it over and see what it turns looks like.

we turned it over it was the oms pod. it was hit with materials out of the left-wing as well. so basically, this is the diagnose that shows -- diagram that shows the leading edge parts that were recovered, and about where the hole was. as has been said, there's an inedble amount of -- incredible amount of analysis that went on. all aspects of possibility of the damage and the scenario and how this came about was studied and included every aspect that anybody can think of. we ruled things out. this is a chart just shows all of the different things that were looked at, that could have caused problems with rcc or the various part of the shuttle, they were ruled out through study and testing. this is a chart talks about some

aspect of this that are somewhat troubling. obviously back at the time -- these are observations that cake away with, it showed the incredible importance of having enough data from the flights to actually figure out what happened. if you're going fly again, so you to have enough information to know what caused you the failure. there was something that was going around the program at the time called -- when they had something off -- they had prior foam releases, and never caused a problem. so they became -- we have seen this before. the problem is you didn't understand it completely, and it department come off at the right time or hit the right place to cause the damage it caused in the accident. there was also, i think, a general misconception, on my

history of the shuttle program, i never heard it discussed in the early days, everybody was concerned about the tiles, because you can punch a tile with the finger and poke a whole in it. rcc looked tough in comparison. so nobody, to my memory, ever really talked about it before this accident. and so it was generally thought to be pretty tough stuff. there are also problems with requirements at that time. it turns out that the wing -- none of the rcc panels -- none of the tiles had a requirement to be able to withstand a debris hit of foam or anything. why? the foam wasn't supposed to come off. and so that requirement was never there, it was never qualified for the condition and it was a difference in the different prompts that were independent of each other to some degree. so and also at this point in

time, because of the time had gone by since the challenger, the cnn i, the system engineering and integration office had dwindled in size they were not able to do expensive analysis. there was a crater model which was a mathematical model with calibration of testing to indicate what kind of damage can be cone -- done with a piece of debris. that was in place. it was talked about during the period, and the fact of the matter is it was not meant to predict damage from -- to rcc. there was also scheduled pressure. and i'll talk some about that. there are other vulnerabilities that were actually discovered during the intense investigation of other problems that might have been the next accident. and so this -- a lot of this

showed what problems could be out there, and actually indicated the degree to which we misunderstand the vehicle we were flying. then there are other possible outcomes. i don't know how probably they were. they were looked at during the cave experience, and then are organization and cultural issues that john alluded to. there was a history of foam loss, and it was in family basically because it happened. we never had a severe problem. we had damages on tiles at time. they were never severe enough to cause a severe problem. there was scheduled pressure during the point in the shuttle program. we had a space station to build, and we had already had -- we had down time in the program due to other problems. and so the at the same time we had other problems that grounded

the fleet. the schedule dates didn't change. it just more pressure on it. it was a pressure that was on the program office. this is a chart out of the presentation. there were issues during the time of the flight. there were -- the engineers knew that the shuttle had been hit. they had the photograph d.a. that. they asked for ground pictures to be taken to see if there was damage of the shuttle. there -- they were denied, they were not done. and so there were people wanting to find out more during the flight about what damage there might be, but they talked about the crater model, they talked about past experience and family that sort of thing. and so these opportunities did not happen. there are other cases the bolt

catcher. this was a bolt that is separation bolt between the external tank and the srb, the solid rocket boosters. there was -- there were weld issues in the cabin. it turns out the piece of hardware was never fully qualified ever, in the program. it might have been the next accident. in fact, there is radar data from sts107 that showed big metal pieces coming off at separation. it didn't hit anything on the flight. in the future, maybe it would. these things were found. on sts107 was found there was x-rays done of the weld of the dome on the catcher and should never have passed inspection. so there are other things that were found. there are other things that will aspects of the flight as well. this is a picture out of the back window on the upper deck, and the area damaged is just out

of view. unfortunately. so this was taken during flight, and it's showing panel 12, panel 8 is the one that was hit. there was a study done by the mission opens folks to look at would there a possibility if it were pursued to look uva do a contingency uva there were studies that looked at this and said we could have done this. and there were -- they also asked, well, can we -- could the crew stuff to the fleeting toning try to keep it from burning through as quickly? that sort of thing. there were a number of observations made by the -- there were issues of independence of smna safety and mission assurance that was called out, and their

independence. so there were some criticisms on the organization and that sort of thing response given all of this, and the memory of it, so what are the concerns for today in this is not a cave chart. this is mine. i pointed out the importance requirements. do we have the ability to impose requirements? one of the concerns and questions is under the approaches we are taking on programs now, do we have the ability to impose requirements? and in particular, and do we have the right level requirement? you can overdo requirement as well. we're good at that as overspecifying things. there has -- you have to find where the fine line is and all of this. when i was there, i had -- i put the emphasis on common set of human rating requirements because we have different kind of programs. we have the commercial programs

that i didn't mention earlier. they were mine too. the commercial cargo and crew when i was -- we had those and -- where is the fine line you draw? the same set of requirements that protect people should be as good for one program as they are for another. and so if you can come up with a good validated set of requirements that are throwing off but not overdoing it. why would you have different types of requirements for different programs? a concern i have and one that maybe will be a followup session of some sort is spaces and act agreements. you can't impose requirements. the lawyers tell you can't impose requirements under a space act. you have the safety process and the program goes on in a daily basis. if you look at shuttle program or any development program, you make design decisions of some type every day grow to work.

and the safety people are with you looking at the design decisions and weighing in on whether or not it's safe enough. and so the question is, under space acts are we able to impose requirement in a they will have confidence later that we're safe? we're going to fly people still. and the same thing goes for oversight. you are only you can't impose oversight of the processes and development in a space act. the programs have sertdifications -- certification contract with the develop fors the commercial crew. it comes late in the process. a lot of the design has already happened. the question is going back to the comments this morning, are we early enough in the process to have the confidence in the

systems that were developing? that's a question. the attention to detail is another aspect. in the design detail, you can see small things that in the accidents that you didn't expect. there is incredible amount of detail that is going to the shuttle program in terms of understanding and trying to get to a safe situation. another thing that happens is as you become successful, it showed up in the shuttle program before each accident. you become successful and knocking flights out and going well. can t can breed to over confidence that leads to other problems that you see crop up in the failures. there were political influences in the shuttle program. the flight dates, the schedule pressure there's obviously political tension around our programs today. it has an effect and it can

effect safety. i have a question -- i'm not trying to answer it. i'm asking questions or pointing out concerns. have we drifted away from that the things that we learned during the colombia accident. immediately following the accident and following the challenger accident, nasa became stronger. the people involved in the decisions, the people that were involved in it from whatever standpoint became stronger, and worked from these lessons. but as time goes by, you can drift away from them. they become less relevant as you work your day-to-day job. in the end, you have to ask yourself those questions and whether or not you are safe. because we know the consequences for the missteps or misconceptions can be catastrophic. in the end, the people that fly

on the mission, that fly on the spacecraft are family members, they are friend, coworkers, and they dependent, they can't know everything that goes on in the vehicle they're flying. they depend on the operators, they depend on the engineers, they depend on the program managers, they depend on people in washington who are studying policy they are depending on all of us for getting them as safely as we can. understanding the high-risk proposition. that's my comments, and probably don't have much time. but i would be happy to answer questions. [inaudible conversations]

we have time for a couple of questions. [inaudible] >> about the investigation is there anything that you would change looking back as far as the breadth or the depth of the investigation or do you think that it's a good molgtdz -- model if we need do that again? >> from my viewpoint, there was a investigation. there was the nasa work and analysis. it was a beginned effort, actually, in the end. the cave had a job to do to review it. but there was a tremendous amount of work done by nasa in support of this. i think it was very thorough in the end. personally. >> and the brought in the best expertise we could find in the country to support our analysis. we didn't think we were leaving anything june turned -- unturned.

can you talk about the parallels between the family issues related to the foam and those related to the the blow by? >> that's farther back in memory for it to go back that far. there were instances where there was erosion of the o rings prior to challenger accident. i don't think it was understood that cold weather had a factor. until the investigation happened, i don't know that people understood it that well. ymedz there was some of that going on too. that's a natural thing in human nature to say we have seen it before. the problem is, when that

occurs, we might have seen it before. you dpontd know where you are with respect to the cliff. and that's the way we curably call it. you studied things within a certain boundary. you have done analysis. you have done testing qualified in these conditions. and so something happens that goes outside the boundary. we didn't have a problem. but we never analyzed that. so next time you go a little bit further where do you fall off the cliff and have catastrophic problems? that's the danger in that mind set, i believe. >> one of the people that consulted with the investigation a woman named dianne now with colombia university who are written a detailed look at the challenger accident, and it's causes and used sociological literature to talk about being an academic she didn't say in

family, she said normalization of deviant. it's basically the same thing, and i remember very vividly at one of our public hearings dr. sally ride who will been on the challenger commission and listening to someone testify saying i hear echoes of challenger. there were some similarities in the process. i wanted to make -- i agree with that there were similarities. there was one fundamental difference between the engineering aspect and the two accidents. so engineers are people too and the sociological things were worth pointing out. with challenger, the solid mechanics of joint behavior as a structure were not understood until well after the accident. it literally rotates -- it rotated differently in a different direction than the

engineers thought when it was designed. so had the joint behaved as it was believed to have behaved, the design would have been adequate. in the case of the foam, i think everybody knew it's possible if you hit the wing hard -- whether or not foam could that. there wasn't a fundamental misunderstanding of the physics. it's a question of the level involved. forces involved. with the challenger solid rocket motor joint there was a understanding with how it worked at all. those are different things. >> on my recollection of the foam, i don't remember there being evidence that the work had been done to understand the involvesty and the momentum of the foam before the accident. the foam had come off before. i don't think -- i never saw anything that i remember saying that they looked at what it took.

they thought the light piece of material couldn't do the damage. when you get to the vilos velocity even at the march mass you have the issue. >> on that note. i have a film of the southwest research test where we actually . >> they didn't want us to do that. so this is that was cone of rcc southwest research to see at the right involvesty to see -- velocity what the damage could be from a piece of foam. >> can i make one comment . >> jim with the faa. and at one time i was rock well manager for colombia. you mentioned the important of requirement. another stool to the engineering

and design reference commission. one of the things we learned on shuttle ere -- every time we analyzed the report missions they sized everything. if you design system just to the nominal missions or shuttle one, two, three, and 3 b. you miss all the design levels. withly to redesign several things when we finally got around too analyzes the missions. that's another requirement that is -- i don't know if it's employed well enough today. [applause] thank you. [applause] on the next washington journal,

politico changes in state as part of the affordable care ability. then we're joined by former fema director james lee wit and the former head of the transportation security administration admiral james loy. an organization focusing on national disaster preparedness. will discuss efforts to abolish the death penalty. we'll take your call, e-mail, and tweet. washington journal each morning at 7:00 eastern on c-span. now more from the conference on the tenth anniversary of the space shuttle accident. a look at lessons learned from a management perspective with the learn of the returned to flight operation of nasa. this is about an hour. so we had a lot of technical discussions earlier and we have

more denial pieces. but what this panel talked about is sort of lessons learned, unlearned, really more are from a manager perspective. a liar -- higher level perspective. my purpose being on here. i was deputy chief of staff for sean oh kef at the time of the accident. as she said at the beginning with all of us lived the accident through our personal lens. i'll share mine. we have bryan o'connor who is former chief of the nasa safety administration. bill parsons the space shuttle program manager for return to flight who had to incorporate the mess sons, and george mason university who wrote a nice book between challenger and colombia. lessons learned and unlearned. i shamelessly stole the tight of the program from. i figured i would start with

discussing some of the personals on -- observations and a little bit of synthesis. >> as i said these are my personal impressions of the accident. frankly, i was asleep when the phone rank. -- rang i got a call from kennedy waiting for the challenger -- to return. and said that the vehicle was late. you don't lose shuttles. something is bad. i had to get to the office fairly quickly. on the way there, of course, we had the report of the breakup 0 occurring in the skies over texas. we set up a war room on the sixth floor. deputy administrator rick gregory come in. a lot of folks had come in that weekend. we had a crisis response plan set up for notification and

coordination as several earlier speakers mentioned. it was something created after the challenger accident. i think something we were greatful in providing structure and organization for the first few weeks after the event. it after the first couple of weeks we were in new territory. the plan only took you so far. in terms of providing a structure and organization initially within i think it was very, very important to have those contingency plans in place. the next few days, and weeks as people have described were a bit of a blur. one of the immediate issues that came to my attention and those at headquarter was assessing the dabbling on the ground and 66 of local community. we had schools close, roads blocked for debris, local police forces guarding hunks of debris sitting in the middle of the street and schoolyards. i worked with gnat is a chief

medical officer, rich williams who was -- excuse me, i thought invaluable in working with some of the fema, state, and local authorities. rich was air force flight surgeon, but he he also had role taking care the crew not only working about morale and health of nasa employees, but formed an interdisciplinary function where you had people responsible at headquarter working with first responders and dave king on sight. coordinating agencies back here in d.c., and so you would have these amazing telecom as everybody was trying to pull together to do the right thing. we were concerned about civilian being injured and removing debris and immediate risk of hazard. we didn't want anymore harm occurring to people on the ground. and of course we were worried about valuable data being

surprised if the debris removed or lost. it was quickly apparent that the major breakup occurred sooner or later. maybe -- among the many miracles, with the fact that no one immediately on the ground killed or injured. we did lose two folks later in a helicopter accident. we were communication with the white house, of course, we were tied in closely and cave mentioned how that was helpful in clarifying change command early on. we also needed to organize, you know, the nasa response team as we move from a first responder needs to supporting what we knew to be an exhaustive and indeptd investigation. admiral was announced as chairman, again, i think sean's predilection were certainly known. i think it was not an accident we had a lot of military and aviation people on the board.

we were looking for the best people in the country we could get. what we knew to be an inner disciplinary analysis. other names were added later as doctor described. we were trying to pull on what the country had to offer. in the course of the activities, again, from my particular -- i had the unusual duty of chairing the final approval group for releasing responses to inquiry. it's a process and i think it worked quite well. a tone was set early on we would be as forward leans as possible and release the material from prior to the accident as well. -- materials released would come to a conference room and get one last week for personal identifying information social security numbers and addresses. we would ensure that the specialists themselves knew what was about to be released. with approval the material would

be uploaded to nasa website for simultaneous access by the press. so it was sober to see material on your desk one day on the front page of the "new york times." it could have been argued that we didn't have to release as much. we had a number of exemptions that could have been used. it was a top level decision that john made, i think it was a wise one in setting a toned in as well as outside the agency that would be as fully and bluntly honest with our failings. frankly, we knew people would see things and connect dots probably fatser than we would additionally. that was to the good the point was to find out what happened and why. a week or so after the accident, as we were in out process, nasa general counsel paul was there, and he was a lawyer from louisiana with a special education long time friend of the administrators and really smart guy.

i remember saying to him, you know, paul, before it's over you're going hear a phrase called normalization of deviance. the challenger decision, book. i won't to attempt imitate his accent and he said normalization of what? the rather odd sociology term. it certainly came clear what we meant. and when the first theory about the foam shedding came out, you could see the skepticism in the firsthand. i think on one hand there was a reluctance to embrace the theory because as one of the other charts said, first information is often wrong. there's danger in the organization in finding a convenient answer in locking in to it soon. everybody is looking for meaning to look to impose patterns maybe where they don't exist. the point doug made about chasing down all other avenues

avenues is important being honest. i personally certainly got the analogy of told to me bay number of people that couldn't possibly be the foam. it would be like a foam ice chest being thrown off a prupt and you are following it and it hits you and shatterses and it's scary. what can it do? it was a maintenance issue for years. it was more than a maintenance issue. michael greenfield, the chief engineer was showing me historical foam strikes on the underside of the shuttle when i was trying to figure it out. i used the phrase, are all of these family events? do they exceed tolerance levels omar gin of some kind? and, you know, he looked at me and he said, well, scott, that's the problem. there is not supposed to be any strike on the bottom of the. it's zero. you have the moment of oh my god. in short, the orbiter was

performing as expecting. everything was performing as expected. the system as a whole was exinting a dangerous behavior we didn't recognize. it was complex highly coupled system we failed to listen to the vehicle. failure in systems occur not just in the part and component but crucially at the interface between system elements. that is first place to look. now i was reminded of being when i was a young engineer at rock well and down any when the challenger accident occurred, and my first thoughts were of the ssme which had experienced several explosion during the development testing in the '70s. we found it was srbo ring. i remember being surprised at seeing a design different from the icbm systems i had seen earlier. it's not just ignorance that can hurt. it's believe what you believe to be true ha that's is not.

a lesson i would take away from the accident indeed other major space and aviation accidents is have a degree of human millty in front of the hardware, listen to and others paying close attention. because by definition failures are going occur in odd and unusual ways when reality trumps our assumption about what we think is reality. with that i would like to pass it to byron. >> okay. >> can you hear this in the back? imy name bryan 0 connor, i was the officer for the agency when the accident happened. i had been in that job for about six months, and when i think back on lessons learned, i put them in four different categories. and they tend to be in the route cause of the organizational, the cultural part of what came out of colombia accident

investigation board. i was struck by a quote i saw once saying, do not look where you fell, but where you slipped. and certainly the cave did that. we looked at where we fell but also where we slipped. some of the things they looked at affected my organization and me personally quite a bit. for example, today when i'm watching the movie of leroy and the folks there in mission control, several times leroy asked the question, well, is there something common here? do these failures you have seen here the four sensors or the three parameters or whatever several times he asked the question. do they have anything in common? the answer came back no. there's nothing in common.

in retrospect, of course they had something in common. we know it now. it reminded me of the importance of doing analysis of your design not just from the failure mode themselves, which tend to drive flight rules and so on. you look at the different failure mode. you figure out which ones can happen. what kind of things lead to the failure modes, and that gets to the question of do these things have in common? you have to do top down analysis. it's the purpose of hazard analysis. top down plus bottoms up you are still not done. you adopt do sideways analysis. which tends to be in things like reliability or problem listic risk analysis or accident analysis. they are things that the safety admission insurance community that i was in charge of helping programs deal with the contractors, with the engineers, with the s cnn i people especially with systems engineering and integration

people. because that's where a lot of these things tend to wind up being important. anything that can kill a crew, lose the vehicle tends to be, in my opinion, an integration issue. again the period rightly had a section on integration. s had someone earlier mentioned had dwindled quite a bit over the years. we had 87 successful flights. south carolina which shortly after the challenger accident was beefed to significant level of effort including those that fell over to the safety admission assurance, the integrate safety issue -- efforts at boeing or at the time, i guess it was a different company then, rock well. there was an awful lot of work done after challenger to read baseline. all of the analysis and so one of the things i learn trd this, you can't just depend on certain

able cease. you need to have a theme credible and capable to ask why are you sure it's going work the way it does? the design engineers tend to like to do things that will work. you need to have somebody there that will ask why. and what if it doesn't? and that's the purpose of the safety admission assurance team. to get there and ask those tough questions. in overtime that had dwindled as well. but safety admission assurance. and part goes to a second pin i put the things in. i call flight test. after a period of time, we goat a mode where we considers ours operational. we didn't need to think like flight test people as much like before. we can start phasing out of the mentality. we can tell the engineers to put

on their may tag repairment uniform and give them a call if we need them. we sure don't want them hoovering around anything. that's expensive. and they'll find something to work on. and there's a tension there. you don't want too much. you can't afford to do too much. butover -- overtime we got feeling like we were operational and no longer in a flight test mode. i'm not talking about the klum boo diserchlt. we were in that mode before the challenger accident. we got in to that mode again. sally ride said she hundred thing -- heard things. she had reminiscent of challenger things when she was looking at the accident that fold. by now by the time we got colombia we had flown 87 h 86 flights since the challenger.

they were successful light flights by and large. we handled the technical matter of them. by the time of the challenger accident, we couldn't really say we were in nearly the flight test mentality we were by the time we got colombia scent they -- accident we were after the challenger accident when we said we will no never do it again. it's not really operational inspect is a tough thing, because after awhile you get to that bit that says aren't we finished learning yet? i mean, the anomalies are fewer, we're not having the big problems showing up. at some point can we back down a little bit and get the cost down on the thing so we can go do other things in the agency? it's going to be a pressure. ont for is something that i saw in august seen's law. a lot of you have read the book. number 25 is interesting. he drew a plot in there that

showed how much flight test was done for a whole bunch of missile and rocket systems. he did this back in the '80s. he missed out on some more recent ones. he had rockets and missiles in there down from a little 1.98 hand held rocket to the tight end missiles. there were about twenty or thirty different rocket systems and missiles systems in the defense department. he laid those in to his chart cost of the unit, unit cost versus number of flight tests. that were done. the number of flight tests were inversety proportional to the cost of the unit. there were many fewer test flights done on the titan, for example, than on a small relatively simple hand held

rocket where they did a thousand test flights before they declare it operational. it's not the way airplanes work. when you look at defense department and the faa, they're looking at many test flights before they approve something for, quote, operational use. before it's allowed to conduct operational misses -- missions. in human space flight we were not following and never will when it comes to airplane model. we cannot wait to do the reck with -- number of test flights to declare them operation. what we have to do is fly our missions relatively early in the flight test phase. we have to admit to other and be honest with ourself that we're doing flight test for the life cycle of this system. this system meaning space shuttle, freaks, we were

learning stuff and in the flight test mode right until flight 139, that's good. it's expensive, it's the right mind set. i thought when we wound up the program, we had a good mind set on that. they had enough money to deal with problems that came up. the engineering community was very involved, they weren't driving the cost as much as they probably would like. but they were mag tag repair guys either sitting in the back room waiting to be called up. the reserve that the program manager had by the end of the program were sufficient to do the detailed analysis that he needed when things came up in flight. right up until the end of the mission. when you go back to just before colombia. there was a record low amount of reserve what they call apa in the program. the day before the accident. it had never been that low. there was very little money for the program manager to use to

chase down problem. i'm not saying it's a money people's problem. it's a big problem across the board everybody shares in that. i touched a little bit on check and balance. technical authority is the third bucket of lessons learned. again, the accident investigation board compared what they saw with the shuttle program with three or four other programs, and institutions that were doing at love engineers and programs and they didn't like what they saw when it came to the authority of the technical personnel with respect to the authority of the program macker -- manager. that balance had gotten out of wack even within nasa. i think when we look back, i think we realize the balance had gone where the program manage her more authority than in the shuttle program when engineering was more involved. and much more author at a

authorityivity. it's very good to get to where your engineers and sma folks have north to deal with things. but that's not enough. and i can tell you they spent the rest of my career in that jock of safety mission assurance trying to make sure we are the capability to go with it. there's nothing worse than having people with authority that don't know what they're talking about. it's disruptive. so if we're going get the authority and have technical authority, we have got get good people in there. i have to give to the center directors. they turn to and got us good people in human space flight safety admission assurance organization. that was helpful, i think to the program manager. you can ask them. i think it was if they had sma people who knew what they were talking about. it was easier to answer the devil advocate question. the last intuct complacent sei. i don't need say much about it. i think some of the other things i talked about, not doing enough

analysis, not having the right amount of technical authority and checks and balances. not having anything in your reserve pot to go and chase problems with. all of them are signs of institutional complacent sei. it's hard to say there was anybody in the shuttle program or operations program or officer i.t. and there was an institutional complacent that we're not in fright test. e -- i think that is a form of complacent sei -- i was the

shuttle program manager fee retirement flight. on the particular day was at directer probably been there less than a year, maybe less than six months. it was a saturday morning i was driving to pensacola, a friend of mine had gotten ms, and he was in bad shape he was in a nursing home. i was going visit with him over the weekend. and, of course, got a call on the way there, i left pretty early in the morning, and i was able to go in tell him hello, watch it on cnn n and turn around and go back to the center. i was in touch with some of the folks at the center. they were locking down information and starting the process in place for us to be ready for it an investigation like we were fixing to go through. u didn't have a clue about what to do. i picked up the phone and called former director at kennedy.

i said what do we do? get back to the center and wait for the call. things will happen quick after this. our relationship -- i didn't know the crew very well. i knew mike anderson well. we were on astronaut selection committee together. we did a lot of interviews. i got to know him well. and, you know, it's just it becomes personal when you have somebody that you are that close to. i can understand how some of the other folks that felt that knew the crew better than i did. i want to go back a little bit and tell you that i was the deputy center directer. so some of the things rhode bryan touched on i observed. as the international space station was doing cost overrun. we were making decisions, i was apart of that we were makings decisions how we can cut costs. and the shuttle program became,

it looked more operational than most people. we were cutting things we didn't use often. some was sc analysis. we weren't doing that work. we could let the people go. because apparently we didn't need to do that kind of work. we were losing that expertise within the shuttle program. i don't think we realized it. that was whatting. another thing that i would tell you is that ron of 6 program manager. some months before colombia he announced he was leaving and going to retire. he was in search of new shuttle program manager. as senate director i was a consulted a number of times and i'm sure others were as well on the names on the list. my name -- if it was on the lie, it was at the bottom of the list somewhere. so there were a number of people being considered to be the shuttle programmer manager after

ron retired in a few months, he was supposed to retire, i believe, just a little after it happened. he stayed on a few more months after that but eventually left. i will tell you that as i said, i didn't think i was on the list, and i'll tell you a story about that in a minute. i want to tell you one thing that bob once said to me. maybe it's a lesson learned. maybe it's not. it's for you to decide. once so you been in a job four or five years. a lot of times it's good to move on. at some point you are trying to fix the mistakes you made. it's something we have to think about. there's a point in time in some of the jobs that are complex jobs that require you to have a fresh look at the things that maybe we stay on a little too lounge. -- long. we like the jobses we enjoy being program manager or chief engineer. at some point, a fresh view at the program, the things we're doing can help you maybe find

the things going wrong better than somebody been there. i just naught out there, f something to think about. during recovery, you know, dave talk abouted that. i will tell every person pitched in and did many things. one of the things i thought of and thought we should do is the stress on the people doing recovery was great. it was huge. and dave didn't touch on it too much. it was huge on dave having to set up on dave king trying to set up the organization to get it kicked off. in the meantime, he also got very sick, and, you know, he did -- i think he left with a pair of socks and didn't have a lot of stuff when he got there. so we offered up mike and allen flynn. they rotated in and out. i'm sure other people rotated in and out for the recovery. it was long days and a lot of hard decisions.

you needed to be as fresh as you could. you needed to have people aware of what was going on. it was one of the thingsivity it was a important thing during recovery. you have backup and people willing to get out there, yes, so you to have your pointmen, pointwomen, whatever. you also have to have people willing to go in and make sure they can jump in and help you out and give you a break. let you get refreshed a little bit and get back in there. -- [inaudible] >> yeah. so how i got assigned to be the program manager, we were doing a lot of recovery and somehow i guess they had gone down the list and crossed off names. asked a few people and they said no. one day we were having a little bit of a appreciation ceremony for the people in luff the people in the community patting the them on the back. i was telling dave king you need to be ready.

i think they are fixing to announce you as shuttle program manager. it's a tough job and so on and so forth. he was smiling, he didn't let on to me that maybe he knew something, but that evening we were sitting over where sean oh kef had a condo or something. a few of us were talking and everybody went on the porch. i walked in to get a beverage of some sort, probably a beer. and i heard the door open behind me, i felt a presence on me. i turned around and there was sean. it was me and him in the kitchen, he said, bill, are you ready to step up? and i said, sure, sir. being a marine -- i was in the marines. did fell in to marine mode. yes, sir, whatever you need me to do. >> can i a beer. >> and i gave him a beer. he said what would you family feel about? i still don't know what we're talking about.

i was naive at the moment. i said, sir, they'll adapt. i'll figure that out. he said, good and walked off. i was like, well, -- [laughter] so about two days later i called bill and said, what was that conversation about? and basically he said you're the man. that's when i found out i was going to be the shuttle program manager for return to flight. i will tell you, i share this with you, i didn't feel qualified or fell like there was any way in the world i can do this. let me tell you, it was not as -- i know it was not my skills in the shuttle program. i worked operation at kennedy space center like dave king. i didn't have a strong technical background. but i had been a marine, i had done some -- i had been a leader in a number of different places

and i was thinking that's why i was allowed to do the job or asked to do the job. but one of the first things that dave did for me, you can pick your team. and that is a pretty -- you know, when you find yourself in a crisis like this and you put somebody in a leadership position to give them the full range of you can pick your team, and you have anybody in the agency. they are available to you. and i sat down with then senate director at johnson space director and a few other key people in the agency, and we came up with a names. and of course, that's where wayne was picked, john shannon was picked, steve po lis, i can go down the name, leroy, ed, nancy, john casper, i mean, it -- i got the -- i got the best, and tell you that was an

extremely important lesson for me when you find yourself in a position like this, you goat pick your team. now i will say there's a bad side of this. that meant everybody that was in the positions before that had been a part of the shuttle program that had the history that had the -- they just learned a lesson probably in the hardest they anybody could ever learn it. many of the people moved on to do other things. and so we were a brand new team coming in with a brand new perspective. we were trying to get our legs under us. luckily some of the people that were in the positions before stuck around with us and talked to us and kept -- and fold us what was going on. they didn't back down, they didn't fadeway. they helped us. we needed their help that was really important during that time period. there a lot of other names i can go through and a lot of them are in the room today. and he touched on something --

as i went to the job, i had to change the culture. that was my, you know, it was change the culture and get there and be transparent, open up, have the conversation, have the tough conversations. but as you heard earlier, there was still a lot of raw emotion. there were a lot of disagreements, and yet we had to work our way through those every day. i can tell you it pushed my patience to the limit that i -- and i didn't realize i even had. and yet, it was required because we had to work our way through that. a lot of difficult decisions were made, i remember people in tears, and our requirements review board. i remember people walking out, just they're, you know, they're done with it. they're not going -- they can't stay in there anymore. we had to go through the process. i'm not sure that it was there's nothing to be learned from that

other than the fact when you put the team together, you put them in a situation like that they have to go through that process. and it just takes time. you're not going it get back -- we were saying, you know, we're going go back to flight in december, we're going go back -- yet, it was not going happen. and the team knew that. but that was our messaging that we were doing at the time trying to don't keep funding, i guess, our support from congress, i'm not really sure. whatever it was, it was the message. we were having to work through a lot of issues during the time. one thingly add is even though we were changing the culture and there was a lot of support for changing the culture, i was still around great deal of pressure to get return to flight. to do return to flight. ..

had the. >> och we did get a few things wrong and that is a lesson learned. we found out after the summit that the heater could build ice and we needed to do the modification.

that was ready to be installed. we've rolled back from the pad to do the modification and. another ball in and our discussion was the ramp down the side of the external take. a lot of foam could have come off and it did. i kid goes through how and why but we as a team talked long and hard to take it off but it was a delay to the program but evidence said it did not shed the foam and we decided to fly. that was a tough lesson. we knew what we should have done yet we talked ourselves

into it because we needed to fly with low risk. it was higher than anticipated. there are lessons in there. take them, think about them, they may apply but what i took away from that experience. it was the hardest thing i have been overdone. i grew old during that time. it was the tough thing to bear. a after it was over i had to get away and weighing and john shannon took that burden when there that's stressful you have to do is think about somebody is

ready to take over for the next guy. that is all i have. >> this is unusual with the academic because the grass band of the nasa guy does not. [laughter] >> i think sally ride said there are eerie similarities with the organizational elements preceding the loss of the challenger and columbia. thinking of organizational learning and it seemed to me that there was a lesson to be learned how could it nasa

not be a learning organization? that does not make sense. i started to investigate how this happened. what i would like to talk about is the relationship forgetting may be connected with a normal accident most of you know, that is the inevitable consequence of having technical systems interactive the and coupled unexpected interactions with these parts and once they begin and there is a failure because there is no way to stop the process from continuing. the solution is backed away

from technology. we see that no from technology. we see that normal accident happened in a lot of accidents like katrina. i suggest it is not just technical systems the managerial and organizational systems as well. you can have organizational systems complexly interactive comment tightly coupled with devastating consequences. this is too much but bear with me. with complex interactions with the organizational and managerial system we talk about policies, and procedures that are complex -- complexly interactive because bits' get lost

overtime. with organizations and learn the responses of the past past, when they forget parts of responses are solutions solutions, suddenly those systems suddenly become compaq -- complexly interactive. of high relief formalize procedures this can lead to a tight coupling, no way to stop the process once it is started. nobody has the authority or the information. so there are analogies to the antecedents with a managerial and organizational systems and

what we think of is un-learning and forgetting. our major competitors to these accidents. by forgetting, the unintentional loss of lessons we had before that will create gaps in what we think we know and what generates these complexities. the cause of forgetting, how do forget elements of procedures well you reorganize? anytime you reorganize you paralyze it. because most of the organization's know why, it is not written down or what they do. what they do is the embedded

knowledge the unconscious knowledge people have of how to get things done. if you follow all of the rules of the time, you see a paralyzes reorganization. simply lack of practice over time several of you have mentioned the shuttle had a long period that things went relatively well so the procedures for investigating what could be a near miss or potential accident or not exercise because they hadn't been. a key and be forgotten simply as a result of missing pieces of these

routines to keep things going and with the challenger in colombia of reorganization, a downsizing, a time. with the intention old jettison of lessons they appeared to be outmoded and appear unattractive. this generates gaps in knowledge, some causes like management reform with faster, better, cheaper. [laughter] there are so many versions. thank you. but those are necessary but to undo the structural changes that happened after

the loss of the challenger. with new budgets in priorities that the race for the redundant organizational structures that was the of follow-up return to fight after challenger. if new agency and administration comes with new ideas cheerfully and great enthusiasm and do what the previous administration and abroad in an new contractual relationships complicate. so we see a shift of funding levels, of relationships, priorities for the space station program, national performance review is a corollary with faster better cheaper at the agency staged.

the well intentioned changes led to losing knowledge, lessons we had from previous rounds of analyzing. what have we learned about forgetting and un-learning. wateree for getting out as a result of the coast shuttle era? what lessons were reid putting into practice are we not practicing any more and for getting? what are we cheerfully un-learning? knapsack after the challenger learned with debilitating budget cuts and schedule pressure, slowing down, to declare what could or could not be done.

those adaptations were lost as the schedule and budget pressure ramp up. we're not out of the woods. we have the other management reforms. so i would leave you with that. i wish i had the image that was shown a while ago because you want to show the image of culture you show the french for. american strength and innovation, a scientific capacity, the human spirit we show the of pitcher of a shuttle launch. with ever we can learn and apply to the next programs

are important. thank you. [applause] >> we invite questions and comments from the audience. >> you really brought up on my mind. we talked about the past, and i am very concerned where we go in the future. a point* with consolation that i supported where we were learning from the of apollo people and how they did things and lessons

learned with networking with those who were still around that we could connect with. then that closed even though it was knowledge capture, my concern we don't know when the next mission will be. what is your assessment how well these lessons of challenger, colombia, and apollo could be transferred in whatever program comes next? >> in some ways that is a difficult question to answer that is prospective to make a guess where things may go. and the answer is speculative but to say the

problems with these tightly interactive systems the un-learning is not specific just to the shuttle. i can talk about nuclear weapon design, or the role of factive design of the 787 aircraft or power plant certification. there are a lot of things that we do that are prone to accidents. some academics say we need to go out to do dangerous things. how to say capture the lessons learned? i said have humility in

front of the hardware. but also flight test not to give statistics, by degree not with launch vehicles but to train organizations, and who is the engineer who does the annual budget report and who do you want to fixing the vehicle late at night? you cannot tell who those people are from there resonate. the background and training they have in their capacities and as managers dummy have to have operational experiences that allow you to marry analysis to real-world operations and an organization.

that are equipped to learn from my answers your question is public-private sector to we have the a opportunities to gain that confidence to fly? one of my many disagreements, not going political. [laughter] but to say we have been to the middle ready is to say may be my grandfather went to the moon but we have not been to the moon. that is a young bird generation has not. how we give opportunities so they can capture the lessons academically but tacit knowledge so we fly in and fly safely.

want answers. >> can i add a little bit? >> the importance of passing on knowledge from one organization and generation to the next especially with downsizing you lose so much of permission -- information they need to overlap people so they could pass on the lessons that will never make it into a rule book or policy or standard operating procedure. like a journeyman system that makes it possible to learn the fix that people have found in the past to carry those aren't. >> we are on time and doing

well and i would like to call up the panel. [applause]

>> fet for letting me come i was there when we lost columbia to work closely throughout this although this panel is called technical lessons learned i was to offer the prospective what was going through columbia from the chief astronaut point* of view we had a brief of that and the amount of liberation you covered in that amount of time was great. thank you. as chief astronomic timing

has been good for i think this is the exception. columbia was of first mission i launched. the one before i became chief when he was in orbit for the of landing but i never launched a shuttle mission before. so i was fairly new from the chief perspective. so i want to talk about the leadership opportunities, communications is the central and with the columbia accident, what do we think is the right thing to do? interestingly the day lost

columbia i was in florida expecting to see it to show up and chased it down and that did not happen so that was a sobering day. immediately lessons showed a positive we had a plan for the families, a spouse's. with columbia i felt masses did a nice job from the administrator down tree been the family's right with the right support in doing everything we could now there was a plan that isolated them to gave them the privacy they deserved fetid is not what they had for a challenger so some were used.

when i got back to houston we had a meeting it was very emotional as he motions for all over the map. the astronauts were very experienced the more experienced the more outspoken to save maybe this shuttle is too risky. the majority of my office had never flown with the shuttle vague did not care absolutely when will i get my chance to fly? the office was spread across the spectrum. we had meetings every three

weeks because at this point* there is about 100 of us to understand and have a position on what we find. it was a recommendation because as chief many cases don't officially have the say but provide a recommendation or be the cheerleader. so determining the past four right thought it was important we came to what was the right thing to do. at of the 100th 13 missions we've lost touche shuttle and crew so the odds are one out of 57 for a bad day. with the trustee tomcat

might chances of being killed is one at a 20,000 it is much safer to fly in combat did on the shuttle. that started to dawn on us and you talk about risk vs. reward. it is risky and what is the reward? does that justify the risk? absolutely. we have local commitments on a space station, however the other thing we recognize when you lose a national asset, seven astronauts, the whole nation takes a hit in the further we go along the

maurice lee except that if you want a healthy space flight program, it cannot lose the crew. so do the basic math have emissions does it take to build the space station? twenty-five. the odds are we will not lose another shuttle and build the space station but also we desperately wanted to go to mars is that through the moon or street there? i believe in going back to the moon it does take more time i think the chances of success is the way to go. we need one that can go beyond the orbit and is

safer than the shuttle. it can be safer. so as the office be generated the white paper and turn did in and interestingly that in fact, was the vision we've rolled out. i don't know if it was coincidence or had influence or not but the reality is as a phenomenal machine as it is, it was time to move on to explore deep space. when you talk about leadership and immediately realize communication is the

most important tool. whether dr. horowitz about in this field for talking to the station i remember the first time i talk to astronauts on station including sox, the whole attitude was we are here for you, anything we can do, leave this on orbit one year, don't worry about us. take care of columbia that is the attitude i saw across the board even with the shuttle program and the recovery team. interestingly we were part of the recovery team to say it was not plean