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: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.