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”Building rockets is hard” -first sentence of the CAIB report – Volume1, Chapter 1

On February 1, 2003 the Space Shuttle Columbia exploded. The crew of STS-107 was lost. It became the job of the CAIB (Columbia Accident Investigation Board) do discover why, and to make recommendations for returning the grounded space shuttle fleet to flight. The entire report can be downloaded from the CAIB website (www.caib.us); this is a summary for those of you who don’t want to read all 250 pages. There is some very good discussion of the accident at STS-107, check it out for more detail.

CAIB Members

Chairman of the Board: Admiral Hal Gehman, USN

Rear Admiral Stephen Turcotte, Commander, Naval Safety Center
Maj. General John Barry, Director, Plans and Programs, Headquarters Air Force Materiel Command>
Maj. General Kenneth W. Hess, Commander, Air Force Safety Center
Dr. James N. Hallock, Chief, Aviation Safety Division, Department of Transportation, Volpe Center
Mr. Steven B. Wallace, Director of Accident Investigation, Federal Aviation Administration
Brig. General Duane Deal, Commander, 21st Space Wing, USAFM
Mr. Scott Hubbard, Director, NASA Ames Research Center
Mr. Roger E. Tetrault, Retired Chairman, McDermott International, Inc.
Dr. Sheila Widnall, Professor of Aeronautics and Astronautics and Engineering Systems, MIT
Dr. Douglas D. Osheroff, Professor of Physics and Applied Physics, Stanford University
Dr. Sally Ride, Professor of Space Science, University of California at San Diego
Dr. John Logsdon, Director of the Space Policy Institute, George Washington University

The board was supported by over 200 investigators.

The report was complied and presented before the White House, Congress, and NASA on August 26, 2003. The 11 chapter report included detailed descriptions of the history behind the accident, why and how it occurred, and also a list of recommendations to return the shuttles to flight.

The Columbia Accident Investigation Board Report – Volume 1 (A Summary)

Part 1 - The Accident

Chapter 1: The Evolution of the Space Shuttle Program

Chapter 1 sums up the history of the space shuttle program from its very beginnings not as a purely scientific and engineering endeavor, but as a way of beating the USSR

”For the US not to be in space, while others do have men in space, is unthinkable, and a position which America cannot accept” - NASA administrator James Fletcher – 1972 memo to White House
NASA had problems with funding from the very beginning. The pressure was on to be on time and under budget and this mentality caused the design of the shuttle to trade off safety and long-term operational costs for low short term cost and quick development. Some of these changes included the removal of a crew escape pod from the early designs and the use of solid fuel boosters. The essence of the preliminary concept was altered. The shuttle was no longer a safe, efficient, powerful vehicle ready at a moment’s notice – but an inefficient vehicle with large operational costs that was far less safe then originally planned.

Under pressure to approve the shuttle for manned use it was considered to be fully operational after only 4 flight tests. The shuttles started to fly – demanding flight schedules took their toll on the crafts. The stage was set for managerial acceptance of deviations from standard operation procedures. However, the shuttles were considered safe… safe enough, at least, to launch a teacher, Christa McAuliffe into space. The result was an accident from which NASA apparently failed to learn.

Chapter 2: Columbia’s Final Flight

Chapter 2 details in an unbiased way the preparation, crew, launch, accident, and aftermath. It discusses the reasons STS-107 was delayed for over two years, the training of the crew, and the preparation of the shuttle, including flight readiness tests. It details wind shear and other weather conditions that occurred the day of the launch, and the debris strike to Columbia’s left wing that was detected upon post-launch inspection. The events of all 17 days of the mission are discussed.

The details of the accident and cleanup are presented in a factual matter. No reasons for the accident are given in this chapter. Photographs, accident timelines, flight paths, and communications transcripts are provided.

Chapter 3: Accident Analysis

Chapter 3 details the physical cause of the accident, a breach in the thermal protection system initiated by a strike to the lower half of a reinforced carbon-carbon panel on the left wing caused by a piece of foam insulation shed from the left bipod ramp of the external tank during lift-off. The strike occurred at 81.9 seconds after lift-off. Pre-existing defects in the foam were cited a partial cause of the shedding. Foam loss, however, is common. 80 percent of the 79 launches for which imagery is available showed foam loss, and 10 percent of launches that have images of the left bipod ramp show foam shedding from this area.

The chapter also discusses the structures of both the foam, wing, and wing panels.

The board reported the following findings about the foam and wing.

  • More than one piece of foam was generated – there is no evidence that these struck the orbiter
  • The strike occurred to the area between panels 6 and 9, close to the body of the orbiter.
  • The estimated relative velocity of the foam was 625-840 feet per second
  • The strike occurred parallel to the fuselage
  • The approximated size of the foam was 15 X 24 inches
  • The approximated size of the hole was 16 X 17 inches, with cracks of up to 11 inches.

  • When the orbiter re-entered the atmosphere with the damaged wing, due to the high temperatures associated with re-entering, the support structure and spar behind panel 8, and the wiring behind the spar melted, finally resulting in catastrophic failure.

    Chapter 4: Other Factors Considered

    Chapter 4 looks at other factors in the accident. This included debunking many original theories and looks at problems that may or may not have occurred, or may or may not have contributed to the disaster. This chapter included the possible failure of the solid bolt catchers, which keep the 65 pound bolts that attach the solid rocket boosters to the shuttle from slamming into the orbiter when the boosters separate. It rules out wiring failure, payload problems, sabotage, terrorism and space junk as possible causes of the accident.

    Part 2 – Why the Accident Occurred

    ”The NASA organizational culture had as much to do with the accident as the foam”

    Chapter 5: From Challenger to Columbia

    Chapter 5 looks at the time period just before the Challenger accident to the Columbia accident. A common thread of failure to communicate and poor management decisions was drawn between the two tragedies. It discusses NASA administrative culture and its continuing history of trying to do “too much with too little”. It paints NASA as an agency without the funds to develop its ideas for new vehicles in the envisioned time frame trying to tenuously hold on to an outdated piece of equipment.

    Chapter 6: Decision-making at NASA

    Chapter 6 looks at the decision-making process of the agency. The finger was wagged at improper replacing of tiles, schedule pressure from the International Space Station and most importantly the poor decisions made during the shuttle’s mission. It outlined eight missed opportunities to get early warning that the crew of STS-107 was in mortal danger. They include:

  • Sunday, January 26, 2003: Structural Engineer Rodney Rocha emails a JSC (Johnson Space Center) engineering manager asking if Columbia’s crew had received a mission request to inspect the left wing. He never received a reply.
  • Lift off – Mission Specialist David Brown films the launch. The 35 seconds of film he downlinked as part of the mission summary (reviewed on the ground during the course of the mission) showed no evidence of missing foam because the bipod ramp area had rotated out of view. Ground Crews failed to ask for additional footage. It has been determined that additional footage probably existed, and this footage might have shown evidence of the missing foam.
  • The foam strike and the possibility of obtaining images was mentioned at an (unrelated) meeting between NASA and NIMA (National Imagery and Mapping Agency). This was followed up by a phone call request to the Department of Defense which was “working on the request.” No action was taken. Rodney Rocha sends a request to “Petition (beg) for outside agency assistance.”
  • Wayne Hale phones the Department of Defense, which starts to identify resources. DoD stopped per Linda Hale’s orders.
  • Mike Card of the Safety and Mission Assurance office contacts Mark Erminger of the Johnson Space Center and Mission Assurance. No action is taken.
  • Mike Card discusses imagery request with Brian O’Connor, Associate Administrator for Safety and Mission Assurance. No action is taken.
  • Barbara Conty discusses image request with Rodney Rocha. Conty calls LeRoy Cain, Entry Flight Director who checks with Phil Engelauf. After discussion with Engelauf, Cain replies “no” to Conty and Rocha.
  • Mike Card discusses imagery request with William Ready, Associate Administrator for Space Flight, who informs him that imagry should only be gathered on a “not to interfere” basis. No action was taken.
  • The report makes no qualms at blaming poor management. The signals that there might be a problem, and the voices shouting the need to investigate, were ignored outright and the management showed ”no interest in understanding a problem and its indications.” It boils down to poor analysis, poor communication, management’s low levels of concern, failure of the role of the safety department, and a lack of effective leadership.

    Chapter 6 goes on to discuss what could have been done if a problem was discovered. These included rescuing the crew with an (albeit dangerous) emergency launch of the Atlantis and conducting in-flight repairs. Emergency docking at the International Space Station was not an option.

    Chapter 7: The Accident’s Organizational Causes

    Chapter 7 goes on to detail the organizational problems at NASA. It largely blames lack of independence and authority of the Safety Board and indifference related to development of integrated, risk analysis systems.

    Chapter 8: History as a Cause: Columbia and Challenger

    Chapter 8 again touches on the eerie parallels between the two accidents. It cites “failure of foresight” and “normalization of deviance” as a main cause of both. Despite the many changes to NASA following the loss of the Challenger one thing remained unfixed: the failures in the institution itself.

    Part 3 – A Look Ahead

    Chapter 9: Implications for the Future of Human Space Flight

    Chapters 9 discusses the future of human space-flight. It can be summed up nicely in it’s final sentence: a quote from president George. W. Bush from the day of the accident:

    “Mankind is led into the darkness beyond our world by the inspiration of discovery and the longing to understand. Our journey into space will go on.”

    Chapter 10: Other Significant Observations

    Chapter 10 discusses the problems with the current systems that could be corrected in future flight plans, and future flight vehicles.

    Chapter 11: Recommendations

    Throughout the report, the Board cited recoommendations to form a Return to Flight (RTF) plan. Chapter 11 sums these recommendations up, with references to the chapters they involve. The main recommendations the Board made were:

  • Develop orbit inspection/repair capacity
  • Conduct wing restructuring to strengthen wings
  • Reduce foam shedding on external tank
  • Organize filming of launches to include more cameras (ground, on ship, and orbital) on the shuttle during lift-off to look for problems. These cameras must show a list of very specific views.
  • Make independent the engineering and safety programs
  • Use a more conservative flight schedule.
  • ”Based on NASA’s history of ignoring external recommendations, or making improvements that atrophy with time, the Board has no confidence that the Space Shuttle can be safely operated for more than a few years based solely on renewed post-accident vigilance.”

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