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."

Comments

*sigh*

[rwven]

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.

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/2003/05/29/10541776 72378.html

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... :-/

It's Huge!

[Jeremy Erwin]

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

Key excerpts from Executive Summary

[Ridgelift]

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.

Re:Failure is not an Option?

[urbazewski]

They have no fire in their belly,

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.

Re:A rare opportunity

[cybercuzco]

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%)

Re:The "Culture of NASA"????

[Gulthek]

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."

Chapter 10 is a must read for R&D engineers

[TNN]

p.217: "In the years since the Shuttle was designed,NASA has not updated its engineering drawings or converted to computer- aided drafting systems.The Board's review of these engineering drawings revealed numerous inaccuracies.In par- ticular,the drawings do not incorporate many engineering changes made in the last two decades."

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.

Once again...

[TastyWords]

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.

Read chapter 6

[Animats]

Much of the report is background, filled out with huge glossy pictures from the NASA PR department. Read chapter 6, though, for what actually went wrong in the organization. The whole process of organizational denial is laid out in detail.

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.