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NASA Culture Played Major Role Columbia Accident

Report Says NASA Culture Played Major Role in Columbia Accident

Investigation board releases final report

The Columbia Accident Investigation Board has determined that physical and organizational causes played equal roles in the loss of the space shuttle Columbia and seven astronauts on February 1.

The 13-member board, which on August 26 released its 248-page final report on the causes of the shuttle accident, also concluded that while the present space shuttle system of the National Aeronautics and Space Administration (NASA) is not "inherently unsafe," a number of mechanical fixes are required to make the shuttle safer in the short-term.

Officials determined months ago that a chunk of foam insulation that struck and damaged the leading edge of Columbia's left wing during its launch on January 16 was the direct physical cause of damage to the shuttle that led to its disintegration upon re-entry into the Earth's atmosphere.

The investigation board, citing disturbing "echoes" of the shuttle Challenger disaster of 1986, said it was convinced that the management practices followed in overseeing the space shuttle program "were as much a cause of the (Columbia) accident as the foam that struck the left wing." It concludes that NASA's current organization "does not provide effective checks and balances, does not have an independent safety program, and has not demonstrated the characteristics of a learning organization."

The board also said that, during Columbia's last mission, NASA managers missed opportunities to evaluate possible damage to the left wing's heat shield from the flying foam insulation. Such insulation strikes had occurred on previous missions and the report said NASA managers had come to view them as an acceptable abnormality that posed no safety risk.

"Perhaps most striking is the fact that management ... displayed no interest in understanding a problem and its implications," the report said.

The board makes 29 recommendations, including steps necessary before the shuttle flies again and those needed to make the shuttle inherently safer in the longer term. But the board adds that based on NASA's history of ignoring external recommendations or making improvements that atrophy with time, it has "no confidence that the space shuttle can be safely operated for more than a few years based solely on renewed post-accident vigilance." The board said "The changes we recommend will be difficult to accomplish -- and will be internally resisted."

The board said NASA's failings were due in part to a lean budget and other pressures, such as the need to build an international space station, and called for a national debate about the future of human space flight.

President Bush, in a statement released August 26, said the next steps for NASA would be determined after a review of the entire report, including its recommendations. "Our journey into space will go on," he said. "The work of the crew of the Columbia and the heroic explorers who traveled before them will continue."

The board's entire report can be found at the following Web site: HYPERLINK "http://www.caib.us/news/report/default.html"

Following is the text of the executive summary and synopsis of the board's report:

The Columbia Accident Investigation Board
August 26,2993

Accident Investigation Board Report

Executive Summary

The Columbia Accident Investigation Board 's independent investigation into the February 1, 2003, loss of the Space Shuttle Columbia and its seven-member crew lasted nearly seven months. A staff of more than 120, along with some 400 NASA engineers, supported the Board's 13 members. Investigators examined more than 30,000 documents, conducted more than 200 formal interviews, heard testimony from dozens of expert witnesses, and reviewed more than 3,000 inputs from the general public. In addition, more than 25,000 searchers combed vast stretches of the Western United States to retrieve the spacecraft's debris. In the process, Columbia's tragedy was compounded when two debris searchers with the U.S. Forest Service perished in a helicopter accident.

The Board recognized early on that the accident was probably not an anomalous, random event, but rather likely rooted to some degree in NASA's history and the human space flight program's 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 budgetary considerations, compromises, and changing priorities over the life of the Space Shuttle Program. The Board's 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 Program's 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 organization's rules.

This report discusses the attributes of an organization that could more safely and reliably operate the inherently risky Space Shuttle, but does not provide a detailed organizational prescription. Among those attributes are: a robust and independent program technical authority that has complete control over specifications and requirements, and waivers to them; an independent safety assurance organization with line authority over all levels of safety oversight; and an organizational culture that reflects the best characteristics of a learning organization.

This report concludes with recommendations, some of which are specifically identified and prefaced as "before return to flight." These recommendations are largely related to the physical cause of the accident, and include preventing the loss of foam, improved imaging of the Space Shuttle stack from liftoff through separation of the External Tank, and on-orbit inspection and repair of the Thermal Protection System. The remaining recommendations, for the most part, stem from the Board's findings on organizational cause factors. While they are not "before return to flight" recommendations, they can be viewed as "continuing to fly" recommendations, as they capture the Board's thinking on what changes are necessary to operate the Shuttle and future spacecraft safely in the mid- to long-term.

These recommendations reflect both the Board's strong support for return to flight at the earliest date consistent with the overriding objective of safety, and the Board's conviction that operation of the Space Shuttle, and all human spaceflight, is a developmental activity with high inherent risks.

REPORT SYNOPSIS

The Columbia Accident Investigation Board's independent investigation into the tragic February 1, 2003 loss of the Space Shuttle Columbia and its seven-member crew lasted nearly seven months and involved 13 Board members, approximately 120 Board investigators, and thousands of NASA and support personnel. Because the events that initiated the accident were not apparent for some time, the investigation's depth and breadth were unprecedented in NASA history. Further, the Board determined early in the investigation that it intended to put this accident into context. We considered it unlikely that the accident was a random event; rather, it was likely related in some degree to NASA's budgets, history, and program culture, as well as to the politics, compromises, and changing priorities of the democratic process. We are convinced that the management practices overseeing the Space Shuttle Program were as much a cause of the accident as the foam that struck the left wing. The Board was also influenced by discussions with members of Congress, who suggested that this nation needed a broad examination of NASA's Human Space Flight Program, rather than just an investigation into what physical fault caused Columbia to break up during re-entry.

Findings and recommendations are in the relevant chapters and all recommendations are compiled in Chapter 11.

Volume I is organized into four parts: The Accident; Why the Accident Occurred; A Look Ahead; and various appendices. To put this accident in context, Parts One and Two begin with histories, after which the accident is described and then analyzed, leading to findings and recommendations. Part Three contains the Board's views on what is needed to improve the safety of our voyage into space. Part Four is reference material. In addition to this first volume, there will be subsequent volumes that contain technical reports generated by the Columbia Accident Investigation Board and NASA, as well as volumes containing reference documentation and other related material.

PART ONE: THE ACCIDENT

Chapter 1 relates the history of the Space Shuttle Program before the Challenger accident. With the end looming for the Apollo moon exploration program, NASA unsuccessfully attempted to get approval for an equally ambitious (and expensive) space exploration program. Most of the proposed programs started with space stations in low-Earth orbit and included a reliable, economical, medium-lift vehicle to travel safely to and from low-Earth orbit. After many failed attempts, and finally agreeing to what would be untenable compromises, NASA gained approval from the Nixon Administration to develop, on a fixed budget, only the transport vehicle. Because the Administration did not approve a low-Earth-orbit station, NASA had to create a mission for the vehicle. To satisfy the Administration's requirement that the system be economically justifiable, the vehicle had to capture essentially all space launch business, and to do that, it had to meet wide-ranging requirements. These sometimes competing requirements resulted in a compromise vehicle that was less than optimal for manned flights. NASA designed and developed a remarkably capable and resilient vehicle, consisting of an Orbiter with three Main Engines, two Solid Rocket Boosters, and an External Tank, but one that has never met any of its original requirements for reliability, cost, ease of turnaround, maintainability, or, regrettably, safety.

Chapter 2 documents the final flight of Columbia. As a straightforward record of the event, it contains no findings or recommendations. Designated STS-107, this was the Space Shuttle Program's 113th flight and Columbia's 28th. The flight was close to trouble-free. Unfortunately, there were no indications to either the crew onboard Columbia or to engineers in Mission Control that the mission was in trouble as a result of a foam strike during ascent. Mission management failed to detect weak signals that the Orbiter was in trouble and take corrective action.

Columbia was the first space-rated Orbiter. It made the Space Shuttle Program's first four orbital test flights. Because it was the first of its kind, Columbia differed slightly from Orbiters Challenger, Discovery, Atlantis, and Endeavour. Built to an earlier engineering standard, Columbia was slightly heavier, and, although it could reach the high-inclination orbit of the International Space Station, its payload was insufficient to make Columbia cost-effective for Space Station missions. Therefore, Columbia was not equipped with a Space Station docking system, which freed up space in the payload bay for longer cargos, such as the science modules Spacelab and SPACEHAB. Consequently, Columbia generally flew science missions and serviced the Hubble Space Telescope.

STS-107 was an intense science mission that required the seven-member crew to form two teams, enabling round-the-clock shifts. Because the extensive science cargo and its extra power sources required additional checkout time, the launch sequence and countdown were about 24 hours longer than normal. Nevertheless, the countdown proceeded as planned, and Columbia was launched from Launch Complex 39-A on January 16, 2003, at 10:39 a.m. Eastern Standard Time (EST).

At 81.7 seconds after launch, when the Shuttle was at about 65,600 feet and traveling at Mach 2.46 (1,650 mph), a large piece of hand-crafted insulating foam came off an area where the Orbiter attaches to the External Tank. At 81.9 seconds, it struck the leading edge of Columbia's left wing. This event was not detected by the crew on board or seen by ground support teams until the next day, during detailed reviews of all launch camera photography and videos. This foam strike had no apparent effect on the daily conduct of the 16-day mission, which met all its objectives.

The de-orbit burn to slow Columbia down for re-entry into Earth's atmosphere was normal, and the flight profile throughout re-entry was standard. Time during re-entry is measured in seconds from "Entry Interface," an arbitrarily determined altitude of 400,000 feet where the Orbiter begins to experience the effects of Earth's atmosphere. Entry Interface for STS-107 occurred at 8:44:09 a.m. on February 1. Unknown to the crew or ground personnel, because the data is recorded and stored in the Orbiter instead of being transmitted to Mission Control at Johnson Space Center, the first abnormal indication occurred 270 seconds after Entry Interface. Chapter 2 reconstructs in detail the events leading to the loss of Columbia and her crew, and refers to more details in the appendices.

In Chapter 3,the Board analyzes all the information available to conclude that the direct, physical action that initiated the chain of events leading to the loss of Columbia and her crew was the foam strike during ascent. This chapter reviews five analytical paths -- aerodynamic, thermodynamic, sensor data timeline, debris reconstruction, and imaging evidence -- to show that all five independently arrive at the same conclusion. The subsequent impact testing conducted by the Board is also discussed.

That conclusion is that Columbia re-entered Earth's atmosphere with a pre-existing breach in the leading edge of its left wing in the vicinity of Reinforced Carbon-Carbon (RCC) panel 8. This breach, caused by the foam strike on ascent, was of sufficient size to allow superheated air (probably exceeding 5,000 degrees Fahrenheit) to penetrate the cavity behind the RCC panel. The breach widened, destroying the insulation protecting the wing's leading edge support structure, and the superheated air eventually melted the thin aluminum wing spar. Once in the interior, the superheated air began to destroy the left wing. This destructive process was carefully reconstructed from the recordings of hundreds of sensors inside the wing, and from analyses of the reactions of the flight control systems to the changes in aerodynamic forces.

By the time Columbia passed over the coast of California in the pre-dawn hours of February 1, at Entry Interface plus 555 seconds, amateur videos show that pieces of the Orbiter were shedding. The Orbiter was captured on videotape during most of its quick transit over the Western United States. The Board correlated the events seen in these videos to sensor readings recorded during re-entry. Analysis indicates that the Orbiter continued to fly its pre-planned flight profile, although, still unknown to anyone on the ground or aboard Columbia, her control systems were working furiously to maintain that flight profile. Finally, over Texas, just southwest of Dallas-Fort Worth, the increasing aerodynamic forces the Orbiter experienced in the denser levels of the atmosphere overcame the catastrophically damaged left wing, causing the Orbiter to fall out of control at speeds in excess of 10,000 mph.

The chapter details the recovery of about 38 percent of the Orbiter (some 84,000 pieces) and the reconstruction and analysis of this debris. It presents findings and recommendations to make future Space Shuttle operations safer.

Chapter 4 describes the investigation into other possible physical factors that may have contributed to the accident. The chapter opens with the methodology of the fault tree analysis, which is an engineering tool for identifying every conceivable fault, then determining whether that fault could have caused the system in question to fail. In all, more than 3,000 individual elements in the Columbia accident fault tree were examined.

In addition, the Board analyzed the more plausible fault scenarios, including the impact of space weather, collisions with micrometeoroids or "space junk," willful damage, flight crew performance, and failure of some critical Shuttle hardware. The Board concludes in Chapter 4 that despite certain fault tree exceptions left "open" because they cannot be conclusively disproved, none of these factors caused or contributed to the accident. This chapter also contains findings and recommendations to make Space Shuttle operations safer.

PART TWO: WHY THE ACCIDENT OCCURRED

Part Two, "Why the Accident Occurred," examines NASA's organizational, historical, and cultural factors, as well as how these factors contributed to the accident.

As in Part One, Part Two begins with history. Chapter 5 examines the post-Challenger history of NASA and its Human Space Flight Program. A summary of the relevant portions of the Challenger investigation recommendations is presented, followed by a review of NASA budgets to indicate how committed the nation is to supporting human spaceflight, and within the NASA budget we look at how the Space Shuttle Program has fared. Next, organizational and management history, such as shifting management systems and locations, are reviewed.

Chapter 6 documents management performance related to Columbia to establish events analyzed in later chapters. The chapter begins with a review of the history of foam strikes on the Orbiter to determine how Space Shuttle Program managers rationalized the danger from repeated strikes on the Orbiter's Thermal Protection System. Next is an explanation of the intense pressure the program was under to stay on schedule, driven largely by the self-imposed requirement to complete the International Space Station. Chapter 6 then relates in detail the effort by some NASA engineers to obtain additional imagery of Columbia to determine if the foam strike had damaged the Orbiter, and how management dealt with that effort.

In Chapter 7, the Board presents its view that NASA's organizational culture had as much to do with this accident as foam did. By examining safety history, organizational theory, best business practices, and current safety failures, the report notes that only significant structural changes to NASA's organizational culture will enable it to succeed.

This chapter measures the Shuttle Program's practices against this organizational context and finds them wanting. The Board concludes that NASA's current organization does not provide effective checks and balances, does not have an independent safety program, and has not demonstrated the characteristics of a learning organization. Chapter 7 provides recommendations for adjustments in organizational culture.

Chapter 8, the final chapter in Part Two, draws from the previous chapters on history, budgets, culture, organization, and safety practices, and analyzes how all these factors contributed to this accident. The chapter opens with "echoes of Challenger "that compares the two accidents. This chapter captures the Board's views of the need to adjust management to enhance safety margins in Shuttle operations, and reaffirms the Board's position that without these changes, we have no confidence that other "corrective actions" will improve the safety of Shuttle operations. The changes we recommend will be difficult to accomplish and will be internally resisted.

PART THREE: A LOOK AHEAD

Part Three summarizes the Board's conclusions on what needs to be done to resume our journey into space, lists significant observations the Board made that are unrelated to the accident but should be recorded, and provides a summary of the Board's recommendations.

In Chapter 9, the Board first reviews its short-term recommendations. These return-to-flight recommendations are the minimum that must be done to essentially fix the problems that were identified by this accident. Next, the report discusses what needs to be done to operate the Shuttle in the mid-term, 3 to 15 years. 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.

Chapter 9 then outlines the management system changes the Board feels are necessary to safely operate the Shuttle in the mid-term. These changes separate the management of scheduling and budgets from technical specification authority, build a capability of systems integration, and establish and provide the resources for an independent safety and mission assurance organization that has supervisory authority. The third part of the chapter discusses the poor record this nation has, in the Board's view, of developing either a complement to or a replacement for the Space Shuttle. The report is critical of several bodies in the U.S. government that share responsibility for this situation, and expresses an opinion on how to proceed from here, but does not suggest what the next vehicle should look like.

Chapter 10 contains findings, observations, and recommendations that the Board developed over the course of this extensive investigation that are not directly related to the accident but should prove helpful to NASA.

Chapter 11 is a compilation of all the recommendations in the previous chapters.

PART FOUR: APPENDICES

Part Four of the report by the Columbia Accident Investigation Board contains material relevant to this volume organized in appendices. Additional, stand-alone volumes will contain more reference, background, and analysis materials.


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