Failure Knowledge Database / 100 Selected Cases

Failure of Return to the Earth of Space Shuttle 'COLUMBIA'
Feb. 1st, 2003, High Above Texas
KOBAYASHI, Hideo(Yokohama National University)
TERADA, Hiroyuki(Japan Aerospace Technology Foundation)(Summary)
Space shuttle Columbia disintegrated in midair over Texas while it was returning to the earth after killed.
(See, Fig. 1) This became the second tragedy in the 113 flights of the Space Shuttles, the first tragedy being
the m idair ex plosion of C hallenger so on after th e lif t-off in Jan uary 1986. The Indep endent A ccident
Investigation Committee concluded that damage that had occurred to the leading edge of th e left wing at
the moment of lift-off was the cause of the accident.
1. Components
Space Shu ttle Co lumbia w as t he first s pace shu ttle launched by N ASA. The fir st fli ght w as made i nApril 1981. The flight on February 1st, 2003 was her 28th flight. The total flight time was to be 284 days,
19 hours and 19 minutes. The shuttle had been repaired in the spring of 2002 at the maintenance field to fix
a liquid H 2 leak that had occurred in 1999. Columbia was the space shuttle that carried Mrs. C. Mukai, thefirst Japanese woman astronaut, in 1994 and Mr. T. Doi in 1997.
2. EventColumbia was launched on January 16th, 2003 from Kennedy Space Center. Seven crew, led by captain
Rick Husband, were on board. The crew carried out the scientific experiments that comprised their mission
while on the orbit around the earth for sixteen days.
The scheduled time for lan ding at the space center w as 9:16 February 1st. H owever, contact w ith thecontrol center at Johnson Space Center was lost about a half an hour before the designated landing time. At
the same time, all data on its flight condition were not received thereafter.
At aro und 9 am, sm all g littering p ieces li ke m eteors w ere observed fro m the ground, and somewreckage from the space shuttle was a lso re covered in T exas aft erward. T hen it w as c oncluded that
Columbia had disintegrated in midair.
3. Course
Just after lift-off, a piece of the i nsulator of the e xternal fuel tank came off and hi t the l eading edge ofthe left wi ng of th e orb iter. (See, Fig. 2) At tha t t ime, NASA made the f ollowing sta tement in a press
interview: "There is no problem and the space shuttle will land as scheduled".
Regarding t he comm unication betwee n t he c ontrol ce nter a nd t he space s huttle at that t ime, NASA
officially a nnounced on June 30t h t hat t he fli ght director of Kenne dy Space Center ha d se nt f ollowing
message to c aptain Rick Husband o n J anuary 23rd, a w eek af ter lift-off: " A bl ock of ins ulator hi t th e
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Failure Knowledge Database / 100 Selected Cases

leading edge of the left wing of the orbiter. However, from photographic analysis, we have concluded that
there has been no harmful effect on the insulation properties of the orbiter." The captain's reply was simply"Thank you".
4. Cause
The Independent Accident Investigation Committee issued its final report on 26th of August, 2003. The
report concluded that damage to the left wing of the orbiter at the moment of lift-off was the initial cause ofthe accident. The report also concluded that NASA's lack of attention for safety was another cause. As acondition for resuming the space shuttle flights, the Committee advised twenty-nine items for revisi on inorder to prevent the recurrence of the accident.
On Jan uary 1 6th, a bout e ighty sec onds a fter lift-off, a piece of th e i nsulator of t he ex ternal fu el ta nk
came of f and hi t t he le ading edge of t he lef t w ing of the orb iter with the sp eed of 8 50 km/h. It w asconcluded t hat th e or biter d isintegrated at the m oment of reen try on February 1st, because air w ith very
high temperature blew in from the damaged area.
Although pieces of insulator had fallen off frequently in the past, NASA ignored many concerns raisedby people about the possible damage that could occur and did not take any steps to cope with the issue. TheCommittee severely criticized NASA's attitude, stating that this failure to cope with the issue was one of
the main factors contributing to the accident.
5. Immediate Action
The final report by the Independent Accident Investigation Committee concluded that the widespread
reduction in attention to the mission safety issue by NASA was due in part to budget cuts and high priority
placed on keeping to the launching schedule.
The report advised that an independent section should be set up to supervise the safety of the flight plan,maintenance situation and other critical parts of the space shuttle operation.
6. Countermeasure
The final report by the Independent Accident Investigation Committee highlighted the following items
in addition to the setting up the above-mentioned independent safety supervision section.
･ Periodical inspection of the leading edge of the orbiter wings･ Photographing the moment of lift-off using a high sensitivity camera･ Observation of the orbiter in orbit utilizing a reconnaissance satellite･ Live coverage of the entire surface of the orbiter from reentry to landing using onboard cameras.
･ Establishing a system to repair the space shuttle in orbit
The administrator of NASA made a statement that they would do everything in their power to follow therecommendations given in the report.
7. Knowledge
2Failure Knowledge Database / 100 Selected Cases

Although pieces of insulator had fallen off frequently in the past, NASA did not take any actions to copewith the issue. This failure to cope with the issue was apparently a part of a widespread tendency in NASA
to place higher priority on keeping the schedule than on safety issues.
The accident of the Space Shuttle Columbia can be summarized by the tendency to place higher priority
not on quality but on profits, which is a typical kind of failure of enterprise management.
8. Sequel
On February 19th, 2004, NASA announced that they would reserve another space shuttle on the groundto c omply with t he em ergency, wh en the proj ect resu med. This is t he first example in th e h istory of th e
shuttle project of a ba ck-up system for assurin g that the crew would be able to avoid serious problems inspace.
As a countermeasure for the acc ident of Co lumbia i n Fe bruary 2003, NASA h urried t o establish asystem for inspecting and repairing the fuselage of the orbiter at the International Space Station (ISS) that isin orbit 400km above the earth.
However, if the problems are beyond the scope of repairs that can be done by the ISS, there is no otheralternative to the resc ue by another Spac e Shut tle launched fro m the eart h. NASA concl uded that it isnecessary to r eserve a space shuttle for re scue of s tranded crew, before the food, water and oxygen of ISS
become depleted.
9. On the SideOn January 14th, 2004 President Bush announced a new ambitious strategy for space development. Thatis:･ The USA will complete the ISS project by the year 2010, thereby allowing the Space Shuttle Progra mto be retire d. Research t hat had been car ried out in t he Space S huttles, such as t he ef fect of s paceflights on human health, will be continued on the ISS.
･The USA will begin the development of large-scale rockets and space ships. Unmanned test flights
and manned flights will be started by 2008 and 2014, respectively. Although the primary objective of
the project is to make possible the flight to outer orbit from the earth, the space ships will be able toplay the role of transportation to the ISS, when the Space Shuttle is retired.
･ In relation to the exploration to t he moon, several unmanned lunar surveyors will be launched by theyear 2008, and a lunar landing by manned vehicle is scheduled for sometime between 2015 and 2020.
After that, the USA aims to construct a lunar base that can support long-term habitation.
･ The U SA aim s to se nd sur veyors t o Ma rs an d other planets us ing rockets launched from the lunar
base.
These programs seemed to be rath er ambitious proposals, particularly before the presidential election,requiring the huge amount of money that is necessary to pursue the programs.
However, it is possible that the failure of Columbia to return to earth may be the trigger that finalizes theretirement of the Space Shuttle Program.
3Failure Knowledge Database / 100 Selected Cases

10. Information Source(1) Final Report, Independent Accident Investigation Committee on Space Shuttle 'Columbia', (Aug. 26,2003).
11. Primary Scenario
01. Poor Value Perception
02. Poor Safety Awareness03. Poor Sense of Risk
04. Insufficient Analysis or Research
05. Insufficient Prior Research
06. Lack of Evaluation/Revision
07. Usage
08. Operation/Use
09. Launching of Space Shuttle
10. Failure
11. Fracture/Damage
12. Coming out of Insulation material of External Fuel Tank
13. Damage of Left Wing Leading Edge
14. Usage
15. Operation/Use
16. Reentry of Space Shuttle
17. Failure
18. Large-Scale Damage
19. Flow-in of Ultra-high Temperature Air
20. Midair Disintegration
21. Loss to Organization
22. Economic Loss
23. Retirement of Space Shuttle
24. Damage to Society
25. Change in Perception
26. Loss of Credit to Science/Technology4

Failure Knowledge Database / 100 Selected Cases

Leading edge of left wing washit by fragment of insulator

Auxiliary Rocket

External Fuel Tank

Insulator

Midair Disintegration of Columbia.

External
Fuel Tank

Fig. 1

Space Shuttle'Columbia'

Fig. 2Insulator Fragment of External Tank Hit the Leading Edge of Left Wing.

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