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Columbia Accident Investigation Board: Final Report
ssclift writes "After nearly 7 months the Columbia Accident Investigation Board
has released its final report into the
February 1st
loss of the Shuttle Columbia and all
7 crew members. This is more than a technical
assessment of the immediate causes of the accident.
Once again, sadly,
the world's flagship space agency
gets a thorough and grim review. Press briefings will begin at 11:00
EDT along with a webcast."
It's interesting that the first thing they said about it was that there was only a tiny chance that the foam had anything to do with it. It's weird how things turn around like that.
6 72378.html
:-/
I think the bottom line behind all this is most likely money. They have cut so many budgets as far as space goes and forced them to do fewer and fewer pre-flight inspections that something like this was almost guaranteed.
"Confidential interviews with shuttle workers at NASA and its contractors, 'from line technicians all the way through management', found no one who believed that preflight safety inspections were adequate, a member of the independent board investigating the loss of the Columbia has said." Linkage (and more of the same): http://www.smh.com.au/articles/2003/05/29/1054177
It's sad that it had to come to something like this for a wakeup call to be heard, but i guess all they can get out of it is to be more careful and not let it happen again. what else can ya get i guess...
Look's like a 10 megabyte pdf-- you can download chapters individually,but unless you're piqued by soul inspiring names such as "Chapter 3", Chapter Nine", and "Chapter Seven", it's a bit of a black box.
So, for handy reference, here are the chapter titles.
PART ONE THE ACCIDENT
Chapter 1 The Evolution of the Space Shuttle Program
Chapter 2 Columbia?s Final Flight
Chapter 3 Accident Analysis
Chapter 4 Other Factors Considered
PART TWO WHY THE ACCIDENT OCCURRED
Chapter 5 From Challenger to Columbia
Chapter 6 Decision Making at NASA
Chapter 7 The Accident?s Organizational Causes
Chapter 8 History as Cause: Columbia and Challenger
PART THREE A LOOK AHEAD
Chapter 9 Implications for the Future of Human Space Flight
Chapter 10 Other Significant Observations
Chapter 11 Recommendations
PART FOUR APPENDICES
Appendix A The Investigation
Appendix B Board Member Biographies
Appendix C Board Staff
This is a little long, but it gets to the heart of the accident and why it happened:
Executive Summary: Paragraphs 2,3 and 4
The Board recognized early on that the accident was probably not an anomalous, random event, but rather likely rooted to some degree in NASAs history and the human space flight programs culture. Accordingly, the Board broadened its mandate at the outset to include an investigation of a wide range of historical and organizational issues, including political and budgeary considerations, compromises, and changing priorities over the life of the Space Shuttle Program. The Boards conviction regarding the importance of these factors strengthened as the investigation progressed, with the result that this report, in its findings, conclusions, and recommendations, places as much weight on these causal factors as on the more easily understood and corrected physical cause of the accident.
The physical cause of the loss of Columbia and its crew was a breach in the Thermal Protection System on the leading edge of the left wing, caused by a piece of insulating foam which separated from the left bipod ramp section of the External Tank at 81.7 seconds after launch, and struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel number 8. During re-entry this breach in the Thermal Protection System allowed superheated air to penetrate through the leading edge insulation and progressively melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused loss of control, failure of the wing, and breakup of the Orbiter. This breakup occurred in a flight regime in which, given the current design of the Orbiter, there was no possibility for the crew to survive.
The organizational causes of this accident are rooted in the Space Shuttle Programs history and culture, including the original compromises that were required to gain approval for the Shuttle, subsequent years of resource constraints, fluctuating priorities, schedule pressures, mischaracterization of the Shuttle as operational rather than developmental, and lack of an agreed national vision for human space flight. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing in accordance with requirements); organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion; lack of integrated management across program elements; and the evolution of an informal chain of command and decision-making processes that operated outside the organizations rules.
Ruby on Rails Screencast
I agree that NASA seems to be wandering rathering than striding forward. I personally think the primary cause is lack of a clear goal. I worked as a contractor at the NASA Ames Research Center for several years, and I had a look at NASA's 'mission statement' which came out in a very glossy 25 page booklet. (This was when Dan Goldin was Chief Admin.) It had a vision statement, key values, crosscutting procedures, about 10 significant questions, which all had subquestions, as well as some goals. My overall impression was "this could only have been produced by an organization that has no idea whatsoever what it's trying to do." A bit of an overstatement, but I think that the individual researchers and engineers (including myself) had plenty of drive but not enough direction.
Not to mention, NASA had its share of PHB type memos, particularly the ones Goldin used to send around about 'safety'. Worse was the requirement for each group to have a 'safety marshal' to give little talks on 'safety'. Alas, no shiny plastic badges or hats were issued with the job.
foldplay your photos won't know what hit them.
Unfortunately, I think NASA is pretty low on every candidates radar. Things here on earth tend to take precedence. So NASA makes an easy target for people who need a few million dollars here and a few million dollars there. Same thing happens with foriegn aid. People think its alot more than it is, and nobody really corrects them, so when candidates say "slash foriegn aid" people think its ok. (Americans think that 15% of the budget goes to foriegn aid, and it should be around 5%, wheras in reality its more like .4%)
Because NASA regulations didn't allow anyone to go out and look at the damned wing in orbit without specific orders
There was no way to do so even if they had an idea there might be something wrong. It's impossible to be crawling around the underside of the craft in orbit.
It had nothing to do with regulations. It was simply not possible.
I don't need no instructions to know how to rock!!!!
See this News Article for information about NASA's Space Launch Initiative program.
"The reusable space plane, equipped with crew escape and automatic landing systems, would be far safer than the shuttle, officials said Tuesday in unveiling 15 design concepts. It also would be much cheaper to operate, they promised."
Sorry. False.
"Fisher did ultimately develop a pressurized pen for use by NASA astronauts (now known as the famous "Fisher Space Pen"), but both American and Soviet space missions initially used pencils, NASA did not seek out Fisher and ask them to develop a "space pen," Fisher did not charge NASA for the cost of developing the pen, and the Fisher pen was eventually used by both American and Soviet astronauts."
p.219: "While ISO 9000/9001 expressed strong principles, they are more applicable to manufacturing and repetitive-procedure industries, such as running a major airline, than to a research-and-development, non-operational flight test environment like that of the Space Shuttle"
And it goes on with interesting points regarding maintenance documentation, procedures, design flaws, and managerial training.
Another thing I think NASA needs to do is make the public more aware of just how much *good* it does, especially commercially.
I think they should produce quarterly/yearly results of their findings/discoveries, commercial applications, patents, etc along with thier respective monetary implications. Then maybe people like my dad will stop complaining about the "hundred of millions" of dollars wasted by some people just "floating around in space" and can see some of the more tangible benefits of space exploration.
I think the public in general doesn't have any idea how much comes from NASA's experiments. They probably still think the only things to come out of it are Tang and the pen that writes upside down!
Also, I would like for someone to simply give them a fixed budget for 3-5 years, saying "Here's all the money you are getting for a while. In 5 years, I want a fully detailed report on how you spent it. If you don't operate at X level of efficiency, you're getting budget cuts." Something like that in order to force NASA to think lean and aggressively, instead of trying to spend every dime they get in order to look like they really need it all. No more $10 million toilet re-designs! Force them to think more like a private company (but without the whole 'stepping on anyone who gets in their way' attitudes.)
We see a situation whereby engineers feel (maybe can't substantiate it at the moment) or know something "isn't right". They pull the rip cord and are made to feel like an idiot, usually instigated by a herd of PHBs. There were stories of this happening in this story. Engineers thought something wasn't right but were afraid to stand forward. Unfortunately, this likely helped cause the loss of the mission. Sure, the engineer(s) should have stood their ground, even to the point of their job(s)/reputation(s), but...suppose they'd hit the red button and nothing bad happened?
Secondly, Look at the missing tiles, et alia? They're applied manually, one-by-one. Do we need sensors (e.g., a filament) on every one of them so we know which ones are still there (or not)? The same goes for all of the other sections of the shuttle. Sensor mesh ingrained to various parts of the body, inside & out, learning to know "what's normal" and "what's not"? We take a lot of chances simply because we've gotten away with it. (It's good if it works - not unlike the software industry) If we had to make another landing on the moon, could we do it (and return safely) without a lot of flights to start over, just as we did in the 60s (for those reading this who were alive in the 60s) to get us "ready" for such a trip? How long will it be before we have a real-life "Capricorn One" (including OJ Simpson in the cast) and this is the twenty-fifth anniversary of that movie: Capricorn One There really wasn't any science in this movie - it's the suspense from finding out what happens with a doomed flight to Mars and the fact the public can't be told it fails. (Let's hope no schlockmeister gets the opportunity to remake it just as they did with other classic such as RollerBall.) Seriously, Capricorn One is worth the rental or late-night viewing.
Scientists restrict study to entire physical universe; creationist
I remember a NASA PowerPoint slide from a few years ago that said that the impact resistance of the RCC was something like 16 inch pounds. A 2 pound piece of foam travelling 500 MPH exerts slightly more than that (KE=1/2 MV^2).
I've always believed that one of the contributing factors to the loss of the orbiter and crew was that not one engineer remembered the (high school) equation for kinetic energy.
You really ought to compare fatalities per million passenger-minutes. Its a more reasonable measure in this game of how to lie with statistics.
If you do that, the quick back of the envelope calculation has cars at about 100, urban transit at about 45, school bus at about 10, and shuttle at about 2.
However, it only makes sense to use shuttle passenger-minutes (or passenger-miles on the orbital track) if you consider it a pleasure craft with the goal being to circle the earth.
If you consider that it has an actual orbital destination that is about 200 miles from where it started (400 miles round trip), then you should compare fatalities per million passenger-miles based on a 400 mile round trip for the shuttle. This works out to about 44, worse than a school bus, but better than a car or urban transit.
-Rick
In the 60's, the mandate was to spend what was necessary to build the best solution that could be conceived...
And the 60's was also the era of the moon missions, the SR-71 Blackbird, and lots of other projects that modern engineers look back on with total amazement. Remember that 3GHz 32-bit CPUs hadn't even been dreampt of, yet--these engineers did things in their minds and with slide rules (yes, boys and girls, that is possible without Matlab and Pro/ENGINEER!).
Healthcare article at Kuro5hin
After seeing the way they did software development--no formal testing, no design reviews, some groups didn't even use configuration management! This was on the system that stored and distributed the Shuttle telemetry. I actually worked up the nerve to take advantage of an opportunity to speak with a top level manager about my concerns.
Now, maybe I'm not the most persuasive speaker. I was just a guy in the trenches with some experience from the "real world" that new how to do some things better. It took all the gumption I had to pursue the issues for as long as I did, speaking with various people in all of the levels of management. Since no one else saw things as I did, I was just the guy "crying wolf".
Most people don't realize that most of the people working in the Shuttle program are not NASA employees, but contractors--most working for USA. So it's more than just a NASA culture issue, it's also the NASA contractors and their management.
Here's a question on a related topic: How many times has NASA tried and failed to replaced the launch control system and failed. (Hint: the last one was called CLCS!). Here's some info
Answer: 2 (that I know of)
The basic problem, of course, is that the Shuttle's foam insulation flakes off and the thermal protection tiles are too fragile. Both of those problems have been known for decades, but not fixed. The only reason this didn't happen earlier is that a big piece of foam hadn't happened to hit a weak tile in a vulnerable spot. Big pieces of foam have fallen off before, they've hit tiles before, and they've caused damage before. Twenty years ago, foam caused serious tile damage. The damaged tile just happened to be covering an antenna mounting plate, so there was extra metal there to protect the structure. So that shuttle survived.
Buran, the USSR space shuttle, had a better tile design. (Buy surplus Buran tiles here.) The designers of Buran had the advantage of doing it after the US, and Buran has some advantages over the US shuttle. It's sad that Buran was retired so early.
The shuttle has retrieved 2 satellites (STS 51-A), and repaired 2 satellites in orbit: Canada Telecom's Syncom IV (STS 51-D) and The Hubble space telescope (STS 61, STS 82, STS 103, STS 109.) Aside from the Hubble, the last time the Shuttle fixed or retrieved a satellite in orbit was in 1985.
And for your information there are several systems that have performed all of the mission of the shuttle. The most direct was the Saturn V used in the Apollo and SpaceLab programs.
Actually, looking through 100 missions the missions for the shuttle break down as follows: (My spreadsheet crashed during tabulation, here's the jist)
Most shuttle missions where either launching a satellite or puttering in orbit to perform experiments. Very late in the day, it hoisted parts up to the ISS.
Off the top of my head I can tell you one other system that can hoist stuff into orbit and shuttle people in relative safety: The Russian Proton rocket (for lifting) and the Soyuz for people transport.
"Learning is not compulsory... neither is survival."
--Dr.W.Edwards Deming
Dealing with graphite particles, eraser particles, and wood shavings in a closed, microgravity environment are all non-trivial problems.
So it's not as cut-and-dried as you would like to believe.
Why yes, I AM a rocket scientist!