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Historically, the type of roasting that NASA received from independent teams investigating the 2024 Starliner Crew Flight Test would follow a fatal accident—one triggered not only by technical failings but also by agency safety blind spots.

In the case of the CST-100 Starliner Crew Flight Test (CFT), NASA averted disaster, but its leadership’s lapses were as chilling as the mischaracterizations and missteps that led to the 1986 Challenger and 2003 Columbia space shuttle accidents.

• The flight test is now a Type A mishap

• The root cause of propulsion issues are still unknown

• The NASA administrator pledges transparency and accountability

“We failed them,” NASA Associate Administrator Amit Kshatriya told reporters on Feb. 19, referring to the agency’s astronauts Barry “Butch” Wilmore and Sunita Williams, who flew the Starliner CFT mission.

After years of delays and several crew changes, Wilmore and Williams lifted off aboard a Starliner capsule on June 5, 2024, for a planned 8-14-day shakedown flight to the International Space Station (ISS.) The CFT mission followed a pair of uncrewed Starliner flight tests and was expected to lead the way to operational ISS crew-rotation missions for NASA.

But as the Starliner neared the station for docking the next day, multiple thrusters failed, temporarily leaving the astronauts without six degrees of freedom (6 DoF) control. “We almost did have a really terrible day,” Kshatriya said.

“Losing 6 DoF control is a huge deal,” added NASA Administrator Jared Isaacman, who assumed leadership of the agency in December. “I give a lot of credit to the flight controllers who made the decision to challenge some of our flight rules and bring that crew to a safe haven, which is the ISS. Had that not taken place, had thrusters not been recovered, it could have been a very different outcome.”

In hindsight, NASA should have declared the CFT a Type A mishap, which would have shifted the subsequent debate about how to proceed with the mission and initiated an independent investigation, among other actions, Isaacman said.

Instead, NASA and sparred over technical issues related to the Starliner service module’s reaction control system jets. The debate about how to return Wilmore and Williams safely to Earth grew contentious and was occasionally characterized by unprofessional behavior, including yelling matches. “It was emotionally charged and unproductive,” an independent report on the CFT mission, released on Feb. 19, quoted one unnamed NASA official as saying.

“There wasn’t a clear path for conflict resolution between the teams,” another unnamed NASA official said. “That led to a lot of frayed relationships and emotions.”

More important, the discussions were inappropriately framed by NASA’s programmatic goal of having two independent crew transportation systems to the ISS, the report and Isaacman noted. The CFT was intended to pave the way for to join SpaceX in ferrying crews to and from the orbital outpost.

Ultimately, NASA reassigned Wilmore and Williams to serve as ISS staff, extending their flight from two weeks to nine months and bumping two other astronauts from station posts. The Starliner came back to Earth uncrewed. “The spaceship was not healthy,” Isaacman said. “We got to the right place. How we got there was not correct, and that’s why we are trying to set the record straight and classify the situation accordingly.”

In a Feb. 19 letter to employees, Isaacman wrote: “NASA permitted overarching programmatic objectives of having two providers capable of transporting astronauts to and from orbit influence engineering and operational decisions, especially during and immediately after the mission. We are correcting those mistakes by formally declaring a Type A mishap and ensuring leadership accountability so situations like this never reoccur.”

Isaacman later told reporters: “I think setting the record straight and classifying CFT as a Type A mishap ensures that what happened with this mission is appropriately recorded and can be referenced for future learning. This is how you course-correct a culture.”

The Starliner’s propulsion system issues surfaced long before the CFT mission. During the Starliner’s uncrewed debut in December 2019, a mission timing error prevented the guidance software from calculating orbital insertion burn timing, which triggered excessive thruster firings, incorrect orbital insertion and major propellant use. Ten thrusters failed, one of which was not recovered.

During the countdown for a repeat flight in August 2021, 13 of 24 oxidizer valves in the service-module propellant system were stuck in the closed position, scrubbing the launch campaign. The service module was removed and replaced, resulting in the launch of Orbital Flight Test-2 on May 19, 2022, and docking at the ISS a day later. The mission was considered a success, although three aft service module reaction control system thrusters failed during the flight.

“Investigations did not drive to or take sufficient action on the actual root cause of the anomalies that we observed,” Isaacman wrote to employees. “The investigations often stopped short of the proximate or the direct cause, treated it with a fix, or accepted the issue as an unexplained anomaly. In some cases, the proximate cause diagnosis itself was incorrect due to insufficient rigor in following the data to its logical conclusion.”

During the Starliner’s initial rendezvous during the CFT, five of the spacecraft’s thrusters failed, one of which was not recovered. The Starliner stayed attached to the ISS for three months while NASA and wrangled; it then made a successful autonomous landing in New Mexico on Sept. 7, 2024. A crew module thruster failed during descent.

Analyses are underway to uncover the root cause of the Starliner propulsion system anomalies. NASA said it would not clear the Starliner for its upcoming planned cargo flight or any possible future crew missions until the issues are resolved.

In a statement, said it remains committed to working on the Starliner program for NASA.

“In the 18 months since our [crew] test flight, has made substantial progress on corrective actions for technical challenges we encountered and driven significant cultural changes across the team that directly align with the findings in the report,” the company said. “NASA’s report will reinforce our ongoing efforts to strengthen our work and the work of all Commercial Crew Partners, in support of mission and crew safety, which is and must always be our highest priority. We’re working closely with NASA to ensure readiness for future Starliner missions.”