Why does a mission that is supposed to demonstrate that a spacecraft is fit to commence regular crew flights leave astronauts living months in a space station? With an abnormally direct diagnosis, NASA found out that the CST-100 Starliner Crewed Flight Test by Boeing was having the worst issues on its side when it concluded that the most critical issues were not of a valve, leak, and thruster nature. The episode was eventually classified as a Type A mishap, the highest ranking mishap category of NASA, and one that is reserved to occurrences that involve high cost, high cost, or high risk to a crew. Put simply, the system curved in the manner that the human spaceflight programs are designed to avoid.
The mission takes place June 5, 2024, and NASA astronauts Butch Wilmore and Suni Williams are on board Starliner on a test run that should take about one to two weeks. Shortly after liftoff, mission managers noticed that the propulsion system was leaking helium and soon afterwards there were issues with thrusters as the system was approaching docking. The state of affairs was critical as the spacecraft briefly lost six-degree-of-freedom control the type of ability required to accurately aim, move laterally, and maneuver a vehicle safely around a crewed outpost. Starliner was well enough to dock, but the report presents that as a close call and not as a promising success.
The uncomfortable part was boldly put forward by NASA itself leadership. NASA Administrator Jared Isaacman noted a “culture of mistrust” in the release of the findings, and said that the route we took was not NASA at its best. Isaacman also put the larger failure in organizational terms: Starliner has design and engineering issues that need to be fixed, yet the worst failure that this investigation has identified is not hardware. It is its decision-based and leadership that given freer rein would lead to a culture that was not conducive to human spaceflight.
The same cultural criticism can be found in business specifics. Investigators outlined competency gaps and managerial miscalculations as well as “chaotic meeting timetables”, irregular transparency and dissent which was interpreted as push instead of pull. Other personnel were perceived as not included in critical data and consultations, especially those who were not part of the Commercial Crew Program in Boeing and NASA, which supports the opinion stated in the report that programmatic goals were dragging engineering rigor and operational discipline. NASA itself recognized that high level goals, in particular the need to have two commercial crew providers, influenced choices “particularly during and immediately after the mission”, a telling concession in a programme that was supposed to combine industry agility with NASA agility.
At some point, NASA found it to be the safest thing to get Starliner back home without the crew. Following long durations of on-orbit troubleshooting and ground testings, Starliner landed uncrewed in New Mexico in September 2024 with Wilmore and Williams still on board the International Space Station awaiting another ride. In March 2025, they flew back in SpaceX’s Crew Dragon, and the experiment that once was never meant to be, a test flight whose largest deliverable was an object lesson of how oversight, incentives, and communication breakdowns can increase technical risk, was closed.
More importantly, the report prepared by NASA does not give the story as an accomplishment. The agency said root-causal work still goes on technically and Isaacman pointed out that NASA will not launch another crew on Starliner until technical causes are learned and fixed. In a program constructed to offer redundancy in the wake of the Space Shuttle, the message is not blame, but rather recovery of a safety-oriented culture in which schedule pressure and institutional inertia can no longer be used to supersede what the hardware is telling them and what the individuals in the closest system are telling them.
