National Aeronautics and 

Space Administration 

Loss of Signal
 

Aeromedical Lessons Learned from the 

STS-107 Columbia Space Shuttle Mishap 

Executive Editor 

Philip C. Stepaniak 

Editor in Chief 

Helen W. Lane 

Foreword 

Jeffrey R. Davis 

NASA/SP-2014-616

National Aeronautics and 

Space Administration 

Loss of Signal
 

Aeromedical Lessons Learned from the 

STS-107 Columbia Space Shuttle Mishap 

Executive Editor 

Philip C. Stepaniak 

Editor in Chief 

Helen W. Lane 

Foreword 

Jeffrey R. Davis 
Cover photos: 

Front: An overall view of the shuttle flight control room in 

Houston’s Mission Control Center (MCC) at the Johnson 

Space Center (JSC). At the time this photo was taken, flight 

controllers had just lost contact with the Space Shuttle 

Columbia at 08:59:32 CST, February 1, 2003. 

Back: The Space Shuttle Columbia is just about to clear 

the tower at Launch Pad 39A for STS-107. Following a 

flawless and uneventful countdown, liftoff occurred on-time 

at 10:39 EST, January 16, 2003. 

Spine: The United States flag, in front of the Johnson Space 

Center’s (JSC) Project Management Facility (Bldg. 1), is flown 

at half-staff in memory of the seven Space Shuttle Columbia 

crewmembers who lost their lives on February 1, 2003. 

ii
iii

DEDICATED TO THE CREW OF COLUMBIA STS-107
 

From the left (bottom row), wearing red shirts to signify their shift’s color, 


are astronauts Kalpana Chawla, mission specialist; Rick D. Husband, mission commander; 


Laurel B. Clark, mission specialist; and Ilan Ramon (Israeli Space Agency), payload specialist. 


From the left (top row), wearing blue shirts, are astronauts David M. Brown, mission specialist; 


William C. McCool, pilot; and Michael P. Anderson, payload commander.
 
Foreword 

Jeffrey R. Davis 

On the morning of February 1, 2003, the Space Shuttle 

Columbia underwent a high-altitude, high-velocity 

breakup during the entry-to-landing phase of flight. 

The external investigation by the Columbia Accident 

Investigation Board (CAIB) provided the overall causes 

of the accident in a report that included an analysis by 

the Crew Survivability Working Group to determine 

the cause of the crewmembers’ deaths and the lessons 

learned. The next year the Space Shuttle Program 

commissioned the Spacecraft Crew Survival Integrated 

Investigation Team to perform a comprehensive analysis 

of the accident, focusing on factors and events affecting 

crew safety and developing recommendations for 

improving crew survival for future human space flight. 

This report was published in December 2008. 

Loss of Signal presents the aeromedical lessons learned 

from the Columbia accident that will enhance crew 

safety and survival on human space flight missions. 

These lessons were presented to limited audiences 

at three separate Aerospace Medical Association 

(AsMA) conferences: in 2004 in Anchorage, Alaska, 

on the causes of the accident; in 2005 in Kansas City, 

Missouri, on the response, recovery, and identification 

aspects of the investigation; and in 2011, again in 

Anchorage, Alaska, on future implications for human 

space flight. As we are embarking on the development 

of new spacefaring vehicles through both government 

and commercial efforts, the NASA Johnson Space 

Center Space Life Sciences Directorate (SLSD)1 

proceeded to make this information available to a 

wider audience engaged in the design and development 

of future space vehicles. 

Historically, the SLSD has always prepared for space 

flight mishaps. From the beginning of the Space Shuttle 

Program with the launch of the first Space Shuttle 

mission in 1981 through the Challenger accident in 

1 The Space Life Sciences Directorate was renamed the Human Health and 

Performance Directorate in 2012. 

2 Armed Forces Institute of Pathology was disestablished in 2011 as part of the Base 

Realignment and Closure Act. 

1986, the SLSD interfaced with the Department of 

Defense Manned Space Flight Program Support 

Office (DOD DDMS), Patrick Air Force Base, Florida, 

with preparation for launch and landing emergencies. 

After the Challenger accident, these efforts were 

upgraded by enhancing crew safety including improved 

egress, escape, and bail-out procedures with the new 

Launch Entry Suit. In preparation for return to flight 

in 1988, the SLSD developed a flight surgeon training 

program, the Space Operations Medical Support 

Training Course. These improvements led to a more 

direct interface of NASA with DOD DDMS in training 

medical personnel and trauma teams at landing sites 

in the United States and international locations on 

equipment, procedures, and communications for 

response, search, rescue, and recovery operations. 

In 1998, the SLSD Medical Operations Branch formed 

a Contingency Medical Group, a cadre of flight 

surgeons that specialized in preparation for any aviation 

and spacecraft mishap. This group met with the Office 

of Armed Forces Medical Examiner and Armed Forces 

Institute of Pathology2

 in 1999 to renew and improve 

the SLSD relationships with these organizations for 

mishap investigations. This coordination greatly 

assisted the recovery and identification efforts during 

the Columbia tragedy. 

Loss of Signal summarizes and consolidates the 

aeromedical impacts of the Columbia mishap process— 

the response, recovery, identification, investigative 

studies, medical and legal forensic analysis, and future 

preparation that are needed to respond to spacecraft 

mishaps. The goal of this book is to provide an account 

of the aeromedical aspects of the Columbia accident 

and the investigation that followed, and to encourage 

aerospace medical specialists to continue to capture 

information, learn from it, and improve procedures and 

spacecraft designs for the safety of future crews. 

iv
Preface and Acknowledgments
 

The editors of Loss of Signal wanted to document 

the aeromedical lessons learned from the Space 

Shuttle Columbia mishap. The book is intended to 

be an accurate and easily understood account of the 

entire process of recovering and analyzing the human 

remains, investigating and analyzing what happened 

to the crew, and using the resulting information to 

recommend ways to prevent mishaps and provide better 

protection to crewmembers. 

We organized this book into 5 sections— 

• The Mission 

• The Response 

• The Investigation 

• The Analysis 

• The Future 

Our goal is to capture the passions of those who 

devoted their energies in responding to the Columbia 

mishap. We have reunited authors who were directly 

involved in each of these aspects. These authors tell the 

story of their efforts related to the Columbia mishap 

from their point of view. They give the reader an honest 

description of their responsibilities and share their 

challenges, their experiences, and their lessons learned 

on how to enhance crew safety and survival, and how to 

be prepared to support space mishap investigations. 

As a result of this approach, a few of the chapters have 

some redundancy of information and authors’ opinions 

may differ. In no way did we or they intend to assign 

blame or criticize anyone’s professional efforts. All 

those involved did their best to obtain the truth in the 

situations to which they were assigned. 

Our gratitude goes out to all members of the editorial 

board who guided us patiently through the various 

sections of this undertaking. We thank the NASA/ 

Johnson Space Center Space and Clinical Operations 

Division and NASA Human Research Program that 

provided the financial resources. 

We want to acknowledge the multitude of local, 

state, and federal government agencies as well as 

civilian agencies, especially citizen volunteers, whose 

organizational efforts were a great achievement despite 

the magnitude of this tragedy. 

By going forward with these aeromedical lessons 

learned to enhance crew safety and survival, we honor 

the families of the crewmembers, who have lost 

their loved ones. We pay tribute to the crewmembers 

themselves for their courage. Their efforts and sacrifice 

of their lives will benefit survival of future fliers in the 

exploration of space. 

Executive Editor 

Philip C. Stepaniak 

Editor in Chief 

Helen W. Lane 

v
Contents
 

Dedication ........................................................................................... iii
 

Foreword 

Jeffrey R. Davis .......................................................................................... iv
 

Preface and Acknowledgments ....................................................................... v
 

Editorial Board ...................................................................................... viii
 

Introduction 

Michael Barratt .......................................................................................... ix
 

Section 1 – The Mission ..................................................................... 1
 

The Mission and The Crew 

Helen W. Lane, Smith Johnston, and John B. Charles ............................................................ 2
 

The Mishap 

Stevan Gilmore and Charles Campbell ........................................................................ 8
 

Section 2 – The Response ................................................................. 17
 

Search and Recovery Team Operations 

James D. Wetherbee .................................................................................... 18
 

Mishap Investigation Team Medical Efforts for Crew Recovery and Identification 

Philip C. Stepaniak, Michael R. Chandler, and Robert Patlach ...................................................... 32
 

Mishap Response and Lessons Learned: The Role of the Office of 

the Armed Forces Medical Examiner and the Armed Forces Institute of Pathology 

Craig Mallak ........................................................................................... 41
 

Johnson Space Center Space Life Sciences Response and Crew Survival Investigation 

Jeffrey R. Davis ......................................................................................... 49
 

Kennedy Space Center Operations – Commitment to Safety and Preparedness 

Philip J. Scarpa ........................................................................................ 54
 

Crew Medical and Psychological Support Operations 

Smith Johnston and Christopher Flynn ....................................................................... 65
 

vi
Section 3 – The Investigation ............................................................. 75
 

Columbia Accident Investigation Board Medical Operations and Crew Survivability Working Group 

James P. Bagian ........................................................................................ 76
 

The Columbia Crew Survival Investigation Report: The Five Potentially Lethal Events 

and Crew Survivability 

Nigel J. Packham, David J. Pogue, and Pamela A. Melroy ........................................................ 86
 

Section 4 – The Analysis ................................................................... 95
 

Aerospace Medical Forensic Analysis 

Michael Barratt, Robert Banks, Philip C. Stepaniak, and Helen W. Lane .............................................. 96
 

Legal Analysis and Issues from Recovery and Investigation of the Columbia Accident 

Donna M. Shafer and Amy V. Xenofos ...................................................................... 114
 

Section 5 – The Future ..................................................................... 123
 

Human Space Flight Incidents and Crew Survival Lessons Learned 

Jonathan B. Clark ...................................................................................... 124
 

The Future: Crew Survival Investigations 

Karon Woods ......................................................................................... 134
 

Appendix ....................................................................................... 153
 

Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
 

Selected Readings ................................................................................. 155
 

Recognition and Acknowledgments ................................................................ 156
 

Contributors’ Biographies .......................................................................... 160
 

Index .............................................................................................. 167
 

vii
Editorial Board 

N. Wayne Hale, Jr. 

Editorial Board Chair 

Mr. Hale retired from NASA in 2010 as the Deputy 

Associate Administrator of Strategic Partnerships at 

NASA Headquarters in Washington, DC. Mr. Hale 

served in the senior leadership of NASA’s Space 

Shuttle Program from 2003 to 2008 including Launch 

Integration Manager at the Kennedy Space Center and 

then assignments as Deputy Program Manager and 

finally as Program Manager during the post-Columbia 

return to flight effort. From 1988 to 2003, he was a Space 

Shuttle Flight Director for 40 Space Shuttle flights, 

and prior to that as an orbiter systems flight controller 

in Mission Control for 15 early Space Shuttle flights. 

Donna M. Shafer, JD 

Editorial Board Legal Counsel 

Ms. Shafer is the Deputy Chief Counsel at the NASA 

Johnson Space Center. Ms. Shafer served as the 

legal advisor to the Columbia Task Force and the 

Spacecraft Crew Survival Integrated Investigation 

Team which published the Columbia Crew Survival 

Investigation Report. 

Denise L. Baisden, MD 

Dr. Baisden is the Deputy Regional Flight Surgeon 

for the Federal Aviation Administration’s Southwest 

Region. She was a NASA flight surgeon from 1989 to 

2000 and served as the crew surgeon or deputy crew 

surgeon for 17 Space Shuttle missions. Dr. Baisden also 

served as the Chief of Flight Medicine at the NASA 

Johnson Space Center. 

Jeffery R. Davis, MD 

Dr. Davis is the Director, Human Health and 

Performance and Chief Medical Officer at the NASA 

Johnson Space Center. 

Janet L. Kavandi, PhD 

Dr. Kavandi is the Director of Flight Crew Operations 

at the NASA Johnson Space Center, where she is 

responsible for the NASA Astronaut Corps and the 

Aircraft Operations Division at Ellington Field. 

Dr. Kavandi was selected to the astronaut class of 1995, 

and is a veteran of three Space Shuttle flights – STS-91, 

STS-99, and STS-104. Dr. Kavandi served as the Lead 

Casualty Assistance Calls Officer for the families of 

the STS-107 crew.
	

Peter W. Merlin 

Mr. Merlin is a Staff Historian and Senior Public Affairs 

Specialist under contract to Jacobs Engineering at the 

NASA Armstrong Flight Research Center (AFRC), 

Edwards, California. He has written numerous articles, 

technical papers and books, many of which were 

sponsored by NASA Aeronautics Mission Directorate’s 

Office of Education and Communications. He was lead 

author of Breaking the Mishap Chain (NASA SP-2011-

594), author of Crash Course: Lessons Learned from 

Accidents Involving Remotely Piloted and Autonomous 

Aircraft (NASA SP-2013-600), and serves as editor for 

AFRC Public Affairs products. 

Terrance A. Taddeo, MD 

Dr. Taddeo is currently the Chief of the Space and 

Clinical Operations Division at the NASA Johnson 

Space Center. Dr. Taddeo has been with NASA Space 

and Clinical Operations since 1996. 

David A. Tipton, MD 

Dr. Tipton is the Kennedy Space Center (KSC) 

Chief Medical Officer. He has been with NASA at 

KSC for over 30 years and was involved with the KSC 

aspects of both the Challenger and Columbia accident 

investigations. Dr. Tipton was the Emergency Medical 

Services coordinator in the Launch Control Center at 

KSC for the STS-107 mission. 

Laurence A. Ulissey, Colonel, USAF, MD 

Colonel Laurence A. Ulissey, MD is an active duty 

US Air Force flight surgeon assigned at NASA’s 

Johnson Space Center as a DOD Aerospace Medicine 

Liaison Officer, and operational flight surgeon for 

the International Space Station Program. He was the 

Chief of Bioastronautics for the DOD Human Space 

Flight Support Office from 2010 to 2012 in support 

of the Space Shuttle Program when he was stationed 

at Patrick Air Force Base, Florida. During his active 

duty tours with the US Air Force he has participated in 

Class-A aircraft mishap investigations throughout his 

assignments to Utah, Alaska, Florida, and Texas. 

viii
Introduction 

Michael Barratt 

Seated in front are astronauts Rick D. Husband (left), mission commander; Kalpana Chawla, mission specialist; and William C. McCool, pilot. 

Standing are (from the left) astronauts David M. Brown, Laurel B. Clark, and Michael P. Anderson, all mission specialists; and Ilan Ramon, payload 

specialist representing the Israeli Space Agency. 

On the morning of February 1, 2003, the US Space 

Shuttle Columbia broke apart during reentry into 

Earth’s atmosphere at the end of a highly productive 

16-day science mission. The usual upbeat anticipation 

associated with the return of a ship and its crew from 

space was utterly shattered with this loss. Mourning 

for Columbia’s seven-member crew was followed 

by a 21⁄2-year stand down of Shuttle flights, in spite 

of NASA and its international partners being in the 

midst of a flight-intensive period of constructing the 

International Space Station. 

NASA Administrator Sean O’Keefe commissioned 

the Columbia Accident Investigation Board (CAIB) 

within hours of the accident. This board worked 

diligently to produce a report, released in August of 

2003, that detailed the causal factors, from hardware 

failures to organizational and technical oversight 

anomalies, that contributed to the mishap. The CAIB 

offered a set of recommendations for actions to be 

taken before Shuttle flights were resumed. A constituent 

group of the CAIB, the Crew Survivability Working 

Group (CSWG), concentrated their analysis on the 

ix
T-38s flying over Johnson Space Center during the Columbia memorial service on February 4, 2003. 

crew environment, the forces inflicted on 

crewmembers, and cause of death. They released 

their final report in October 2003 as an appendix 

to the CAIB report. In 2004 NASA established the 

Spacecraft Crew Survival Integrated Investigation 

Team to complete the work of the Crew Survivability 

Working Group with more extensive resources. Their 

report, published in 2008, provided comprehensive 

understanding of the forces and factors that directly 

affected crew survival. They analyzed performance 

and failures of structures and crew equipment designed 

to protect human space flyers, with a deliberate aim to 

improve these for future flights and vehicles. 

The Columbia accident was the second loss of a US 

Space Shuttle and its crew. As was true for the previous 

US space tragedies, the Columbia mishap sparked 

fundamental questions and vigorous public debate about 

flight safety, mission planning and oversight, and the 

very justification of human space flight. Fortunately our 

nation’s resolve to continue to explore won over; Shuttle 

flights resumed in 2005, and the International Space 

Station was completed without mishap. 

The methodical investigation of a vehicle accident is 

one of the most important responses to such a tragedy, 

and its contribution to progress is well established. 

The rapid pace of aviation development in the 1940s 

and ’50s, during which significant advances in aircraft 

speed, altitude, and maneuverability were realized, 

was unfortunately punctuated by spectacular accidents 

and significant loss of life. But the rigorous analysis of 

mishaps provided valuable lessons that were applied 

directly to ongoing development programs and led 

to future successes. An implicit understanding was 

that a mishap investigation must be as disciplined and 

documented as any other aspect of a flight. Aircraft 

accident investigation is now a well-developed 

discipline. The return from this discipline is seen in the 

realities of modern-day high-performance aviation and 

civil jet transport, with expectations of safe operations 

and exceedingly low rates of accidents per mile. 

In many respects, human space flight is analogous to 

the aviation test programs of decades ago. Hardware 

and systems operate near the limits of their performance 

specifications, space crews are highly trained and fit 

x
individuals, and each launch may be considered a 

test flight. The space flight environment, however, is 

decidedly different from the aviation environment. 

The two most dangerous phases of space flight are 

launch and reentry into Earth’s atmosphere; during 

these phases a spacecraft requires enormous energies to 

overcome gravity and attain orbital velocity, and then 

to shed that velocity upon return to Earth. The space 

flight environment is really three different environments, 

and all contain many hazards to human health. The 

outer space environment is a near-vacuum, with 

highly reactive monatomic oxygen, radiation (ionizing 

and solar ultraviolet), acceleration forces, extreme 

temperature shifts, and hypervelocity and shock 

wave interactions; near the spacecraft are hazards 

such as propellants and coolants; and the weightless 

environment deconditions crewmembers. After every 

mission, engineers methodically analyze data on 

these environmental factors along with the flight’s 

performance, and subsequently brief mission managers 

on these aspects. 

All spacecraft mishaps will invariably involve 

combinations of these factors. Thoroughly understanding 

the environmental factors, and determining which of 

them led to specific hazards and injuries, is of paramount 

importance in understanding a mishap event for 

causation, timing, and sequence. The loss of Columbia 

constituted the first high-altitude hypersonic breakup, 

exposing crew and hardware to an unprecedentedly 

hostile environment.
	

Reflecting current efforts and understanding,
	

Loss of Signal aims to present the story of Columbia 

from an aerospace medical angle, focusing holistically 

on what is important for future investigations and 

analysis of spacecraft mishaps. This book is written 

by those who participated in the crew recovery and 

analysis and is written from their first-hand perspective 

of the events. The loss of a human crew implies 

sensitivities that must be balanced against the public 

and industry need to know, with the guiding principle 

being prevention of further mishaps and enhanced 

protection for crewmembers.
	

Two factors prompted the production of this book.
	

First, the passage of time has caused some of the 

sensitivities to ease. Second, and critically important, 

are the vigorous activities now underway in the design 

and production of new human space vehicles. It is a 

unique time in human space flight, in that there have 

never been so many new human-rated spacecraft 

in design and production. These are meant for low 

Earth orbit and space station servicing, exploration 

beyond Earth orbit, and a burgeoning suborbital tourist 

industry. This activity drastically increases the benefits 

of disseminating lessons learned from such events. 

Human space flight is a very public endeavor, with 

high-profile operators and continual open debate about 

the balance between cost and benefit. There is a great 

sense of public ownership and of sharing the adventures 

and successes; in turn, our tragedies and losses are 

keenly felt on a nearly global level. However, it is a 

truism that we are defined as much or more by how we 

respond to our failures as by how we respond to our 

successes. In the long run this is what moves us forward, 

as individuals, as nations, and as a civilization. In 

particular when technology progresses and boundaries 

are pushed, the learning curve is steep. We cannot 

anticipate the mishaps that may occur in the future, and 

thus it is vital to study every aspect of a current mishap 

to prepare and prevent, to learn the lessons and apply 

them. Aside from prevention, developing a methodical 

approach to spacecraft mishaps ensures a rapid and 

aggressive response to future events. 

Loss of Signal and other works before it contain 

knowledge that has been given to us at a very high 

price, and the space medical community is morally 

and professionally bound to make the best use of it. 

Educating our community enables these facts and 

observations to be integrated into every relevant aspect 

of human space flight. With this information and with 

every subsequent flight, we continue down a path toward 

safer and more routine access to space, ultimately 

making space flight similar to jet transport today. 

xi
xii
 
Section 1 – The Mission
 

The Mission and The Crew 

The Mishap 
2 SECTION 1 – THE MISSION

The Mission and The Crew 

Helen W. Lane, Smith Johnston, and John B. Charles 

NASA dedicated a majority of the Space Shuttle 

missions to science with focus on the effects of 

microgravity on biological, chemical, and physical 

systems. These included cellular, animal, and human 

types of experiments as well as atmospheric sciences, 

combustion, fluid mechanics, crystal growth, protein 

properties, and basic physics. After 20 years, NASA 

along with her international partners and commercial 

organizations had developed expertise in conducting 

these types of experiments during Space Shuttle flights. 

STS-107 was the final Space Shuttle flight totally 

dedicated to science to provide the foundation for future 

ISS research programs. It was the 113th mission of the 

Space Shuttle Program and the 28th flight of the Shuttle 

orbiter Columbia, launched on January 16, 2003, at 

10:39 a.m. EST for a 16-day mission. At 11:20 a.m. 

EST, a 2-minute burn of the orbital maneuvering system 

engines began to position Columbia in its proper orbit, 

an inclination of 39° to the equator and about 175 miles 

above the Earth. 

Before we recount the mission’s purposes and the 

skills of the crewmembers who made it possible, we 

will briefly describe the structure of the Space Shuttle, 

emphasizing the capabilities of the orbiter Columbia, 

and the environment at NASA at the time of the mission. 

Photo of Columbia STS-1 on the launch pad at Kennedy Space Center, ready for the historic first launch on April 12, 1981. Columbia, the first 

orbiter in the Shuttle fleet, was named after the Boston, Massachusetts-based sloop captained by American Robert Gray. On May 11, 1792, 

Gray and his crew maneuvered the Columbia past the dangerous sandbar at the mouth of a river (now named Columbia River, extending more 

than 1,000 miles through what is today southeastern British Columbia, Canada, and the Washington-Oregon border). Gray also led Columbia 

and its crew on the first American circumnavigation of the globe, carrying a cargo of otter skins to Canton, China, and then returning to Boston. 

Other sailing ships have further enhanced the luster of the name Columbia. The first US Navy ship to circle the globe bore that title, as did the 

Command Module for Apollo 11, the first lunar landing mission. 
SECTION 1 – THE MISSION 3 

The Vehicle 

The Space Shuttle had three major components: the two 

solid rocket boosters, the external tank, and the orbiter. 

Each of the six orbiters was slightly different from the 

others, and each was given a name: Atlantis, Challenger, 

Columbia, Discovery, Endeavour, Enterprise. Each 

orbiter contained three Space Shuttle main engines and 

the orbiter thrusters, crew compartment, and payload bay. 

The crew compartment included the flight deck, from 

which the commander and pilot controlled the spacecraft, 

and the middeck, the location of some research and 

the crew facilities such as sleep stations, galley, waste 

collection system, crew supplies, and environmental 

control system supplies. The crew compartment structure 

“floated” inside the forward fuselage and was attached 

to it at four discrete points. This construction provided 

greater thermal isolation and potentially ensured pressure 

integrity even if the orbiter aluminum shell cracked. 

Columbia was the first space flight-worthy orbiter and 

therefore unique in several ways. (The first orbiter, 

Enterprise, was built to perform approach and landing 

tests and was never converted to a spacecraft with 

rockets such as the Orbiter Maneuvering System and 

Reaction Control System engines). In 1981 and 1982 

Columbia flew the first five Space Shuttle flights—the 

first three were test flights, the fourth was a test and 

Department of Defense flight, and the fifth was the first 

operational flight, which included an expanded crew 

of four. These test flights were successful and they 

allowed NASA to begin flying payloads sooner than 

anticipated. Columbia’s early flights as a test platform 

validated the concepts and techniques for the fledgling 

Shuttle program. 

Columbia was built to carry a laboratory for scientific 

research in its payload bay. The first laboratory to 

occupy Columbia’s payload bay was Spacelab, which 

was first flown in space in 1983 on the STS-9 mission. 

For the STS-107 flight, Spacehab, Inc provided the 

last of these pressurized payload laboratories, the 

SPACEHAB Research Double Module. 

The NASA Environment 

The climate at NASA during the time leading up to 

the Columbia launch was rapidly changing in response 

to political and financial pressures on the agency. A 

growing federal deficit led to a push for reductions in 

government spending, and NASA’s budget, like that of 

other federal agencies, was reduced. Budget constraints 

reduced the Space Shuttle Program workforce and 

operations budget by an estimated 40% relative to the 

previous decade. At the same time, however, Shuttle 

operations were essential for continuing support 

of development, assembly, and operation of the 

International Space Station (ISS). The Space Shuttle 

Program was under significant pressure to meet launch 

dates to ensure the timely construction of the ISS. The 

STS-107 Columbia flight, unique in its purpose and 

significance, had a limited budget in this environment 

of reduced federal spending. NASA science managers 

were forced to constantly justify the role of a sciencededicated flight in an otherwise ISS-focused agency. 

The STS-107 mission was delayed many times from 

the announced launch date in 2000 to the final launch in 

2003. These delays occurred because higher priority was 

given to launches for ISS construction and for repair and 

upgrades of the Hubble Space Telescope, and because at 

different times damaged insulated wiring and damage in 

the main engines of Columbia had to be repaired. Finally, 

in early 2003, Columbia was slated for launch. By this 

time the crew, who had been training together for the 

better part of 3 years, functioned as an organized and 

integrated team, and close friendships had been formed 

among crewmembers, family members, and support staff. 

The Mission 

When STS-107’s flight was announced, the Space 

Shuttle Program was focused on assembling the 

ISS. However, NASA decided to have this one last 

research-dedicated Space Shuttle mission using the 

SPACEHAB laboratory. STS-107 research focused on 

the consequences of microgravity on physical and living 

systems. The underlying goals were to enhance the wellbeing of people on Earth, using microgravity for basic 

scientific understanding; this knowledge might enable 

scientists to build better spacecraft and to understand 

the human system. Also, the goal was to develop 

countermeasures to allow astronauts to stay healthy 

during long duration missions such as those on the ISS 

or beyond low Earth orbit. With a large set of submitted 

proposals, NASA and its international and commercial 

partners conducted peer review to determine the best 

scientific studies that could be implemented during this 

Space Shuttle flight. Once the science was selected, 

NASA mission managers and the STS-107 crew worked 

with the investigators to ensure the highest quality of 

research. The crew trained diligently to ensure they 

could conduct the research at the highest levels. 
4 SECTION 1 – THE MISSION

 

This is the insignia for 

STS-107, which is a multidiscipline microgravity and 

Earth science research 

mission with a multitude 

of international scientific 

investigations conducted 

continuously during the 

planned 16 days on orbit. 

The central element 

of the patch is the 

microgravity symbol, 

μg, flowing into 

the rays of the 

astronaut 

symbol. 

The mission 

inclination is 

portrayed by the 39-degree 

angle of the astronaut symbol 

to Earth’s horizon. The sunrise is 

representative of the numerous 

experiments that are the dawn of a new era for continued 

microgravity research on the International Space Station 

and beyond. The breadth of science conducted on this 

mission will have widespread benefits to life on Earth and 

our continued exploration of space illustrated by Earth and 

stars. The constellation Columba (the dove) was chosen to 

symbolize peace on Earth and the space shuttle Columbia. 

The seven stars also represent the mission crewmembers 

and honor the original astronauts who paved the way to 

make research in space possible. The Israeli flag is adjacent 

to the name of the payload specialist who is the first person 

from that country to fly on the Space Shuttle. 

This science mission had a mixed complement 

of experiments that had been selected through 

competition. The mission had 32 payloads, 40% of 

which were international or commercial. Sponsoring 

organizations ranged from multiple NASA research 

divisions to military research organizations, educational 

institutions, and international partners. The research 

was proposed by 59 separate investigators and 

represented numerous scientific fields, including 

biology, medicine, materials science, physics, and 

atmospheric sciences. The astronauts served as 

researchers and test subjects for experiments related 

to astronaut health, including respiratory monitoring 

and bone physiology studies, and an investigation of 

circadian rhythms and light exposure. 

International payloads were from Canada, Germany, 

the European Space Agency, and Israel. The Israeli 

Space Agency sponsored a payload bay project called 

Mediterranean-Israeli Dust Experiment (MEIDEX), 

and it was designed to study atmospheric dust over 

Africa and the Mediterranean to provide important 

understanding of dust and weather, and thus climate 

changes. As part of this project, the first Israeli 

payload specialist flew, causing the flight to have 

significant attention from the international community 

and, of course, Israel. 

The Crew 

The complex payloads on this mission required an 

exceptionally qualified crew with strong scientific, 

medical, and research backgrounds. Also, because 

the astronauts would function as both scientists and 

test subjects, NASA asked for volunteers from the 

astronaut corps who would be dedicated to successful 

accomplishment of scientific goals. 

Rick Husband, an Air Force test pilot, embraced his 

role as the commander of the STS-107 mission. His 

pilot was William McCool, a Navy test pilot. Both 

Husband and McCool had engineering backgrounds, 

and both were active participants in multiple research 

projects during the flight. Michael Anderson, the payload 

commander, had a background in physics and astronomy, 

and was well suited to lead research efforts on orbit. 

The mission’s flight engineer, Kalpana Chawla, had a 

background in aerospace engineering. The crew had two 

Navy flight surgeons: David Brown, a naval aviator, 

physician, and scientist, and Laurel Clark, a naval 

commander, physician, and zoologist. Ilan Ramon, a 

colonel in the Israeli Air Force and a fighter pilot, had a 

background in computer engineering. Ramon, the first 

Israeli astronaut to take the ride into orbit, worked with 

the Israeli Space Agency MEIDEX investigation. 

This crew’s rigorous preparation included about 

5,000 hours of general training, as well as an additional 

3,500 hours of training specific to the research payloads 

and the objectives and procedures for each experiment. 

Some of the research was dedicated to biological and 

medical sciences, and thus required consultation with 

the crew flight surgeons throughout training and the 

mission itself. The medical impact of this mission, which 

included a wide variety of experiments, was important. 

Research 

Crew research activity was planned for every hour 

of the day, and called for crewmembers to work in 

two shifts, called the Blue Team and the Red Team, 
SECTION 1 – THE MISSION 5 

on opposite schedules during the mission. This 

required careful preparation of schedules to ensure 

that crewmembers had enough time to rest. The Red 

Team comprised Commander Richard Husband, Flight 

Engineer and Mission Specialist 2 Kalpana Chawla, 

Mission Specialist 4 Laurel Clark, and Payload 

Specialist Ilan Ramon. The Blue Team consisted of 

Pilot William McCool, Mission Specialist 1 David 

Brown, and Mission Specialist 3 and Payload 

Commander Michael Anderson. 

During their flight on January 28, the STS-107 crew 

honored those who lost their lives in the Apollo 1 

fire and the Challenger accident. The Columbia crew 

never anticipated the danger that was awaiting them, 

or that, ironically, they too would be honored and 

never forgotten. 

At the end of their final research day, the crew had 

completed all the experiments. By all indications at 

this time, the STS-107 crew and the researchers on the 

ground had had a highly successful science mission, 

and all were ecstatic over completion of the mission 

objectives. On February 1, 2003, the Columbia and its 

crew would make preparations to reenter the Earth’s 

atmosphere and return home. 

Commander 

Rick D. Husband 

(Colonel, US Air Force) 

A native of Amarillo, 

Texas, Rick earned 

a BS degree in 

mechanical engineering 

from Texas Tech 

University and an 

MS degree in the 

same discipline from 

California State 

University, Fresno. 

Rick served as the 

Astronaut Office 

representative for 

Advanced Projects 

and served as Chief of Safety for the Astronaut Office. 

He served as pilot for STS-96 (1999), a 10-day 

mission during which the crew performed the first 

docking with the International Space Station. STS-107 

was Rick’s second Space Shuttle mission and his first 

as Commander. 

Pilot 

William C. “Willie” McCool 

(Commander, US Navy) 

Willie was born in 

San Diego, California. 

He held a BS degree 

in applied science 

from the US Naval 

Academy, an MS 

degree in computer 

science from the 

University of 

Maryland, and an 

MS degree in 

aeronautical 

engineering from the 

US Naval Postgraduate 

School. Willie logged over 3,000 hours of flight 

experience in 24 aircraft and more than 400 carrier 

arrestments before NASA selected him as an astronaut 

candidate in 1996. STS-107 was Willie’s first Space 

Shuttle mission. 

Mission Specialist 

Michael “Mike” P. Anderson 

(Lieutenant Colonel, US Air Force) 

Mike was born in 

Plattsburgh, New York, 

but called Spokane, 

Washington, home. 

He received a BS 

degree in physics/ 

astronomy from 

the University of 

Washington and an 

MS degree in physics 

from Creighton 

University. With 

over 4,000 hours in 

various models of 

the KC-135 and the T-38 aircraft, Mike served as an 

aircraft commander, an instructor pilot, and a tactics 

officer before he was selected as an astronaut for 

NASA in 1994. He flew on STS-89 (1998), the eighth 

Shuttle-Mir docking mission. STS-107 was Mike’s 

second Space Shuttle mission. 
6 SECTION 1 – THE MISSION

 

Mission Specialist 

Kalpana “K.C.” Chawla, PhD 

K.C. was born and 

raised in Karnal, 

India. She received 

a BS in aeronautical 

engineering from 

Punjab Engineering 

College, Chandigarh, 

India, an MS in 

aerospace engineering 

from the University 

of Texas, and a PhD 

in aerospace 

engineering from the 

University of Colorado. 

In 1988, she started work at NASA Ames Research 

Center, and she was selected as an astronaut candidate 

by NASA in December 1994, reporting to the Johnson 

Space Center in March 1995 as an astronaut candidate 

in the 15th group of astronauts. K.C. flew as a mission 

specialist on STS-87 (1997). STS-107 was K.C.’s 

second Space Shuttle mission. 

Mission Specialist 

David “Dave” Brown, MD 

(Captain, US Navy) 

Dave was born in 

Arlington, Virginia. 

He received a BS 

degree in biology 

from the College of 

William and Mary 

and a doctorate in 

medicine from Eastern 

Virginia Medical 

School. Brown 

joined the Navy and 

completed flight 

surgeon training. In 

1988, he was the only 

flight surgeon in a 10-year period to be chosen for 

pilot training. He was ultimately designated a naval 

aviator, ranking number one in his class. Dave logged 

over 2,700 flight hours, with 1,700 hours in highperformance military aircraft, and was qualified as 

first pilot in NASA T-38 aircraft. NASA selected 

him as an astronaut candidate in 1996. STS-107 was 

Dave’s first Space Shuttle mission. 

Mission Specialist 

Laurel Blair Salton Clark, MD 

(Commander, US Navy) 

Laurel was born in 

Ames, Iowa, but called 

Racine, Wisconsin, 

her hometown. She 

received both a BS 

degree and a doctorate 

in medicine from 

the University of 

Wisconsin-Madison. 

Prior to her selection 

as an astronaut 

candidate in 1996, 

she served as a flight 

surgeon for the Naval 

Flight Officer advanced training squadron (VT-86) in 

Pensacola, Florida. While at NASA, Laurel worked on 

International Space Station and Space Shuttle medical 

systems and payload operations and development. 

STS-107 was Laurel’s first Space Shuttle mission. 

Payload Specialist 

Ilan Ramon 

(Colonel, Israel Air Force) 

Ilan was born in 

Tel Aviv, Israel. 

He received a BS 

degree in electronics 

and computer 

engineering from 

the University of 

Tel Aviv, Israel. He 

graduated as a fighter 

pilot from the Israel 

Air Force Flight 

School. In 1997, Ilan 

was selected as a 

Payload Specialist. 

He was designated to train for a Space Shuttle mission 

carrying an Israeli payload (MEIDEX) that included 

a multispectral radiometric camera for recording 

atmospheric desert aerosols from space. In August 

1998, he started basic Shuttle training at Johnson 

Space Center. In August 2000, he was assigned as one 

of the seven crewmembers for this flight. STS-107 

was Ilan’s first Space Shuttle mission, and he was the 

first Israeli to fly in space. 
SECTION 1 – THE MISSION 7 

Crew Activities During Flight of STS-107, Representing Research and Education Outreach 

STS-107 Commander Rick D. Husband works the controls on 


the support hardware for the European Research in Space and 


Terrestrial Osteoporosis experiment located in the SPACEHAB 


Research Double Module. 


STS-107 Pilot 

William C. “Willie” 

McCool views 

data on a laptop 

computer at a 

workstation on 

Columbia’s aft flight 

deck. He holds a 

checklist in one 

hand and a portable 

communications 

system in the other. 

STS-107 Payload 


Commander and 


Mission Specialist 


Michael P. “Mike” 


Anderson works with 

the Laminar Soot 

Processes experiment 

in the Combustion 

Module -2 in the 

SPACEHAB 

Research Double 

Module. 

STS-107 

Mission 

Specialist 

Kalpana “KC” 

Chawla at 

work in the 

SPACEHAB 

Research 

Double Module. 

STS-107 Mission 

Specialist David 

“Dave” Brown, 

holding papers, 

smiles for the 

camera from 

orbiter Columbia’s 

flight deck/ 

middeck access 

way. Beside 

him is a spare 

mission specialist 

seat in stowed 

configuration. 

STS-107 Mission 

Specialist 4 Laurel 

Blair Salton Clark 

looks over her 

shoulder as she 

enters data on a 

Payload General 

Support Computer 

at a workstation 

on Columbia’s aft 

flight deck. 

STS-107 Payload Specialist Ilan Ramon works with the 


Space Technology And Research Students (STARS) 


educational payload housed in an Isothermal Containment 


Module (ICM) in the SPACEHAB Research Double Module. 


The STARS payload included the following experiments: 


“The Chemical Garden,” sponsored by Israel; 


“Astrospiders — Spiders in Space,” sponsored by Australia; 


“Silkworm Lifecycle During Space Flight” sponsored by China; 


“Flight of the Medaka Fish,” sponsored by Japan; 


“Carpenter Bees in Space,” sponsored by Liechtenstein; 


and “Ant Colony,” sponsored by the United States.
 
8 SECTION 1 – THE MISSION

The Mishap 

Stevan Gilmore and Charles Campbell 

Normal Launch and Reentry Dynamics 

The process of launching an object into low Earth 

orbit and then returning it to Earth is an energetic 

and dynamic process. To understand the nature of the 

Columbia mishap and the ballistic effects that produced 

the debris field, it is important to understand launch 

and reentry dynamics. 

The launch of the Shuttle demanded a dynamic 

expenditure of energy as the vehicle accelerated from 

rest to an orbital velocity of 17,500 miles per hour 

(mph). Including crew and cargo, a typical Shuttle with 

a complete payload weighed about 110 metric tons, 

and the acceleration of such a mass to orbital velocity 

required nearly one million watts of energy, or enough 

energy to power the average house for 41 years. 

Before landing, the energy of the vehicle in orbit had 

to be dissipated; this was accomplished by converting 

kinetic energy into heat. As the orbiter reentered the 

atmosphere, the vehicle slammed into air particles in 

the atmosphere, creating a shock layer where the kinetic 

energy of the Shuttle was transferred to molecules 

of air, ripping these molecules apart. 

Within the shock layer, temperatures reached over 

10,000°F, an environment with characteristics 

approaching those of plasma-phase matter. In a 

true plasma, free electrons significantly affect the 

gas dynamic properties and involve significant 

electromagnetic effects. During reentry from low Earth 

orbit, however, the main effect of the large number 

of free electrons is the loss of radio communications. 

The orbiter surface did not make contact with this 

superheated gas in the shock layer but instead was 

protected with a thin boundary layer of atmosphere 

that limited heat transfer. The temperature of the orbiter 

surface, which was protected from these very high 

temperatures because of this boundary layer, normally 

had peak temperatures approaching 3000°F. Most 

Flow

Nitrogen and 

oxygen molecules 

are dissociated in 

the shock layer. 

Atoms may recombine 

and form molecules 

on the vehicle surface. 

Oxygen molecules 

in the shock layer 

separate into 

O+ and O­ atoms. 

Recombination of atoms on 

the surface of the vehicle 

adds heat of dissociation to 

the Thermal Protection System. 

Shock

 Layer 

Boundary

Layer 

This image illustrates how the Thermal Protection System protected the orbiter’s aluminum shell. 
SECTION 1 – THE MISSION 9 

After the Columbia accident, NASA instituted a policy that the orbiter 

would be inspected after it reached orbit. These photos were taken 

from the International Space Station for STS-114, 2005. The photo 

shows the Thermal Protection System (TPS) tiles on the belly of the 

orbiter Discovery; the insert is a closeup of the reinforced carboncarbon panels on the leading edge of the wing, the location of the hole 

in Columbia’s TPS that caused the accident. 

of the lower surface of the orbiter had temperatures 

above 2000°F. However, the orbiter’s aluminum 

airframe started to lose structural integrity at 345°F 

and had a melting point of 1220°F, far lower than the 

boundary layer temperatures. The Thermal Protection 

System (TPS), the specialized covering of the orbiters 

that was made of tile and high-temperature carboncarbon materials, provided the protection vital for 

maintaining orbiter integrity during the extreme 

temperatures of reentry. 

Reentry into the Earth’s atmosphere after any Shuttle 

mission required complex choreography of effort and 

activity. For the flight crew, it signified the completion 
10 SECTION 1 – THE MISSION

This image illustrates the angle of the orbiter as it enters the Earth’s atmosphere beginning with the belly facing the atmosphere. Flying through 

the atmosphere decreases the speed due to aerodynamic drag. By rolling the orbiter left and right, the guidance brings the crew to a precision 

unpowered touchdown on the runway. 

of on-orbit mission objectives and required a sudden 

focus of activity to reconfigure the orbiter from a 

work and science platform back into a flying machine. 

In Mission Control, analysts, flight controllers, 

and management teams had to prepare for the 

reentry to Earth’s atmospheric operations with the 

deployment of personnel to landing sites and the 

active analysis of orbiter systems, reentry weather, 

and landing conditions. 

Flight controllers divided the orbiter reentry profile 

into three phases for tracking: reentry, terminal area 

energy management (TAEM), and approach through 

landing. The reentry phase began with entry interface, 

arbitrarily determined to occur at an altitude of 

400,000 ft. Entry interface signifies the beginning 

of reentry, where the atmosphere is about to begin 

exerting drag on the orbiter. During reentry, Shuttle 

computers commanded the orbiter to perform a series 

of banks and roll-reversals, decelerating the orbiter 

from the initial reentry speed of Mach 25. At the same 

time, these maneuvers protected the TPS surfaces, 

limiting surface heating and surface temperatures 

to within operational performance range. The flight 

software running on the computer was designed to 

carefully control the reentry path such that the 

orbiter would achieve TAEM with enough energy to 

reach the runway. TAEM would typically occur at 

83,000 ft and a speed of Mach 2.5, about 52 nautical 

miles from the runway. The distinctive “double sonic 

boom” would thunder from the vehicle until it slowed 

to subsonic speeds at an altitude of 49,000 ft, about 

22 nautical miles from the runway. TAEM would 

transition into the approach and landing phase below 

10,000 ft after the Shuttle attained the appropriate glide 

slope and air speed for landing. 

The Columbia Reentry Mishap 

Damage to the Columbia Orbiter 

By the time of reentry, the Columbia crew had 

completed 16 days of rigorous scientific endeavors 

and they eagerly anticipated their return trip to Earth. 

Columbia’s crew busily prepared to return home. 

Beginning on January 31, 2003, members of the nightshift Blue Team (Anderson and Brown) woke up about 

3:30 p.m. CST. McCool, also a member of the Blue 

Team, earned a slightly longer sleep period and was 

awakened 2 hours later than his teammates so that he 

could be well rested for performing his flight duties 

associated with reentry. The team began their final day 

of activities, including configuration of the SPACEHAB 

and orbiter middeck and flight deck in preparation 

for reentry. The Red Team awakened shortly before 

1:00 a.m. CST February 1 for final deorbit preparations. 

However, the launch 2 weeks before this day had 

included significant events that would ultimately lead 

to disaster during reentry. As with all Shuttle missions, 

numerous videos of Columbia’s launch and ascent 

sequence were thoroughly analyzed by engineering 

experts during and after launch. These experts promptly 

recognized that an anomaly had occurred during launch: 

foam debris from the external tank had shed during the 

extreme conditions of launch and struck the left wing 

of Columbia exactly 81.9 seconds into the flight. In the 

context of operations in early 2003, foam strikes were 

not particularly unexpected or unusual. In fact, foam 

debris was shed on every launch before STS-107, and 

resultant debris strikes had become a regular occurrence. 

When it was recognized that Columbia had suffered a 

debris strike, analysis and engineering experts worked 

to identify the significance of this event for vehicle 

integrity. The videos of launch showed that the foam 
SECTION 1 – THE MISSION 11 

Launch of STS-107 at Kennedy Space Center on January 16, 2003. 

struck Columbia’s left wing on or near a leading edge, 

an area covered in reinforced carbon-carbon panels 

because of the extreme heating of this region during 

reentry. Some analysts expressed concern about this 

event, given the limited analysis available and the 

possible implication of such a strike on the TPS and 

vehicle integrity. Because operational experience with 

previous foam debris strike events had shown that such 

strikes had never caused significant structural damage, 

this event ultimately was not considered mission critical 

and the flight continued uninterrupted. 

Reentry Sequence 

In Houston, responsibility for the mission was handed 

over to the reentry Mission Control team at about 

2:30 a.m. CST, February 1, and this team began 

monitoring crew activities and vehicle telemetry, 

coordinating reentry and landing site weather 

assessments, and relaying entry parameter updates to 

Left Bipod Foam Ramp where the loss of debris occurred on 

STS-107. Left side is the external tank, and right side is the orbiter. 

The foam strike on the leading edge of the wing at 81.9 seconds 

after lift-off. 

the crew for entry into the flight computers. At 8:10 a.m., 

members of the reentry team were polled for “Go/NoGo” status for final approval of the reentry procedure. 

At 8:16 the capsule communicator (CAPCOM) 

informed the commander that he was cleared for reentry 

and a landing at the Kennedy Space Center (KSC). 

Five minutes after receiving clearance for landing, 

as the Shuttle orbit passed above the Indian Ocean, 

Husband and McCool initiated a deorbit burn that lasted 

2 minutes 38 seconds. This procedure fires the engines 

against the direction of the orbital trajectory so that 

engine thrust works to slow the vehicle. The action 

slowed Columbia by only about 250 mph, but the new 

trajectory created by this deceleration placed the orbiter 

in a path that would contact the upper regions of the 

atmosphere. As they finished this maneuver, Husband 

and McCool reoriented the vehicle from the inverted 

orbital position (with the payload bay pointed down 

toward the Earth’s surface) to an upright, nose-forward, 
12 SECTION 1 – THE MISSION

pitched-up orientation, maximizing exposure of the 

vehicle’s heat-resistant surfaces to the atmosphere. 

Entry interface, the entry of the orbiter into the 

atmosphere, occurred on time and as expected at 

08:44:09 CST over the Pacific Ocean. On board and in 

the Mission Control Center, the crew and the ground 

team monitored the performance of the digital autopilot 

as it commanded flight maneuvers. At 08:49:32 CST, 

Columbia executed the first in a series of energymanagement maneuvers designed to reach the landing 

site with the appropriate conditions for an aerodynamic 

landing. The initial move in this energy management 

choreography, a bank to the right, occurred without 

incident. At 08:50:53 CST, Columbia was gliding 

roughly 300 nautical miles west of the California coast 

and entered a 10-minute period of peak heating on the 

TPS as it was slowed by the atmosphere. At 08:53:25 

CST, Columbia crossed the west coast of California at 

231,600 ft and traveling at Mach 23. All procedures and 

events appeared to be normal. 

The orbiter Columbia had the heaviest airframe of 

the orbiter fleet, and that frame had a multitude of 

integrated sensors for accurate measurements of 

vehicle performance and the flight environment. The 

inclusion of these sensors, so important for the first 

Shuttle flights by Columbia, ultimately contributed 

significantly to the reconstruction and understanding of 

the events that were to unfold during its last mission. At 

08:54:24 CST, as Columbia crossed from California into 

Nevada, flight controllers in Mission Control received 

the first nonstandard telemetry from the vehicle. The 

maintenance, mechanical, and crew systems (MMACS) 

officer, who was responsible for monitoring all of the 

orbiter structural and mechanical systems, reported 

to the flight director that four hydraulic sensors in the 

left wing were indicating off-scale low. As Mission 

Control specialists analyzed the telemetry signature and 

discussed possible causes, Columbia continued along its 

reentry path over the western United States. At 08:56:30 

CST, while transiting over northern Arizona, Columbia 

executed its nominal roll-reversal from a right to left 

bank as the flight-control computers continued the 

reentry energy-management choreography. 

At 08:58:20 CST, Columbia entered the skies over 

Texas, traveling at Mach 19.5 and at an altitude of 

209,800 ft. Shortly after this, CAPCOM received a 

broken call from Columbia, “And, uh, Hou...” At 

08:59:15 CST, MMACS reported a second unexpected 

telemetry signature, the loss of tire pressure reading 

data from both left main gear tires, to the flight director. 

CAPCOM relayed the receipt of these telemetry 

signals to the crew and requested a repeat of the crew’s 

interrupted transmission. Shortly thereafter, CAPCOM 

announced to the crew that a fault message about backup 

tire pressure had been registered by ground telemetry; 

this fault message may have been the reason the 

commander had initiated the final voice communication. 

At 08:59:32 CST, loss of signal occurred with a midsentence interruption of the final voice call from 

Commander Husband: “Roger, ...” At this time the 

orbiter was in the vicinity of Dallas, TX, at an altitude 

of 200,700 ft and traveling at Mach 18. Although the 

significance was only recognized in retrospect, the 

time at which loss of signal occurred coincided with an 

expected transition between West coast communication 

assets tracking the Shuttle to those positioned on the 

East coast and on the ground at KSC. Unknown to those 

in Mission Control at the time, 08:59:32 CST would 

mark the time at which no further useful telemetry was 

received from Columbia. This moment would come to 

be known as the Loss of Signal. 

Flight controllers continued to discuss the possible 

causes of the unexpected tire pressure and telemetry 

signatures received from the orbiter. Additionally, 

the instrumentation and communications officer, 

responsible for monitoring communication systems 

and telemetry links between the vehicle and the ground, 

reported that the communications drop-out was rather 

longer than expected. The mission control team began 

to step through processes to confirm the last known 

configuration of communication assets and then 

reacquire communication with the orbiter. 

Unknown to Mission Control, observers located in the 

vicinity of the orbiter’s ground track across the western 

and central United States witnessed unexpected events 

as they watched Columbia’s reentry. A series of separate 

observers on the ground were filming the orbiter, using 

a variety of modalities ranging from amateur video to 

advanced optics from government assets. Starting near 

the coast of California, these observers documented 

discrete debris-shedding events as well as irregularities 

in Columbia’s wing profile. At 09:00:18 CST, as 

Mission Control began its series of steps to reacquire 

communications, military assets located in the Dallas 

and Fort Hood areas documented this catastrophic event. 

State and local authorities began to be inundated by calls 

from witnesses reporting a loud sonic boom followed 

shortly thereafter on the ground by falling debris. This 

visual confirmation of the catastrophic reentry event 

was part of the information that was eventually relayed 
SECTION 1 – THE MISSION 13 

STS-107 Debris Timeline

13:53:46 

Debris 1 

13:53:48 

Debris 2 

13:55:23 to 13:55:27 

Debris Shower A 

13:55:24 

Debris 8 

13:54:36

Debris 6 

13:54:33 

Flash 1 

13:53:56 

Debris 3 13:54:02 

Debris 4 

13:54:09 

Debris 5 

13:55:05 

Debris 7 

13:55:27 

Debris 10 

13:55:37 

Debris 11 

13:55:45 

Debris 12 

13:55:39 

Debris 11A 

13:55:40 

Debris 11B 

13:55:44 

Debris 11C 

13:55:56 

Debris 13 13:55:58 

Debris 14 

13:56:10 

Debris 15 13:57:24 

Debris 16 

13:59:47 

Debris A 

14:00:02 

Debris B 

14:00:03 

Debris C 

14:00:10 

Debris D 

14:00:11 

Debris E 

14:00:12 

Debris F 

14:00:15 

Debris Shower 

14:00:18.3 

Catastrophic

Event 

14:00:05.7 

Late Flash 1 

14:00:06.7 

Late Flash 2 

13:58:00 

Flare 2 

13:57:54 

Flare 1 

13:55:18 

Debris 7A

 Hours: Minutes: Seconds 

STS-107 Global Positioning Satellite Trajectory 

STS-107 Predicted Trajectory 

Debris Event 

Video Observer 

Major City 

00:00:00 = 

Houston Austin 

El Paso 

Phoenix 

Los 

Angeles 

San 

Diego 

San 

Francisco 

San Antonio 

Fort 

Worth Dallas 

This graphic illustrates the sightings by amateurs and the Department of Defense during the reentry of Columbia. These videos and photos 

allowed NASA to better characterize the pre-breakup debris and ground impact areas. Time is represented as Greenwich Mean Time (GMT). 

to the Mission Control team in Houston as the team 

searched for the cause of the extended loss of signal 

from Columbia. 

At 09:02:21 CST, when Columbia was expected to be 

within range of communication with KSC, personnel 

at the Merritt Island Launch Annex (MILA) in Florida 

reported to the Houston team that they were unable to 

contact the crew on the radio. CAPCOM attempted to 

regain communication with the orbiter by means of an 

ultra-high-frequency antenna. The ground control officer 

reported that ground assets at the MILA were not in 

radio contact with the orbiter. 

At 09:09:29 CST, when Columbia was expected to enter 

TAEM, the flight dynamics officer again reported that 

they were not receiving any tracking data. A few minutes 

later, when Columbia was expected to be entering the 

third phase of reentry and the characteristic double sonic 

boom was conspicuously absent, the flight director was 

informed of events as witnessed by the public. Private 

citizens, news media, military personnel, and others were 

already witnessing and videotaping the significant events 

taking place over the skies of Texas and Louisiana. 

At 09:12:39 CST the flight director instructed that 

the control room doors be locked and that control 

team members begin securing their stations and the 

data within. 

Recovery Operations 

Once the Control Team became aware of the situation, 

the Shuttle contingency action plan was activated. 

This plan was made up of a number of actions including 

notification, through the NASA chain of command, 

of members of the astronauts’ families and members 

of the government. At Johnson Space Center (JSC), 

the Mission Management Team (MMT) convened a 

meeting in the action center of Mission Control at 

9:30 a.m. CST. One of their first actions was to prepare 

responders for immediate deployment to the disaster 

site. By 10:30 a.m. CST, the NASA administrator had 

named Admiral Harold W. Gehman, Jr., Chair of the 

Columbia Accident Investigation Board (CAIB). 

Soon after, President Bush informed the Israeli Prime 

Minister of the mishap and then declared the affected 

areas Federal disaster areas, mobilizing government 

relief and recovery resources for assistance. 
14 SECTION 1 – THE MISSION

Reconstruction of the Columbia from parts found in East Texas and western Louisiana. From this layout, NASA was able to determine that a large 

hole occurred in the leading edge of the wing and identify the burn patterns that eventually led to the destruction of the orbiter. 

At 11:30 a.m. CST, a second meeting of the MMT 

occurred at which the management team presented 

information from local state agencies and the 

Department of Defense about the approximate 

coordinates of the orbiter breakup. Team members 

from a number of disciplines at the JSC were assigned 

to the Mishap Investigation Team (MIT), whose task 

was to spearhead NASA’s efforts in conjunction with 

other federal, state, and local entities to locate, preserve, 

and protect the hardware debris and human remains. 

The MIT deployed to Barksdale Air Force Base (AFB) 

in Louisiana from Ellington Field in Houston, Texas, 

at 3:30 p.m. CST to coordinate the recovery of the 

Columbia vehicle and her crew. Other members of 

the MIT deployed to Disaster Field Offices that were 

subsequently established in Lufkin, Texas; Fort Worth 

Naval Air Station, Texas; and other areas throughout 

northeastern Texas and western Louisiana. This initial 

response was vital in locating the Columbia vehicle and 

its crew and in preserving and protecting evidence for 

the mishap investigations conducted by the CAIB. 

Investigation (FBI) worked together with state and local 

agencies in what was to be the largest recovery effort 

ever undertaken anywhere. More than 25,000 people 

participated in recovery efforts. Over 700,000 acres 

of land were walked in a grid pattern to locate debris, 

and more than 37 helicopters and 7 airplanes were used 

to search 1.6 million acres by air. Even scuba divers 

searched a number of lakes in the affected areas. 

Debris Recovery 

In total, 83,013 debris pieces weighing 84,900 pounds 

were recovered, equaling roughly 39% of the weight 

of the orbiter. The Modular Auxiliary Data System 

recorder that contained critical data needed for the 

accident analyses was found near Hemphill, Texas. 

It recorded data about the local flight environment and 

dynamics, including data recorded for an additional 

14 seconds after the loss of signal to Mission Control 

in Houston. Searchers photographed and geo-tagged 

recovered debris in the field, then sent the items 

to designated sites across Texas for archiving and 

Federal agencies including the Federal Emergency identification. Much of the recovered hardware debris 

Management Agency (FEMA), the Environmental was forwarded to KSC from February 12 to May 6, 

Protection Agency (EPA), the National Transportation 2003, and assembled on a full-scale grid for further 

Safety Board (NTSB), and the Federal Bureau of analysis and reconstruction efforts. 
SECTION 1 – THE MISSION 15 

President George W. Bush spoke at the 

Columbia memorial service at the Johnson 

Space Center on February 4, 2003. The 

President was accompanied by NASA 

Administrator Sean O’Keefe (left) and Chief of 

the Astronaut Corps Captain Kent Rominger. 

Memorials 

A memorial service to honor the 

crew occurred on February 4, 

2003, at JSC and was televised 

worldwide. President George W. 

Bush was accompanied by NASA 

Administrator Sean O’Keefe and 

Chief of the Astronaut Corps 

Captain Kent Rominger. President 

Bush stated to the assembled 

group of employees, retirees, crew 

families, and other dignitaries, “Their mission was 

almost complete, and we lost them so close to home.... 

For these seven, it was a dream fulfilled. Each of these 

astronauts had the daring and discipline required of their 

calling. Each of them knew that great endeavors are 

inseparable from great risks. And each of them accepted 

those risks, even joyfully, in the cause of discovery.” 

On February 7, at KSC the orbiter Columbia was 

memorialized. Robert Crippen, Columbia’s first pilot, 

remembered the great matriarch of the Space Shuttle 

fleet with these touching words during the KSC 

memorial service: “Just as her crew has, Columbia has 

NASA and contractor employees attended the Columbia memorial left us quite a legacy.” 

service at the Johnson Space Center on February 4, 2003. 

A Columbia Crew Memorial Service was held at the Shuttle Landing Facility for KSC employees and invited guests on February 7, 2003. Columbia’s 

first pilot and former KSC Director Robert Crippen is at the podium. Seated to his right are NASA Associate Deputy Administrator for Institutions 

and Asset Management James L. Jennings, Florida Gov. Jeb Bush, and NASA Administrator Sean O’Keefe. The Columbia and her crew of seven 

were lost on February 1, 2003, over East Texas as they returned to Earth after a 16-day research mission. Taking part in the service were NASA 

Administrator Sean O’Keefe, former KSC Director Robert Crippen, astronaut Jim Halsell, several employees, area clergymen, and members of 

Patrick Air Force Base. The service concluded with a “Missing Man Formation Fly Over” by NASA T-38 jet aircraft. 
16
 SECTION 1 – THE MISSION
SECTION 2 – THE RESPONSE 17 

Section 2 – The Response
 

Search and Recovery Team Operations 

Mishap Investigation Team Medical Efforts for 

Crew Recovery and Identification 

Mishap Response and Lessons Learned: 

The Role of the Office of the Armed Forces Medical Examiner 

and the Armed Forces Institute of Pathology 

Johnson Space Center Space Life Sciences Response 

and Crew Survival Investigation 

Kennedy Space Center Operations – 

Commitment to Safety and Preparedness 

Crew Medical and Psychological Support Operations 
18 SECTION 2 – THE RESPONSE

Search and Recovery 


Team Operations 

James D. Wetherbee 

A difficult but essential component of aerospace 

accidents is the recovery of human remains. Members 

of the teams that participated in the search and recovery 

of the human remains of the Columbia crew felt a 

personal responsibility to succeed for the crewmembers’ 

immediate family members, the workers of NASA, the 

citizens of the United States, and the international space 

community. The participants had the guiding principle to 

recover the remains of the astronauts with dignity, honor, 

and reverence. The purpose of this chapter is to describe 

this noble recovery effort, its organizational structure, 

and the leadership that met this guiding principle. 

Immediately after confirmation of the Columbia mishap, 

NASA initiated its contingency action plan. The NASA 

Flight Crew Operations Directorate, which includes the 

Astronaut Office at the Johnson Space Center (JSC), 

was responsible for the search and recovery of the 

human remains of the Columbia crew. More than two 

thousand people contributed to this effort with inspiring 

and humbling self-sacrifice. The work was dangerous 

and the terrain was challenging; sometimes it rained 

and sometimes temperatures were just above freezing. 

Recognizing the complexity of the task, the number 

of teams working, and the speed required, the leaders 

of the search and recovery effort rapidly developed a 

centralized plan to guide the work and coordinate the 

teams involved. Over the two weeks that followed, the 

leaders adjusted the plan and refined the operations, 

based on valuable input from personnel in the field. 

Organizations involved in the effort were extraordinarily 

helpful. However, operational leaders quickly faced 

the challenge of knowing how much help to accept 

and how to coordinate effectively the valuable external 

assistance that was offered into a comprehensive and 

cohesive operational plan. Overcoming this challenge 

required the establishment of a clear and organized 

hierarchy of leadership. 

Initial Organizational Development 

The Federal Bureau of Investigation (FBI) was 

responsible for managing the investigation of this 

mishap. The location of the debris pattern on the 

ground in East Texas led to joint jurisdiction being 

shared by the Dallas and Houston Field Divisions of 

the FBI. Soon after the accident, when the FBI learned 

that possible human remains were being discovered 

on the ground, the FBI and NASA jointly decided to 

draw on the valuable experience of the FBI’s Evidence 

Response Teams (ERTs), which follow established 

protocols to recover all human remains with dignity. 

Members of these teams had previously participated 

in the Oklahoma City bombing investigation in 1995 

and the September 11, 2001, events at the World Trade 

Center and the Pentagon. The Dallas Field Division 

of the FBI assumed the lead and FBI Special Agents 

Multiple Organizations Contributed to 

the Search for and Recovery of the 

Human Remains of the Columbia Crew 

Federal Bureau of Investigation (FBI) 


Federal Emergency Management Agency (FEMA) 


Environmental Protection Agency (EPA) 


White House Liaison Office 


NASA Centers (including Ames Research 


Center, NASA Headquarters, Johnson Space 

Center, Kennedy Space Center, and Marshall 

Space Flight Center) 

Texas Army National Guard 


Texas A&M Forest Service 


Native American search teams 


Air Land Emergency Resource Team 


Local citizens of Sabine and San Augustine 


Counties (including the cities of Hemphill, 


San Augustine, and Lufkin) 


Department of Public Safety (Texas Police) 


Local Fire Departments 


Lufkin Civic Center 


Lufkin Mortuary
 

Carroway-Claybar Funeral Home
 

The Salvation Army 


McDonald’s Restaurant (Lufkin)
 
SECTION 2 – THE RESPONSE 19 

from Dallas, Houston, and Lufkin were the principal 

field operatives. Special Agent Mike Sutton from the 

Houston Field Division coordinated the ERT operations. 

With knowledge and experience in disaster recovery, 

these ERTs made effective decisions in organizing and 

conducting the recovery operations. The FBI provided a 

well-functioning operation with exceptional personnel. 

NASA will always remember their valuable, selfless, 

and dedicated contributions. 

The Federal Emergency Management Agency (FEMA) 

was responsible for managing the crisis. Through 

mutual assistance agreements, FEMA provided funding 

and logistical support to enable the FBI to conduct the 

investigation and multiple agencies to recover the debris. 

The Environmental Protection Agency (EPA) was 

responsible for the safe recovery of hardware debris. 

EPA officials postponed hardware recovery to allow 

time for each piece of hardware to be assessed for 

contamination with toxic fuel and oxidizer from the 

propulsion systems in the Space Shuttle. For three 

days after the mishap, local sheriff, police, and fire 

department personnel guarded the locations of debris 

until each item was determined by EPA officials to be 

uncontaminated and safe for collection. Initially, NASA 

search leaders decided that, although the contamination 

analysis might delay the recovery of human remains, the 

delay was acceptable to reduce risk to personnel. 

On the third day of the search (February 3), the search 

leaders determined that the contamination-analysis 

process was inefficient and that the officials who were 

guarding the hardware were needed to accelerate the 

search for human remains. Because NASA personnel 

could accurately identify which items of debris were 

not part of the propulsion systems and were free 

from contamination, the EPA agreed to allow NASA 

personnel in the field to designate the debris items 

that were safe for collection by the search teams. The 

efforts to recover hardware debris and human remains 

safely proceeded in parallel without waiting for 

contamination analyses. 

Selecting Command Centers 

Three types of command centers—strategic, tactical 

and forward—were established according to operational 

requirements and locations. First, a strategic command 

center was created at Barksdale Air Force Base (AFB) 

in Shreveport, Louisiana. This became the center of 

operations for FEMA management activities and the 

Command Centers 

According to the operational requirements, three 

types of command centers were needed in the 

locations described: 

Strategic Command Center – Barksdale Air Force 

Base (AFB), Shreveport, Louisiana, was chosen 

as the major command center for the hardwaredebris recovery operations. This was a large base 

located near the debris field, chosen because 

the US Air Force personnel on site were able 

to provide logistical, operational, and medical 

support for the recovery team. 

Tactical Command Center – The directors of the 

search needed to be close to the search teams 

that would be deployed into the recovery field, 

so the Lufkin Civic Center was selected as the 

Tactical Command Center for the human remains 

recovery operation. The large, open space in 

the building was quickly arranged to allow the 

organizational leaders of the various agencies to 

have line-of-sight and direct physical access to 

each other while decisions were made in the early 

stages of team formation. 

Forward-Deployed Execution Posts – Two smaller 

forward posts were needed in the field for staging 

and briefing the search and recovery personnel. 

These were the areas where the operational 

plan, generated at the Lufkin Tactical Command 

Center, was disseminated to the search team 

leaders before the teams deployed into the field to 

execute the search and recovery operations. 

hardware-debris recovery, and the mortuary for the 

human remains. Barksdale AFB was located close to 

the debris field, and the US Air Force personnel on site 

provided the logistical, operational, and medical support 

for the recovery team. 

On the first day of operations (February 1), the recovery 

team determined that the planning and coordination 

of the search and recovery activities should take place 

much closer to the field operations. They chose the 

Lufkin Civic Center as the tactical command center for 

the human-remains recovery operation. 

On the basis of their extensive past experience 

with large-scale disaster operations, FBI personnel 

recommended that the operational team use a large, 

open room for the managers to establish the search 

and recovery planning and coordination activities. 
20 SECTION 2 – THE RESPONSE

The Lufkin Civic Center was the Tactical Command Center for the human remains recovery operation. 

The Lufkin Civic Center had an acceptable area on 

the main floor and this space was configured quickly. 

The team arranged multiple tables to allow the 

organizational leaders of the various agencies to have 

line-of-sight and direct physical access to each other 

while decisions were made in the early stages of team 

formation. NASA installed a computer local area 

network and telephones to improve communication 

and coordination early in the operation. The leaders 

developed and directed the operational plan for the 

search and recovery of human remains at this tactical 

command center in Lufkin, Texas. 

Early in the search effort (February 3) the leaders decided 

that two forward-deployed execution posts were needed 

in the field for the personnel performing the search and 

recovery operations in the two Texas counties of Sabine 

and San Augustine. As the third type of command center, 

these forward posts became staging and briefing areas 

for the thousands of volunteer workers involved in the 

search efforts. The Lufkin Tactical Command Center 

generated the operational plan for the field leaders at 

these sites, who then created field plans which were 

given to individual teams before they deployed into the 

field to conduct the search and recovery. 

Communications were challenging at the beginning 

of the operation, as coverage for cellular phones 

was intermittent in the remote and hilly areas of the 

search corridor. Local mobile transmitters for radios 

were transported to San Augustine and Hemphill, 

Texas, to create improved and nearly continuous 

radio communications coverage for the search teams 

in the field. 

Establishment of the Operational 

Leadership Team 

The senior NASA official at the Lufkin Tactical 

Command Center was David King, from the NASA 

Marshall Space Flight Center. King became the Search 

Director and was accountable for all aspects of the 

recovery of the human remains, including coordination 
SECTION 2 – THE RESPONSE 21 

with executives at NASA and other federal agencies. 

To execute the operational aspects of the mission, 

King appointed astronaut and US Navy Captain James 

Wetherbee as the Operational Search Director to be 

responsible for creating and executing the search and 

recovery plan. Wetherbee was the senior representative 

from the Flight Crew Operations Directorate at NASA, 

Management Positions 

A military style of leadership, management, 

command, and control contributed to the success 

of this mission, which had simultaneous needs 

for centralized and decentralized decisions. The 

following managerial positions were created to 

lead the teams in the search and recovery effort: 

Search Director – responsible for establishing 

the organization and accountable for all aspects 

of the recovery of the human remains, including 

coordination with executives in NASA and other 

federal agencies. 

Operational Search Director – responsible for 

creating and executing the search and recovery 

plan, including the associated operational 

decisions involving the activation and deployment 

of the recovery teams, the methods used 

and locations designated for the search, the 

process and procedures used for the recovery 

and transportation of the human remains, the 

termination of the search, and the post-search 

activities for transition and closeout of operations. 

Ground Operations Officer – responsible for 

developing an operational plan for ground search, 

and coordinating with the different search groups 

to execute the plan each day. 

Air Operations Officer – responsible for developing 

and coordinating an operational plan with all the 

organizations that were offering airborne platforms 

and sensors for use in the search efforts. 

Forward Coordinator – responsible for 

disseminating the operational plan to the search 

team leaders at the Forward Deployed Posts 

before the teams went into the field to execute the 

search and recovery. 

Administrative Officer – responsible for decisions 

regarding the assignment of astronaut support 

personnel, local transportation, lodging, and 

supplies. This officer developed a file system 

for records and arranged the installation of a 

computer network and printer. 

and was responsible for operational decisions involving 

the activation and deployment of the recovery teams, the 

methods used and locations designated for the search, 

the process and procedures used for the recovery and 

transportation of the human remains, the termination of 

the search, and the post-search activities for transition 

and closeout of operations. 

At the start of the operations, the NASA Search 

Directors established a military style of leadership, 

management, command, and control. Astronaut John 

Grunsfeld, PhD, became the Ground Operations 

Officer in the Lufkin Tactical Command Center, and 

was responsible for developing the tactical groundsearch plans from the operational plan and coordinating 

with the different ground-search teams that executed 

the plans each day. He received field observation 

information, which was used as planning feedback each 

night to allow the Operational Search Director and the 

leadership team in the Lufkin Tactical Command Center 

to refine the operational plan. The Ground Operations 

Officer also developed the statistical analysis tool 

that was used to refine the search area and predict the 

location of the human remains during the search efforts. 

An Air Operations Officer had the responsibilities of 

developing an airborne-search plan and coordinating the 

flight activities of the organizations that offered aircraft 

and sensors for the search operations. Astronaut and 

US Air Force Colonel Scott Horowitz, PhD, filled this 

position. Horowitz also used his extensive computer 

applications skills to develop an independent mapping 

tool that provided data used in the analysis to narrow the 

search corridor. 

On the third day of the search (February 3), when the 

NASA team created the forward-deployed execution 

posts in Hemphill and San Augustine, Texas, astronaut 

and US Navy Captain Brent Jett became the Forward 

Coordinator in the field. He disseminated the operational 

plan and the tactical field plans from the leadership team 

in the Lufkin Tactical Command Center to the search 

team leaders in the field before the teams deployed to 

execute their search and recovery tactical operations. 

For the support of the astronaut operations in the 

Lufkin Tactical Command Center, astronaut Marsha 

Ivins was designated as Administrative Officer. She 

was responsible for decisions regarding assignment 

of astronaut support personnel, local transportation, 

lodging, and supplies. Ivins organized a system for 

collection and identification of crew-equipment debris 

and a file system for records, and she generated the 

rotational schedule for the field-deployed personnel. 
22 SECTION 2 – THE RESPONSE

Security personnel from NASA Headquarters and the 

Marshall Space Flight Center provided protection for 

all facets of the operation, including security of human 

remains in the field, record keeping and protection 

of sensitive medical and operational data, and the 

dignified transportation of remains to the temporary 

mortuary at Barksdale. In addition, the security 

personnel from Marshall Space Flight Center supplied 

the cellular phones that were needed to ensure that 

secure communications were always available to 

participating agencies. 

Readiness of Astronaut 

Support Personnel 

As the recovery plan took shape, the NASA Search 

Directors decided that astronauts would provide 

leadership support to the deployed teams in the field. 

Because of the expected psychological difficulties of 

recovering the human remains of fellow astronauts, the 

Operational Search Director established a requirement 

that all astronauts directly involved in the recovery 

operations should return to Houston after a maximum 

of three continuous days of operations in the field. The 

Administrative Officer developed the schedule and 

coordinated with the Astronaut Office at Johnson Space 

Center for personnel rotation into and out of the field. 

Astronauts filling management positions were needed 

to stay in the Lufkin area and support the effort for 

periods longer than three days. Because of the stressors 

involved, these management astronauts were prohibited 

from participating in the search and recovery operations 

in the field. 

When support astronauts arrived for duty at the Lufkin 

Tactical Command Center, the Operational Search 

Director provided briefings on personnel safety, 

the organizational structure, chain of command, 

responsibilities in the field, and potential psychological 

effects, and a description of the coordination required 

Briefing for Arriving Astronauts 

The readiness of newly assigned astronauts to support the search and recovery mission was enhanced by 

setting clear expectations. To set expectations effectively while verifying understanding, and to create a 

common framework for operating, the Operational Search Director provided a briefing to astronauts arriving 

for duty at the Lufkin Tactical Command Center. The briefing contained the following items: 

Organization – A description of the organizational structure and chain of command, and an explanation of the 

various organizations that were supporting the search. 

Operations – A description of the search operations and what to expect after receiving tasking orders. This 

included a safety briefing for operations in the field, a description of the search teams, tasking that might 

be expected, transportation to the search area, search methods, description of terrain and weather, and 

cleanliness precautions for eating in the field. 

Responsibility – A statement of the search and recovery team’s responsibility to recover the human remains 

of the Columbia crew with dignity, honor, and reverence, and guidance detailing the methods and procedures 

used during recovery and transportation to the temporary morgue. 

Psychological Support – A brief description of what the astronaut would likely see in the field, and some 

suggested psychological techniques to use upon recovery of human remains. 

Communications – The communications protocols, including cell phone or radio operations, call signs and 

personnel, information required and desired, check-in and periodic status reports, and the methods used to 

rigorously control the transmission of information because of the highly sensitive nature of the search results. 

Administrative Items – Information on lodging, transportation, meals, search and debriefing times, possible 

press coverage, and tour of duty length (three days maximum). 

Out-briefing – An explanation of the requirement to check in with the Johnson Space Center space medicine 

psychiatrist after returning to Houston at the completion of the astronaut’s three-day tour of duty, regardless of 

self-perceived psychological fitness. 

Security – A description of the security protocols used and personnel assigned to help with transportation of 

suspected human remains. 
SECTION 2 – THE RESPONSE 23 

 – 

for the various organizations supporting the search. 

Each astronaut team leader was made aware of 

individual responsibilities and orders within the 

operation as a whole. The safety briefings included 

information about field operations and hazards, a 

description of the terrain, and precautions for working, 

eating, and operating in the field environment. 

Significant effort was spent in the orientation briefings 

on the safety, decision-making, and emotional aspects 

of the search, to prepare newly arriving astronauts 

for the challenges of search and recovery of the 

human remains of fellow crewmembers that had 

been subjected to hypersonic reentry of the Earth’s 

atmosphere from space. 

The astronaut team leader provided each team member 

a clear statement of responsibility for the dignified 

recovery of all human remains, particularly detailing 

methods and procedures used during recovery and 

transportation of remains. This statement included 

communications protocols such as mobile phone and 

radio etiquette, call signs of teams and personnel, 

information required and desired, status reports, and 

methods used to transmit highly sensitive information. 

All astronaut volunteers also received a briefing on the 

nature of the psychological stressors involved in such 

an operation. Early in the recovery efforts, to reduce 

potential emotional stress, the Operational Search 

Director suggested to the support astronauts (as well 

as other volunteers) that they try not to think about 

identifying the remains but rather try to think of all the 

remains as being part of the Columbia crew. Many of 

the support astronauts appreciated this technique and 

found it helpful. 

All personnel who supported the human remains 

recovery operations had to make critical decisions 

while demonstrating great composure and distinction 

in their actions. They accomplished their mission 

under difficult environmental, physiological, and 

psychological conditions. The tireless efforts and 

leadership skills displayed by the astronauts who 

participated in the search and recovery process led to 

the success of the search and recovery operation. 

Development of the Search and 

Recovery Plan 

The initial phase of developing the search and recovery 

plan consisted of the activation of the command 

centers, the identification of available personnel and 

other assets, and the establishment of communication 

and protocols for transferring information. Immediate 

concerns for the safety of all personnel were identified 

and addressed before further actions were taken. In 

this initial phase, personnel were deployed to multiple 

locations in the predicted debris field to gather 

intelligence information to help shape the development 

of the operational plan. 

On the basis of what was observed in the field, the 

operational leaders at the Lufkin Tactical Command 

Center developed the search and recovery plan and 

filled management positions within the organizational 

Guidelines for Making Decisions 

To succeed in this demanding and complex 

search and recovery effort, which extended over 

thousands of square miles, leaders had to make 

correct decisions. Some operational decisions 

were centralized, whereas others needed to be 

decentralized and made quickly by distributed field 

leaders. The following guidelines helped the search 

and recovery leaders to make effective decisions: 

Mission Statement – We must recover the human 

remains of the Columbia crew with dignity, honor, 

and reverence. 

Timeliness – We must find the human remains 

quickly, because of the dual responsibilities 

we feel to satisfy the shared human value of 

recovering remains and to preserve the possibility 

of learning forensic information that might benefit 

future spaceflight crews through designing 

improvements in space vehicles. 

Integrity – To inspire the highest integrity in 

decision-making, we will follow an “8, 8, 8 Rule” 

a reminder that “8 days, 8 months, and 8 years 

from now, we must be able to live with the 

consequences of the decisions that we will make 

in the field, so every decision must be based 

on our highest judgment using our greatest 

professionalism and human values.” 

Search Area Collapse – We will not reduce the 

size of the search area until all members of the 

leadership team are confident, on the basis of 

technical analysis and justifiable rationale, that the 

reduced area still contained all the human remains. 

Data – To prevent being misled by any theories 

about how Columbia broke apart in the upper 

atmosphere, only the ground-truth data of 

confirmed locations of human remains will be 

used to reduce the size of the search area. 
24 SECTION 2 – THE RESPONSE

hierarchy. Simultaneously, the leaders designed a 

continuous improvement process for the plan. As 

information was reported from the field to the command 

centers, the search and recovery plan was adjusted 

and refined for more effective operations. Planning 

sessions were held each evening after sunset when the 

field team leaders returned, and tasking was revised for 

the operations on the next day. The field team leaders 

provided valuable feedback to improve the quality of 

the plan. A great deal of trust and respect developed 

among the operational management team. Over the 

12 days after the mishap, this integrated and dedicated 

team led 2,000 people in successfully recovering the 

human remains of the Columbia crew. 

Defining the Search Area

The impact pattern of Columbia debris was predicted 

by radar tracking of the falling debris. The prediction 

covered an area that was 200 miles long and 50 miles 

wide, designated as the initial search area. Local 

citizens reported several sightings of suspected human 

remains at sites in an eastern part of this initial search 

area. Local authorities were dispatched to each of 

these sites to provide security, and the FBI immediately 

deployed their ERTs to document the location and 

condition of any suspected remains. 

On the second day of the recovery effort (February 2), the 

Search Directors concluded that the 10,000-square-mile 

search corridor was too large to search expeditiously. The 

designated search area had to be reduced to a manageable 

size that still contained all the human remains. 

Guidelines for Making Decisions

The Operational Search Director developed several 

guiding principles to help the leaders make the correct 

decisions and to maximize the chances for successfully 

recovering the human remains of the Columbia crew.

Above all, the recovery of the human remains was to 

be accomplished with dignity, honor, and reverence. 

Timeliness of searching was of great importance, not 

only to satisfy the human emotional need to recover the 

remains quickly, but also to preserve the possibility of 

learning forensic information that might benefit future 

GALVESTON

Breton Sound

Atchafalaya

Bay

Vermilion Bay

Galveston Bay

Barataria Bay

Terrebonne Bay

Brazos Lake

Whitney

Colorado

Lake

Texoma

Hugo Lake Saline

Ouachita

Red

Sabine

Trinity Lake

Livingston

Ray Roberts

Lake

Neches

Toledo

 Bend

 Res

Mississippi

Tombigbe

Tombigbee

Pearl

Atchafalaya

Lake

Pontchartrain

Big

Black

Yazoo

Leaf

Ross Barnett

Res

Lake

Jack Lee

Calcasieu

Lake

Grand

Lake White

Lake Sabine

Lake

Lake

Tawakoni

Matagorda Bay

MOBI

BILOXI

NEW ORLEANS

SHREVEPORT

FORT WORTH DALLAS

HOUSTON

SAN ANTONIO

JACKSON

BATON ROUGE

AUSTIN

0 100 200 300 Kilometers

0 100 200 300 Miles

NACOGDOCHES

LUFKIN

CORSICANA

Initial Search Area

Final Search Area

Strategic Command Centers

Tactical Command Center

Forward Execution Posts

Initial Search Area (200 mi × 50 mi). Also shown are the locations of the Strategic Command Centers, the Tactical Command Center, 

and the two Forward Execution Posts.
SECTION 2 – THE RESPONSE 25 

space flight crews through design improvements in 

space vehicles. A deliberate reduction in the size of the 

search area was necessary. This reduction should be 

accomplished only if all members of the operational 

leadership team were confident, based on technical 

analysis and justifiable rationale, that the reduced area 

still contained all of the remains. Also, reduction of the 

search area size should not be based on yet unproven 

theories of how Columbia broke apart and the postulated 

trajectory of human remains. To prevent being misled by 

these theories, only the ground-truth data of confirmed 

locations of human remains was used to reduce the 

size of the search area. Finally, to inspire the highest 

integrity in decision-making, the Operational Search 

Director formulated what was briefed as the “8, 8, 8 

Rule,” a reminder that “8 days, 8 months, and 8 years 

from now, we must be able to live with the consequences 

of the decisions that we will make in the field, so every 

decision must be based on our greatest judgment using 

our best professionalism and human values.” 

Statistical Analysis Used to Reduce 

the Size of the Search Area 

Several hundred suspected remains were found during 

the search. The majority of suspected remains that 

were found were later determined to be from animals. 

Although the DNA results of suspected remains might 

have provided conclusive data during the initial 

search operations to determine accurate search areas, 

these DNA results required several days to generate. 

At the same time, some of the suspected remains had 

the distinctive appearance of human tissue that had 

been exposed to hypersonic descent to Earth. The 

team plotted on a map the locations of these knownhuman remains. Though all potential human remains 

were collected and sent for DNA analysis, those that 

appeared to be from animals were not used in the 

mapping analysis. This statistically based analysis 

allowed the leaders to identify a narrow search corridor 

within the larger hardware-debris field. By the second 

day of search and recovery efforts (February 2), the 

operational leaders made the decision to reduce the 

defined search area to a corridor that was 5 miles wide 

and 60 miles long, centered on a statistically averaged 

straight line along the path of distinctive remains 

recovered in the field. 

For the following two days (February 3–4), teams 

searched designated areas with the highest probability 

of finding human remains expeditiously. These were 

areas with easy terrain, which enabled large regions 

to be covered quickly within the 5-mile-wide corridor. 

Search areas were chosen near previously sighted human 

remains. Because of logistical constraints, the search 

patterns were not changed daily. It took two days to 

redirect the extensive search teams effectively to new 

locations or new strategies. A great deal of effort was 

NACOGDOCHES 

LUFKIN 

TEXAS LOUISIANA 

Sam Rayburn 

Reservoir 

Toledo Bend 

Reservoir 

Second-day Search 

Final Search 

Second-day Search Area (60 mi × 5 mi) and Final Search Area (25 mi × 1 mi). 
26 SECTION 2 – THE RESPONSE

made to ensure that team tasking and search directions 

would not lead to wasted time in incorrect recovery areas. 

After DNA results became available, the operational 

leaders of the search developed higher confidence in 

defining the search corridor. A statistical analysis was 

used to reduce the size of the search corridor to only 

1 mile wide and 25 miles long. The analytical reduction 

was accomplished by using two independent mapping 

models that provided a 95% statistical confidence that 

all remains found in the future would be located within 

the 1-mile-wide corridor. 

Final Adjustment of the Search Corridor 

Several days after the accident, the mishap team 

determined the coordinates of the impact sites for the 

densest parts of the Space Shuttle, the three highpressure turbopumps from the main engines. With their 

high ballistic coefficients and therefore their greater 

ability to overcome air resistance, these turbopumps 

traveled the farthest and were found along the debris 

trajectories farthest east in Fort Polk, Louisiana. 

These locations, and the locations of the human 

remains that had been found to the west, were plotted 

on a map. The next step in the mapping analysis was 

to connect the statistical centroid of the location of 

human remains to the impact points of the turbopumps. 

In a gnomonic projection, all great circle lines are 

depicted as straight, so the connecting line represented 

the accurate ballistic trajectory of the high-speed 

debris and human remains. There was a slight angular 

misalignment between this new accurate ballistic 

trajectory and the previously defined search corridor 

(shown as a red box in the figure), which was based 

on a less accurate mapping analysis using a Mercator 

projection. Without moving the centroid of the 

previously defined search corridor, the azimuth of the 

search corridor was rotated so that it was parallel to 

the accurate trajectory of the high-density turbopumps 

using the gnomonic projection. After this final analysis 

was completed by rotating the search corridor using 

the accurate ballistic trajectory, the operational leaders 

had high confidence that any other human remains 

would likely be found in this final search corridor. 

Search teams were directed to different locations 

corresponding to the slight rotation. 

No further analytical refinement of the search corridor 

was possible statistically. Analyses of the locations 

of human remains resulted in reducing the size of the 

corridor to 1 mile wide and 25 miles long. The ballistics 

analysis fixed the proper azimuth of the corridor. At this 

time, the strategy for the search was changed from a 

targeted search of specific areas within the corridor to a 

comprehensive search of the entire corridor. The Texas 

Army National Guard assisted with the comprehensive 

search strategy by providing necessary additional 

resources in the search and recovery. 

TEXAS LOUISIANA 

Toledo Bend 

Reservoir 

Sam Rayburn 

Reservoir 

5 mi 10 km 

Search Corridor 

Turbopumps Trajectory 

Misalignment of Search Corridor Azimuth. The known trajectory of the turbopumps (blue line) was used to make a final adjustment to the 

misaligned search corridor (red box). 
SECTION 2 – THE RESPONSE 27 

Search Methods 

The fundamental search plan was to use line 

searches with large teams of volunteers, using Global 

Positioning System (GPS) coordinates for tracking 

and documenting the location of any suspected human 

remains. This search method, which used the skills 

and judgment of humans, proved to be the most 

effective. During 12 days of searching, as many as 

2,000 volunteers and Texas Army National Guard 

troops engaged in the line searches. These volunteers 

and troops maintained professional demeanors at all 

times and were dedicated to accomplishing the goal. 

The teams faced difficult challenges during the search 

and recovery effort, including hazardous terrain with 

rocky hills, dense forest, and thicket. In some areas, the 

branches and bushes were so dense that the searchers 

walked no farther than an arm’s length away from each 

other to search the underbrush reliably. When these 

conditions were encountered, the progress of the line 

search slowed significantly. The operational leaders 

appreciated the dedication displayed and personal 

sacrifices made by the search teams. 

Dog teams that specialized in human cadaver 

searches were also used. These teams were sometimes 

successful, but the dogs were occasionally confused 

Volunteers and Texas Army National Guard troops conducted line 

searches for crewmember remains. 

Dense forest and thicket were two of the many challenges encountered by searchers. 
28 SECTION 2 – THE RESPONSE

with false indications from other humans in the area. 

The operational leaders had more confidence in the 

reliability and greater numbers of the human search 

teams operating in long lines to search large areas. 

To develop confidence that human remains were not 

overlooked, the search directors used the dog teams 

effectively to search in expanding spirals around the 

sites of suspected human remains after the recovery 

teams had left the area. 

Horse teams were used to search open areas. Because 

they could cover large areas of territory quickly, this 

search method was used effectively in open areas 

just outside the defined corridor to verify that human 

remains had not fallen outside the boundaries. 

Helicopter spotters were used to identify areas of 

the forest where broken branches in the tops of trees 

indicated possible high-speed impacts of remains. 

Though successful initially in identifying the location of 

some human remains, this technique eventually became 

ineffective after high winds in the area led to extensive 

branch damage unrelated to the Columbia mishap. 

Search helicopters operated from the Angelina County Airport, 

six miles south of Lufkin, Texas. 

After 10 days of searching, a significant amount of 

human remains had not yet been found from one of 

the seven crewmembers. Emotions were strained and 

volunteers felt a strong desire to recover the remains 

of each crewmember successfully and bring closure to 

the search effort. On the tenth day of the recovery effort 

(February 10), more human remains were discovered. 

The team leaders attempted to counsel the groundsearch teams to manage their emotions and wait for 

identification that might confirm the recovery of the 

remains of the seventh crewmember. Unfortunately, 

the erroneous belief had already spread among the 

search teams that the search effort had been completed 

successfully. This created an emotional release that 

had to be reversed after it was communicated to 

the team members that the remains of the seventh 

crewmember had not been recovered. The remains of 

that crewmember were recovered successfully on the 

eleventh day of the search. 

Care of Crew Remains 

Each recovery team included members of the FBI ERTs, 

an astronaut, a religious member (minister, priest, or 

rabbi), a NASA security person, and a pathologist, if one 

was available. Ceremonial last rites were administered 

with reverence in the field. The teams recovered the 

human remains with dignity and used appropriate 

medical precautions. The astronaut and security 

personnel escorted the human remains with honor from 

the field to the Lufkin collection point. At this Lufkin 

facility a medical doctor from JSC Space Medicine 

accepted the crew remains. At the end of each day 

astronaut and security personnel escorted the remains to 

a temporary morgue at Barksdale AFB. 

In the morgue at Barksdale AFB, NASA flight surgeon 

Philip Stepaniak, MD, accepted the human remains. Dr. 

Stepaniak provided leadership for the development of a 

NASA medical contingency plan using lessons learned 

from the NASA Challenger accident in 1986 and the 

TWA-800 airliner accident in 1996. At the Barksdale 

AFB morgue, Dr. Stepaniak and his team enacted 

this contingency plan and made arrangements for 

identification and transportation of the crew remains to 

the Armed Forces Institute of Pathology at Dover AFB. 

With the appropriate honor-guard protocol, the initial 

human remains were placed in seven transfer cases to be 

accepted by the US Air Force and transported to Dover 

AFB on February 5, 2003. The seven transfer cases 

were draped with the national flags of the Columbia 

crewmembers, six Americans and one Israeli. 

The decision of when these initial remains would 

be transported to Dover AFB was challenging, as 

opposing considerations had to be balanced carefully. 

There was a desire to wait until the human remains of 

all seven crewmembers were recovered so that seven 

transfer cases could be sent one time to minimize the 

grieving process for the families and the international 

community. At the same time, there was a conflicting 

desire to transport the recovered human remains as 

soon as possible to the Armed Forces Institute of 
SECTION 2 – THE RESPONSE 29 

Pathology to retrieve forensic information before tissue 

breakdown occurred by natural decomposition. This 

decision was further complicated by the fact that it 

was difficult to know if representative human remains 

had been recovered from all seven crewmembers. 

This information would be available only after DNA 

or dental record analyses could be completed and 

verified, a process that might span several days. Four 

days after the accident, a joint decision was reached 

by Operational Search Director Wetherbee and Dr. 

Stepaniak to send the human remains in seven transfer 

cases, despite the fact that not all human remains had 

been recovered and some had not yet been identified. 

This decision, though difficult, was based on shared 

human values with cognizance of the difficulties faced 

by the grieving families, the NASA community, and the 

public at large. 

Analysis of Remains and 

Dissemination of Data 

On arrival at Dover AFB, the remains were transferred 

to the Armed Forces Medical Examiner. The medical 

examiner and his team performed the forensic analyses 

and transmitted the results of the DNA analyses to 

the NASA Space Life Sciences Directorate at JSC 

for immediate dissemination to the families of the 

Columbia crew. 

The medical examiner also provided the DNA findings 

to Dr. Stepaniak and Director Wetherbee to assist in 

field analysis, planning for search operations, and 

establishment of tasks for the search teams to locate 

additional human remains. The dissemination of 

these results was controlled rigorously. Using a code 

generated by Dr. James Bagian, a former astronaut 

and an advisor to the Columbia Accident Investigation 

Board, encoded results of the DNA findings were 

transmitted by means of a landline telephone from 

Dr. Stepaniak to the Lufkin Tactical Command Center. 

Each specimen was identified using a two-letter random 

code array, which enabled the locations of human 

remains to be plotted on a map without crewmember 

identity. Only Drs. Bagian and Stepaniak along with 

Director Wetherbee possessed the key to the code array 

and knowledge of the identity of all human remains. All 

coded data of human remains were tightly controlled, 

with the location information being separated from any 

database containing hardware or debris information. 

Maintaining confidentiality was not an easy task to 

accomplish; in one instance, a potential breach of 

security was identified when a volunteer-generated map 

containing coded data and location of human remains 

was exposed briefly to the Internet. Data security 

personnel acted quickly to secure the breach, and to 

increase security and control over data release. 

Many search team members, including members of the 

leadership team, expressed a desire to remain insulated 

from identity information about the human remains, 

as they felt that they could not operate effectively if 

they were aware of the location of the identified human 

remains. Among the leadership and search teams, only 

Operational Search Director Wetherbee knew this 

information. But this isolation of information introduced 

a risk that an erroneous decision made by Wetherbee 

in developing the plan would be unchecked by his 

insulated leadership team. To mitigate the potential 

consequences of such an error in decision-making, 

Wetherbee presented the comprehensive search plan 

to Dr. Bagian and included the identities of the human 

remains and how this information was used to refine 

the plan and search for additional human remains. 

Dr. Bagian had performed a similar role as the director 

of the search and recovery efforts for the human remains 

from the Challenger accident 17 years earlier. His 

valuable experience and insightful analysis provided 

the necessary confidence in the Columbia search and 

recovery plans and operations. 

Termination of Recovery Efforts 

The decision to terminate the search for human remains 

of the Columbia crew was difficult. After careful 

consideration, this decision was made according to 

the following rationale. Although the recovery teams 

had not found 100% of the crew remains, a high 

percentage of remains of all seven crewmembers had 

been found and identified. Statistical data indicated 

that any remains that had reached the surface of the 

Earth would likely be located within the 1-milewide search corridor. After 12 days, the corridor 

was searched extensively, along with many of the 

marginal areas in the larger 5-mile-wide corridor. 

The only part of the final search corridor that was not 

searched extensively was a small area of particularly 

dangerous wetlands containing potentially dangerous 

snakes. The search leaders decided this area presented 

an unacceptable risk to the volunteers, and the small 

area was left unsearched. Finally, after observing the 
30 SECTION 2 – THE RESPONSE

intense dedication and willingness of 2,000 volunteers 

to risk personal safety to help accomplish the goal, 

and because the search efforts had been so successful 

until that time, the Operational Search Director made 

the decision to terminate the official search for human 

remains on February 13, 2003. 

After conferring with the Armed Forces Medical 

Examiner and the Mortuary Affairs specialists, who 

had relevant experience investigating aircraft accidents, 

the search leaders anticipated that small amounts of 

human remains might be discovered more than a year 

after this accident. The NASA medical group at the 

Barksdale AFB Strategic Command Center arranged 

with NASA Headquarters, the Office of the Armed 

Forces Medical Examiner, the Armed Forces Institute of 

Pathology, and Armed Forces Mortuary Affairs to have 

a plan, with a contract in effect, for future recovery and 

transportation of suspected human remains that might 

be found. One hour before the active search for human 

remains was officially terminated on February 13, 

FEMA disseminated the forward plan to the local law 

enforcement agencies in the State of Texas. The plan 

provided reporting procedures to follow in the event any 

suspected human remains were found, with procedures 

for the delivery of any specimen to the Armed Forces 

Institute of Pathology. 

Because ground and airborne search teams remained 

in the Lufkin area to search for hardware debris, the 

plan contained a recovery process for human remains 

that was similar to the process that had been in 

effect. If suspected human remains were found by the 

hardware search teams, the Lufkin FBI ERTs would be 

notified immediately and deployed to the field site. If 

they thought it was likely that the remains were from 

the Columbia crew, the Lufkin FBI would call the 

Astronaut Office and a medical doctor would deploy to 

the site to recover and transport the remains to JSC in 

Houston. The Emergency Operations Center medical 

representative and the Flight Medicine Clinic at JSC 

would make arrangements with the Aircraft Operations 

Division at JSC to transport the human remains to 

Andrews AFB, where the remains would be received by 

the Armed Forces Medical Examiner. 

On March 7, 2003, teams that were searching the area 

for hardware debris found a small amount of human 

remains from the Columbia crew, less than one-half 

mile north of the northern boundary of the 1-mile-wide 

search corridor. These were the only human remains to 

be found outside this final search corridor. The remains 

were recovered and transported to Andrews AFB with 

an astronaut escort. Teams searching for hardware 

debris completed their search of the adjacent areas up 

to two miles north of the boundary of the final corridor. 

No other human remains were found. 

Psychological Readiness and Support 

for Astronauts 

Profound psychological consequences must be 

anticipated for search and recovery personnel after an 

event such as the Columbia mishap. In light of initial 

reports of the condition of the human remains found by 

local citizens, the recovery process was predicted 

to be difficult for all involved. Compartmentalization 

was embraced as the best coping mechanism for the 

task, and concentrating on the operational task rather 

than considering the tragic nature of the mishap 

allowed volunteers to operate effectively. Some of 

those who participated in the recovery operation 

decided not to initiate their personal grieving process 

or to attend speeches or memorial services, to help them 

maintain compartmentalization of the psychological 

stress involved. 

Personal Commitment of Volunteers 

Throughout the operation many people made 

flawless decisions and displayed remarkable 

leadership, demonstrating the integrity of 

the individuals involved. Many personal sacrifices 

were made, and the overwhelming dedication 

and motivation of all involved was astounding. 

The personal commitment and selfless efforts of 

the volunteers will long be remembered. 

Acting on a recommendation from Special Agent 

Sutton, coordinator of the FBI ERTs, the Chief of 

the Astronaut Office directed all deployed astronauts 

who supported the recovery operations to have a 

psychological debriefing session with Dr. Chris Flynn, 

JSC space medicine psychiatrist, after returning to 

Houston. Making this debriefing session mandatory 

provided support to all deployed astronauts regardless of 

their self-perceived psychological fitness or willingness 

to request support. Some astronauts did not foresee 

that the session would be valuable. Other astronauts 

may have desired psychological support but chose not 
SECTION 2 – THE RESPONSE 31 

to request such support because they felt embarrassed. 

Ultimately, most of the deployed astronauts considered 

the psychological debriefing to be a positive experience. 

Some members of the space community had advised 

against using active astronauts in the recovery process. 

Leaders of the search effort after the Challenger accident 

had found that adverse psychological effects could 

occur and linger in an astronaut long after the operation 

had concluded, and that these psychological impacts 

might decrease the performance of the individual 

during future flight operations. At the beginning of the 

search operation for the Columbia crew, the potential 

disadvantages were weighed against the value of having 

astronauts with considerable experience, dedication, 

and compassion conduct the challenging mission. 

NASA managers decided that it would be best to allow 

the volunteer involvement of active astronauts in the 

recovery process. If faced with a similar situation in the 

future, managers likely would make the decision to use 

active astronauts in the same way. 

Conclusions 

Because of the momentous nature of the Columbia 

accident, the people who supported this search and 

recovery effort arrived with an innate and clear sense of 

the mission. More importantly, volunteers understood 

that the recovery mission transcended their individual 

desires and motivations, and they came with a pure 

selfless intention to help. Although these factors created 

powerful conditions for success, the leaders of this effort 

nevertheless communicated an explicit mission statement 

to the people and teams. The mission was to recover 

the human remains of the seven astronauts of the Space 

Shuttle Columbia with dignity, honor, and reverence. 

Ultimately, the remains of the seven crewmembers 

of space flight STS-107 were found, ceremonial last 

rites were administered with reverence in the field, and 

astronaut and military personnel escorted the remains 

with honor to the medical examiner at the Armed Forces 

Institute of Pathology at Dover AFB. 

From the beginning of the recovery efforts, the leaders 

of the search and recovery operations observed that 

those who volunteered for this mission embraced the 

highest of personal values. These values were reflected 

in conversations and behaviors conducted with great 

respect and professionalism. The operational leaders 

made explicit the values that were expected of team 

members, with the intention that such personal values 

would be used collectively to guide actions and 

decisions made by all team leaders and individual 

volunteers. Emphasis was placed on the safety of 

personnel and clear communications between leaders 

and team members. Information gathered from the 

field was recognized for its importance and was used 

to improve the quality of the plan, which led to the 

success of the recovery operation. 

Throughout the operation many people made flawless 

decisions and displayed remarkable leadership, 

demonstrating the integrity of the individuals involved. 

While they were in East Texas and Louisiana, NASA 

personnel came to understand how important the Space 

Shuttle Program was to the local area volunteers. Many 

personal sacrifices were made, and the overwhelming 

dedication and motivation of all involved was 

astounding. Out of tragedy came greatness. 
32 SECTION 2 – THE RESPONSE

Mishap Investigation Team 

Medical Efforts for Crew Recovery 

and Identification 

Philip C. Stepaniak, Michael R. Chandler, and Robert Patlach 

The Space Shuttle Program established procedures for 

the Columbia Mishap Investigation Team (MIT) with 

the purpose to gather, guard, and preserve all evidence 

pertinent to the incident; the MIT was not responsible 

for determination of the cause. Team members included 

a NASA flight crew surgeon. This chapter describes the 

NASA flight surgeon’s relationship to the Columbia 

MIT and the team’s efforts to complete the recovery 

of crewmember remains, identify the crewmembers, 

establish accurate communication with the crewmembers’ 

families, and assist the forensic teams. 

Background 

During the advent of the Space Shuttle Program, the 

flight surgeons of the Medical Operations Branch at the 

Johnson Space Center (JSC) in Houston worked together 

with the emergency medical services (EMS) personnel 

at the Kennedy Space Center (KSC), Florida, and the 

Department of Defense (DOD) Manned Space Flight 

Program Support Office (DDMS) at Patrick Air Force 

Base (AFB), Florida, in preparation for a spacecraft 

mishap that could occur during launch or landing. 

After the Challenger accident in 1986 the JSC Space 

Life Sciences Directorate provided an internal report 

on the cause of death of the Challenger crewmembers. 

The lessons learned included the determination that the 

crew should be protected from the possibility of rapid 

decompression and have a means for bailout. 

The Medical Operations Branch assisted the Space 

Shuttle Program in upgrading crew egress, escape, 

and bailout equipment and procedures. For return to 

flight after the Challenger accident, these modifications 

involved the use of a launch and entry partial pressure 

suit and the addition of an emergency mode procedure 

for crew bailout. In 1994, NASA began using the more 

capable fully pressurized advanced crew escape suits that 

were worn by the STS-107 astronauts. 

These additional upgrades in equipment and procedures 

required further training for EMS personnel during 

launch and landing activities. As a result, the Medical 

Operations Branch provided a training course that began 

in 1988. This course was originally taught at JSC; but in 

response to student feedback, the course was later moved 

and taught at each of the primary landing sites within 

the United States. The course was also taught at military 

bases in Europe that supported the Transoceanic Abort 

Landings at the following air bases: Moron or Zaragoza 

in Spain; Istres, France; Ben Guerir, Morocco; or Banjul, 

The Gambia. The primary reason for the change was to 

provide more specific, detailed training that was needed 

for each particular site. 

Since the Medical Operations Branch had additional 

responsibilities related to spacecraft contingency 

operations, they decided to consolidate these efforts 

into a single Contingency Medical Group (CMG) that 

was formed in January 1998. The CMG, serving under 

the direction of the JSC Space Medicine Division of 

the Space Life Sciences Directorate, selected a group 

of flight surgeons involved in space flight operations 

to develop contingency plans and responses, and to 

investigate any NASA aviation or spacecraft mishaps. 

In May 1998, the Aerospace Medical Association 

(AsMA) held its annual conference in Seattle, 

Washington. During this conference, a panel presentation 

and discussion was held on the 1996 crash of TWA 

flight 800 (Boeing 747) in the Atlantic Ocean. The panel 

members specifically discussed the medical and legal 

challenges of the mishap investigation and the interaction 

of the many federal and local agencies involved. 

Participants in this discussion were members of the 

National Transportation Safety Board (NTSB), the FBI, 

the US Coast Guard, the US Navy, and New York State 

authorities from the Suffolk County medical examiner’s 

office. The Joint Committee on Aviation Pathology of the 

Armed Forces Institute of Pathology (AFIP) provided 

detailed forensic analysis. At this lecture they discussed 

the recovery of wreckage and human remains from the 

ocean, processing of remains, and DNA identification 

of fragmented and decomposed tissues. Members of the 

CMG attended this session and were impressed by the 

efforts that had gone into the TWA 800 investigation, 

recognizing their relevance to space flight operations. 

Upon hearing of the efforts of the AFIP after the TWA 800 

crash, the CMG brought this information to the attention 

of the Medical Operations Branch, which subsequently 
SECTION 2 – THE RESPONSE 33 

arranged a tour of the AFIP Port Mortuary at Dover AFB, 

Delaware, in 1999. NASA flight surgeons, an astronaut 

representative, contingency personnel from both JSC and 

KSC, and medical personnel from the DDMS attended 

this meeting, which included the Office of the Armed 

Forces Medical Examiner (OAFME) and the Office of 

Mortuary Affairs at Dover AFB. 

During this visit, CMG personnel toured the facilities 

in which the processing of human remains occurred 

as well as areas where the deceased were prepared for 

burial. Over the course of the visit, discussions with 

the AFIP included spacecraft contingency scenarios 

that could occur during launch, on orbit, and during 

reentry and landing, and how such scenarios could be 

handled with the resources at the OAFME. Services 

discussed included air transportation of remains to 

Dover AFB, postmortem examinations, reprocessing of 

remains, and air transportation to a location designated 

by the next of kin or other legal authority. JSC’s Space 

Medicine Division would provide all support materials 

including medical, dental, and DNA records as well 

as radiographs and consent forms. Although no formal 

written agreements were produced at this meeting, oral 

agreements were reached to include the assistance of 

the AFIP in the case of a space-related disaster. At the 

same time, contingency medical team members were 

able to coordinate their efforts and skills to develop an 

enhanced approach for any future spacecraft mishap. 

The Mishap – Initial Activation of the MIT 

On February 1, 2003, the Mission Control Center 

(MCC) in Houston lost the signal from Columbia 

at 08:59:32 a.m. CST during its reentry over Texas. 

Shortly thereafter, the entry flight director had the 

MCC secured and in lockdown. All calls from inside 

the MCC to outside lines were disabled, but incoming 

calls were allowed. Richard McCluskey, MD, was the 

flight surgeon on console in the MCC at the time of the 

mishap. Members of the CMG reported to the Action 

Center in the MCC, where the Space Shuttle Mission 

Management Team (MMT) was meeting, to quickly 

begin preparations to activate the MIT for search and 

recovery efforts led by David Whittle. The atmosphere 

at that meeting was solemn, with conjecture regarding 

the mishap very much present. As the formal meeting 

began, managers called for an end to speculation, 

requesting that all involved focus instead on the 

recovery of the crew and the vehicle. It was at this time 

that team members officially learned that the crew had 

perished during the high-altitude breakup of the orbiter 

Barksdale Air Force Base, home of the Eighth Air Force, was the 

strategic site for the Columbia Mishap Investigation Team. 

Columbia over Texas. Exact details of the altitude, speed 

of the breakup, and location of the debris field were later 

provided by the Department of Defense (DOD). 

During this initial meeting of the MMT, managers 

discussed potential staging of the recovery operation 

at various locations in Texas and Louisiana. Multiple 

locations around the debris field were discussed, with 

security and transportation constituting the major 

concerns. Staffing of the MIT was also discussed and 

decisions had to be made, particularly regarding the 

choice of the medical support team members. Standard 

operating procedure called for the primary and deputy 

mission crew surgeons (Smith Johnston, MD, and 

Stephen Hart, MD), the physicians assigned to the crew 

throughout their training, to act as the primary medical 

members of the MIT. However, these physicians were 

at KSC with the crew families at the time of the mishap 

and were occupied by caring for family members in the 

wake of the disaster. Since these physicians were well 

known to the families and had close personal bonds 

with the crew, the Space Life Sciences Directorate 

recommended that these physicians remain at KSC with 

the crew relatives. Instead, members of the CMG, Philip 

Stepaniak, MD, NASA flight surgeon, and Michael 

Chandler of Wyle Laboratories Inc., Houston, space 

flight medical contingency coordinator, were appointed 

as medical representatives to the MIT. Space Medicine 

Division management, with concurrence from the 

Space Life Sciences Director, provided a single point 

of contact to disseminate information to all levels of 

management, thus releasing the flight surgeon at the 

MIT location to focus on recovery and identification. 

By 11:30 a.m. CST, the MMT decided to stage recovery 

efforts at Barksdale AFB, Louisiana. This location was 

north of the main debris field, but was selected as the 

best choice because of its security and capabilities for 

rapid air transportation in multiple types of aircraft. 
34 SECTION 2 – THE RESPONSE

Medical members of NASA MIT at Barksdale Air Force Base confer with military officers of the DDMS. 

At the same time, NASA established a Disaster Field 

Office (also called the Tactical Command Center, 

headed by astronaut James D. Wetherbee) in Lufkin, 

Texas, for the recovery of human remains because 

of its proximity to reports of remains in the area. 

By 3:30 p.m. CST that day, the advance MIT members 

were flying from Ellington Field in Houston to 

Barksdale AFB. During the flight to Barksdale AFB, 

Stepaniak and Chandler carefully reviewed the 

contingency action plans for space operations while 

preparing for the recovery effort ahead. The 2nd Bomb 

Wing Vice Commander, Col. Charles McGuirk, met 

with the MIT members around 4:30 that afternoon. 

Despite concurrent operations at the base, specifically 

ongoing preparations for an international conflict 

with Iraq, Col. McGuirk informed the MIT that the 

base would offer full support for their efforts. 

Barksdale AFB personnel immediately provided 

resources for the establishment of MIT operations, 

including office space, transportation, local lodging, 

communications, and computers. 

The MIT medical representatives were next introduced 

to members of the Barksdale Flight Surgeons Office, 

US Air Force flight surgeon Col. Jerry Owens and the 

Squadron Services Mortuary Affairs Officer, Maj. John 

Ogden. Representatives from the NTSB and OAFME 

flight surgeon US Navy CAPT Douglas Knittel, MD, 

were also present for assistance, given the extreme 

nature of the accident and the extensive debris field. The 

medical representatives discussed the operational plan 

with these individuals, particularly regarding personnel, 

equipment, procedures, and communications. These 

discussions took place amid a nearly continuous stream 

of incoming calls from the Lufkin Disaster Field Office 

and JSC, as team members at these locations raced to 

establish an operational plan. 

One of the first challenges faced was the designation 

of a hierarchy, particularly as medical team members 

were acutely aware of the need to control the flow of 

information regarding human remains recovery. Jeffrey 

Davis, MD, the director of the JSC Space Life Sciences 

Directorate, became a single point of contact for the 

medical teams, to avoid confusion and the inadvertent 

release of private crew-related information. Throughout 

this period, local citizens made multiple calls about 

possible human remains and toxic debris sightings. 

It was quickly realized that search and recovery 

team members and civilians alike would need clear 

information about procedures for handling both human 

remains and toxic debris. 

On the evening of February 1, Dr. McCluskey, NASA 

flight surgeon and pathologist, and Robert Patlach, 

space flight medical contingency coordinator, deployed 

to Lufkin. They met with astronaut physician Dafydd 

(Dave) Williams, MD, and FBI Evidence Response 

Team members at the office of local pathologist James 

Bruce, MD. Bruce’s office became the initial collection 

point for all recovered Columbia crewmember remains. 

Facility security was provided by the Texas Department 

of Public Safety, the US Marshals Service, and the 
SECTION 2 – THE RESPONSE 35 

DOD Criminal Investigative Service. Plans called for 

remains recovered in the field to be transported to the 

collection point in Lufkin. After preliminary review 

and assignment of tracking numbers, the remains were 

transported to Barksdale AFB. The Batesville Casket 

Company, Batesville, Indiana, donated caskets for 

crewmembers, and the Carroway–Claybar Funeral 

Home in Lufkin donated hearse services. 

Crew Remains Recovery 

As the news media presence grew exponentially the 

next day, Barksdale AFB established enhanced security 

measures at the base to maintain privacy and allow 

operations to proceed unhindered. Simultaneously the 

number of MIT personnel numbers increased since 

team members had arrived late the night before. The 

atmosphere at the morning operational meeting was 

increasingly intimidating as high-ranking members 

of federal and local government agencies arrived 

to oversee operations. The Federal Emergency 

Management Agency (FEMA), the Environmental 

Protection Agency (EPA), and the NTSB provided 

a number of personnel to support NASA’s recovery 

efforts. The lead of the MIT, David Whittle, began the 

meeting by stating that the primary mission of the field 

teams was to collect all human remains, vehicle debris, 

and evidence for transport to the MIT at Barksdale AFB 

and from there, to final locations for analysis. 

As the meeting concluded, medical team members 

gathered with all personnel participating in human 

remains recovery activities. This medical assembly 

consisted of personnel from the AFIP; DOD; NTSB; 

EPA; FEMA; FBI; KSC Security; the Barksdale Flight 

Surgeon’s Office, Mortuary Affairs Office, Security 

Office; JSC Public Affairs Office, Legal Affairs Office, 

Photography, and Aircraft Operations. This initial 

meeting served the important purpose of ensuring that 

all team members were known to one another for the 

difficult operation ahead. Working with the Lufkin 

Tactical Command Center, Stepaniak defined the 

plan for the recovery of crew remains in the field and 

transportation of the remains to an initial collection 

post in Lufkin, then to a temporary morgue facility at 

Barksdale AFB for identification, and finally to Dover 

AFB for analysis and for release of remains to the 

crewmembers’ families. 

Afterward, the day was filled with multiple activities 

needed to prepare Barksdale AFB for the receipt of 

remains. First, Stepaniak contacted the JSC Flight 

Medicine Clinic to request the crewmembers’ medical, 

dental, and DNA records that were essential for 

February 2, 2003 – First recovered remains transfer from Lufkin, 

Texas, to Barksdale Air Force Base in Louisiana. 

This facility at Barksdale Air Force Base served as the 

temporary morgue. 

identification; these records were delivered to the 

Barksdale AFB Mortuary Affairs Office for safekeeping. 

Later that afternoon, two Blackhawk helicopters 

provided by the Texas National Guard transferred the 

initial set of remains from the Lufkin collection point to 

Barksdale AFB. These helicopters arrived at Barksdale 

AFB about 5:00 p.m. CST on February 2, with the 

remains being escorted by the OAFME advance team 

under the lead of US Navy CDR Craig Mallak, MD, 

Armed Forces Medical Examiner, and accompanied 

by US Navy CDR James Caruso, MD. A military 

honor guard protocol was instituted for the transfer of 

these remains to the temporary morgue facility. 

All subsequent remains were transported by ground 

convoy with a security escort from Lufkin to Barksdale 

AFB at the conclusion of each search day. Stepaniak 

also met with Dr. James Bagian, the medical consultant 

to the Columbia Accident Investigation Board, who 

was briefed on NASA MIT medical operations. Bagian, 

together with Wetherbee, later revised the plan for 

locating and recovering the crewmember remains. 
36 SECTION 2 – THE RESPONSE

Public Misconceptions 

On the evening of February 2, Whittle and other senior 

management of the MIT told Stepaniak that they had 

received a call from the Governor’s Office of the State 

of Texas about concerns that remains had not yet been 

recovered, requesting an explanation for the apparent 

delay. It became known that the Governor’s Office 

was receiving numerous calls from citizens regarding 

their willingness to help with recovery efforts. The 

Governor’s office was concerned that these reports 

did not seem to generate an immediate response 

from NASA officials. It was clear that the public was 

unaware of the scope of the operation. Because the 

initial debris field included an area of about 10,000 

square miles with dense foliage and hazardous terrain, 

recovery team efforts were simply dwarfed by the 

magnitude of the mission. 

At the same time in various offices, misunderstandings 

occurred about the nature of the mishap, with concern 

that foul play or acts of terror were involved in the 

orbiter’s destruction. NASA was forced to recognize 

the need for better distribution of information, and set 

about reassuring the public that Columbia had been 

destroyed because of a mechanical accident with no 

acts of terror involved, and that recovery teams were 

exerting every effort to promptly and appropriately 

recover all remains and debris while ensuring the safety 

of those searching. 

Recovery and Identification of 

Human Remains 

The primary mission of the MIT medical team was to 

receive, identify, preserve, and transport human remains 

to the AFIP at Dover AFB. At the same time, the recovery 

of initial remains gave significant insight into the nature 

of the accident and provided some understanding of 

the forces involved in the crewmembers’ deaths. First, 

it was noted that none of the remains were recovered 

with any donned life-support equipment, such as their 

reentry suits. From this observation, it became clear that 

the shear forces involved at the speed and altitude of the 

breakup caused all life support equipment to be torn away 

from the bodies. 

Patterns of injury were observed, including multipleforce trauma. It was later determined that these patterns 

Crewmember remains and life-support equipment were found within a corridor in East Texas that was approximately 30 statute miles long 

and 2 statute miles wide. 

TEXAS LOUISIANA

Toledo Bend 

Reservoir 

Sam Rayburn 

Reservoir 

TEXAS LOUISIANA 

ACES - Advanced Crew Escape Suit 

EOS Bottle - Emergency Oxygen System Bottle 

AGS/PCA - Anti G-Suit/Pressure Control Assembly 

PRC-112 - Personal Communications Radio-112 

ACES 02 QD - ACES Oxygen Quick Disconnect 

Helmet 

Helmet 

Helmet 

Helmet 

Helmet 

Helmet 

Helmet 

ACES 

Relief 

Valve 

Left Wrist 

Disconnect 

Crewmember 

ACES 02 QD 

Crewmember 

Crewmember 

Crewmember 

Crewmember 

Crewmember 

Crewmember 

Crewmember 

EOS Bottle 

AGS/PCA 

EOS Bottle 

PRC-112 

PRC-112 

PRC-112 

5 mi 10 km 
SECTION 2 – THE RESPONSE 37 

were caused by seating arrangements on the two decks 

of the crew compartment, with crewmembers being 

exposed to certain types of injuries according to their 

location within the compartment. It was also noted that 

all remains had a pachydermic appearance, indicating 

exposure to the severe thermal insults and low pressure 

conditions of extreme altitude during reentry. 

All crewmembers were identified by dental forensics 

and DNA analysis. Through the use of dental records 

provided by the JSC medical clinic, the remains of five 

crewmembers were formally identified by February 4. 

A sixth crewmember was formally identified by dental 

records on February 11, and the final crewmember 

was formally identified on February 12, 2003. All 

identifications of disassociated crew remains were 

confirmed by the use of DNA analysis conducted at the 

OAFME Rockville, Maryland facility. 

Throughout the recovery and identification of human 

remains, it became apparent that the contingency medical 

group required additional personnel. Peter Bauer, MD, 

NASA flight surgeon, Mark Swann, space flight medical 

contingency coordinator, Wyle, and Richard Pettys, 

advance projects engineer, Wyle, provided operational 

and data management support. 

Providing Information to the Families 

Family members returned to Houston from KSC the 

afternoon of the mishap, and awaited information 

about their loved ones. The MIT medical representative 

provided identification information to the mission crew 

flight surgeons, who had close bonds with both the 

crewmembers and their families. These mission crew 

flight surgeons, Drs. Johnston and Hart, coordinated 

with the Casualty Assistance Calls Officers (CACOs), 

astronauts assigned to assist the family in the case of a 

disaster. To prepare for this exchange of information, 

on February 3, the MIT medical lead and the OAFME 

lead held a teleconference with Johnston and Wetherbee 

to discuss the duties of the CACOs and the flow of 

information to the families. These conferences were 

repeated daily, and information was provided to the 

crew flight surgeons and CACOs, who ensured that the 

families had the most accurate and complete information 

available regarding recovery efforts and dispelled any 

rumors reported by the media or the general public. 

As crewmembers were identified, the mission crew 

flight surgeons along with the CACOs notified the 

families. Once OAFME completed the forensic analysis 

of the remains, the Dover Mortuary Affairs Office 

coordinated with family members, again with the help 

of the crew flight surgeons and CACOs, to prepare 

the remains for burial or cremation and return them 

to their families. A unique approach was required for 

Ilan Ramon, the Israeli astronaut, to respect cultural 

sensitivities and religious preferences. An Israeli flight 

surgeon and rabbi, Col. Ahron Zwi Black, MD, arrived 

at Barksdale AFB on February 3 to observe MITOAFME operations and to ensure that cultural and 

religious customs were followed. US Navy CAPT Rabbi 

Harold Robinson assisted Black, who later accompanied 

the remains when they were transported by aircraft to 

Dover AFB and oversaw the final disposition of this 

crewmember’s remains. 

Transfer of Remains 

Multiple challenges were involved in the transfer of 

human remains from Barksdale AFB to Dover AFB. 

First was the issue of timing since the OAFME staff at 

Dover AFB needed to receive the remains and tissue 

samples as quickly as possible to assist with their 

forensic analysis before valuable evidence was lost to 

degradation. At the same time, it was important that the 

remains be transported with dignity, honor, and respect, 

for the families’ sake, in as few shipments as possible. 

Pathologists provided tissue samples taken from all 

recovered remains, and the samples were flown on a 

NASA T-38 to Andrews AFB for immediate delivery to 

OAFME at its Rockville, Maryland, facility for DNA 

analysis. The first shipment occurred on February 3. On 

February 5, seven transfer cases containing the majority 

of the recovered remains were sent with military honors 

by an Air Force C-141 aircraft to Dover AFB. These 

transfer cases were accompanied by Dr. Black; US Air 

Force Col. Rex Walheim, NASA astronaut; and Craig 

February 5, 2003 – Seven transfer cases containing Columbia 

crewmember remains were transported to Dover Air Force Base. 

Israeli Col. Rabbi Black and US Navy CAPT Rabbi Robinson provided 

a blessing for the fallen astronauts. 
38 SECTION 2 – THE RESPONSE

 

 

 

 

 

Honor guard protocol for the Columbia crewmembers at Barksdale 

Air Force Base. 

Fischer, MD, from JSC Space Life Sciences Directorate, 

along with the OAFME advance team. OAFME 

provided duplicates of all reports and photographs on 

a compact disc to the JSC medical MIT. Astronauts 

US Navy CAPT Barry Wilmore and US Navy CAPT 

Kenneth Ham escorted the subsequent transfers to 

Dover AFB on February 11 and 12, respectively. 

In addition to the remains, search teams found debris 

from parts of crewmembers’ reentry suits that they had 

been wearing. Debris included helmets, suit parts such 

as wrist rings, suit oxygen bottles, and radios and other 

equipment. All equipment had identification numbers 

that associated each piece with a particular crewmember. 

This crew life-support equipment was kept with the crew 

remains and transferred to Barksdale AFB and then to 

Dover AFB. JSC engineers from the Crew and Thermal 

Systems Division initially reviewed this hardware at 

Barksdale AFB and then traveled to Dover AFB for 

comparative analysis of the hardware to provide a better 

understanding of the crewmembers’ injuries. 

In addition, the Air Force sent an experienced former 

NASA flight surgeon, Maj. Hernando (Joe) Ortega, 

to Dover AFB to assist with the forensic analysis of 

the human remains and the crew life-support 

equipment. The JSC engineers also provided a 

complete reentry suit (advanced crew escape suit) 

to OAFME as well as technicians and engineers to 

assist with the functional analysis. 

Terminating Operations 

Twelve days after the mishap, all crewmembers had 

been identified and the medical team began the transition 

toward the termination of recovery operations and the 

initiation of a sustainable long-term support plan. The 

MIT management and the JSC Director of Space Life 

Sciences approved a final long-term plan developed by 

the MIT medical representatives, which was subsequently 

distributed to all members of the MIT. This plan also 

established procedures for the handling of commingled 

remains that might be discovered with orbiter debris 

shipped to KSC. The official search for human remains 

terminated on February 13, 2003. Through the JSC 

Emergency Operations Center, the CMG supported 

recovery of human remains until February 22. 

Barksdale AFB information technology personnel, in 

coordination with FEMA personnel, erased all pertinent 

data from the base medical computers. The MIT medical 

lead provided updated schematics of crewmembers’ 

remains to the Lufkin Disaster Field Office so that they 

would have adequate information in case more remains 

were found. The medical team returned to JSC the 

following day to brief JSC management on the status of 

the medical operations and crew recovery efforts. 

Summary: Medical Mishap Investigation 

Team Mission Objectives at Barksdale 

Air Force Base 

The mission objectives at Barksdale AFB were divided 

into primary and additional issues. This division became 

obvious as personnel were working in the field and 

determined that multiple items needed to be addressed 

by the team. These items needed to be coordinated to 

keep members of the team informed and management 

satisfied with the team’s efforts. The primary (#1) and 

additional objectives were as follows: 

1. Receive, analyze, identify, and transport human 

remains to the Armed Forces Institute of Pathology 

at Dover AFB. 

2. Provide assistance in the human remains 

recovery efforts to the prime Disaster Field Office 

at Lufkin, Texas. 

3. Brief the astronaut CACOs and the crew surgeons for 

the STS-107 mission daily so they could inform the 

families with the latest recovery details. 

4. Provide information, plans, and guidelines for 

medical concerns and occupational health care issues 

associated with spacecraft toxic substances to the 

search teams, local physicians, and civilians. 

5. Receive, store, and transport crew life-support 

equipment to Dover AFB for analysis. This equipment 

eventually was transported to Kennedy Space Center. 
SECTION 2 – THE RESPONSE 39 

 

 

 

6. Receive, store, and transport biological payloads from 

STS-107 to the Kennedy and Johnson Space Centers. 

7. Develop long-range plans for human remains 

recovery and transport after departing the base of the 

MIT operations at Barksdale AFB. 

Lessons Learned 

Personnel 

Due to the nature of the mishap, it was appropriate 

to have the mission crew flight surgeons remain with 

crewmembers’ families for medical and psychological 

support rather than reassigning them to investigative 

and recovery roles. Personnel in the CMG proved 

uniquely suited to act as members of the MIT. Initial 

operations were marked by a significant lack of 

necessary support personnel needed for operational 

assistance, record keeping, and similar activities. The 

identification of contingency teams before a mishap 

occurs, with associated training of team members, 

could alleviate much of the burden placed on the MIT 

medical representatives by providing adequate support 

for initial operations. Personnel with expertise in 

computerized mapping and plotting of recovered human 

remains and crew equipment would have provided great 

benefit for a more efficient search. 

The introductory medical team meeting held at Barksdale 

AFB for all individuals involved in human remains 

recovery proved to be extremely valuable. Not only 

did this meeting provide an opportunity to establish 

responsibilities for early, clear coordination of efforts, but 

it also allowed all team members to meet other parties 

involved and understand their roles, leading to smoother 

operations once recovery efforts were underway. 

It was noted that many of the MIT personnel turned to 

the MIT medical representatives for routine medical 

advice. Although this was an understandable occurrence, 

the primary mission of the MIT medical team was 

recovery of human remains, not provision of medical 

care to other team members. Future medical teams must 

consider the health of team members and identify local 

medical care facilities, providing this information to 

their team members. 

Equipment 

Barksdale AFB personnel were extremely helpful in 

providing adequate work space and supplies for the 

initial operations, but it would be desirable in the 

future for team members to deploy with equipment and 

supplies sufficient for the first few days of an operation. 

In particular, dedicated and secure cell phones, a secure 

computer, and adequate office supplies are essential 

to early activities. FEMA provided many of these 

supplies later in the operation, but such supplies are 

needed from the start. 

Procedures 

The serendipitous meeting of the JSC CMG and 

the OAFME and AFIP at Dover AFB in 1999 was 

extraordinarily valuable. This meeting established 

familiarity among the various organizations and 

helped to develop an initial concept of operations. In 

retrospect, however, specific protocols for the handling 

of vehicle debris, crew and personal equipment, human 

remains, and other biohazardous material were lacking. 

In particular, the type of personal protective gear 

needed in any recovery operation and how it will be 

provided should be established so that clear protocols 

and appropriate equipment can be provided to the 

team. Contingency medical personnel who may need to 

respond to a similar future mishap should be aware that 

they will be part of an integrated team that will include 

professionals experienced in photographing, coding, 

and identifying GPS coordinates of any recovered 

debris or remains. 

Chain-of-custody procedures should be well established 

and controlled. This is important both at field operations 

collection points and at temporary morgue facilities. 

Transport of all human remains to the forensic analysis 

facility needs to occur as soon as possible to prevent 

tissue decay and loss of toxic materials by off-gassing, 

so that accurate data can be obtained. Further, procedures 

should be established for the handling of commingled 

human remains discovered within spacecraft debris. 

Honor and respect guided the coordination of 

religious and cultural provisions for the international 

crewmember, and such efforts were greatly appreciated 

by both the family and the international community. 

Similarly, the use of an honor guard protocol for the 

transfer of human remains provided dignity, honor, and 

respect to crewmembers. 

Transitional and long-term plans were carefully 

considered toward the end of the recovery efforts. 

These plans proved to be quite useful and will be 

useful in the future, since additional remains will 

almost invariably be discovered after search and 
40 SECTION 2 – THE RESPONSE

recovery operations are terminated. These plans should 

be coordinated with all members of the MIT and 

supporting agencies. 

Communications 

It was extremely useful to have identified a single 

point of contact in the management chain who was 

responsible for the appropriate dissemination of 

information. This point of contact relieved field team 

members of the responsibility of reporting to multiple 

individuals, ensured that data were not misconstrued 

or distributed to inappropriate parties, and allowed the 

team to focus on recovery tasks. 

Daily briefings with the Lufkin Tactical Command 

Center, the mission crew surgeon, and CACOs enabled 

an effective flow of information to the families provided 

by individuals whom the families knew and trusted. 

This process rallied the families and provided comfort 

in the knowledge that they were receiving accurate and 

verified information directly from the field. 

During the TWA 800 discussion at the AsMA 

conference in 1998, a panelist was asked to identify 

the greatest detriment to the investigation of the 

accident. The panel member responded with the 

memorable statement that political grandstanding 

led to the distribution of unsubstantiated information 

as certain individuals fought for their turn in the 

media spotlight. This false information led to great 

emotional disturbance for family members and the 

public at large, and made the distribution of accurate 

data even more challenging in an already difficult 

situation. This lesson was well heeded by the MIT 

medical team, and they made a considered decision 

to make information available first to the families to 

protect privacy and trust. NASA as a whole worked 

tirelessly to ensure that no false or unsubstantiated 

information was ever reported to the media during the 

search and recovery efforts. 

Communications were a continuing issue for the 

individuals working in the cauldron of a major public 

mishap such as the Columbia accident. Under these 

stressful conditions, a good rule was to never promise 

anything that could not be personally delivered. The 

MIT medical team received multiple questions from 

the media, senior government officials, and political 

officials—all wanting immediate answers to questions 

about the identification and disposition of the crew. 

The MIT flight surgeon relied on NASA senior 

managers, such as the Director of Space Life Sciences, 

and NASA Public Affairs officials to interact with these 

questioners. This need to make accurate information 

available while working to recover and identify 

crewmember remains was difficult. One must always 

remember to be flexible yet realistic, balancing the need 

to accomplish objectives with the need to deal with the 

perception of how well the recovery is going by those 

in authority who may attempt to inject politics into the 

accident investigation process. 

Conclusions 

As long as humans continue to fly in space, mishaps 

will occur. The monumental risks inherent in space 

flight guarantee that tragedies, though deplorable, 

cannot always be prevented. A team involved in search, 

rescue, recovery, and investigation efforts must have 

appropriate personnel who are trained to conduct this 

mission. The coordination of these efforts before a 

mishap occurs will provide for more efficient operations 

in the event of a disaster. 

Mishap preparations for a spacecraft disaster should 

include, at a minimum, coordination among NASA, 

its international partners, the DOD, the NTSB, 

FEMA, EPA, the FBI, and the Federal Aviation 

Administration. Medical and legal experts should 

provide guidance in the coordination of both recovery 

and communication efforts. Communications must be 

carefully controlled to ensure appropriate release of 

accurate and reliable information. 

Tragedies of this magnitude impart extreme stress to 

those involved, yet those who respond are capable of 

remarkable feats in such times. After the Columbia 

mishap, the MIT and the medical team demonstrated 

efficiency and determination, using the lessons learned 

from the TWA 800 accident and the Challenger disaster 

to better respond to this contingency. The lessons 

learned from the Columbia disaster will provide 

guidance for future operations. It is our responsibility 

to ensure that the sacrifices made and the knowledge 

gained by all involved will be available for use by 

those conducting this type of response in the future. 

“We don’t rise to the level of our expectations, we fall 

to the level of our training.” 

Archilochus, Greek Soldier, Poet, c. 650 BC 
SECTION 2 – THE RESPONSE 41 

Mishap Response and Lessons 

Learned: The Role of the Office of the Armed 

Forces Medical Examiner and the Armed Forces 

Institute of Pathology 

Craig Mallak 

The Columbia accident presented a difficult situation 

for pathologists, because of the unexpected nature of 

the high-altitude breakup of the space vehicle and the 

large area in which crewmembers’ remains could have 

been found. East Texas was a difficult terrain in which to 

manage recovery operations, and methods to ensure an 

efficient and highly proficient evaluation were necessary. 

Complicating matters was the issue of chemical toxicity 

(propellants) as well as the hazards of the spacecraft 

debris. This chapter is the story of how NASA and 

the Office of the Armed Forces Medical Examiner 

(OAFME) worked together to recover and identify the 

crew remains. This team had methods that worked, to 

make sure the families of the STS-107 crewmembers 

received a dignified yet accurate accounting of the deaths 

as well as to provide the information to NASA and the 

external investigation teams for an understanding of the 

mishap. The lessons learned will benefit future space 

flight accident investigations. 

Capabilities of the Armed Forces 

Medical Examiner and the Armed Forces 

Institute of Pathology 

At the time of the incident, the OAFME was a branch of 

the Armed Forces Institute of Pathology (AFIP), which 

was disestablished as part of the 2005 Base Realignment 

and Closure Act. OAFME is now a separate agency 

within the Department of Defense, known as the Armed 

Forces Medical Examiner System. The mission of the 

OAFME, which was established in 1988, was to conduct 

scientific forensic investigations for determining the 

cause and manner of death of members of the armed 

forces and, under special circumstances, civilians in the 

United States and overseas. In 1999, the jurisdiction of 

the office was defined by 10 US Code 1471 to include 

assisting other federal agencies by way of agreement 

or through requests to the Department of Defense. 

Before 1988, the AFIP consisted of a forensic science 

The Office of the Armed Forces Medical Examiner. 

department and an aerospace mishap department that 

worked in a consulting capacity for military mishaps. 

With the formation of an Armed Forces Medical 

Examiner System, these departments were enveloped by 

the larger system. 

In addition to performing multiple autopsies every 

year, the OAFME is further responsible for conducting 

medicolegal investigations, particularly regarding 

medical, dental, forensic, toxicological, laboratory, 

and DNA analyses. The staff of the OAFME consists 

of pathologists, anthropologists, investigators, 

photographers, toxicologists, DNA scientists, and 

other scientific and administrative personnel. Forensic 

pathologists are active-duty members of the US 

Air Force, US Navy, and US Army, and are board 

certified in anatomic, clinical, and forensic pathology. 

Many staff members have a variety of other skills 

in veterinary medicine, legal affairs, and hyperbaric 
42 SECTION 2 – THE RESPONSE

The Army Medical Museum located in Washington, DC, 

from 1887 to 1955. 

The Army Medical Museum, now named the Armed Forces Institute 

of Pathology, on the grounds of Walter Reed Army Medical Center, 

1955 until it was closed in 2011. 

medicine, together with expertise in combat, aviation, 

and water-related deaths. On the whole, the OAFME 

was well suited to manage the forensic investigation 

resulting from the Columbia mishap. The Columbia 

disaster was not the first time that NASA interacted 

with the OAFME, as previous generations of military 

medical examiners investigated the Apollo 1 and 

Challenger fatalities. 

The AFIP was a US government institution concerned 

with diagnostic consultation, education, and research in 

the medical specialty of pathology. It was founded 

in 1862 as the Army Medical Museum and was located 

in Washington, DC, on Independence Ave until it 

moved to the grounds of Walter Reed Army Medical 

Center in 1955. 

The unique character of the AFIP rested in the 

expertise of its civilian and military staff of diagnostic 

pathologists whose daily work consisted of the study of 

cases that are difficult to diagnose owing to their rarity 

or their variation from the ordinary. 

Contingency Planning Between NASA 

Flight Surgeons and AFIP – OAFME 

In 1998 the AFIP presented a panel discussion at the 

Aerospace Medical Association Annual Conference in 

Seattle, Washington, on the 1996 TWA 800 in-flight 

mishap, one of the deadliest US aviation accidents of all 

time, which occurred in August over the Atlantic Ocean 

near Long Island, New York. This panel discussed the 

lessons learned by the recovery and response teams 

involved in that accident. The lead pathologists of the 

Joint Committee on Aviation Pathology of the AFIP 

chaired this discussion. Members of NASA’s Space 

Medicine Division were impressed by the lessons 

learned presented by this panel and, as a direct result, 

wanted to put in place a medical contingency plan for 

use in case of a NASA spacecraft mishap in the future. 

In 1999, members of the Johnson Space Center (JSC) 

Contingency Medical Group, the Kennedy Space 

Center (KSC) Aerospace Medicine and Occupational 

Health Branch, and the Department of Defense (DOD) 

Manned Space Flight Support Office (DDMS) visited 

the AFIP facility at the Port Mortuary at Dover Air 

Force Base (AFB) in Delaware. The purpose of this 

visit was to outline procedures for the handling of 

crewmember remains after any spacecraft mishap in 

the future. The visit included a site tour, particularly 

of the unique fatality processing and autopsy facilities. 

Dover AFB is the only medical examiner’s office that is 

designed for a multidisciplinary approach that includes 

an onsite Explosives Ordinance Disposal clearing area, 

FBI disaster identification component, and radiological 

and dental identification capability. The team also met 

with their experts and toured the Mortuary Affairs 

section of the facility where the deceased are prepared 

for disposition, including burial and cremation. At this 

meeting no formal agreement between the OAFME 

and NASA was put into place; however, a discussion 

did occur regarding the informal procedure that would 

be followed in case another spacecraft accident should 

occur. In 1999, NASA and the OAFME reaffirmed that 

casualties resulting from the loss of a spacecraft would 

be ultimately examined by the AFIP at Dover AFB. 

Recovery Operations 

On February 1, 2003, the STS-107 Columbia accident 

occurred. Following the loss of signal from the 

Columbia spacecraft, the medical organizations at both 

JSC and KSC scrambled into action. At 10:00 a.m. EST 
SECTION 2 – THE RESPONSE 43 

The Dover Port Mortuary is located at Dover Air Force Base, Delaware. In October 2003, the Charles C. Carson Center for Mortuary Affairs 

replaced this 48-year-old facility that had been in use since 1955 to identify and process the remains of more than 50,000 service members and 

many victims of numerous fatal incidents of federal interest, as well as the crew of the Space Shuttle Columbia. In 2011 the national mass fatality 

campus was completed at Dover Air Force Base including the reassignment of the Armed Forces Medical Examiner System and the US Personal 

Effects Depot, all within a secured compound at the base. 

the medical team at OAFME assembled and engaged 

in a telecommunication consultation with DDMS 

representatives from Patrick AFB, Florida, and 

NASA’s medical team from the Space Life Sciences 

Directorate at JSC. During the initial conversations 

it was unknown whether any human remains would 

be recovered because of the extreme altitude of the 

incident, the speed at which the vehicle was traveling, 

and various forces that would have been applied to the 

crew. For this reason, operations were suspended at 

noon while team members awaited further information. 

By 4:00 p.m. EST, JSC officially requested on-site 

assistance from the OAFME as reports of significant 

human remains in the extensive debris field began to 

emerge. Immediately, OAFME sent an advance team 

to the primary Disaster Field Office managed by the 

Tactical Search Director, at Lufkin, Texas, to begin 

the preliminary examination of recovered remains. At 

the same time OAFME sent a pathologist to Barksdale 

AFB, Louisiana, to work with the Columbia Mishap 

Investigation Team (MIT). 

The first remains found were temporarily held in a local 

pathologist’s office in Lufkin, Texas, and this became 

the main collection point for human remains found at 

all the search sites. A preliminary review of the remains 

was completed at this Lufkin facility. 

In order for the OAFME staff to complete a preliminary 

identification, as well as cataloging and initial 

evaluation of the injuries suffered by the crewmembers, 

a temporary morgue was set up at Barksdale AFB. The 

pathologist detailed to Barksdale AFB worked with 

base leaders to find a space suitable for the work that 

had to be done. In a matter of a few hours a facility 

was identified, and with the assistance of base staff 

was prepared for receiving and evaluating the remains. 

The Barksdale AFB temporary morgue had sufficient 

space, lighting, water, electricity, medical support from 

a local military medical treatment facility, security, 

and availability for air transportation. This temporary 

morgue was available within 24 hours of occurrence of 

the mishap and was fully operational by the time the 

first human remains arrived at the base on February 2. 

The MIT from NASA immediately began to coordinate 

with the Flight Medicine Clinic at JSC to obtain all 

crewmembers’ medical, dental, and DNA records. 

The MIT flight surgeon, Philip Stepaniak, MD, also set 

up daily evening dialogues with the crew flight surgeon, 

Smith Johnston, MD, Casualty Assistance Calls Officers 

(CACO) from the JSC Astronaut Office, an experienced 

mortuary affairs officer from the Air Force, and the 

Tactical Search Director, James Wetherbee, at Lufkin 

Disaster Field Office. The early coordination of these 

assets proved vital for ongoing operations. 

Recovered remains were temporarily held at the office of a local 

pathologist in Lufkin, Texas. 
44 SECTION 2 – THE RESPONSE

Challenges for OAFME and NASA 

Once the OAFME was called into action certain 

challenges became evident. These challenges 

included jurisdiction; organization and logistics; 

recovery, analysis and identification of remains; death 

certificates; and international issues. Initially it was 

assumed that remains of the crew might be difficult to 

locate because the accident occurred at high altitude 

and speed. This type of accident had never occurred 

before, and considering the nature of the forces and 

large debris field, the expectations were that not many 

remains of the crew would be recovered. However, this 

was not the case. 

Jurisdiction 

The initial challenge was determining who would 

have jurisdiction over the remains. The medicolegal 

jurisdiction is dictated by where death is pronounced. 

The involvement of the states of Texas and Louisiana, 

with their numerous counties and municipalities, 

created a legal challenge. However, the President of 

the United States federalized the recovery efforts and 

thus the local authorities ceded jurisdiction to the 

OAFME, which lessened the burden of negotiations 

with multiple local medical examiners. 

Organization and Logistics 

The team that had assembled in Lufkin, Texas, 

on day 1 (February 1) moved with the remains to 

Barksdale AFB, providing a full scope of investigative 

personnel. A team of forensic odontologists and an 

FBI fingerprint specialist arrived at Barksdale AFB 

the next day to supplement the team members 

already in place. A military epidemiologist came 

on February 4 to catalog and analyze the growing 

amount of material. This epidemiologist greatly 

assisted the recovery of the remaining crewmembers 

by triangulating the coordinates of recovery sites 

and by plotting and extrapolating geographic data 

to identify recovery zones. Finally, as the Columbia 

mishap involved Israeli astronaut Ilan Ramon, 

a representative of the Israeli Defense Forces, 

Col. Ahron Zwi Black, a medical doctor and rabbi 

with forensic experience, came to Barksdale AFB as 

part of the investigative team. 

Recovery, Analysis, and Identification 

of Remains 

The primary objective at the Barksdale AFB facility was 

to identify crewmembers before their remains were sent 

to the forensic center at Dover AFB. After the remains 

were transported to Dover AFB, the OAFME assigned 

a pathologist to remain at Barksdale AFB on a rotating 

basis through the remainder of the formal search and 

recovery effort. NASA transported all recovered remains 

to Dover AFB for the OAFME evaluations. The Port 

Mortuary Affairs Office provided the arrangements for 

disposition of remains in accordance with the wishes of 

the families. 

Recovery 

The recovery of crewmember remains involved the 

tireless efforts of members of the Federal Bureau of 

Investigation, NASA personnel, local police, emergency 

medical services personnel, and volunteers from across 

Texas in a well-coordinated search and recovery process. 

Initially, recovery efforts were made in response to calls 

made by civilians reporting potential sightings of human 

remains. Findings on the ground led to concentric search 

patterns in the area, but this approach proved to be more 

cumbersome than necessary, and a more sophisticated 

pattern was developed as insight was gained into the 

sequelae of the vehicle breakup. The best approach 

was to have field personnel recover anything that might 

be considered human, with analysis performed by 

forensic professionals for definitive identification. The 

consequence of this decision was that eight nonhuman 

specimens arrived at Barksdale AFB and Dover AFB for 

every recovered human portion. Although this decision 

resulted in extra hours of work, it was necessary to 

ensure that the greatest possible representation of the 

remains of the crewmembers was recovered and all 

crewmembers were identified. 

Analysis and Identification 

All remains recovered in the field were sent to the 

Lufkin collection point and then were escorted by 

security to Barksdale AFB for further examination 

by the OAFME investigation team. This team 

photographed all remains, charted them by recovery 

location, and provided anatomical schematic outlines 

of each crewmember. Initial screening of disassociated 

remains included first an examination by a forensic 
SECTION 2 – THE RESPONSE 45 

anthropologist to evaluate whether the remains were 

human and to determine the part of the body recovered. 

Any portion of the hands or feet was triaged to the FBI 

for identification. Likewise, fragments of the jaw or 

teeth were evaluated by the forensic odontologists on 

the team. The pathologist took samples from the tissue 

and bone for DNA analysis. These tissues were flown 

almost on a daily basis by NASA aircraft to Andrews 

AFB and then sent to the facilities of the OAFME at 

Rockville, Maryland, for DNA identification. Most 

tissue samples were identified within 24–48 hours 

after their arrival at the Rockville facility. This timely 

and rapid identification through mitochondrial and 

nuclear DNA analysis assisted NASA in the search 

and recovery process. When nuclear DNA was 

not available from the tissue, OAFME technicians 

performed mitochondrial DNA analysis. Mitochondrial 

DNA helped analysts segregate nonhuman tissue 

from human tissue and bone. At least one portion of 

each crewmember was positively identified by dental 

forensics at Barksdale AFB. 

During this process, a question quickly arose regarding 

how long remains should stay at Barksdale AFB. The 

OAFME requested that all remains be transferred to 

Dover AFB as soon as possible for a more detailed 

forensic analysis as there were concerns that tissue 

decomposition could cause valuable data to be lost if 

the remains were not evaluated in a timely manner. 

In response, the MIT made arrangements with the 

Barksdale AFB Mortuary Affairs Office and the US Air 

Force Mortuary Affairs Department to coordinate rapid 

transfer of all remains. The initial formal transfer from 

Barksdale AFB to Dover AFB occurred on the morning 

of February 5, with full military honors for the remains 

in transit. Two other formal transfers were made on 

February 11 and 12. 

The KSC Medical Operations team coordinated with 

the Barksdale AFB mortuary team concerning any 

commingled human remains found with the vehicle 

and crew compartment, which were shipped to KSC 

for evaluation of the orbiter debris. Processing of 

these remains underwent the same procedures that 

were conducted by the MIT at Barksdale AFB, ending 

with the established protocol for transfer of all human 

remains to Dover AFB. 

Once the remains of the Columbia crew arrived at Port 

Mortuary, Dover, initial processing of remains began 

with a screen for any hazardous or toxic items. As 

tissues were declared safe for processing, subsequent 

procedures called for the collection and review of 

relevant documents such as casualty or investigative 

reports provided by the field teams at Barksdale AFB 

and the Lufkin facility. Photographs were made of all 

remains, with assignment of barcodes for tracking. 

This was followed by postmortem processing of 

finger- and footprints with comparative pre- and 

postmortem analysis as well as a dental record review 

and analysis of dental imaging. Body imaging and 

skeletal surveys followed, and x-rays were reviewed 

for basic injuries and the presence of any foreign 

metallic objects or identifying features. Next, an initial 

external examination was conducted, with careful 

documentation of injuries. Technicians collected the 

appropriate specimens for toxicology findings together 

with a complete examination of internal organs. 

A forensic anthropologist assisted with triage and 

reassociation of any dissociated remains, performed 

by comparison of DNA profiles as much as possible to 

account for all recovered tissues. The anthropologist 

was also instrumental in separating the human from the 

nonhuman material that arrived daily at Barksdale AFB 

and Dover AFB. All of the remains and personal effects 

were then transferred to the Mortuary Affairs section 

for disposition. Mortuary Affairs coordinated with the 

families for determination of funeral arrangements 

according to the family’s wishes. The families received 

all crewmember personal effects at this time. The 

whole operation for the Columbia crew, from search 

and recovery to transport, autopsy, and burial, was 

completed and accounted for through this process. 

Issue: Determination of Injury Patterns 

As of 2003, studies had determined that previous 

techniques used to evaluate injury patterns in aircraft 

mishaps were less than scientifically sound. Thus, the 

team could not use their previous experiences with 

aircraft to determine the factors leading to loss of crew 

life. The OAFME staff decided that such speculative 

analyses could not be provided given the now-known 

lack of accuracy and precision of such opinioned reports. 

A major complication was the breakup of the orbiter 

at high altitude, which involved a variety of forces, 

including the destruction of a highly complex vehicle 

with metal, glass, and other materials interacting with the 

astronauts’ bodies in the most extreme of environments. 
46 SECTION 2 – THE RESPONSE

 

The OAFME decided not to provide conclusions about 

the cause and timing of injuries because they would have 

been speculative and inappropriate. 

Recovery and Analysis of LifeSupport Equipment 

Crew life-support equipment such as helmets and 

reentry suit oxygen bottles, and suit hardware like wrist 

rings and suit emergency radios, that were found in the 

debris field were also sent to the temporary morgue at 

Barksdale AFB. Members of the JSC Crew and Thermal 

Systems Team (the organization that is responsible 

for all crew-worn equipment) initially evaluated the 

equipment at Barksdale AFB and then sent it to Dover 

AFB for further analysis of injuries sustained. At the 

request of NASA, the Department of Defense also 

sent an experienced, NASA-trained military USAF 

flight surgeon, Maj. Hernando (Joe) Ortega, to Dover 

AFB for additional consultation. The JSC Crew and 

Thermal Systems team and the military flight surgeon 

reassociated the life-support equipment and remains 

recovered, providing valuable information used to 

understand the nature of injuries that occurred at altitude 

under such extreme conditions. 

Death Certificates 

Another challenge was the processing of the death 

certificates. The location of death and municipalities 

where the death certificates should be filed were 

debated. The JSC legal team, with the recommendations 

of the OAFME, resolved this process with the 

municipalities of Texas and Louisiana. Also, the JSC 

Flight Medicine Clinic needed to collect additional 

information that was required for the certificates from 

the crewmembers’ families. The death certificates 

were prepared at Barksdale AFB and sent to Texas for 

processing and certification. The recorded cause of 

death on the certificates issued by the State of Texas 

was “blunt force and thermal injuries in association with 

exposure to extreme altitude with underlying cause of 

spacecraft mishap.” 

International Affairs 

International issues were another factor to consider as an 

Israeli astronaut was a member of the crew of STS-107. 

Special religious customs and autopsy procedures needed 

to be honored and respected. This process was handled 

with dignity by making sure Israeli flags and proper 

transfer cases were available during the transfer of the 

remains. Also, NASA’s medical MIT arranged to have a 

US Navy rabbi and an Israeli flight surgeon rabbi present 

at Barksdale AFB and Dover AFB to oversee handling of 

the Israeli astronaut’s remains. 

Termination of Recovery Efforts 

OAFME and the NASA MIT terminated the formal 

medical operations at Barksdale AFB on February 13 

after consultation with the Tactical Search Director at 

Lufkin, Texas. NASA and the US Air Force Mortuary 

Affairs Office developed a long-term recovery plan 

to be implemented for remains recovered after the 

termination of formal search efforts. OAFME and 

the AFIP concurred. According to this plan, any crew 

remains recovered within the debris field after the 

termination of recovery efforts would be sent to 

Dover AFB for analysis and disposition. For several 

years, biological remains found in the debris field 

were sent to the OAFME facility at Dover AFB for 

evaluation. The probability of subsequent recoveries 

was discussed with the families of the crewmembers, 

and each family controlled the eventual disposition 

of any scientifically identified remains. This included 

whether they wished to be notified about such 

identification of remains and how they wished them 

to be handled by the Port Mortuary. This backup 

plan is still in effect today and the families have the 

opportunity to change their wishes at any time. 

Lessons Learned 

Lessons learned from the Columbia disaster were 

developed to make improvements in the response, 

search, recovery, and investigative process. The main 

lessons learned for the OAFME and the AFIP during the 

Space Shuttle Columbia mishap were the following: 

1. The preplanning by NASA with the Department 

of Defense Manned Space Flight Support Office 

(DDMS) and the OAFME before the accident 

contributed to strong communication and 

familiarity among the groups, which prepared 

them for this mishap. 
SECTION 2 – THE RESPONSE 47 

 

 

 

 

 

 

2. Having single points of contact with the Tactical 

Search Director at the primary Disaster Field Office 

site, Lufkin, Texas, and NASA’s medical MIT site 

at Barksdale AFB, during the search, recovery, and 

transport of remains prevented miscommunications 

up the chain of command and helped to create a sense 

of trust among those who were in charge within the 

field of operations. 

3. Having a temporary morgue available at the NASA 

MIT site with all available equipment to do a 

preliminary evaluation and preservation of remains 

within 24 hours after the accident contributed to the 

timely identification of remains. 

4. Having medical and dental records including DNA 

cards from NASA’s Flight Medicine Clinic available 

contributed to the timely identification of remains. 

5. Having a means of rapidly transporting remains 

with military honors to the Port Mortuary at 

Dover AFB enabled the team to preserve valuable 

toxicology evidence. 

6. Having daily situation reports with NASA’s medical 

MIT that included passing along accurate information 

to the search teams and the CACO representatives for 

the crewmembers’ families created a sense of trust 

and confidence. 

7. Recognizing the needs to respect and honor the 

customs of crewmembers from other countries 

by having representatives present prevented any 

misunderstandings by the crewmember’s family or 

the international partner country. 

NASA launched a return-to-flight mission, STS-114, 

in July of 2005. Before this launch, several visits and 

exchanges of ideas were coordinated between NASA 

and the OAFME. It was of specific interest that a written 

memorandum of understanding be developed to detail 

any future involvement and responsibilities of each 

party in the event of a future spacecraft mishap with loss 

of crewmember life. Aeromedical and legal teams at 

NASA and the OAFME coordinated the details of this 

agreement. This memorandum is reviewed annually and 

remains in effect today, and OAFME and NASA teams 

meet regularly to update plans for responding to any 

future fatal mishaps. 

The Findings 

NASA’s initial expectation from the OAFME and AFIP 

was that these offices would provide a formal and 

in-depth forensic analysis on the factors involved in 

the loss of crew life during the STS-107 breakup. This 

expectation was not met for multiple reasons. The first 

was that reductions in OAFME/AFIP budget and staff 

occurred in the years before the incident. In addition, 

the OAFME staff was making preparations for the US 

military to be potentially engaged in a conflict with Iraq 

that ultimately began within 2 months of the Columbia 

mishap. This potential conflict required significant 

efforts on the part of the OAFME and the AFIP to 

prepare for casualties of war from a major military 

operation, and these efforts required the full support of 

its staff. Most importantly, resolution of many issues 

that NASA was interested in learning about was beyond 

the state of the science at the time and would have 

been mere speculation, especially considering that 

this very unique mishap occurred at high altitude with 

aerodynamic and thermal effects. 

Although specimens of tissue such as lung, liver, heart, 

and bone were sent to other departments at the AFIP 

for evaluation, these consultations proved of little 

assistance in further defining the effects on the human 

body of exposure to the conditions that occurred during 

the breakup of Columbia. As a result, NASA outsourced 

the development of the detailed forensic analysis to a 

private contractor to provide additional insight needed 

to clarify the source of the injuries and the forces that 

the astronauts sustained during a high-altitude, highspeed thermal event. 

Future Recommendations and Summary 

The actions taken in response to future spacecraft 

mishaps will be dictated by the nature of the accident. 

Preparations and planning for mishaps occurring 

during launch, on orbit, or during reentry or landing are 

essential for guiding the actions of response, rescue, 

recovery, and investigation teams. Many commercial 

companies are now in the arena of space travel together 

with the military services and NASA. The details of 

who will be involved and responsible in handling a 

mishap need to be predetermined, particularly regarding 
48 SECTION 2 – THE RESPONSE

The Wall of Fallen Heroes greets each visitor as they walk into the Charles C. Carson Center for Mortuary Affairs, Dover AFB, Delaware. 


Each tragedy is engraved into the glass for remembrance of the date and the number of fallen heroes, including Space Shuttle Challenger and 


Space Shuttle Columbia.
 

the authority of each office or agency involved, such 

as the Federal Aviation Administration, National 

Transportation Safety Board, Department of Defense, 

private space flight company, or NASA. An analysis 

of the causes of any accident must be given priority, 

to gain insight that can ultimately enhance the safety 

of vehicles, crews, and space flight as a whole. At the 

same time, expectations for medical evaluation and 

analysis must be realistic and within the boundaries of 

objectivity to best serve the space flight community. 

During this time of national tragedy, the OAFME and 

AFIP proudly conducted this difficult investigation with 

honor, dignity, and respect for the fallen crewmembers. 

It was a great privilege for the OAFME and the AFIP to 

assist NASA during the Columbia mishap. All members 

of the OAFME and the AFIP were dedicated in their 

efforts to complete their mission, and conducted their 

work in remembrance of the crew of STS-107. 

This panel from the Wall of Fallen Heroes at the Charles C. Carson 


Center for Mortuary Affairs includes the Space Shuttle Columbia. 


Photo credit: US Air Force/ Photo credit: US Air Force/Tech. Sgt. Catherine Carbullido Tech. Sgt. Catherine Carbullido 
SECTION 2 – THE RESPONSE 49 

Johnson Space Center Space 

Life Sciences Response 

and Crew Survival Investigation 

Jeffrey R. Davis 

The United States, Texas, and NASA flags, in front of the Johnson Space Center’s (JSC) Project Management Facility (Bldg. 1), fly at half-staff in 

memory of the seven Space Shuttle Columbia crewmembers who lost their lives on February 1, 2003. 

At the time of the STS-107 flight, the Space Life 

Sciences Directorate (SLSD) at Johnson Space Center 

(JSC) was engaged in human space flight operations and 

research. The directorate worked with the Space Shuttle 

Program as well as the International Space Station. The 

directorate included the Space Medicine Division and 

the Medical Operations Branch, which had responsibility 

for astronaut health, and this included working with the 

astronauts before, during, and after their space flight. 

The flight surgeons assigned to the flight were the 

crewmembers’ advocate for all issues related to health. 

Besides keeping the astronauts healthy, the directorate 

set standards and requirements for astronaut selection 

and retention, and provided behavioral health support 

for the astronauts and their families. Each flight had 

two crewmembers trained to provide medical care 

on orbit, and the SLSD provided such training and 

supplied the medical kits for each flight. Other support 

efforts included establishment of aeromedical flight 

rules, ground rules/constraints such as the wake/sleep 

cycles, and providing 24/7 support for the mission in the 

Mission Control Center. Furthermore the directorate set 

standards and monitored air and water quality and crew 

consumables such as food. For the STS-107 mission 

the directorate provided coordination with the scientific 

payload community including in-house investigators. 

The directorate was also responsible for occupational 

health for JSC and had expertise in toxicological hazards. 

The purpose of this chapter is to identify all the major 

phases of activities and interfaces after the STS-107 

mishap that involved the SLSD at JSC in Houston, 

Texas. The discussion is divided into the phases of 

support for the accident. 
50 SECTION 2 – THE RESPONSE

Acute Phase, Initial Response 

to the Accident 

On the morning of February 1, 2003, after NASA 

learned that the Space Shuttle Columbia broke up 

over the skies of Texas, representative members of 

the SLSD – Charles Stegemoeller, Associate Director 

of SLSD, and Sam Pool, MD, Assistant Director of 

SLSD, attended the Space Shuttle Mission Management 

team meeting at the Action Center of the Mission 

Control Center at JSC. The Mission Management Team 

activated their Mishap Investigation Team (MIT). 

Immediately, SLSD activated its Contingency Action 

Plan (CAP) for Space Flight Programs. The SLSD CAP 

for Space Flight Programs reflects the directorate’s 

response activities and key personnel who would be 

involved in the event of a space flight contingency. 

The plan defines the responsibilities and procedures 

used by SLSD personnel for taking initial action in 

the event of a mission contingency such as a mishap, 

investigating and reporting mission failure, accidents, 

or incidents under the directorate’s jurisdiction. The 

Director of the NASA Johnson Space Center, General 

Jefferson Howell, USMC (retired), supported this 

investigation along with NASA headquarters Chief 

Health and Medical Officer, Richard Williams, MD. 

The SLSD assigned several key individuals to the MIT. 

Generally, these members would be the crew flight 

surgeons for the mission. However, the crew surgeons 

were with the crewmembers’ families at the Kennedy 

Space Center (KSC) Shuttle Landing Facility, where 

Columbia was to have landed. Thus, SLSD appointed 

members from the Medical Operations Branch: NASA 

flight surgeon Philip Stepaniak, MD, and the support 

contractor (Wyle) contingency coordinator, Michael 

Chandler. They were deployed the afternoon of 

February 1, 2003, the day of the mishap, to the strategic 

MIT site at Barksdale Air Force Base (AFB), Louisiana, 

leaving from Ellington Field, Houston, Texas, and 

arriving by 4:30 p.m. CST. The purpose of their mission 

was to gather, guard, preserve, and identify all human 

remains evidence for analysis of the incident. 

At 10:30 a.m. CST the day of the accident, SLSD, 

through the DOD Manned Space Flight Support Office 

(DDMS) at Patrick AFB, Florida, had discussions 

with the Armed Forces Institute of Pathology (AFIP), 

Rockville, Maryland, to determine how to recover 

and identify crew remains if any were found. Initially 

the assumption was made that very small amounts of 

human remains would be recovered because of the 

altitude and speed of the breakup. Therefore NASA told 

the AFIP to stand down for deployment until further 

notice. Later that afternoon, because members of the 

public reported significant human remains in the debris 

field, SLSD recalled the AFIP team to organize the 

support needed for recovery and identification of the 

crew. That day an advance team from the AFIP Office 

of the Armed Forces Medical Examiner (OAFME) went 

to Lufkin, Texas, as that was the tactical site of the 

primary Disaster Field Office responsible for the crew 

recovery. The OAFME also sent a pathologist to the 

MIT strategic site at Barksdale AFB. 

Within hours of the Columbia loss, the NASA 

administrator, Sean O’Keefe, formed the Columbia 

Accident Investigation Board (CAIB) under the 

leadership of Admiral Harold Gehman, USN (retired). 

The CAIB also contacted a former astronaut, James 

Bagian, MD, who had provided the medical support for 

the Challenger accident investigation. Bagian became 

the medical consultant and chief flight surgeon for the 

CAIB. By February 2 Bagian was at the search and 

recovery sites in East Texas to understand those efforts 

and began the overview of the impacts of the accident 

on the crewmembers. 

During this initial phase, SLSD together with members 

of the JSC toxicology working group, directed by John 

T. James, PhD, provided guidelines for the collection 

of Space Shuttle material in the debris field. The 

Columbia orbiter had toxic propellants associated with 

the various propulsion and power systems. The toxic 

compounds that were potentially present included the 

hypergolic propellants nitrogen tetroxide and hydrazine. 

The SLSD toxicology group provided guidance for 

the safe detection and handling of these propellants. 

NASA personnel worked with members of local, state, 

and federal law-enforcement agencies including fire, 

medical, and emergency medical services, US and Texas 

forest services, the Federal Emergency Management 

Agency, and the Environmental Protection Agency. 

The guidelines given by NASA personnel included 

information on what to do when encountering hazardous 

or potentially hazardous materials and procedures for 

collecting Space Shuttle materials. 
SECTION 2 – THE RESPONSE 51 

 

 

 

 

 

 

 

 

 

 

MIT Recovery Phase 

Over the next 2 weeks the medical members of the 

MIT at Barksdale AFB worked with the Columbia 

crew flight surgeons, Smith Johnston, MD, and Stephen 

Hart, MD, who interfaced with the Casualty Assistance 

Calls Officers (CACOs) to provide accurate and timely 

information to the families of the crewmembers about the 

recovery efforts and identification of the crew. The SLSD 

always kept the family needs first in their objectives. 

The SLSD enlisted the services of the JSC Behavioral 

Health and Performance group to provide psychological 

support to family members and to NASA civil servants 

who were involved in the collection of human remains. 

Crewmember remains were later sent with military 

honors from Barksdale AFB to Port Mortuary, Dover 

AFB, Delaware, for further analysis and preparation 

for eventual burial. During this time, SLSD staff also 

interacted with the payloads community regarding 

disposition of the recovered biological payloads, 

and SLSD worked with KSC on crew compartment 

components and possible commingled human remains. 

Initial Analysis Phase 

The CAIB requested the formation of the Crew Survival 

Working Group (CSWG) to provide needed input to the 

investigation. General Howell commissioned the CSWG, 

which was managed by SLSD Director Jeffrey Davis, 

MD, and Laurie Hansen from the JSC Engineering 

Directorate. NASA flight surgeon Rainer Effenhauser, 

MD, US Air Force Lt Col Donald White, and James 

Bagian, MD, provided medical support to the CSWG. 

The CSWG initiated a crew-centric investigation of 

the Columbia mishap. Their charter was to define the 

fate of the crew module and the crew. Craig Stencil 

from SLSD led organizational meetings that were 

attended by representatives of medical forensics, flight 

crew operations, safety, flight crew equipment, vehicle 

engineering, flight dynamics, and video analysis. Their 

results were eventually published in a one-page crewcentric summary in the CAIB report that was published 

in August 2003. The CSWG published their final report, 

authored by James Bagian, MD, and Lt Col Donald 

White, in CAIB Volume 5: Other Significant Documents, 

Appendix G.12 in October 2003. 

Final Analysis Phase 

The SLSD director worked to expand this initial 

CSWG-CAIB report, to have a much more complete 

analysis that was needed to enable NASA to determine 

ways to build better spacecraft to mitigate crew risks 

in the event of a vehicle accident. After its funding 

was established, the CSWG became the Spacecraft 

Crew Survival Integrated Investigation Team (SCSIIT), 

formed in 2004. The leadership of the SCSIIT 

consisted of project manager Greg Hite, who chaired 

the team, astronaut Pam Melroy, who served as 

cochair and was involved with operations and vehicle 

components, and Craig Fischer, MD, SLSD pathologist, 

who was involved with medical forensics. Robert 

Banks, MD, and his team from Biodynamic Research 

Corp., in San Antonio, Texas, provided the major 

contribution to the SCSIIT report. The task list for the 

SCSIIT was the following: 

1.		 Review the CAIB reports. 

2.		 Establish subject expert working groups to locate 

and analyze all data related to the Challenger and 

Columbia mishaps. 

3.		 Reconstruct the breakup sequence of the Columbia 

forward fuselage/crew module complex. 

4.		 Establish a comprehensive archive for manned 

spacecraft accidents, involving both data and 

artifacts, for all mishaps both foreign and domestic. 

5.		 Determine the atmospheric pressure, thermal 

environment, and acceleration forces that 

the Columbia and Challenger crews experienced. 

6.		 Determine the cause of death of the Columbia crew. 

7.		 Develop lessons learned for application to future 

spacecraft designs. 

8.		 Develop lessons learned for application to future 

mishap investigations. 

9.		 Educate managers, engineers, and physicians 

who support manned space flight (government and 

civilian) about mishap survival. 

10. Periodically review and assess manned space 

flight projects to make sure that survival goals 

are addressed. 
52 SECTION 2 – THE RESPONSE

 

 

 

Crew Team and Consultants for Spacecraft Crew Survival 

Integrated Investigations Team (SCSIIT) 

Crew Team Crew Team Consultants 

NASA Johnson Space Center 

Jeffrey R. Davis, MD, MS 

Craig L. Fischer, MD 

Sara Margerum, MS 

National Space Biomedical Research Institute 

Jonathan B. Clark, MD, MPH 

College of Engineering and School of Medicine, 

Stanford University 

Gregory Kovacs, MD, PhD 

Armed Forces Institute of Pathology, 

Rockville, Maryland 

Glen Sandberg, MD 

Science Applications International Corporation, 

Houston, Texas 

Dennis Pate, MS 

Office of the Armed Forces Medical Examiner 

(OAFME) 

Craig Mallak, MD 

James Caruso, MD 

Scott Kornman, MD 

Jerry Hodge, MD 

Elizabeth Rouse, MD 

William Ramirez, PhD 

Bob Veasey 

Forensic Toxicology Laboratory, OAFME 

Eric Shimomura, PhD 

Barry Levine, PhD 

Scientific Laboratories, AFIP, Rockville, Maryland 

José Centeno, PhD 

Linda Murakata, MD 

Florabel Mullick, MD 

Chemistry Unit, FBI, Washington, DC 

Mark LeBeau, MS 

Biodynamic Research Corp., San Antonio, Texas 

Robert Banks, MD 

Richard Harding, PhD 

Harry Smith, PhD, MD 

Boeing Corp., Huntington Beach, California 

Duke Tran 

Forensic aviation medical consultants 

Robert McMeekin, MD, JD 

Charles Stahl, MD 

Charles Rheule, MD 
SECTION 2 – THE RESPONSE 53 

 

 

 

 

To accomplish these assigned tasks, the SCSIIT was 

organized into the following discipline teams: crew, 

crew operations, crew equipment, crew module, 

vehicle, video analysis, and concept evaluation 

laboratory. Each team was given specific tasks to 

accomplish. For example, the specific tasks of the crew 

team were to determine the following: 

1. During the mishap, what was the crew 

situational awareness? 

2. What actions if any did the crew take? 

3. How did the crew equipment perform? 

4. What was the cause of death? 

The medical portion of the SCSIIT report contained 

substantially more technical data than are normally 

found in an aviation mishap report. The SCSIIT 

report not only concentrated on crew event 

awareness and crew actions and response to events, 

but also on the sequence of crew exposures that led 

to the potential lethal events. The SCSIIT collected 

the objective data that included forensic medical 

findings, onboard recorded data, telemetry, groundbased and recovered video data, air-to-ground 

communications, and data from examination of 

debris and materials testing. Analysis also involved 

derived data from ballistics, thermal analysis, 

aerodynamic analysis, shock-wave interactions, flail 

modeling, thermal injury mapping, simulations, 

structure analysis, and systems analysis. 

The SCSIIT’s reported goal was to identify 

problems to aid current and future spacecraft 

designers in developing safer vehicles and systems 

and aid in the development of a medical protocol for 

investigating spacecraft accidents. NASA published 

the final SCSIIT report in December 2008 for a 

target audience that included NASA administration, 

personnel involved in spacecraft design, NASA 

flight crews, NASA spacecraft operations personnel, 

space medicine physicians, spacecraft accident 

investigators, researchers, commercial space flight 

operators, spacecraft safety professionals, aerospace 

academics, and members of the US Congress and 

the general public. 

Summary and Lessons Learned 

The Columbia accident investigation required 

preparation and coordination of operations at the 

directorate level across many technical disciplines of 

the SLSD, and required effective work with many 

teams at NASA, the CAIB, and state and federal 

agencies. The initial key to success was having a 

contingency action plan that enabled the deployment 

of a rapid-response team for search, rescue, recovery, 

and identification of crewmembers, a team that had 

the appropriate personnel trained in these operations. 

Equally important was the provision of psychological 

support to family members. 

Communications in real time with the multiple medical 

organizations from local, state, and federal agencies 

to define responsibilities and goals produced a team 

effort in accomplishing the recovery and identification 

of the crew. Contingency mishap planning requires 

negotiations with these organizations to produce a clear 

agreement on roles and responsibilities that results in 

a written memorandum of understanding. Any future 

mishap will require the work of a multidisciplinary team 

to provide a thorough forensic investigation that should 

enhance crew safety for future spacecraft missions. 

The SLSD team served professionally in all phases 

of the mishap and believes that its contributions will 

provide the spacecraft requirements and personnel 

training necessary for future generations that participate 

in human space flight. 
54 SECTION 2 – THE RESPONSE

Kennedy Space Center 

Operations – Commitment to 

Safety and Preparedness 

Philip J. Scarpa 

The Vehicle Assembly Building (VAB) is one of the largest buildings in the world. It was originally built for assembly of Apollo/Saturn vehicles and 

was later modified to support Space Shuttle operations. High Bays 1 and 3 were used for integration and stacking of the complete Space Shuttle 

vehicle. High Bay 2 was used for external tank (ET) checkout and storage and as a contingency storage area for orbiters. High Bay 4 was also 

used for ET checkout and storage, as well as for payload canister operations and solid rocket booster contingency handling. 

Kennedy Space Center (KSC), located on the central 

east coast of Florida, hosted all the Space Shuttle 

launches and a very high percentage of the landings. 

Launch and landing support teams at KSC were 

well aware of the potential for aeromedical 

contingencies during a Shuttle mission. For this 

reason, they implemented procedures for safe 

launches and landings, and prepared and practiced 

for medical contingencies. However, on the morning 

of February 1, 2003, no one was thoroughly prepared 

for what was to come. KSC responded immediately 

and became a part of the major recovery of Columbia 

and consequential analysis of the Columbia debris. 

This chapter describes what KSC personnel did and 

what they learned about this accident. 

Description of KSC Medical Support for 

Space Shuttle Launches and Landings 

Initially the future site of KSC was near a US military 

base, the Cape Canaveral Air Force Station, known for 

its remoteness, minimal inhabitation, security, yearround summer weather, accessibility by waterways, 

proximity to the Earth’s equator, and access to a chain 

of Caribbean islands that provided for a network of 

downrange monitoring stations over the ocean. KSC 

developed, next to this base, into a large complex for 

space flight launches and landings along with a large 

surrounding community of cities and tourist attractions. 

A medical emergency could occur at any phase of a Space 

Shuttle mission, including on the launch pad, during 

launch, on orbit, reentry, or during landing. Potential 
SECTION 2 – THE RESPONSE 55 

sources of injuries included burns, blasts, toxic exposures, 

deceleration, impact, hypoxia, and hypothermia. For 

this reason, every launch and landing of the Shuttle 

was monitored closely by mobile triage forces staged 

throughout the space center, ready to respond to any 

potential Shuttle emergency. These triage forces included 

dedicated fire and rescue responders, environmental 

health teams, medical personnel (including physicians, 

nurses, and paramedics), logistics and transport, along 

with communication personnel. At their disposal were 

fire decontamination trucks, a supply van, ambulances, 

helicopters, an all-terrain vehicle, Hagglunds BV 206 

Bearcat, and several M-113 armored personnel carriers 

used for hazardous escape. US Department of Defense 

physicians, Patrick Air Force Base (AFB) paramedic 

jumpers, helicopters, as well as crew surgeon(s) from 

Johnson Space Center (JSC), and community medical 

personnel further augmented the triage forces. Medical 

personnel and equipment were also staged at the KSC 

clinic, biomedical offices, Shuttle Landing Facility (the 

KSC runway, known as the “SLF”), Environmental 

Health Facility, KSC fire stations, and logistically 

throughout the space center for visitor support. 

Medical personnel staged in the biomedical offices 

served as liaisons to area support hospitals, supported 

the astronaut crew quarters, and provided preflight 

and postflight medical examinations and experiment 

data collection. All of these forces were directed by 

the Emergency Medical Services (EMS) Coordinator, 

located in the KSC firing room of the Launch Control 

Center and assisted by a biomedical engineer. During 

launches, the JSC deputy crew surgeon coordinated 

closely with this team. 

Mission preparation of all aspects of the KSC EMS 

plan began months in advance with hospital readiness 

checks, distribution of completed astronaut physical 

examinations, participation in medical operations 

readiness reviews, a medical and equipment briefing to 

physicians and paramedic jumpers, and preparation of 

a personnel coverage schedule for all EMS positions 

during all scheduled launch, landing, and mission days. 

During normal launches, triage forces were positioned 

by the EMS Coordinator in a strategic location for 

maximum geographic coverage response. Crew 

surgeons and KSC medical personnel provided any 

needed medical assistance for the crewmembers at the 

astronaut quarters during quarantine, which began about 

3 to 4 days before launch, through crew examinations 

on launch day. On launch day, medical monitoring 

began at the time the astronauts were instrumented 

in crew quarters before they donned their spacesuits, 

and monitoring continued during all activities on the 

launch pad and normal launch phases. If the launch was 

canceled, the EMS forces would monitor crewmembers 

until they returned to the crew quarters. 

During landing operations, EMS forces would again 

perform a readiness check of all planned medical 

components before landing day. A few hours before a 

scheduled landing, triage forces would be strategically 

placed around KSC to provide coverage concentrated 

at the Shuttle landing runway. KSC medical personnel 

would be located in the Crew Transport Vehicle with the 

crew surgeons, in a convoy on the runway, to provide 

additional support for returning astronauts. 

Upon landing normally, the crew would egress from 

the Shuttle crew compartment into the Crew Transport 

Vehicle or down the Shuttle stairs. Most crewmembers 

chose to then perform an inspection walk around the 

orbiter while it was positioned on the runway. After this 

brief excursion, the crew would be transported by the 

Crew Transport Vehicle or the astronaut van to the KSC 

astronaut quarters. Triage forces deployed for landing 

were released only when astronauts were safely 

returned to quarters. At this time, returning astronauts 

were able to visit briefly with their families and then 

were directed through the Baseline Data Collection 

Facility to undergo postflight medical examination and 

procedures required for flight experiments. The crew 

would complete their examinations within a few hours 

of landing and, after a brief press conference, would 

spend the rest of the day with their families offsite or in 

crew quarters. Generally, crewmembers returned to JSC 

in Houston the day after landing. 

Emergency Planning 

For any Shuttle emergency, KSC EMS forces were 

trained to respond with four essential elements: mode 

declaration, rescue, triage, and medical evacuation. The 

first element, mode declaration, identified the nature 

and location of the emergency and initiated a particular 

response. For Space Shuttle operations there were 

eight predetermined modes: four for launch and four 

for landing. The four launch modes consisted of those 

that could occur during prelaunch contingencies on the 

launch pad. The four landing modes could occur during 

any landing contingency or even during postlaunch 

contingencies such as launch aborts, return to launch 

sites, abort after one complete orbit around the Earth, or 
56 SECTION 2 – THE RESPONSE

bailouts over the ocean. Launch or landing emergency 

modes were ranked from low numbers to high numbers 

by the difficulty of egress and rescue execution and by 

the potential number of victims involved. 

Rescues included the egress of any victims and their 

transportation to the triage forces, emergency teams 

located closest to and upwind of the Shuttle contingency. 

Egress could be assisted by fellow non-injured 

crewmembers, the Shuttle closeout crew, and fire and 

rescue personnel. Transportation could be provided 

by launch pad egress systems, ground vehicles, or 

helicopters. Transportation by helicopter could also 

bypass triage forces and deliver victims directly to a 

hospital if this was determined to be the best option for 

the victim. In the case of a medical contingency, the 

medical response plan called for triage forces in the field 

to receive and evaluate the victim, decontaminate any 

victim exposed to potential toxins, and provide initial 

medical stabilization and treatment. Medical evacuation 

could be provided, if needed, by ground or helicopter to 

local area hospitals or to the KSC onsite medical clinic 

as determined by the Triage Officer at the triage site and 

the EMS Coordinator at the launch control center. 

Final disposition of any victim would be influenced 

by multiple factors, including the specific injuries 

sustained, the urgency of the medical case, accessible 

transportation, and resources available. Flight crew and 

non-flight crew fatalities would be managed by the KSC 

Medical Code Zero Plan, completed in 1999 with the 

cooperation and assistance of the DOD Department of 

Mortuary Affairs and the DOD Armed Forces Institute 

of Pathology. Psychological care was available on site 

and could be provided as needed for victims, families, 

and KSC employees through trained Critical Incident 

Stress Debriefing (CISD) employee assistance program 

(EAP) counselors. 

KSC Mishap Response: Support on 

Landing Day 

The Plan 

The day before STS-107 was to land, the KSC medical 

team rehearsed and choreographed normal Shuttle egress 

procedures and medical personnel coverage for postflight 

experiments scheduled in both the crew transport vehicle 

and in the Baseline Data Collection Facility. STS-107 

was a dedicated science mission, and as such it had 

multiple experiments on board and an exceptionally 

full postflight experiment data collection schedule. 

Special considerations were discussed with the primary 

investigators: for example, four crewmembers required 

recumbent positioning for appropriate data collection 

after landing. These special needs were incorporated 

into a meticulously planned medical schedule for 

the returning crew. The scheduled landing was on a 

weekend; as a result, only essential medical personnel 

would have been scheduled to be on site at the time of 

the landing. However, because of the busy post-landing 

test schedule and the large number of experiments on 

board this particular flight, several additional medical 

personnel were on site and available for the landing. 

In retrospect, this simple coincidence was particularly 

fortuitous, as each of these medical personnel became 

essential for the ensuing mishap support. 

NASA mission managers were aware of the vehicular 

debris strike during the launch phase of Columbia’s 

flight. This debris strike had been discussed a few days 

before the scheduled landing and it was ultimately 

determined not to be a significant issue to the mission; 

as a result, landing preparations were normal. On the 

day of landing, KSC medical forces took position on site 

about 90 minutes before landing. According to standard 

practice, all support hospitals were contacted and 

confirmed ready, and EMS forces took their positions to 

await Columbia’s return. 

The Response 

At 8:59 CST on the morning of February 1, 2003, loss 

of signal occurred and no further communications 

were received from Columbia. Within moments, 

a contingency was declared and KSC initiated 

emergency operation procedures. Medical personnel 

immediately began readying medical kits for rapid 

response by mishap investigation teams that might 

be needed for deployment. As information began to 

reach personnel at KSC, it became clear that there 

was no local crash scene at which medical responses 

would be concentrated, and the immediate primary 

concern became refocused on the astronaut families 

and KSC employees. At this time, KSC activated 

the psychological triage support plan. This plan was 

relatively new, identified as a need during the STS95 mission in 1998. The plan covered the delivery of 

psychological support after contingencies to astronauts 

and their families and friends, as well as to employees, 

visitors, and witnesses. It called for the establishment of 

a Psychological Triage Officer to provide CISD within 

72 hours of an incident, and to provide additional CISD 

if needed in the case of a larger disaster. 
SECTION 2 – THE RESPONSE 57 

As soon as KSC knew that a mishap had occurred, 

medical personnel assisted in the relocation of the 

astronauts’ immediate families from the landing site to 

the crew quarters as well as the simultaneous relocation 

of the astronauts’ extended families and friends to 

the KSC training auditorium. KSC medical staff also 

provided medical treatment for the families and friends 

as needed. By the early afternoon, KSC staff escorted 

the families in ground vehicles to air transport at the 

nearby Cape Canaveral Air Force Station for return 

to their homes in Houston. CISD was made available 

by EAP personnel for families, friends, and all KSC 

employees within 24 hours of the accident. 

Recovery Efforts and Occupational 

Medicine, Environmental and 

Medical Support 

Recovery field operations began within hours of the 

loss of the orbiter. A rapid response team of about 40 

personnel, many from KSC, went to Barksdale AFB 

in Shreveport, Louisiana, to begin debris search and 

recovery efforts. At the peak of the recovery effort, a 

total of about 25,000 recovery personnel, including 

1,000 KSC employees, participated at several debris 

recovery sites. The debris search lasted 3 months and 

was, to date, the largest organized recovery effort, 

in terms of both geographic area and number of 

participants, ever conducted in the world. 

The KSC medical team had immediate concerns about 

adequate and coordinated occupational medicine, 

environmental health, and medical services for the 

recovery teams, considering the tremendous number 

of recovery team members and numerous potential 

hazards of this operation. There were no physicians 

or environmental health specialists in the initial 

response team, and medical capabilities were minimal 

at best. Work conditions for the recovery teams were 

not optimal, often including physically demanding 

outdoor conditions of rough terrain and inclement 

weather. Team members labored for prolonged work 

days (typically 12 to 16 hours) over several weeks 

and months, without interruption for rest or diversion. 

In addition, there was a reasonable degree of concern 

about toxic exposure and injury from debris discovery 

and handling. As is typical for such extreme operations, 

the urgency in dispatching personnel to the field sites 

dictated that few to no medical screening exams were 

performed before deployment, raising concerns about 

the physical capabilities of those sent to the sites. 

Columbia recovery personnel working in central East Texas. Work 

conditions were a concern. 

KSC medical personnel worked with JSC counterparts, 

the Federal Emergency Management Agency, the 

Environmental Protection Agency, and the Texas 

A&M Forest Service to deliver adequate occupational 

medicine and environmental health services. Policies 

and procedures were written for the recognition and 

handling of materials discovered in the field, with 

associated levels of personal protective equipment. 

NASA provided a hazard operations briefing tailored to 

the recovery activity for KSC employees before they left 

KSC, then again in the field. Eventually, sufficient work 

rotations and change-outs occurred to limit excessive 

work times and chronic fatigue. Although medical 

screening and certification were not performed before 

deployment of personnel in the recovery effort, NASA 

team members completed a self-administered medical 

screening questionnaire. The plan for EMS services was 

limited but sufficient. It called for first-aid kits or a visit 

to the Barksdale AFB Medical Clinic for minor injuries, 

and reporting to the local 9-1-1 EMS provider or to one 

of the local hospitals for major illnesses and injuries. 

During the recovery operations, two major incidents 

occurred. In the first, a KSC employee lost consciousness 

and was sent to the local hospital for a cardiac 

evaluation. His evaluation was ultimately negative, 

but he was placed on limited duty in the Barksdale 

AFB hangar and subsequently returned to Florida for 

rest and recovery. The second incident involved two 

KSC employees and one Texas A&M Forest Service 

worker who were seriously injured in a helicopter crash 

that killed two other Forest Service workers. The two 

injured KSC employees had chest injuries with resultant 

pneumothorax (punctured lung), and shoulder and pelvic 

trauma. A local hospital provided treatment to the injured 
58 SECTION 2 – THE RESPONSE

personnel and after several days they were stable enough 

to return home to Florida in a fully pressurized medical 

evacuation aircraft. 

KSC and JSC EAPs provided psychological counseling, 

but some recovery personnel reported that if they had 

any sadness or depression, the search and recovery 

work seemed actually “therapeutic.” Many reported 

that what happened to the vehicle and crew did not 

seem to truly become real for them until they returned 

home and had time to reflect, indicating that significant 

compartmentalization of the grieving process occurred 

during recovery operations. 

Columbia Reconstruction: 

Overview of Scope and Process in 

Reconstruction Hangar 

Soon after the first recovery teams arrived at the debris 

field, they began locating orbiter debris. These teams 

recorded the coordinates and sent the decontaminated 

debris to a local field center for collection. Debris 

was then sent to Barksdale AFB for cataloging and 

preparation to send it to the NASA collection and 

reconstruction site, and it was subsequently shipped by 

truck to KSC. The first shipment from Barksdale AFB to 

KSC arrived on February 12, 2003. 

The Reusable Launch Vehicle Hangar, located just off 

the Shuttle landing runway, was relatively new and 

unoccupied at the time of the mishap. As a result, KSC 

designated it as the primary collection and reconstruction 

site of the Columbia accident investigation. KSC 

organized and prepared the Columbia Reconstruction 

Hangar, as it was renamed, for use by February 7, 2003. 

Columbia Reconstruction Hangar at the NASA Kennedy Space 

Center, Florida. 

Handling the Debris from the Orbiter 

Each truck carrying items from Barksdale AFB stopped 

in front of the Columbia Reconstruction Hangar for 

removal of the items, with monitoring for toxic offgassing. Then employees brought these items inside 

the hangar for careful cataloging, with photography, 

barcoding, categorization, and identification. Next the 

items were analyzed and ultimately placed on organized 

shelves for storage, or on the floor grid, on a wing-tile 

grid table, or in a mockup wing display.
	

Crew effects and cabin debris were handled and
	

assessed separately from the rest of the vehicle to better
	

understand the accident’s effects on the cabin and crew.
	

The crew cabin work analysis was performed in a secure,
	

walled-off corner of the hangar to maintain privacy.
	

NASA evaluated the payload items for potential science
	

return. KSC had strict hangar security access with item
	

tracking and release procedures in place.
	

A total of 150 individuals worked in the reconstruction 

hangar, 2 shifts per day, 6 days per week. In total, 

27 truckloads of debris items were delivered from 

February 12 to May 6, 2003. Ultimately 83,013 

items and 84,900 pounds (39% of the vehicle) were 

received, cataloged, and analyzed. The KSC staff laid 

out about 2,800 pieces on the hangar floor grid during 

reconstruction phases of the analysis. 

Medical Involvement: Screening for 

Human Remains 

Remains from all seven crewmembers were recovered 

in the field and shipped to the Armed Forces Institute 

of Pathology (AFIP) for post mortem analysis. 

However, some of the crew remains were never 

recovered. For this reason it was thought prudent 

to inspect any debris in the field or delivered to the 

reconstruction hangar for evidence of human remains 

and, if any suspected human remains were present, 

to send such items to AFIP for analysis. NASA 

instituted a system with designated points of contact 

and a logic flow diagram for handling and disposition 

of these items. In the field, NASA instructed local 

law enforcement agents to ship all suspected items 

directly to AFIP. On request, the KSC Medical Office 

provided written guidance to the recovery teams on 

handling biological specimens in the field. At the 
SECTION 2 – THE RESPONSE 59 

Inside the Columbia Reconstruction Hangar. Clockwise from top: debris floor grid, wing tile grid table, mockup wing display. 

reconstruction hangar, for any item in question the remains, in which case the delivery to AFIP was 

KSC medical officer, Dr. Philip Scarpa, or his designee performed by astronaut escort. Guidance for evaluation 

assessed and evaluated it, especially for evidence of of the biological and human remains was provided by 

potential human remains and, if such evidence was NASA JSC, the Federal Aviation Administration, the 

apparent, sent it to AFIP. Biological items not obviously National Transportation Safety Board, and AFIP. All 

of human origin or belonging to the scientific payload, packing and shipping followed AFIP recommendations 

but possibly from the Shuttle, were also sent to AFIP. and each shipment was coordinated with the US Air 

The team sent these items to AFIP by Federal Express Force Department of Mortuary Affairs. 

next-day shipping unless the item was obvious human 
60 SECTION 2 – THE RESPONSE

Initially, the field recovery team 

sent the debris of biological 

interest that was recovered in 

the field, mostly from payload 

experiments, to JSC for storage. 

Through the course of the recovery 

activities, the decision was made 

that this debris, as well as any 

future debris, should be sent to the 

reconstruction effort at KSC. JSC 

shipped two debris containers to 

KSC for disposition and analysis. 

A designated team inspected all 

incoming debris of biological 

interest as it arrived at the hangar 

from the shipping trucks. This 

team enabled the expedited sorting 

and hazard evaluation of material 

from a biological standpoint. The 

team consisted of a KSC physician 

and personnel from the Astronaut 

Office, Vehicle Integration Test 

Team Office, Payloads Office, and 

KSC Environmental Health. 

KSC received a total of 370 items 

that were evaluated for potential 

biological interest or concern for 

potential human remains. Of the 370, 

KSC sent 15 items in 6 shipments 

(1 by astronaut escort) to AFIP for 

further analysis over an 8-week 

period, but none of the samples 

tested positive for human remains. 

KSC received the final truckload 

of debris from Barksdale AFB on 

May 6, 2003, and it contained no 

items of biological interest. 

Protection of Hangar Personnel 

Several occupational medicine and environmental 

health concerns for the personnel in the reconstruction 

hangar required specific attention. These included 

adequate lighting, indoor air quality, toxic exposure, 

friable debris, fiber inhalation, sharp edges, lifting 

concerns, and impact trauma. KSC implemented hangar 

personal protective equipment (PPE) policies for 

prevention of hazards associated with these concerns. 

KSC used a team approach to meet and inspect all incoming debris of biological interest 

entering the Columbia Reconstruction Hangar. 

Hangar personnel wearing personal protective equipment. 

As in the recovery effort, the potential for hangar 

personnel to be emotionally affected by handling of the 

debris was great. The KSC clinic offered counseling to 

them as requested. 

Early in the reconstruction, hangar personnel were 

concerned with two biomedical issues: exposure to 

blood-borne pathogens and discovery of unexpected 

human remains. KSC medical management quickly 

and adequately provided blood-borne pathogen 

and PPE training, and implemented procedures for 
SECTION 2 – THE RESPONSE 61 

Unlike the Challenger accident debris, the Columbia debris is accessible for investigation and research. 

screening all items of biological interest that entered 

the reconstruction hangar. The screening protocol 

proved very useful because first, it allowed the control 

of all toxic or biohazardous materials entering the 

hangar, limiting unnecessary biohazardous handling. 

Similarly, the protocol provided a point at which all 

debris could be screened for any potential human 

remains overlooked in the field. Screening aided 

in the reconstruction efforts by providing proper 

categorization of items, particularly by providing 

the opportunity to isolate crew cabin items from the 

main flow of debris recovery and reconstruction. The 

screening protocol also allowed the recovery of payload 

experiment items for their potential science yield. 

Long-Term Recovery Efforts 

With the conclusion of the recovery efforts and 

the last major shipments of debris to the Columbia 

Reconstruction Hangar in May of 2003, NASA 

management established a long-term plan to respond 

to the occasional small shipments received, usually 

from local residents who might find an unidentified 

item within the debris field. At first, KSC received 

about one or two items per week, but that quickly 

tapered off, and the last known items were received 

in November of 2005. After the hangar operations 

concluded, the KSC Medical Office maintained the 

capability to evaluate and ship to AFIP any received 

items that it deemed necessary. 

The debris from the Challenger accident in 1986 is 

buried and inaccessible, but NASA decided to honor 

the Columbia astronauts by allowing the Columbia 

debris to be readily accessible for investigation and 

research. In October of 2003, NASA put into effect a 

plan for long-term storage, designating secure facilities 

within the KSC Vehicle Assembly Building for the 

storage and management of recovered items. Columbia 

items may be loaned to scientific, research, academic, 

and government entities with an approved justification 

for use. Scientific studies of the debris have benefited 

NASA’s remaining Shuttle fleet operations and the 

design of future spacecraft. 
62 SECTION 2 – THE RESPONSE

Columbia Memorial Service at the KSC Shuttle Landing Facility, February 7, 2003. This is the site where Columbia was to land. 

Memorials 

In a tribute to both the crew and the vehicle that so 

many KSC employees loved and maintained over their 

careers, KSC conducted a memorial service at the 

Shuttle Landing Facility on February 7, 2003. There, 

with the powerful symbolism of the Shuttle’s landing 

runway, the memorial allowed NASA employees to 

mourn collectively. 

In honor of the recovery and reconstruction efforts 

and before its closing, employees and their families 

were invited by NASA to walk through the Columbia 

Reconstruction Hangar in July 2003 and personally 

witness the debris and the reconstruction efforts. 

Medical first aid and private counseling were available 

on site as needed. About 11,000 persons passed through 

the hangar during the 1-week period in a solemn 

demonstration of respect. 

Lessons Learned 

Immediately after the mishap, it became clear that 

communications were compromised because of the 

demands of multiple simultaneous inquires and a 

saturation of critical phone lines and cell phone service. 

As a result, NASA established dedicated lines of 

communication for use only by medical personnel and 

included communication priorities, with the flow of 

information limited to a need-to-know basis. Dedicated 

cell service in the aftermath of disaster is difficult to 

achieve, but cordless communication at KSC has since 

been instituted in an effort to provide increased mobility 

and privacy in the event of another contingency. 

After the loss of signal from Columbia, those at KSC 

had limited situational awareness of the event, and 

their initial information about the event was sought 

only from NASA data feeds and communications. 

Awareness improved when commercial news services 
SECTION 2 – THE RESPONSE 63 

made available reports of the mishap that were 

streaming in from civilian witnesses in the field. 

Non-NASA information resources are now available 

on site for NASA personnel, even in the Launch 

Control Room and other restricted operational sites. 

These resources include regularly updated television 

news feeds, Internet, social media, and other channels 

of communication. 

Though KSC carefully prepared and practiced 

emergency response plans, a real contingency event 

added layers of complexity and unanticipated stress 

that is difficult to recreate in training scenarios. Many 

parts of the response plan that are most often practiced, 

such as the mode, rescue, and medical evacuation 

procedures, did not apply to the Columbia scenario at 

hand. Therefore, several elements of the KSC EMS 

operating procedures, though they had been practiced, 

did not need to be executed. Instead, the emotional and 

mental health of the astronaut families and KSC visitors 

became the highest priority, yet only a few medical care 

providers (EAP personnel) were on site and prepared to 

support such psychological stress. 

Extra personnel would have been reassigned from 

existing staff already on site, but this option was limited 

because of the reduced weekend staffing at the time of 

the scheduled landing. It was great good fortune that 

extra medical personnel were present on site preparing to 

support the busy post-landing experiment data collection 

process; these individuals immediately made themselves 

available for assistance where needed, and it was only 

with their efforts that it was possible to fully cover the 

level of medical support needed after the mishap. 

In retrospect, it has become clear that multiple 

alternative contingency possibilities must be 

considered, with careful planning and incorporation 

of all potential scenarios into training and medical 

planning. Further, it is crucial to anticipate and plan for 

the need of more support than is generally available 

in normal scenarios. The KSC Medical Office has 

subsequently added both non-emergent medical 

care and the disposition of crewmembers with nonsurvivable injuries to all training and exercise scenarios. 

The Medical Office has also strengthened its on site 

and on-call personnel lists during off-hour and weekend 

mission support. As the provision of psychological 

counseling was of utmost importance, and was one of 

the most limited aspects of the contingency response 

due to a lack of available personnel, all KSC medical 

care personnel are now provided with CISD training. 

In addition, JSC Medical Operations now provides 

behavioral health specialists to accompany astronaut 

families for every NASA astronaut launch and landing. 

Finally, although agreements, plans, and procedures 

regarding flight crew fatalities occurring at KSC 

were in place several years before the accident, after 

the accident further technical exchanges with the 

DOD Department of Mortuary Affairs and the DOD 

AFIP substantially improved KSC’s preparations for 

responding to an astronaut fatality. 

Recovery Support and Reconstruction 

Lessons Learned 

The massive recovery effort after the Columbia 

accident quickly placed large amounts of personnel 

and assets into the field with limited planning for 

safety and health. Unfortunately, illnesses, injuries, 

and fatal accidents occurred during the recovery 

operations. In an ideal world, responders should never 

become victims, and support responses should always 

emphasize safety and health with careful planning and 

coordination. Adequate emergency medical services, 

occupational medicine, environmental health, medical 

screening, pre-deployment and in-field training, postrecovery debriefing, and return-to-work examination 

and counseling should be made available for all remote 

assignments or assignments with limited support and 

exceptional work demands. Routine post-recovery 

debriefings and return-to-work fitness examinations 

were not instituted for the Columbia search and 

recovery effort but might have benefited returning 

recovery workers. This should be considered for any 

future operation of this kind. 

Infrastructure (policies, plans, and procedures) for safe 

operations in the reconstruction hangar did not exist 

before the accident and was created during the mishap 

response. Hangar personnel had significant concerns 

about biological exposures; this had an impact on 

initial reconstruction operations. KSC immediately put 

training and safety measures for potential exposure to 

blood-borne pathogens into place for all screening of 

biological items. This both reduced concerns and aided 

medical personnel in identifying biological material 

coming into and existing in the reconstruction hangar. 
64 SECTION 2 – THE RESPONSE

Conducting several separate assessments of the 

same biological item became cumbersome and 

inefficient; as a result, a team approach was used 

whenever potential biological material arrived at the 

reconstruction hangar. The team consisted of a KSC 

physician and representatives from the Astronaut 

Office, Vehicle Integration Test Team (VITT) Office, 

Payloads Office, and KSC Environmental Health 

Department. Representatives of the Astronaut Office 

and VITT Office determined whether any crew 

cabin or crew items were present, and the Payloads 

Office representative identified the payload items. 

The physician determined whether the material was 

biological, belonging to Shuttle components, and 

whether suspected human remains were present. The 

environmental health specialist assessed the potential 

for toxic exposure from the items. Many payload 

items were identified at this time, allowing recovery of 

useful science. For example, in one instance a payload 

experiment involving live worms was recovered intact. 

To improve the likelihood of receiving biological 

material sent from the field, NASA provided training 

for field personnel to recognize such items and KSC 

medical personnel pre-screened transmitted images 

of items sent from the field. Despite plans being 

in place, new issues would sometimes arise that 

required innovative solutions. It was realized that 

biomedical support needed to stay flexible, and be 

continually learning and adapting to provide the best 

support possible. Biomedical support was a process in 

continual evolution. 

The recovery and reconstruction activities, like many 

accident investigations, had high visibility and were the 

object of great public interest, both within and outside 

of NASA. The potential existed that hangar operations 

could become distracted or interrupted by the pressures, 

influences, and sensitivities of political, media, or 

societal entities. Simple awareness training provided to 

hangar personnel concerning these potential influences 

could help future operations from being affected by any 

of these social influences. 

Conclusions and Recommendations 

The KSC medical response to the Space Shuttle 

Columbia accident was multifaceted and tested KSC’s 

capabilities and readiness. In contrast to the commonly 

practiced contingency scenarios, the mishap did not take 

place at KSC, was not lifesaving in nature, and included 

mental health concerns and primary care support to 

astronaut families and site visitors that were not fully 

anticipated. The KSC biomedical support was needed 

for recovery, not rescue. Occupational medicine and 

environmental health support were more important in 

support of this event than providing emergency medical 

services. A need was identified to maintain safety and 

health in all operations that involve NASA employees 

whose work places them in harm’s way. As the center 

with the largest NASA workforce exposed to workrelated hazards, KSC will continue to make such factors 

a primary concern and responsibility. 

KSC employees and their families, whether or not they 

were directly involved in the event, suffered emotionally 

from the loss of the crew and the vehicle. Although the 

needs were outside the scope of the practiced operations, 

the KSC medical community performed admirably by 

providing psychological resources for large numbers 

of people over a prolonged period of time during the 

grieving process. 

Plans and infrastructure must be in place to provide 

biomedical support when it is needed, but it is equally 

important to remain flexible for necessary changes, 

continually learning and adapting to provide the best 

possible support. The lessons learned from this accident 

should never be forgotten; it is now our responsibility 

to apply these lessons to future space flight programs to 

honor and respect the crew and all those who have been 

touched by the loss of Columbia. 
SECTION 2 – THE RESPONSE 65 

Crew Medical and Psychological 

Support Operations 

Smith Johnston and Christopher Flynn 

Collection of flowers, balloons, flags, signs, and other remembrance items placed at the Johnson Space Center sign at the main entrance. 

Background 

At the time of the initial Columbia STS-107 mission 

assignment in July of 2000, the Johnson Space Center 

(JSC) Medical Operations Branch consisted of 15 

certified operational flight surgeons, qualified to act 

as primary care physicians to a mission-assigned crew 

and their family members. These physicians have two 

primary responsibilities. First, they maintain a doctorpatient relationship with each crewmember, providing 

medical guidance and expertise in both normal training 

and emergency situations. Second, the physicians act as 

medical representatives for Space Shuttle operations. 

This includes both recognizing and resolving medical 

concerns that may have an impact on the mission, 

and also acting as an advocate for their crewmembers 

throughout training and flight. As a result, many crews 

become quite close to their flight surgeons throughout 

the course of their training. For each Shuttle mission, 

a lead crew surgeon and a deputy crew surgeon were 

assigned about 9 months before launch to ensure that 

all the crewmembers were physically and mentally 

prepared for their mission responsibilities. 

The behavioral health and performance group at the 

Johnson Space Center (JSC) worked closely with 

both the Astronaut Office and the Medical Operations 

Branch in 2003. This group included highly trained 

psychologists and psychiatrists who were well 

integrated with training and flight activities. Even during 

normal operations, psychological stress can affect a 

crew or their families. The behavioral health team 
66 SECTION 2 – THE RESPONSE

The STS-107 crew poses in front of the entry into Space Shuttle Columbia during Terminal 

Countdown Demonstration Test activities on the pad. Kneeling in front are (left to right) Payload 

Specialist Ilan Ramon (the first Israeli astronaut), Pilot William “Willie” McCool and Mission Specialist 

David Brown. Standing in back are (left to right) Payload Commander Michael Anderson, Mission 

Specialist Kalpana Chawla, Commander Rick Husband and Mission Specialist Laurel Clark. 

offers crewmembers emotional 

preparation and support for 

handling their mission. The team 

also becomes a valuable asset 

for family members as they learn 

to cope with both the stress of 

the upcoming mission and the 

inevitable celebrity and attention 

that accompanies flight. 

Medical Operations 

for the Columbia 

STS-107 Mission 

The Columbia STS-107 mission 

was unique. It was dedicated 

to research, and crewmembers 

conducted multiple scientific 

experiments and used specialized 

onboard laboratories in the 

SPACEHAB located in the 

payload bay. From a crew 

surgeon’s perspective, the mission 

was particularly challenging 

because crewmembers were 

assigned to it earlier than to most 

other missions. The extended 

time commitment and additional 

training to perform scientific 

experiments was integrated 

into the usual training and 

preparations for the mission. The 

crew flight surgeons acted as 

liaisons between the crew and the 

investigators who had proposed 

and designed the experiments, 

working closely with the mission 

scientists (John Charles and David 

Liskowsky) and the international 

scientific community to ensure 

that experiment and technical 

procedures were appropriately 

addressed in the crewmembers’ 

training. Crew flight surgeons focused on safety issues 

related to the science and worked to ensure smooth 

communication between the mission control surgeon 

console, the investigators, and mission control directors. 

They facilitated the logistics and interfaced with the 

investigation teams in coordination of timeline planning. 

The STS-107 SPACEHAB Research Double Module 

was filled with scientific equipment and experiments. 

To fully prepare for the mission, the crew required 

intense preflight training and simulation time as 

well as multiple trips to the Kennedy Space Center 

(KSC) for familiarization with the module and unique 
SECTION 2 – THE RESPONSE 67 

Shuttle payloads. Of particular interest, multiple life 

science experiments, with organisms from bacteria 

and mosses to nematodes to rodents, were part of the 

flight’s science payload, requiring a sensitive and 

humane understanding of experiment procedures as 

well as extensive coordination with the scientists 

and veterinarians responsible for these payloads. 

The crewmembers served as subjects in human 

research experiments, which required collection of 

data before, during and after flight. Data collection 

sessions required practice for the investigators and 

participation by the crew flight surgeons. Landingday operations for the scientific mission were equally 

complicated because of various experiment protocols 

that had to be followed. These details were extensively 

outlined and coordinated before the mission, and the 

crew and investigators participated in simulations 

involving facilities, equipment, and support personnel. 

Further, post-landing operations required crewmember 

participation at the KSC baseline data collection 

facility before they returned to their families. This 

added a psychological component to the challenges of 

the landing timeline. 

Finally, because of the nature and amount of scientific 

experimentation, the crew was required to perform 

round-the-clock monitoring and activity during 

the mission. This necessitated extensive timeline 

development, circadian sleep-cycle planning, and 

the use of isolated sleep stations to ensure that the 

crewmembers could receive enough rest. To coordinate 

such an intense research schedule, the crew was 

split into two teams, Red and Blue, that would work 

opposing shifts to best utilize their time in orbit. 

The crew surgeon developed these sleep-shift plans 

and worked with the crew, the investigators, and 

mission operations teams to ensure optimization of 

the mission activities. 

Left to right: Mission Specialist Laurel Blair Salton Clark, Commander Rick D. Husband, and Mission Specialist Kalpana ‘KC’ Chawla, all red team 

members, peer out at the world from the comfort of their sleep compartments on orbiter Columbia’s middeck. 
Updated: May 20, 2002

GRAPHIC: 3/25/13

STS-107 Circadian Adjustment Lighting Schedule

 

 

68 SECTION 2 – THE RESPONSE

 

 

Example of STS-107 Circadian Adjustment Lighting Schedule 

Time, 24 hours 

EST 

Sunlight JSC 

Sunlight KSC 

0 1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 0 0 0 1 

CST 0 0 0 1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 0 0

L-8 

L-7 

L-6 

L-5 

L-4 

L-3 

L-2 

L-1 

L-0 

FD 2 

FD 3 

FD 4 

FD 5 

FD 6 

FD 7 

FD 8 

FD 9 

FD 10 

FD 11 

FD 12 

FD 13 

FD 14 

FD 15 

FD 16 

FD 17 LANDING - 02/01/03 

Time: 

EST = Eastern Standard Time 

CST = Central Standard Time 

L-1, etc. = Days before launch 

FD = Flight days 

MELATONIN 

(Taken 30 mins. before 

bedtime as sleep aid) 

Red Team Sleep Schedule 

Blue Team Sleep Schedule 

BRIGHT INDOOR LIGHT 

SUNLIGHT 

GOGGLES (or dim light indoors) 

LANDING 

M

M

M

M

M

M

M

M

M

M

M

M

M

M

M

M

M

M LAUNCH 

Time in Days 

LAUNCH - 01/16/03 

On the ground, 24-hour activities required increased 

support, in both personnel numbers and longer hours, 

from physicians and biomedical engineers. The work 

was dynamic and timelines changed daily, and all 

ground teams had to be fully qualified and capable 

to support the medical and scientific experiments on 

orbit. The entire ground support team worked diligently 

to develop many unique mission-specific flight rules 

that were needed for payload hazardous materials, 

SPACEHAB life-support requirements, and contingency 

responses unique to the altered payload configuration. 

Training specific to the medical support team included 

SPACEHAB payload instruction and multiple integrated 

simulations before launch. In particular, medical 

safety was important. Blood draws and training in 

performing blood draws were required for physiological 

experiments. Twenty-four-hour operations required that 

ground teams, as well as the crew, participate in sleepshifting to ensure that the crew had constant support 

from mission control. 
SECTION 2 – THE RESPONSE 69 

Team Cohesion 

As discussed in previous chapters, the launch of STS-107 

was significantly delayed because of Shuttle technical 

issues and pressures to complete the International 

Space Station. As a result, the crew, the scientists, 

the flight control team, all training personnel, and the 

crew surgeons had worked and trained together for 

nearly 3 years by the time of the launch. Commander 

Husband had set a tone of constant team cohesion and 

camaraderie, both during work and after. Crew spouses 

interacted daily, including setting up biking and camping 

trips, and crewmembers and their families shared 

holidays and other social gatherings with family, friends, 

and their Casualty Assistance Calls Officers (CACOs) 

and crew flight surgeons. Many of the crewmembers’ 

children were of similar ages and became playmates and 

good friends. The multifaceted backgrounds and diverse 

cultures of the families seemed to complement each 

other, and the crewmembers and their families became 

extremely close as a result. 

Casualty Assistance Calls Officer (CACO)

The CACOs are members of the NASA astronaut 

corps and are charged to render assistance 

needed to settle the personal affairs of a 

deceased astronaut or to support a seriously ill or 

seriously injured astronaut. Their duties include 

assisting the family and next of kin in making 

all necessary decisions to deal with a fatality. 

This includes making arrangements for handling 

the remains, making funeral arrangements, 

collecting death gratuities, filing for benefits and 

entitlements, and sorting out other day-to-day 

and personal affairs during the period immediately 

after the death. 

The integration of the medical team into this social 

circle occurred naturally. The flight surgeons and 

physicians were often included in after-work activities 

Crew during their preflight training at the National Outdoor Leadership School. First row, left to right: William McCool, Ilan Ramon, Laurel Clark, 

Kalpana Chawla; back row, left to right: David Brown, Richard Husband, Michael Anderson. 
70 SECTION 2 – THE RESPONSE

and social events. Some behavioral health and 

performance team members worked closely with the 

families to prepare them for the mission. Also, two 

members of the crew, David Brown and Laurel Clark, 

were former Navy flight surgeons themselves with 

significant medical training and experience, further 

deepening the bond between the crew and their 

flight surgeons. Clark’s husband had also been a 

Navy flight surgeon and at the time of the mission was 

a certified NASA flight surgeon in the JSC Medical 

Operations Branch. 

Mishap Response 

At the time of the mishap, the crew flight surgeons 

were at KSC waiting with the crew families for the 

return of their loved ones. As the scope of the disaster 

was realized, the mood rapidly shifted from one of joy 

and anticipation to sudden and crushing devastation. 

Crew surgeons were notified of Columbia’s destruction 

and were faced with the responsibility of sharing that 

information with the families. There was a mixture of 

emotions among the clinicians, including tremendous 

loss, dread, and guilt that NASA actions, or the lack 

thereof, may have contributed to the tragedy. 

Even as they tried to process these emotions, the flight 

surgeons and the psychological team immediately 

began to assess available resources to care for the 

families and close friends, many of whom had been 

at KSC for the landing. Thankfully, a number of 

psychological specialists were also present who 

were already known to the families: two operational 

psychologists, two operational psychiatrists, and 

one child psychiatrist had already become trusted 

consultants. Still, providers were forced to try and 

balance their own grief with the need to help. They 

quickly developed a response strategy based on the 

concept that the families could not be abandoned at 

the worst time of grief. Though words seemed utterly 

inadequate to meet the horror of the losses, the hope 

was that the presence of the support team would 

provide some measure of comfort and sympathy to the 

families to help restore trust and reduce fear. 

Providing Psychological Assistance 

The providers knew that they would not be able to 

answer, technically or existentially, the inevitable 

question of “why.” Technical details were slow to 

arrive, and as they did they often led to more questions, 

as it was simply impossible to comprehend the nature 

of the disaster from the confusing early details of the 

investigation. This amplified the grief and the stress 

of both the flight surgeons and the behavioral health 

providers, but at the same time their role became 

perfectly clear: they would need to find other ways to 

assist the families in their time of suffering. In finding 

other ways, the CACOs were instrumental as each 

had authority to request actions and information from 

NASA, allowing them to become powerful advisors 

for both the families and the medical team. Further, 

each had been chosen individually by the families, and 

as a result they became the most trusted advisors to 

the family members after the accident. They advised 

the behavioral health providers on scheduling visits to 

provide emotional support, ensuring that visits were 

only helpful and never disruptive. The CACOs and 

designated NASA flight surgeons were the liaisons 

between each family’s needs and the organization’s 

response; through them, the medical and psychological 

support teams could act as skilled assets available when 

the families most needed them. 

As the families trusted the flight surgeons and 

psychologists enough to share their grief, the providers 

were determined to be patient, to listen, and to speak 

honestly—not in platitudes. Providers sought out 

indications of how each family member could be best 

helped through the grieving process. Coordination 

with additional community mental health providers 

was established so that families could transition from 

Agency-related care, if desired. Connections to other 

supportive relationships were encouraged, including to 

family members, friends, co-workers, and clergy. The 

support team looked for ways to ensure that there were 

always familiar faces nearby and that no family member 

would ever feel alone when they needed help. 

The constant public and media interest added challenges 

to the grieving process. Providers learned not to allow 

the appearance of a family member “in public” to 
SECTION 2 – THE RESPONSE 71 

define how much support he or she might actually 

need “in private.” Occasionally, the support team 

offered medications to ensure sleep and to reduce 

overwhelming anxiety. As time progressed, the children 

in the families expressed their own questions and fears, 

and the clinicians held group and individual meetings 

in response. The support team encouraged a family’s 

verbal communication and physical contact (including 

hugging and holding by parents and trusted adults) as 

the most helpful soothers for children. 

As expected, there were times when a family member’s 

anger would lead that person to distance him- or herself 

from the medical or psychological providers for a time. 

Some families did not request or allow psychological 

support visits after the first few sessions. However, the 

overwhelming sentiment was that simply talking about 

the loss of the crew, with someone who truly understood 

that loss through “living the mission” with them, was 

uniquely helpful after the tragedy. For families who 

were suffering so greatly, providers were aware that 

they could only offer consistent efforts to build a solid 

connection of support that would be trustworthy, honest, 

and thoughtful. 

The timeline of grief is personal, as each grieving 

individual searches for meaning to the loss in his or her 

life. It is a painful but necessary process, made even 

more challenging because it must occur during a very 

dark emotional time. It was the goal of the medical 

and psychological support team to act as guides and 

companions through this process, no matter how long it 

might take. Sadly, NASA had experienced this process 

previously, after the Challenger disaster, and that tragedy 

brought the wisdom to ensure that prolonged care was 

available for the families. The grief process for a highprofile death is unique, as it is staged first by an extreme 

reversal of fortune as families in a state of elation over 

an event such as a crew’s homecoming suddenly are 

faced with disaster and horror. This extreme pendulum 

swing of emotion only adds to the anguish. Families are 

also regularly reminded of their loss as the world holds 

ceremonies and honors anniversaries for the fallen crew. 

With this in mind, the support team actively sought to 

be available to the families for continued familiar and 

trusted counsel during these times. 

Lessons Learned 

The medical and psychological support teams 

searched for insight from their mishap response. 

First and foremost, a recognition of the depth of the 

challenges facing the grieving family was necessary 

before providers could truly be helpful. Each member 

of the medical team was acutely aware that their 

association with NASA could cause them to be less 

than welcomed into a family’s grieving process. It 

would have been a natural response for families to 

direct anger by affiliation and classify any NASA 

employee as one of the perpetrators of the disaster 

rather than someone offering help. However, all 

families graciously accepted the support of the medical 

team during the initial days of grieving. 

The precoordination and integration of medical and 

psychological support assets before the mission were 

exceedingly valuable for the response to the disaster. 

It would have been terribly difficult for the families to 

accept help from personnel brought in only after the loss 

of the crew. The trust and friendship built over the years 

of association allowed the flight surgeons, behavioral 

health team members, and CACOs to empathize with 

the loss as well as truly understand how best to support 

the grieving families. 

It became clear that the ability to keep the families 

isolated from the press was both necessary and 

relieving. Constant media presence is extremely 

disruptive to the grieving process, as those in the 

spotlight feel the need to suppress emotions and 

provide a “public face” to the cameras. At the same 

time, media presence can heighten negative emotional 

responses such as anger and blame. One of the most 

powerful lessons learned by support personnel was 

a recognition of the great extent of misinformation 

surrounding families and how much it influenced the 

families’ grieving and the organization’s responses. 

Families became frustrated by the wildly diverse 

mishap “facts” (of questionable reliability) that 

circulated constantly. The “latest” information 

was rarely the most accurate information about the 

catastrophe. This created an uncomfortable frustration 

between families, who were hungry for any information 

about the mishap, and NASA officials, who could 
72 SECTION 2 – THE RESPONSE

The Houston Astros honored the crew of Columbia on April 1, 2003, the opening day of the season, by having simultaneous first pitches thrown 

by family and friends of the Columbia crew. 

offer updates only when information was absolutely 

confirmed. The most effective way to respond to these 

concerns was to establish daily, scheduled CACO 

and flight surgeon meetings with the Astronaut Office 

leadership. Early on, these meetings became the 

primary source of information for the families about 

the investigation, providing a source of confirmed 

and complete information that could be trusted by the 

family members. 

The CACOs were instrumental in providing a direct 

line of communication to and from the families. 

They acted as a single point of contact, minimizing 

miscommunication, and further coordinated with 

the search and recovery teams to make sure the 

families would receive the best information and that 

all questions could be answered. One of the most 

difficult aspects of communication was to ensure the 

equivalent flow of information to all families. The 

CACOs provided a means to this end, preventing 

miscommunications that could otherwise have led 

to resentment and a breakdown of the relationship 

between the family and the support team. 

It was extremely important that the families did not feel 

that those around them were hiding details, including 

mistakes. The more honest and open the support team 

was, the more the family could embrace the team as 

trusted advisors. Mistakes are inevitable, and providers 

took the intentional approach of admitting to all 

mistakes while actively working to solve the problem. 

The families expressed great appreciation for the 

honesty and integrity of the support team providers in 

the wake of the disaster. 

Families should never be made to feel abandoned by 

those around them after a loss of this magnitude. The 

medical and psychological team recognized this and 

continued to provide emotional and psychological 
SECTION 2 – THE RESPONSE 73 

The Patricia Huffman Smith Museum, Remembering Columbia, 

opened in Hemphill, Texas, in February 2011. In addition to telling the 

story of Columbia, the museum highlights the efforts of local citizens 

during the recovery of Columbia and its crew. 

support even years after the disaster. After such a public 

mishap, momentous occasions may reopen emotional 

wounds. Memorials, birthdays, anniversaries, and 

similar occasions might be recognized as difficult for 

the family for years to come. However, these events 

also offer them an opportunity to develop closure 

and confirm a sense of pride in the fact that their 

family members are being honored. Maintaining close 

relationships between the providers and the families 

has enabled the support process to continue throughout 

these emotional challenges. 

The response to the disaster was not perfect. One 

of the challenges faced by the providers was the 

management of their own grief. In most cases, the 

support team compartmentalized their own emotions 

to focus instead on caring for the families. Requiring 

the support team, including the CACOs, crew flight 

surgeons, and even the psychological providers, to 

receive some degree of counseling themselves would 

have been helpful. As was done for the astronauts 

participating in field recovery efforts, establishing 

a requirement for psychological decompression 

visit(s) would have reduced feelings of inadequacy 

or embarrassment for those desiring help. Even those 

responsible for helping others grieve must recognize 

and accept the need to care for themselves. 

The medical and psychological providers felt a 

deep sense of privilege in being allowed to respond 

to the needs of the families of the STS-107 crew. 

By describing our goals and methods here, it is our 

hope that the lessons we learned may someday lessen 

the pain felt by others experiencing such devastating 

loss. It is important that these lessons are not lost to 

history, but that instead we may learn from this 

tragedy and the sacrifices made by the STS-107 crew 

and their families. 

A monument on Sabine Street in Hemphill, Texas, honors the 

astronauts who perished in the Space Shuttle Columbia disaster. 

Photo credit: Patricia Huffman—Smith Museum, Remembering Columbia Photo credit: Patricia Huffman—Smith Museum, Remembering Columbia 
74
 SECTION 2 – THE RESPONSE
Section 3 – The Investigation
 

Columbia Accident Investigation Board 

Medical Operations and 

Crew Survivability Working Group 

The Columbia Crew Survival Investigation Report: 

The Five Potentially Lethal Events and Crew Survivability 
76 SECTION 3 – THE INVESTIGATION

Columbia Accident Investigation 

Board Medical Operations and 

Crew Survivability Working Group 

James P. Bagian 

The Columbia Accident Investigation Board (CAIB) 

appointed advisors to the chair to assist in the focus 

and management of the investigations. These advisors 

included a chief flight surgeon (CFS) and medical 

consultant, James Bagian, MD, former astronaut and 

lead medical investigator for the Challenger accident 

that occurred in January 1986. This chapter tells the 

story of the CFS-led efforts to provide NASA with 

insight into crew recovery and identification as well 

as the events that led to the crew deaths. Included 

are descriptions of the efforts undertaken to ascertain 

the impact of different stages of the accident on the 

crew module, review of the pertinent engineering 

data and information about the crew equipment, and 

determination of what equipment or procedures might 

have kept the crew alive. These efforts concluded with 

the issuance of the CAIB Report Volume V, Appendix 

G.12 Crew Survivability Report.
	

Within hours of the STS-107 mishap, hundreds of
	

personnel converged on East Texas and Louisiana to 

begin the process of gathering information to assist 

in the investigation of the mishap. NASA’s Mishap 

Investigation Team (MIT) medical members and the 

Barksdale Air Force Base (AFB) medical staff set up a 

temporary space to receive crew remains that might be 

recovered. Individuals from the Johnson Space Center 

(JSC) Medical Operations Branch and the Astronaut 

Office arrived at Barksdale AFB the day of the accident, 

February 1. On February 2, Philip Stepaniak, MD, 

NASA flight surgeon and the medical lead for the MIT, 

met with the CFS to discuss aspects of the investigation 

related to recovery, initial identification and transfer of 

the crewmember remains to the Armed Forces Institute 

of Pathology at Dover AFB, Delaware for further 

forensic analysis and final disposition. 

Challenges 

As with any large accident investigation, organization 

and communication were challenges, and the 

Columbia accident investigation experienced many 

of these issues. Compared to the Challenger mishap 

investigation, the Columbia investigation went 

more smoothly with respect to providing the ability 

to recover evidence and to develop and implement 

a mature plan of action. Even so, many obstacles 

were encountered related to logistics, organizational 

responsibility and authority, chain of command, 

technical capability required to allow the investigation 

to proceed, and pressure to block the release of the 

final report regarding crew related information (CAIB 

Report, Volume V, Appendix G.12). Overcoming 

these obstacles required a number of actions in order 

for the CAIB to be successful in determining what 

had happened to the crew and in discerning and 

communicating the lessons that could be gleaned from 

the mishap that would support and improve future 

space flight-related activities. 

As in many field operations, communication of 

the various parties with each other was often difficult. 

In addition, even when communication was possible, 

the ability to conduct secure communication, when 

required, was initially non-existent. As a result, it 

was necessary for key personnel involved with the 

recovery of human remains to have face-to-face 

communication with each other to promote the most 

efficient and effective recovery of these materials. 

Because the debris field was very large and the initial 

recovery operations difficult, access to various forms 

of transportation including helicopters was essential 

to facilitate communication, understanding, and 

direction of the operations. 
SECTION 3 – THE INVESTIGATION 77 

 

Columbia Accident Investigation Board Background 

For mishaps the National Aeronautics and Space 

Administration uses the agency contingency action 

plan (CAP) for space operations (SO), which states, 

“in the case of a high-visibility, mission-related 

SO mishap the NASA administrator may activate 

the independent ISS and Space Shuttle Mishap 

Interagency Investigation Boards (the Board). Board 

activation is anticipated for events involving serious 

injury, significant public interest, and other serious 

mishaps. For mishaps that involve loss of crew or 

loss of vehicle, a Commission will be formed.” 

The Commission’s membership consists of 

the following: 

Board Chair − Appointed by the NASA Administrator 

Board Members 

Commander, Naval Safety Center 

Representative, USAF Materiel Command 

USAF Chief of Safety 

Department of Transportation Director, Aviation 

Safety Division 

Federal Aviation Adminstration Office of Accident 

Investigation 

Representative, USAF Space Command 

NASA Field Center Director 

The Board was supported by the following personnel: 

Standing Board Support Personnel 

Ex officio member: NASA Chief Safety and Mission 

Assurance Officer 

Executive Secretary: NASA Chief Engineer 

Contracts and Procurement Specialist to be 

designated by the Assistant Administrator for 

Institutions and Management 

Additional Personnel Support 

The Board may designate consultants, experts, or 

other government or nongovernment individuals to 

support the Board as necessary. The Department of 

Justice Litigation Team provided document control. 

In addition, the Board may substitute non-NASA 

personnel as Executive Secretary at the discretion 

of the Board chair. The Board appointed an 

aeromedical advisor to the chair, James P. Bagian, 

MD, astronaut retired, who acted as a medical 

consultant and chief flight surgeon. 

The Board responsibilities are the following: 

1. 	Conduct activities in accordance with the policies 

and procedures adopted by the Board. 

2. 	Schedule Board activities, interim Board reports, 

and submission of the final Board report as the 

Board deems appropriate. 

3. 	Determine the facts, as well as the actual or 

probable causes of the mishap in terms of 

dominant and contributing root causes and 

significant observations and recommend 

preventive and other appropriate actions to 

preclude recurrence of a similar mishap. The 

investigation will not be conducted or used to 

determine questions of culpability, legal liability, 

or disciplinary action. 

4. 	Use the established NASA support structure of 

working groups, NASA field center support, and 

supporting facilities to conduct the investigation, 

as the Board deems appropriate. The Board may 

use non-NASA support as it deems appropriate. 

5. 	Activate the working groups appropriate to 

the mishap. 

6. 	Obtain and analyze whatever facts, evidence, 

and opinions it considers relevant by relying upon 

reports of studies, findings, recommendations, 

and other actions by NASA officials and 

contractors or by conducting inquiries, hearings, 

tests, and other actions the Board deems 

appropriate. In so doing, the Board may take 

testimony and receive statements from witnesses. 

All elements of NASA will cooperate fully with the 

Board and provide any records, data, and other 

administrative or technical support and services 

that may be requested. 

7. 	Impound property, equipment, and records to 

the extent that the Board considers necessary. 

8. 	Release mishap information and mishap 

investigation reports as the Board deems 

appropriate. 

9. 	Develop recommendations for preventive 

and other appropriate actions. A finding may 

warrant one or more recommendations or it 

may stand alone. 

10. Provide a final written report at such time and in 

such manner as the Board deems appropriate 

which upon its completion will be immediately 

released to the public. 
78 SECTION 3 – THE INVESTIGATION

Initial Operations of Crew Recovery 

Starting almost immediately after the mishap on 

February 1, multiple individuals from the JSC Flight 

Medicine Clinic, as well as others who would later 

officially be part of the CAIB began to assure that 

human remains were collected and brought to the 

temporary morgue facilities at Barksdale AFB. Many of 

the pivotal individuals involved with the location and 

recovery of crew remains were from the astronaut office 

and had personal familiarity with the deceased crew. 

With regard to human remains, the problem in the field 

was figuring out where to find the remains. Initially, 

NASA did not think that there would be any appreciable 

amount of remains that would have survived the 

mishap. By the afternoon of the accident the physical 

evidence that was immediately recovered demonstrated 

that this was absolutely not true. This necessitated steps 

being put in place to deal with locating and recovering 

crew remains. Close work between the CFS and the 

Search and Recovery Team in East Texas at Lufkin 

ultimately resulted in a more timely location of the 

crew remains than would otherwise have occurred. This 

was the result of the CFS having the ability to examine 

debris as it arrived at Barksdale AFB, having access 

and ability to examine and view recovery operations in 

the field, and integrating this information to help predict 

where additional crew remains might be located. 

These discussions and decisions were guided by actual 

physical findings on the ground, not the myriad of 

theories proffered by individuals in the field. 

The CFS conducted the fact-finding and analytic 

activities primarily on February 3rd and 4th. The CFS 

reviewed the information regarding where the remains 

were recovered and correlated that with other debris 

and its location. This analysis generated an evidencebased plan that was aimed at locating the crew remains 

which had not yet been found. Due to the lack of secure 

and reliable communication links, the CFS flew to 

Lufkin to meet with Search and Recovery Operations 

Director (astronaut James Wetherbee, Captain USN), on 

February 4. This meeting led to a revision to the plan 

for locating the remaining crewmember remains. 

The CFS created and supplied to the Search and 

Recovery Operations Director a coded way by which 

they could discuss ongoing operations and plans through 

the existing non-secure communication links while 

maintaining security. This code prevented revealing to 

searchers and the public where specific crew remains 

were found. The new plan resulted in a more methodical 

search based on concrete information rather than poorly 

founded conjectures given to the search and recovery 

team from well-meaning disparate personnel in the field. 

This resulted in the search for crew remains changing 

from a “hasty search” to a more rationally based 

systematic search. Thus, the Operations Director changed 

the search areas from the northwest to the southeast. 

Over succeeding days the Operations Director continued 

to communicate with the CFS the results of their search 

operations and these efforts led to the recovery of the 

remains of all crewmembers by February 12. 

CAIB Operations 

In the first few days after the mishap, the CAIB was 

in the process of getting organized, and many of the 

activities that were undertaken by CAIB members 

and others were based on individual initiative rather 

than a well-coordinated and planned response. Despite 

the potential challenges stemming from an ill-defined 

processes and command structure, operations went very 

well, being aided by those involved recognizing the 

need to clearly communicate needs and actions to the 

wide variety of entities involved. 

On the evening of February 5, CAIB operations – 

including the CFS – relocated from Barksdale AFB to 

Houston to have access to facilities and personnel at 

JSC. The CAIB and associated staff set up their work in 

the Regency Park office complex that was just outside of 

the gates to JSC. This location allowed ready access to 

JSC technical experts and information that was needed 

to conduct the investigation. 

On February 6, the CAIB chair was briefed by CFS 

about the extent of the crew remains that had been 

recovered and how their condition indicated that the crew 

were not immediately killed at the time of loss of signal, 

as many had incorrectly initially presumed to be the case. 

The CAIB chair understood that the nature and condition 

of the crew remains recovered indicated that the crew 

compartment of Columbia may have stayed intact for 

a significant time and that the crew was probably alive 

after the time of loss of signal. The condition of the 

remains also implied that valuable information might 
SECTION 3 – THE INVESTIGATION 79 

The Columbia Accident Investigation Board 

Left to right: first row, G. Scott Hubbard, James N. Hallock, PhD, Sally T. Ride, PhD, Admiral Harold W. Gehman, Jr, (retired), Steven B. Wallace, 

John M. Logsdon, PhD, Sheila E. Widnall, PhD. Back row: Roger E. Terault, Major General John L. Barry, Rear Admiral Stephen A. Turcotte, 

Brigadier General Duane W. Deal, Major General Kenneth W. Hess, Douglas D. Osheroff, PhD. 

exist that could increase the likelihood of crew survival 

in future Space Shuttle operations and be applied to the 

design of future vehicles. 

The original focus of the CAIB and JSC personnel was 

“why the wing came off.” NASA furnished the CAIB 

a single point of contact (POC) who was responsible 

for providing the technical information requested by 

the CAIB. Initially, the POC provided only information 

that he felt was directly related to “why the wing came 

off” regardless of whether the CAIB requested it or not. 

However, this narrow focus obstructed the CFS efforts 

to address crew survivability and the related engineering 

and processes so as to elucidate the physical/cognitive 

environment that impacted the crew and other 

information that would contribute to understanding 

lessons for the future. This meant that the CFS was 

denied access, by the NASA POC, to important 

information because it was deemed not directly related 

to the root cause of the accident. The CAIB chair had to 

repeatedly intervene to remind the NASA POC that his 

job was to get the information that was requested by the 

CAIB, not to determine whether it should be supplied. 

During this rocky period the CFS used informal 

channels to obtain the information needed to carry out 

his investigation. While this created a real obstacle in 

the beginning, it was eventually rectified through the 

continued efforts of the CAIB chair. 

Early on, the CFS contacted Jeffrey Davis, MD, 

Director of the Space Life Sciences Directorate (SLSD) 

at JSC to discuss the CAIB’s plan related to the crewrelated portion of the investigation and how it would 

be handled including the various ways the CAIB and 

NASA would be required to cooperate to facilitate the 

investigation. From this point forward, Davis and the 

CFS engaged in frequent communications to make sure 

the crew-related investigation moved forward in a timely 

manner. Davis’ active cooperation and collaboration 

was an essential element in the ultimate success of 

the CAIB efforts regarding crew survivability. On 

February 6, Davis also assigned a flight surgeon from the 

Medical Operations Branch, Rainer Effenhauser, MD, 

to be the liaison to the investigation group to facilitate 

the acquisition of any medical information required. 

The CFS also approached Frank Benz, Director of 

Engineering Directorate at JSC, who provided a similar 

liaison, Lauri Hansen, to facilitate support from the 

engineering personnel at JSC and other centers and 

entities concerning crew survivability. 
80 SECTION 3 – THE INVESTIGATION

Because of the sensitive nature of the crew-related 

investigation, this effort was handled in a discreet 

manner between the CFS, the CAIB chair, and certain 

other CAIB members during the formative stages of 

the investigation. Once the crew-related investigation 

clarified its findings, the results were shared by the 

CFS with all the CAIB members, and the findings and 

recommendations were included as part of the initial 

part of the official CAIB report released in August 2003. 

Crew Survivability Working Group 

Organization and Communication 

The CAIB requested the formation of the Crew 

Survivability Working Group (CSWG), which was 

subsequently commissioned by JSC Center Director, 

General Jefferson Howell. The CSWG was operational 

by February 21. The group, chaired by the CFS, was 

comprised of personnel from SLSD, Engineering 

Directorate, Flight Crew Operations, Mission Operations, 

and the CAIB, including Donald White, Lt Col, USAF. 

The CAIB chair tasked the CSWG with a limited 

charter: First, to determine the cause of death of the 

crew; second, to determine the “survival gap” (what 

equipment or procedures might have kept the crew 

alive); third, to pass the results to the CAIB. The CSWG 

investigation was managed solely by the group itself, 

which allowed it to be agile in making decisions. 

The CSWG performed aerodynamic, thermal, and 

structural analysis on individual debris items and an 

intensive study of the crew helmets, suit hardware, 

and seats. In the process, team members made several 

trips to Kennedy Space Center to view debris that had 

been recovered including portions of the crew module, 

crew-worn equipment including helmets, and seat 

debris. The CSWG developed a timeline that was 

consistent with the official CAIB timeline to derive 

the sequence of crew survival events from the data. 

It became evident that the expertise needed to make 

the most effective use of all the evidence that had 

been recovered was not entirely present within NASA. 

For that reason the CFS contacted the FBI laboratory 

facilities at Quantico, Virginia, and the Armed Forces 

Institute of Pathology (AFIP) at Rockville, Maryland, 

to provide additional forensic support. AFIP functions 

are now part of the Office of the Armed Forces Medical 

Examiner System. The inputs from these organizations 

helped to reinforce and complement the information that 

was available from more traditional sources. The AFIP 

had been involved with the Challenger investigation 

in 1986, and had an established relationship with the 

NASA Medical Operations Branch. 

The CSWG kept the CAIB chair aware of major 

developments and decisions and was essentially 

autonomous. The CAIB chair deliberately set up the 

scope of authority in this decentralized manner to 

facilitate timely action and mission success. 

Scope of the Analysis 

The analysis of crew compartment debris was 

pivotal to understanding the environment that the 

crew module experienced and more importantly the 

environment to which the crew was subjected. The 

analysis from an engineering perspective yielded far 

more information than that gleaned from the crew 

remains alone. Information from the condition of 

items worn by crewmembers, such as helmets and 

suit hardware, as well as debris related to the crew 

compartment and the location on the ground where 

they were recovered, allowed a better understanding of 

where in the trajectory the crew module experienced a 

catastrophic structural failure and total dispersal. It also 

allowed the determination of crew positions at the time 

of crew module failure and the manner in which the 

crewmembers used their crew equipment. The analysis 

of this physical information was made possible through 

the expertise and superb support of the JSC Engineering 

Directorate, which was engaged in the CSWG activities 

from the outset and without whose efforts the ultimate 

findings and conclusions would not have been possible. 

All analyses were completed as data became available. 

Prevent Bias 

It is important to note that from the outset many 

theories were circulating as to what caused the mishap 

and what transpired with respect to the dispersal 

of the crew module and the cause of death of the crew. 

The CFS made a deliberate decision early on that 

the people working on the crew-related investigation 

would not engage officially or informally in discussing 

hypotheses relating to potential scenarios that would 

account for the loss of Columbia and the crew. This 
SECTION 3 – THE INVESTIGATION 81 

 

approach was taken to try to minimize as much 

as possible the impact of confirmation bias on the 

activities of the investigation. Confirmation bias is 

always a concern, as there is a decided tendency 

for individuals to give greater credence to pieces of 

information that support their theories and conjectures, 

and to explain away information that does not support 

their theories, often calling the non-supporting 

information “outliers.” 

By essentially banning the discussion or formulation 

of scenarios in the earlier parts of the investigation, the 

group placed their emphasis on collecting all relevant 

physical evidence and then figuring out how all of it fit 

together and generating hypotheses at that time. Using 

this method meant that any hypothesis about what 

happened to the crew had to incorporate all information 

and was formulated only after the physical data was 

collected and available. It also meant that the initial 

discussions about scenarios did not occur until more 

than 2 months after the mishap itself. Members of the 

CSWG believed then and in retrospect that this was 

vital to the success of the CSWG’s activities. 

Engineering Analysis 

All of the engineering-related information and analysis 

was available by the end of the summer of 2003. The 

CSWG undertook a number of initiatives to uncover 

information that likely would have been otherwise 

ignored, such as proof that the crewmembers were in 

their normal shirt-sleeve environment (1 atmosphere of 

pressure and room temperature) from the time of loss 

of signal for at least another 32 seconds and then for 

at least another 15 seconds during which accelerations 

of the crew module were trivial, and that this benign 

environment probably continued until orbiter breakup. 

The CSWG evaluated four types of data—aerodynamic, 

orbiter, forensic hardware, and forensic medical. 

By June 24, 2003, the CSWG had enough data to 

prepare their initial report for the CAIB. These data 

demonstrated that the initial loss of the orbiter wing did 

not immediately cause death. 

Human Forensic Analysis 

After the crew remains were recovered in the field, 

they were transported to Dover AFB for final forensic 

analysis. Tissue samples were also sent to the FBI for 

additional analysis. The Office of the Armed Forces 

Medical Examiner is the department within the AFIP 

that was responsible for determining the cause and 

manner of death of the crew of Columbia. The AFIP 

had been a valuable partner during the Challenger 

investigation in 1986. While they possessed a wealth of 

experience that they ably, effectively and aggressively 

brought to bear during the recovery, identification and 

disposition of the Columbia crewmember’s remains, 

their input was not timely and did not meet the 

expectations for a medical forensic report. 

Eventually the AFIP provided medical evidence 

that showed death was caused by blunt trauma and 

hypobaria, which further demonstrated that the crew 

module failure and death of the crew occurred at a 

time substantially later than the loss of signal. 

Release of the Findings from the CSWG 

The CSWG reported their initial findings in the CAIB 

Report, Vol. 1, of August 2003 and planned to release a 

more in-depth final report several weeks later. 

Ensuring that the full CSWG report would be released 

was considered to be extremely important to avoid 

repeating the experience regarding the handling 

of crew survival-related information during the 

Challenger mishap investigation. In the Challenger 

mishap, the crew survival investigation was controlled 

by NASA, and the details of the investigation into 

what happened to the crew were never allowed to be 

officially placed in any report and resulted in lessons 

learned being either lost or not widely communicated. 

The CFS, who had been an investigator for the 

Challenger mishap, discussed this concern with the 

CAIB chair at the outset of the CAIB activities and 

they agreed that no such outcome would take place 

with the CSWG findings. 

During the initial stages of the CAIB investigation, 

the Director of JSC Flight Crew Operations Directorate 

(the Directorate where the astronauts are organizationally 

located) had strongly expressed concern about how the 

investigation into the fate of the crew could hurt the 

families and this had initially slowed the investigation 

process. In order to anticipate and mitigate these possible 

objections to release of the CSWG report, the CFS had 

directly furnished the families, through their POC – one 

of the crew spouses (Jonathan Clark, MD) – also at 
ACCIDENT INVESTIGATION BOARD

COLUMBIA

Report Volume I August 2003 7 7

82 SECTION 3 – THE INVESTIGATION

200 

Crew Survival Working Group Findings Published in CAIB Report, August 2003, page 77 

The CSWG provided this timeline, which shows where the module failure and decompression started. This timeline was slightly revised 

in future investigations and more details were published with the Columbia Crew Survival Investigation Report, 2008. The forensic 

evaluation of all recovered crew module and forward fuselage components did not show any evidence of over-pressure or explosion. 

This conclusion was supported by both the lack of forensic evidence and a credible source for either sort of event. The failure of the 

crew module resulted from the thermal degradation of structural properties, which resulted in a rapid, catastrophic sequential structural 

breakdown rather than an instantaneous “explosive” failure. 

GPC – Orbiter’s General Purpose Computer – critical for flight 

ORSAT – Object Reentry Survival Analysis Tool – NASA computer code for predicting reentry survivability 

LOS – Loss of Signal from Columbia 

EI – Entry Interface – begins at 400K feet 

At the Boardʼs request, NASA formed a Crew Survivability 

Working Group within two weeks of the accident to better understand the cause of crew death and the breakup of the crew 

module. This group made the following observations. 

Medical and Life Sciences 

The Working Group found no irregularities in its extensive review of all applicable medical records and crew health data. The 

Armed Forces Institute of Pathology and the Federal Bureau of 

Investigation conducted forensic analyses on the remains of the 

crew of Columbia after they were recovered. It was determined 

that the acceleration levels the crew module experienced prior 

to its catastrophic failure were not lethal. The death of the crew 

members was due to blunt trauma and hypoxia. The exact time 

of death – sometime after 9:00:19 a.m. Eastern Standard Time 

– cannot be determined because of the lack of direct physical or 

recorded evidence. 

Failure of the Crew Module 

The forensic evaluation of all recovered crew module/forward 

fuselage components did not show any evidence of over-pressurization or explosion. This conclusion is supported by both 

the lack of forensic evidence and a credible source for either 

sort of event.11 The failure of the crew module resulted from the 

thermal degradation of structural properties, which resulted in a 

rapid catastrophic sequential structural breakdown rather than 

an instantaneous “explosive” failure. 

Separation of the crew module/forward fuselage assembly from 

the rest of the Orbiter likely occurred immediately in front of 

the payload bay (between Xo576 and Xo582 bulkheads). Subsequent breakup of the assembly was a result of ballistic heating 

and dynamic loading. Evaluations of fractures on both primary 

and secondary structure elements suggest that structural failures 

occurred at high temperatures and in some cases at high strain 

rates. An extensive trajectory reconstruction established the 

most likely breakup sequence, shown below. 

The load and heat rate calculations are shown for the crew module along its reconstructed trajectory. The band superimposed 

on the trajectory (starting about 9:00:58 a.m. EST) represents 

the window where all the evaluated debris originated. It appears that the destruction of the crew module took place over a 

period of 24 seconds beginning at an altitude of approximately 

140,000 feet and ending at 105,000 feet. These figures are 

consistent with the results of independent thermal re-entry and 

aerodynamic models. The debris footprint proved consistent 

with the results of these trajectory analyses and models. Approximately 40 to 50 percent, by weight, of the crew module 

was recovered. 

The Working Groupʼs results significantly add to the knowledge 

gained from the loss of Challenger in 1986. Such knowledge is 

critical to efforts to improve crew survivability when designing 

new vehicles and identifying feasible improvements to the existing Orbiters. 

Crew Worn Equipment 

Videos of the crew during re-entry that have been made public 

demonstrate that prescribed procedures for use of equipment 

such as full-pressure suits, gloves, and helmets were not strictly 

followed. This is confirmed by the Working Groupʼs conclusions that three crew members were not wearing gloves, and one 

was not wearing a helmet. However, under these circumstances, 

this did not affect their chances of survival. 

300 

250 

100 

150 

50 

0 

:59:31 :59:46 :00:01 :00:16 :00:31 :00:46 :01:01 :01:16 :01:31 :01:46

0 

1 

2 

3 

4 

5 

6 

7 

8 

9 

Altitude (kft), Heat Rate 1 Ft radius

(btu/ft ^2 sec)

Equivalent Velocity (mph) 

700 

500 

600 

300 

400 

650 

450 

550 

350 

200 

250 

Acceleration (g's) 

Heat rate 

Nominal Altitude 

Altitude 

Equivalent Velocity 

4 Sec of Data Loads (g's)

-64o roll angle 

39o alpha 

1

o beta 

:59:33-37 Main Body 

STS-107 CREW SURVIVABILITY 

Ro

EI + 953 

Ballistic Flight 

:00:01 

ll Alarm 

MADS 

Record

power 

er los

-assu

fuselag

: es 

med forward 

e separation 

Breakup (video) 

00:20.6 

:

E

59:46 

I + 938 :00:18-19 

EI + 970 Cabi

(OR

n Breach :00:50 

SAT predicted) 

148,800 ft 7.7 g'

max 

s 

LOS 

:59:3

1 

2 

Nosecap

(predic

 sep 

ted) 

2 Final Se

Cabin Pr

Cabin Te

Cabin 

:0

EI + 9 Unknown 

Attitude 

c of GPC Data 

essure 14.64 

dp/dt 0.004 

23 

mperature 71.6 

0:03-05 

138,690 ft 

:01:11

10

.9 

5,483 ft 

Ft. Worth Dallas 

Cabin Items 

(predicted) 

:00:57 –:01:21 
SECTION 3 – THE INVESTIGATION 83 

that time a NASA flight surgeon, a draft version of the 

report so that the family members had an opportunity 

to understand what was in the report and why it was 

included. The families were also informed by the CFS 

that if they had concerns surrounding any facts that 

were included, the CFS would be glad to entertain their 

concerns but that the decision for inclusion would be 

the decision of the CFS and the CSWG. The families 

were comfortable with this arrangement and after 

reviewing the draft report responded that they did not 

want anything changed. 

By the early fall of 2003, all the information was 

available to produce the final report of the CSWG. 

The day before the report was to be issued the Office 

of the NASA Administrator directed the CFS and 

CAIB that the report not be released due to their 

concerns for the families. This intention to block 

the release of the final report was strenuously 

opposed by the CFS who then informed Jon Clark of 

NASA’s intention to block the release of the report 

and suggested that if Clark and the families wanted 

the report released that they write the CAIB Chair, 

Admiral Harold Gehman, to make the families’ wishes 

clear, an action that they did take. 

The CSWG report with the final findings and 

recommendations was ultimately published as intended 

in Volume V, Appendix G.12 of the CAIB Report in 

October 2003. This chain of events raises the question 

that had the CAIB not been established as an independent 

part of NASA’s investigation that the CSWG final 

report may not have been released which would have 

prevented the Agency and the aerospace community 

from gaining the maximal amount of learning from the 

tragic loss of the Columbia and its crew. 

-----Original Message-----

From: CLARK, JONATHAN B. (JSC-SD2) (NASA) <jonathan.b.clark@nasa.gov>

To: GEHMAN, HAROLD (JSC-MA) (NASA) <harold.gehman-1@nasa.gov>; BARRY, JOHN

(JSC-MA) (NASA) <john.barry-1@nasa.gov>; WHITE, DON (JSC-MA) (NASA)

<don.white-1@nasa.gov>; BAGIAN, JIM (JSC-MA) (NASA) <jim.bagian-1@nasa.gov>

CC: ‘Jim Bagian (James.Bagian@med.va.gov)’ <James.Bagian@med.va.gov>

Sent: Fri Oct 17 00:15:05 2003 

Subject: CAIB Crew Survival Section 

Gentlemen,

First of all let me offer my profoundest admiration for the tremendous work

on the Columbia Accident Investigation. This has been a trying time for us

all and the thoroughness of your efforts have been a great comfort to us.

The STS 107 families will be sending the CAIB a statement concerning the

report and have had much to deal with in the aftermath of the investigation.
 

I have had discussions with the Crew Survival Working Group concerning the 1

page section dealing with crew survival in the CAIB Report volume 1 (Page

77) to ensure that it would not be distressful to the Columbia spouses. The

Columbia spouses met tonight and I discussed that a follow on section on

crew survival would be coming out with more detail than Volume 1. The draft

of this has been vetted of any crew specific issues and I believe that it is

an accurate representation of the facts concerning crew issues in the final

moments. In discussion with the Columbia spouses we were entirely unified in

our desire to ensure that all the lessons learned from this mishap be

applied to prevent this type of accident from happening again. We discussed

the crew survival section and our desire is to ensure this information is 

made available to learn all we can from it. A fundemental aspect of every

aerospace mishap investigation is the understanding of crew survivability

issues and there is much still to learn about survival during upper

atmospheric reentry. As sensitive as this issue is, it is essential that the

facts related to crew survival be disseminated to ensure the next generation

of spacecraft are afforded the maximum protection. This is particularly

apparent with the upcoming Orbital Space Plane and future commercial

spacecraft. Perhaps the greatest legacy of the Columbia crew will be these

enduring lessons applied to future human space endeavors. 

Jonathan B. Clark M.D., M.P.H.

Neurologist/ Flight Surgeon

Space Medicine Office 
84 SECTION 3 – THE INVESTIGATION

 

Lessons Learned & Recommendations 

Relative to the Challenger mishap investigation, the 

Columbia investigation went much more smoothly. 

However, there were a number of lessons learned 

or reinforced from past experiences that should be 

considered when planning for similar activities in the 

future that are summarized below: 

• The accident investigation board should be independent 

of NASA to mitigate inappropriate personal and 

political influence on the operation and to mitigate 

potential bias in the final findings and recommendations 

that the board is charged with producing. 

• Team leads and principal investigators of the 

accident investigation board should not be current 

NASA employees. This requirement would 

mitigate real or apparent conflicts of interest; they 

could be former employees, as their specialized 

knowledge and experience could be invaluable to the 

success of the investigation. In any case, members 

with no previous NASA connection should balance 

the board’s membership. 

• Any human space flight mishap investigation team 

should include a group that performs the function 

that was provided by the CSWG. Because the fate 

of the crew will usually be subject to inordinate 

scrutiny, it is desirable to have a CSWG-like group 

operate as a semiautonomous unit within the overall 

mishap investigation team, in order to provide 

independence and a greater ability to maintain 

appropriate confidentiality and minimize interference 

with their activities. 

• Both the Challenger and the Columbia activities to 

recover the crew remains involved participation by 

astronauts from the crew office at a very intimate level 

including the handling of crew remains. Although 

these individuals are very capable, bring many 

valuable assets to the table, and were responsible 

for much of the timeliness and effectiveness of the 

operations, it is probably ill-advised to have close 

associates of the deceased participate in the material 

recovery of the remains from the standpoint of 

their own future welfare. Although critical stress 

debriefings were offered to these individuals during 

the Columbia mishap operations, this is a secondary 

prevention mechanism; it is better to develop 

alternative methods to obviate the need to subject
 

them to these stressors.
 

• Communication was often difficult among personnel 

who were planning or performing recovery 

operations. This was true of both open and secure 

communication capabilities. In planning for mishap 

response, adequate provision should be made for both 

open and secure communication. 

• Every human space flight mishap investigation board 

should include an individual who has an aeromedical 

background. In addition, it is highly desirable for this 

individual to have technical knowledge of the aerospace 

platform being investigated and it is even better for
 

the individual to have an engineering background as
 

well. If one person with all of these characteristics 

cannot be appointed, then an additional person with an 

engineering and systems-based background should be 

teamed with the aeromedical specialist. 

• NASA should identify appropriate internal and 

external resources to provide the various types of 

technical expertise needed to perform a thorough and 

credible investigation. Identification and assurance of 

the availability of the required experts before a mishap 

occurs would preclude the potential reduced efficiency, 

effectiveness, and timeliness that can occur if the 

board is forced to identify and locate experts after the 

incident has happened. 

• The capacity and competency of the identified internal 

and external experts and organizations that would be 

relied upon to participate in a mishap investigation 

need to be periodically evaluated to ensure that they 

are still competent, able, and available to furnish the 

desired services. Failure to do this resulted in problems 

during the CAIB investigation when it was incorrectly 

assumed that the AFIP could perform critical 

pathological evaluations based on past experience 

with their performance during the Challenger mishap 

investigation. Unfortunately, it became apparent that 

in the intervening years, the AFIP had changed their 

emphasis away from aerospace mishap investigations. 
SECTION 3 – THE INVESTIGATION 85 

Conclusions 

The activities of the CAIB, and the CSWG in 

particular, ultimately produced a thorough report. 

This was accomplished through outstanding 

commitment and tireless effort by the CAIB, the 

CSWG, as well as a multitude of people both within 

and outside of NASA. While the ultimate product 

accomplished its intended goal it should not have been 

so difficult. Better prior planning would have made it 

possible for the investigation to have been completed 

in an even timelier manner and not have necessitated 

the reliance on individual initiative instead of a wellplanned and implemented system to produce a thorough 

and timely report. 

Finally, and most importantly, absolute independence 

of the CAIB and CSWG from NASA was of paramount 

importance to ensure that the release of information 

could not be readily blocked as occurred in the 

Challenger mishap investigation and was attempted in 

the case of the CAIB and CSWG. Had the CAIB not 

been independent of NASA, it is quite possible that a 

loss of critical information, as occurred in the Challenger 

investigation, would have occurred again. 

“The right to search for the truth implies also 

a duty; one must not conceal any part of what one 

has recognized to be true.” 

Albert Einstein 
86 SECTION 3 – THE INVESTIGATION

The Columbia Crew Survival 

Investigation Report: The Five Potentially 

Lethal Events and Crew Survivability 

Nigel J. Packham, David J. Pogue, and Pamela A. Melroy 

At the conclusion of their deliberations, the Columbia 

Accident Investigation Board (CAIB) made multiple 

recommendations to NASA for the improvement 

of systems and processes. However, they made no 

recommendations regarding improvements that could 

specifically address crew survival. In their report (which 

was published in August of 2003 and can be found 

at http://caib.nasa.gov), the CAIB did identify one 

observation (CAIB Report Observation 010.2-1) that reads 

Future crewed-vehicle requirements should 

incorporate the knowledge gained from the 

Challenger and Columbia accidents in assessing 

the feasibility of vehicles that could ensure crew 

survival even if the vehicle is destroyed. 

The Space Shuttle Program recognized the importance 

of capturing the lessons learned from the loss of 

Columbia and its crew to benefit future human 

exploration, particularly future vehicle design. 

In October 2004, the Program commissioned the 

Spacecraft Crew Survival Integrated Investigation 

Team (SCSIIT). The SCSIIT was asked to perform a 

comprehensive analysis of the accident, focusing on 

factors and events affecting crew survival, and 

to develop recommendations for improving crew 

survival for all future human space flight vehicles. 

To do this, the SCSIIT investigated all elements of 

crew survival, including the design features, equipment, 

training, and procedures intended to protect the 

crew. The investigation relied on data in the form of 

vehicle telemetry (while Columbia was still intact and 

transmitting data), video (both from the general public 

and the news media), recovered debris, and medical 

findings, each supplemented with modeling and 

Visual Representation of the Breakup Sequence 

This simulation represents the Orbiter just before loss of control.	 The Catastrophic Event (CE) was a period of time during which the 

orbiter vehicle was undergoing a major structural breakup. At this 

time, the accelerations on the forebody were estimated to be 3.5 Gs. 

The breakup sequence progressed over several seconds. Analysis of 

ground-based video of the event established the first detectable signs 

at GMT 14:00:18. 
SECTION 3 – THE INVESTIGATION 87 

analyses when needed. The SCSIIT used these data to 

identify all events with lethal potential (even those that 

occurred after the crew was deceased) during reentry 

into Earth’s atmosphere so that threats to crew survival 

could be described and methodically approached in 

future designs. In the course of the investigation, five 

events with lethal potential were identified. 

The analysis proved to be extremely difficult for 

many reasons. First, recovered debris items from 

adjacent locations inside the vehicle (the middeck 

floor, for example) showed highly variable degrees 

of thermal damage. Developing a failure scenario 

based on just one piece of debris could result in 

incorrect conclusions, so failure scenarios needed 

to be developed taking into account all recovered 

debris items. Second, it was difficult to model the 

reentry dynamics of the separated forebody because 

no aerodynamic models existed for that one section 

of the Space Shuttle orbiter (an aerodynamic model 

did exist for an intact orbiter). Third, a large set 

of well-understood data from civilian and military 

aircraft accidents exists, but data from spacecraft 

accidents at very high altitude and velocity/acceleration 

environments did not exist; this lack of data hampered 

Definition of Greenwich Mean Time 

Greenwich Mean Time (GMT), also known as 

Greenwich Meridian Time, is measured from the 

Greenwich meridian line at the Royal Observatory 

in Greenwich, England. It is the place from where 

all time zones are measured. Even though the 

term GMT is used frequently in documents, the 

actual time used in space flight is Coordinated 

Universal Time (UTC). 

the team. Finally, many members of the team knew 

the crew personally, so the investigation of the final 

moments of the crewmembers’ lives was emotionally 

difficult and occasionally resulted in periods of 

“burnout” for some members of the team. 

Some conclusions were purely factual, drawn from 

hard data recovered from telemetry, such as the exact 

timing of the forebody separation from the rest of the 

orbiter. Conclusions drawn from analytical techniques 

other than vehicle telemetry were associated with 

varying degrees of certainty. In general, the team defined 

its conclusions along a continuum of certainty, using 

This simulation represents the orbiter just after the catastrophic event. 

The three main items in this view are the payload bay doors, the 

forebody, and the main portion of the orbiter. The left wing has already 

departed from the orbiter and is not visible in this view. 

Based on engineering analysis, the CE is thought to have started with 

the compromise of the payload bay doors, exposing the payload bay 

longeron sill to entry heating. The skin splice between the midbody and 

the Xo 582 ring frame bulkhead area, aft of the starboard x-link, failed 

due to a combination of mechanical and thermal loads. The forebody 

rotated away from starboard to port, causing the port x-link to fail due 

to bending loads. As the forebody separated from the midbody, various 

power, data, and Environmental Control Life Support Systems lines 

failed and the crew module was free to move forward and strike the 

inside of the forward fuselage. 
88 SECTION 3 – THE INVESTIGATION

 

 

 

 

 

The Catastrophic Event is depicted in these three frames of video that cover 0.1 second. There is no change in the magnification/zoom factor. 

The third frame represents GMT 14:00:18.30 

“possible,” “likely,” or “probable” to define increasing 

levels of confidence. 

Once the team completed its investigation and 

deliberations, the findings, conclusions, and 

recommendations were documented in the “Columbia 

Crew Survival Investigation Report” (NASA/SP-2008-

565, available at http://history.nasa.gov/columbia/ 

columbiacrewsurvival.pdf). The report also includes the 

highly technical data that were used in the development 

of those findings, conclusions, and recommendations. 

The exhaustive data were included because of 

difficulties finding relevant technical data from the 

previous Challenger accident; the investigation team 

believed that it was important to include all data in one 

location for future investigators to easily reference. 

NASA disseminated this report publicly in the hope 

that the world’s spacefaring organizations (governmentsponsored and commercial) could benefit from the 

findings and incorporate into their spacecraft designs to 

maximize crew survivability. 

The report identified the five potentially lethal events 

that the crew experienced during the mishap. For each 

of the five events, the report addressed whether current 

technology existed that could have precluded the 

lethality of the event. It is important to note that the 

crew of Columbia was exposed to all five of the events, 

and that the Columbia accident was not survivable. 

The five events with lethal potential will now be 

discussed at a high level along with some key 

recommendations associated with each one and a brief 

discussion of how NASA’s Multi-Purpose Crew Vehicle 

(MPCV) program is addressing the recommendations. 

For more details or a deeper technical understanding of 

the events surrounding the Columbia accident from the 

crew survival perspective, the reader is referred to the 

“Columbia Crew Survival Investigation Report.” 

The following were the five potentially 

lethal events: 

1. The first event with lethal potential was 

depressurization of the crew module, which started at 

or shortly after the breakup of the orbiter vehicle. 

2. The second event with lethal potential was the 

exposure of unconscious or deceased crewmembers 

to a dynamic rotating load environment with nonconformal helmets and a lack of upper-body restraint. 

3. The third event with lethal potential was separation of 

crewmembers from the crew module and the seats, with 

associated forces, material interactions, and thermal 

consequences. This event is the least understood, 

because of limitations in current knowledge of 

mechanisms at this Mach number and altitude. Seat 

restraints played a role in the lethality of this event. 

4. The fourth event with lethal potential was exposure 

to near vacuum, aerodynamic accelerations, and 

cold temperatures. 

5. The final event with lethal potential was ground impact. 

1. Cabin Depressurization 

Description of the event 

The Space Shuttle Columbia crew module was not 

recovered intact. In fact, the crew module debris footprint 

was more than 50 miles long, indicating that the crew 

module broke up at altitude. Obviously, a cabin breach 

occurred at some point during the orbiter crew module 

breakup sequence. The SCSIIT concluded that the 

Columbia crew module cabin pressure was nominal 

(14.7 pounds per square inch absolute) and the crew 

was capable of conscious actions up to the beginning of 
SECTION 3 – THE INVESTIGATION 89 

the orbiter breakup. The crew module depressurization 

began at or shortly after the orbiter breakup (when the 

vehicle was at about 180,000 ft altitude), and was caused 

by cabin breaches above and below the middeck floor. 

Impact on the crew 

Evidence indicates that the crew was aware of the 

vehicle loss of control (which began 41 seconds before 

the vehicle breakup) and was responding to failures 

of orbiter systems before the vehicle breakup. The 

pressure suit helmets that Space Shuttle crewmembers 

wore included a pressure visor that could be lowered 

quickly to protect crewmembers in the event of a cabin 

depressurization. However, analysis of recovered suit 

components indicates that none of the crewmembers 

lowered their helmet visors. The accelerations acting 

on the crewmembers during this time were not 

severe enough to preclude this action. Therefore, the 

depressurization rate was high enough to incapacitate 

the crewmembers within seconds so that they were 

unable to perform actions such as lowering their visors. 

Once the depressurization occurred, the crewmembers 

were rendered unconscious or deceased and were 

unaware of the subsequent events. Given the level of 

tissue damage observed in the remains, crewmembers 

could not have regained consciousness even if the cabin 

could have been repressurized. At this point survival 

was possible but would not have been likely, even 

with immediate and extensive medical intervention. 

Although respiration would have ceased after 

depressurization, circulatory functions can exist for a 

short period without respiration. 

Survivability using today’s technology 

After the Space Shuttle Challenger accident in 1986, 

all Space Shuttle crewmembers wore pressure suits 

during ascent and reentry. The pressure suits and 

their attached emergency oxygen system could protect 

the crewmembers from a cabin depressurization. 

However, the pressure suits were added to the Space 

Shuttle after the vehicle was designed, and this 

retrofit resulted in some operational inefficiencies 

and incompatibilities. For example, the deorbit 

preparation period of Shuttle missions was so busy 

that crewmembers often did not have enough time 

to complete the deorbit preparation tasks (putting on 

their pressure suit, helmet, gloves, parachute, and other 

equipment, strapping into the seat, and so on) before 

the deorbit burn. Suit debris evidence indicates that 

three of the seven Columbia crewmembers did not 

finish putting on their suit gloves for reentry. One 

of these three crewmembers did not have the helmet 

donned at the time of the vehicle breakup. 

Additionally, as mentioned above, none of the 

crewmembers lowered their helmet pressure visors, so 

none of the pressure suits provided protection against the 

Image from Apache video showing the crew module debris and the 

orbiter’s three main engines. Based on engineering analysis, the crew 

module catastrophic event is thought to have started with the failure of 

the forward fuselage. Once the forward fuselage began to break away, 

the exposed crew module rapidly failed due to the combined effects 

of the high G-loads, aerodynamic forces, and thermal loads. The flight 

deck maintained structural integrity longer than the middeck. 

Image is from the Apache video. Dotted circle indicates area where 

the crew module debris was last visible. The three points in the lower 

right are the orbiter’s three main engines. The forward fuselage and 

crew module fragmented into pieces quickly and became too small to 

detect by ground-based video. At approximately GMT 14:35:00, the 

crew remains and the majority of the crew module debris completed 

the free fall to the ground. 
90 SECTION 3 – THE INVESTIGATION

Overall Timeline 

Phase 1 

(~4.3 hours) 

Phase 2 

(~15.5 minutes) 

Phase 3 

(46 seconds) 

Phase 4 

(35 seconds) 

Phase 5 

(17 seconds) 

Phase 6 

(~35 minutes) 

Start Deorbit Prep Deorbit Burn Entry Interface at 400,000 ft LOS CE CMCE TD Ground Impact 

(~9:25:30) (13:15:30) (13:44:09) (13:59:32) (14:00:18) (14:00:53) (14:01:10) (~14:35:00) 

This timeline represents the best fit to known and inferred data, but it is subject to some inherent uncertainty. 

It is divided into six phases, based on key events. Each phase of the timeline is addressed in sequence. 

Phase 1 (GMT 09:15:30 to entry interface (GMT 13:44:09.): The deorbit preparation timeline begins 4 hours 

prior to the deorbit burn. After the burn, the orbiter descends in altitude until atmospheric drag effects become 

noticeable, roughly an altitude of 400,000 feet and approximately 4,300 nautical miles from the landing site, 

traveling in excess of Mach 24. 

Phase 2 (GMT 13:44:09 to GMT 13:59:32): Loss of signal (LOS) is the loss of voice and real-time data 

transmissions from Columbia. 

Phase 3 (GMT 13:59:32 to GMT 14:00:18): From LOS to the Catastrophic Event (CE). The CE is defined as the 

initiation of the orbiter breakup into the primary subcomponents of the forebody, midbody, and aftbody. 

Phase 4 (GMT 14:00:18 to GMT 14:00:53): From the CE to the Crew Module Catastrophic Event (CMCE). The 

CMCE is defined as the initiation of the forebody breakup. 

Phase 5 (GMT 14:00:53 to GMT 14:01:10): From the CMCE to Total Dispersal (TD). TD is defined as the time 

when the crew module was substantively broken down into subcomponents and was no longer visible on 

ground-based videos. 

Phase 6 (GMT 14:01:10 to approximately GMT 14:35:00): Ground impact of the crew remains and the majority 

of the crew module debris. 

cabin depressurization. Had the suits been configured 

with the visors down and locked, gloves on, and 

emergency oxygen system activated, the depressurization 

event by itself probably would have been survivable. 

Recommendations to future programs 

The “Columbia Crew Survival Investigation Report” 

contains many recommendations related to pressure 

suits. The two key recommendations listed below 

are related to the cabin depressurization lethal 

event. The findings and conclusions related to these 

recommendations are described in detail in the 

“Columbia Crew Survival Investigation Report.” 

Recommendation L1-21 

“Future spacecraft and crew survival systems should 

be designed such that the equipment and procedures 

provided to protect the crew in emergency situations are 

compatible with nominal operations. Future spacecraft 

vehicles, equipment, and mission timelines should be 

designed such that a suited crewmember can perform all 

operations without compromising the configuration of 

the survival suit during critical phases of flight.” 

Recommendation L1-3/L5-1 

“Future spacecraft crew survival systems should not rely 

on manual activation to protect the crew.” 

1 The recommendation numbers trace to the recommendations listed in the “Columbia 

Crew Survival Investigation Report.” 
SECTION 3 – THE INVESTIGATION 91 

How NASA’s MPCV program is addressing 

the recommendations 

The next vehicle NASA is developing for human 

space flight, the Multi-Purpose Crew Vehicle (MPCV), 

includes pressure suits in the design. The suits will 

be worn for ascent and reentry. They are included in 

the vehicle design from the beginning, and critical 

controls are designed to be compatible with a 

pressure-suited crew. Additionally, vehicle operations 

will address the incompatibilities described in 

Recommendation L1-2. 

2. Exposure to a Dynamic Rotating 

Environment with Non-Conformal 

Helmets and a Lack of Upper-Body 

Restraint 

Description of the event 

The initial breakup of Space Shuttle Columbia 

resulted in an intact nose portion, or “forebody,” 

of the vehicle separating from the rest of the major 

vehicle components. The forebody consisted of the 

forward fuselage (outer skin) structure and the crew 

module (pressure vessel) structure. This forebody was 

not aerodynamically stable. From the time of vehicle 

breakup until the crew module breakup, the forebody 

was rotating about all three axes at about 0.1 revolution 

per second (6 revolutions per minute, 36 degrees per 

second) with increasing rates and accelerations. The 

increasing atmospheric drag on the forebody and the 

rotational motion of the tumbling forebody resulted in 

the crew being exposed to oscillatory and increasing 

accelerations in all three axes. 

Impact on the crew 

Shortly after the vehicle breakup, the crewmembers lost 

consciousness as a result of the loss of cabin pressure. 

Debris evidence indicates that the seat inertial reel 

mechanisms on the crewmembers’ shoulder harnesses 

did not lock and that the inertial reel straps were 

extended. Therefore, the unconscious or deceased 

crewmembers were exposed to the cyclical rotational 

motion while being restrained only at the lower 

body. The suit pressure helmets were not conformal. 

Consequently, lethal trauma occurred to the unconscious 

or deceased crewmembers because of the lack of upperbody support and restraint. 

Survivability using today’s technology 

The Shuttle seat and helmet design and operational 

practices did not protect the crewmembers from this 

lethal event. Complete strap-in with inertial reels locked 

would have reduced the risk of injury or death; however, 

even in this configuration, the Shuttle seat and restraint 

system provided limited protection from dynamic 

acceleration events (specifically, it had no lateral 

restraints, no control of extremity motion, and no head 

and neck support). Better restraint designs that include 

head and neck support (that is, conformal helmets), 

extremity control, and spine support are achievable to 

reduce the risk of injury or death. 

Crashes in automobile racing are common, and it is not 

unusual for crashes to expose the driver to dynamic 

rotating environments as the car tumbles. The racing 

community has evolved driver seats, seat restraints, 

helmets, and head-and-neck restraint devices that protect 

drivers during crashes. The technology exists to protect 

occupants of a spacecraft from a dynamic rotating 

environment such as was experienced by the Columbia 

crew during lethal event #2. 

Recommendations to future programs 

The three key SCSIIT recommendations listed below 

are related to the dynamic rotating environment 

lethal event. The findings and conclusions related to 

these recommendations are described in detail in the 

“Columbia Crew Survival Investigation Report.” 

Recommendation L2-4/L3-4 

“Future spacecraft suits and seat restraints should use 

state-of-the-art technology in an integrated solution 

to minimize crew injury and maximize crew survival in 

off-nominal acceleration environments.” 

Recommendation L2-7 

“Design suit helmets with head protection as a 

functional requirement, not just as a portion of the 

pressure garment. Suits should incorporate conformal 

helmets with head and neck restraint devices, similar to 

helmet/head restraint techniques used in professional 

automobile racing.” 
92 SECTION 3 – THE INVESTIGATION

Recommendation L2-9 

“The use of inertial reels in future restraint systems 

should be evaluated to ensure that they are capable of 

protecting the crew during nominal and off-nominal 

situations without active crew intervention.” 

How NASA’s MPCV program is addressing 

the recommendations 

The MPCV spacecraft seat design includes side bolsters 

and more robust seat restraints. Also, the seat does not 

use inertial reels. 

3. Separation from the Crew 

Module and Seats with Associated 

Forces, Material Interactions, and 

Thermal Consequences 

Description of the event 

This lethal event occurred around the time of the crew 

module breakup. The breakup of the crew module and 

resultant exposure of the crew to reentry conditions 

was an extremely significant event but was difficult 

to characterize, as many related events occurred in a 

short period. During this lethal event, the crewmembers 

were separated from their seats and the crew module, 

and were exposed to the hostile reentry environment. 

The seat restraints played a role in the lethality of this 

event. All crewmembers were deceased before, or by the 

end of, this event. 

Impact on the crew 

The seat restraint system caused lethal-level injuries 

to the unconscious or deceased crewmembers when 

they separated from their seats. Upon separation 

from the seat and crew module, the crewmembers’ 

bodies were exposed to aerodynamic forces, elevated 

temperatures, and the chemical environment associated 

with the disintegration of the vehicle structure. 

Analysis of the recovered suit debris indicated that 

the pressure suits completely failed and separated from 

the crewmembers’ bodies. Suit failure was caused 

by mechanical loading (due to aerodynamic forces), 

and hastened by thermal exposure and possibly 

chemical effects from the atomic oxygen present in 

the upper atmosphere. 

Survivability using today’s technology 

Although the seat restraints played a significant role 

in the lethal injuries, there is currently no full range of 

equipment to protect for this event. The event was not 

survivable by any means known to the investigative 

team, other than by ensuring the integrity of the crew 

module until the airspeed and altitude were within 

survival limits. This was not possible for the Space 

Shuttle design; however, future vehicle designs 

incorporating a principle of “graceful degradation” 

and crew module stabilization may be possible. 

Recommendations to future programs 

The two key SCSIIT recommendations listed below 

are related to the separation lethal event. The findings 

and conclusions related to these recommendations are 

described in detail in the “Columbia Crew Survival 

Investigation Report.” 

Recommendation L2-4/L3-4 

“Future spacecraft suits and seat restraints should use 

state-of-the-art technology in an integrated solution to 

minimize crew injury and maximize crew survival in 

off-nominal acceleration environments.” 

Recommendation L3-5/L4-1 

“Evaluate crew survival suits as an integrated system 

that includes boots, helmet, and other elements to 

determine the weak points, such as thermal, pressure, 

windblast, or chemical exposure. Once identified, 

alternatives should be explored to strengthen the 

weak areas. Materials with low resistance to 

chemicals, heat, and flames should not be used on 

equipment that is intended to protect the wearer from 

such hostile environments.” 

How NASA’s MPCV program is addressing 

the recommendations 

The MPCV spacecraft seat design includes side bolsters 

and more robust seat restraints. Suit design currently is 

in the preliminary stages. The suit is being designed to 

be compatible with the various environments to which it 

may be exposed. 
SECTION 3 – THE INVESTIGATION 93 

 

 

 

 

4. Exposure to Near Vacuum, 

Aerodynamic Accelerations, and 

Cold Temperatures 

Description of the event 

This lethal event occurred as the crewmembers’ bodies 

were in free-fall from about 140,000 ft, after being 

exposed to the hostile, chaotic environment discussed in 

lethal event #3 above. 

Impact on the crew 

At the altitude and speeds that the deceased 

crewmembers departed the crew module, the 

environmental risks included lack of oxygen, low 

atmospheric pressure, high thermal loads as a result 

of deceleration from high Mach numbers, shock wave 

interactions, aerodynamic accelerations, and exposure 

to cold temperatures. 

Survivability using today’s technology 

The Shuttle pressure suit system was certified to 

operate at a maximum altitude of 100,000 ft, and 

certified to survive exposure to windblast associated 

with 560 knots equivalent air speed. The operating 

envelope of the orbiter was much greater than this. 

The actual maximum protection environment for the 

Shuttle suit system is not known, and the Shuttle suit 

was not evaluated for protection from high temperature 

exposures. The only protection that is achievable is 

to ensure the integrity of the crew module until the 

airspeed and altitude are within the suit capability, 

which was not precisely determined. 

On October 14, 2012, the Red Bull Stratos highaltitude skydiving project had Austrian skydiver Felix 

Baumgartner fly a helium balloon to about 127,000 ft 

over New Mexico. Wearing a pressure suit similar to 

the Space Shuttle suits, Baumgartner jumped from the 

balloon’s capsule, free-falling for more than 4 minutes 

before landing safely under parachute. Baumgartner 

reportedly reached a maximum speed greater than 840 

mph or 1.25 times the speed of sound. The Stratos 

project demonstrated the possibility of surviving a highaltitude free fall. 

Threat Matrix and Survival Gap 

Table summarizes the events of lethal potential 

that the crew members of STS-107 faced, 

the possible threat mitigations at the time of 

the STS-107 accident, and the potential future, 

achievable threat mitigations. 

Lethal Threats* STS-107 Achievable 

1. Depressurization 

2. Off-nominal dynamic G 

environment 

3. Thermal intrusion into 

crew cabin 

4. Exposure to high-speed/ 

high-altitude environment 

5. Ground impact 

R G

R G

R Y

R Y

R G

* As configured during STS-107 (visors open, some gloves off, 

inertial reels unlocked, etc) 

Red (R) = Threat could not be mitigated. 

Yellow (Y) = Threat can probably be mitigated with new 


designs, operational procedures and/or hardware. 


Green (G) = Threat can be mitigated 

Recommendations to future programs 

The key SCSIIT recommendation listed below is related 

to the lethal event of exposure to the high-altitude 

environment. The findings and conclusions related 

to this recommendation are described in detail in the 

“Columbia Crew Survival Investigation Report.” 

Recommendation L3-5/L4-1 

“Evaluate crew survival suits as an integrated system that 

includes boots, helmet, and other elements to determine 

the weak points, such as thermal, pressure, windblast, or 

chemical exposure. Once identified, alternatives should 

be explored to strengthen the weak areas. Materials with 

low resistance to chemicals, heat, and flames should 

not be used on equipment that is intended to protect the 

wearer from such hostile environments.” 
94 SECTION 3 – THE INVESTIGATION

How NASA’s MPCV program is addressing 

the recommendation 

Unlike the Space Shuttle, the MPCV does not include 

an in-flight bailout capability with an individual 

parachute for each crewmember. Free-falling from a 

high altitude after a vehicle breakup is not a survivable 

scenario for the MPCV. 

5. Ground Impact 

Description of the event 

After a period of free fall, the crewmembers’ bodies 

struck the ground. 

Impact on the crew 

The deceased crewmembers’ bodies had lethal-level 

injuries caused by ground impact. 

Survivability using today’s technology 

The Shuttle crew escape equipment included a parachute 

that protected against ground impact. However, 

the parachute system required manual action by a 

crewmember to initiate the parachute opening sequence. 

Military and sport parachuting solutions exist for 

opening parachutes independent of crew action. 

Recommendations to future programs 

The key SCSIIT recommendation listed below is 

related to the ground impact lethal event. The findings 

and conclusions related to this recommendation are 

described in detail in the “Columbia Crew Survival 

Investigation Report.” 

Recommendation L1-3/L5-1 

“Future spacecraft crew survival systems should not rely 

on manual activation to protect the crew.” 

How NASA’s MPCV program is addressing 

the recommendation 

Unlike the Space Shuttle, the MPCV does not include an 

in-flight bailout capability with an individual parachute 

for each crewmember. Therefore, automatic opening of 

individual parachutes to protect against ground impact 

is not relevant to MPCV. However, the MPCV design 

incorporates crew seats mounted on stroking struts. 

In the event of a hard landing of the vehicle (due to a 

failure of one of the capsule’s three parachutes), the 

struts will attenuate the loads so the crewmembers will 

not be exposed to excessive forces. 

Conclusion 

The Space Shuttle Program recognized the importance 

of capturing the lessons learned from the loss of 

Columbia and its crew to benefit future human 

exploration. The SCSIIT performed a comprehensive 

analysis of the accident, focusing on factors and events 

affecting crew survival. The SCSIIT report documents 

the five events that had lethal potential, and provides 

recommendations for improving survival of crews on 

future human space flight vehicles. 
Section 4 – The Analysis
 

Aerospace Medical Forensic Analysis 

Legal Analysis and Issues from Recovery and 

Investigation of the Columbia Accident 
96 SECTION 4 – THE ANALYSIS

Aerospace Medical 

Forensic Analysis 

Michael Barratt, Robert Banks, Philip C. Stepaniak, and Helen W. Lane 

Photo credit: Gene Blevins/Los Angeles Daily News 

Columbia streaking over the Owens Valley Radio Observatory in Big Pine, California 

Columbia crossed the California coast west of Sacramento at 8:53:26 a.m. CST, traveling at Mach 23 and 231,600 feet. The leading edge of 

the orbiter’s wing typically reached more than an estimated 2,800oF. Crossing California toward Nevada, the orbiter appeared to observers 

on the ground as a bright spot of light moving rapidly across the sky. Signs of debris being shed were sighted at 8:53:46 a.m. CST, when the 

superheated air surrounding the orbiter suddenly brightened, causing a noticeable streak in the orbiter’s luminescent trail. 

Human space flight involves large energies and forces 

to overcome Earth’s gravity, attain orbital velocity, and 

eventually return through the atmosphere, with flight 

hardware operating at extreme limits of performance in 

a poorly characterized environment. Although the level 

of risk to crew is understandably high, mishaps are rare 

events. When an accident does happen that involves 

human casualties, just as in the aviation world no 

investigation is complete without a forensic pathology 

analysis. That human tissue bears witness to physical 

events is well established and can be extremely useful 

in understanding the processes at work, the sequence of 

events, and causal mechanisms. These findings directly 

contribute to understanding and eventually closing 

gaps in survivability. 

After 16 days in orbit, the crew of Columbia tragically 

died as the orbiter broke apart at an altitude of 

between 181,000 and 140,000 feet while traveling 

at approximately Mach 15. The Columbia accident 

comprises the only source of information on highaltitude hypersonic spacecraft breakup during reentry 

to Earth’s atmosphere and on the resulting human 

exposure to these forces. An interpretation of the 

forensic findings in the context of the physical forces 

involved is crucial to a complete understanding of 

mishap events and crew protection factors that might 

be enhanced to optimize safety and survival. This 

chapter summarizes the human forensic findings of 

the Columbia accident, emphasizing those that truly 

contribute to our understanding. The primary aim is to 

ensure that the lessons learned and recommendations 

resulting from the Columbia mishap investigation are 

available to current and future spacecraft designers in 

the development of new vehicles and systems. 

There is no evidence that the crew contributed to 

this accident. 
SECTION 4 – THE ANALYSIS 97 

Entry simulation of representative vehicle dynamics after loss of signal 

with failed hydraulic pressure and elevons in full up position 

This graphic represents the sequence (1-second intervals) showing a simulation of orbiter loss of control pitch-up from GMT 13:59:37 to 

GMT 15:59:46. The Spacecraft Crew Survival Integration Investigation Team concluded that loss of control occurred as a result of the loss of 

hydraulics at GMT 13:59:37. The white line indicates vehicle trajectory relative to the ground. 

Aeromedical Forensic Analysis 

Crew awareness and actions during reentry, 

loss of signal, and loss of vehicle control and 

before the catastrophic event 

During reentry the flight deck crew of Columbia 

most probably was aware of a multisystem problem 

when tire pressure warnings and ambiguous gear 

deployment indications occurred, involving the 

left main landing gear. The flight deck crew could 

only monitor the problem and acknowledge 

communications from the Johnson Space Center 

Mission Control Center. The orbiter then lost ground 

communications at GMT 13:59:32. At the time 

of loss of signal, the flight deck crew was likely 

troubleshooting the caution-and-warning messages 

associated with the left tire pressure, left gear 

deployment, and flight-control system fault messages. 

Jet firings from the orbital maneuvering system 

thrusters were increasing in frequency to maintain 

vehicle attitude as aerodynamic integrity became 

increasingly compromised. The orbiter then lost all 

hydraulic pressure for flight-control surface activation, 

which further resulted in a rapid override of the orbital 

maneuvering system jets; this, in combination with the 

damage to the left wing, resulted in an uncontrolled 

pitch-up and loss of vehicle control at GMT 13:59:37. 

The orbiter motion can be described as a highly 

oscillatory flat spin. The orbiter was pitching and 

rolling with a strong and consistent yaw component 

of the overall motion, but its “belly” was the structure 

predominantly oriented to the velocity vector. After 

hydraulic pressure was lost, the flight deck crew 

most certainly understood that a serious situation 

had developed. Evidence exists that the pilot tried to 

recover hydraulics by attempting an auxiliary power 

unit restart. This showed good system understanding 

and an appropriate cognitive and motor response 

to the emergency in the face of a hostile motion 

environment. Although G loads at this time were 

still relatively light, after 16 days of weightlessness 

it is expected that the effects of these loads would be 

magnified somewhat, producing spatial disorientation 

out of proportion to that of a normal ground or 

aviation population. The middeck crewmembers 

had no outside visual reference, and this motion 

environment potentially would have produced 

greater disorientation. 

The G loads in the three axes continued and the left 

wing departed the vehicle. The loads were initially 

low and then peaked at 3.5 G at the time of the 

catastrophic event (CE), defined as separation of the 

forebody from the midbody of the orbiter. The time 

of the CE was approximately GMT 14:00:18, when 

the orbiter was at an altitude of between 181,000 

and 140,000 feet, traveling at about Mach 15. The 

crew module remained intact initially after CE but 

depressurized rapidly. The crew module catastrophic 

event (CMCE) involved the complete breakup of the 

crew module after several seconds of high G loads, 

occurring at GMT 14:00:53. Bracing injuries, 

catastrophic depressurization with nearly immediate 

loss of consciousness and pulmonary barotrauma, and 

other mechanical injuries all occurred in sequence 

during the 35-second interval between CE and CMCE. 
98 SECTION 4 – THE ANALYSIS

Crew Configuration During Reentry 

The orbiter had a habitable volume of 2,525 ft3 and consisted of three levels: flight deck, middeck, and utility 

area. The flight deck, located on the top level, accommodated the commander (CDR), pilot (PLT), and two 

mission specialists (MS). The middeck, located directly below the flight deck, accommodated three additional 

crewmembers: two mission specialists and a payload specialist (PS). The crewmembers’ preparation for 

reentry into the Earth’s atmosphere included securing the crew compartment, setting up the seats, and 

donning their Advanced Crew Escape Suit (ACES), which included the suits, helmets, oxygen supply, gloves, 

and radios. For landing they connected their restraint system. 

Middeck seating (views from aft to starboard and forward to port) 

Flight deck seating 
SECTION 4 – THE ANALYSIS 99 

Orbiter Motion Entry Simulation and Representative Vehicle Dynamics After Loss of 

Control and Before the Catastrophic Event 

This graphic illustrates a possible sequence of dynamic vehicle motions derived from best fit synthesis of 

ballistic data, imagery and debris analysis. The view is from a point in front of the orbiter’s direction of travel, 

looking backward along the velocity vector. The snapshot for GMT 14:00:04 shows the left wing departing 

intact. In reality, the left wing did not come off all at one time but was shedding debris over a period of time. 
100 SECTION 4 – THE ANALYSIS

The forensic medical findings of injuries incurred 

during and after the CE and the CMCE can be 

categorized as follows: 

1. Mechanical injuries incurred during the CE 

2. Depressurization injuries incurred after the CE 

3. Mechanical injuries incurred after the CE and before 

the CMCE 

4. Thermal injuries incurred after the CMCE and 

exposure to the atmospheric environment 

5. Common injuries incurred during the CMCE and 

ground impact 

Mechanical injuries incurred during the 

catastrophic event 

Very soon after loss of vehicle control, the left wing 

shed debris for a period of time and then departed the 

vehicle, followed by the CE, separation of the orbiter 

forebody from the midbody. Analysis of structural 

debris supports the hypothesis that an impact occurred 

between the forward fuselage (outer vehicle shell) 

and the crew module (internal pressure vessel) in the 

area of Volume E on the floor of the middeck. When 

the vehicle forebody separated, all resources from the 

midbody were lost, including electrical power from the 

fuel cells required for lighting, crew displays, radios, 

intercommunications, ventilation, and the main oxygen 

supply. At this time the entire crew may have realized 

that it was not a recoverable situation. 

Probably at this time some crewmembers responded 

to the motion associated with the CE by bracing 

against structures, subsequently sustaining defensivetype injuries. Bracing indicates that crewmembers 

were capable of conscious and volitional action up to 

this point. Shoulder harness restraint was apparently 

ineffective because of the relatively low acceleration 

rates involved compared with the designed impact rates 

required to lock the inertia reels on the restraints. 

Catastrophic Event 

This graphic illustrates the catastrophic event (CE). The CE was a period during which the orbiter vehicle was 

undergoing a major structural breakup. At this time, the accelerations on the forebody were estimated to be 

3.5 G. The breakup sequence progressed over several seconds. Analysis of ground-based video of the event 

established the first detectable signs at GMT 14:00:18. On the basis of engineering analysis, the CE is thought 

to have started with the compromise of the payload bay doors, exposing the payload bay longeron sill to entry 

heating. As shown in the illustration, the forebody rotated away, from its starboard side to its port side. As 

the forebody separated from the midbody, various power, data, and life-support systems failed and the crew 

module moved forward with the forward fuselage. 
SECTION 4 – THE ANALYSIS 101 

Depressurization 

The Spacecraft Crew Survival Integrated Investigation Team report concluded that failure of the starboard 

x-link attachment resulted in separation of the forward fuselage. This failure allowed the crew module to 

move within the forward fuselage, resulting in damage to the crew module pressure vessel in the area of 

Volume E (red circle). 

The depressurization was due to relatively small cabin breaches above and below the middeck floor and was 

not a result of a major loss of cabin structural integrity. The crew compartment depressurization began at GMT 

14:00:18. The depressurization rate was high enough to incapacitate the crewmembers within seconds. As the 

crew module lost structural integrity, it was fully depressurized by GMT 14:00:59, if not sooner. 

View of starboard side 

Bracing Injuries 

Probably during the catastrophic event, the crewmembers responded to the motion by bracing themselves 

against structures, resulting in sustained defensive-type injuries. The photos show how the crew may have 

braced themselves. These injuries indicate that crewmembers were capable of conscious and volitional 

action up to this point. This bracing caused fractures as illustrated by the schematic showing a wrist fracture. 

Demonstration of possible bracing position 

in the middeck. 

Demonstration of possible bracing positon 

using legs, middeck. 

Schematic showing defensive injury to wrist. 

Defensive injury to wrist 
102 SECTION 4 – THE ANALYSIS

Depressurization injuries incurred after the at body temperature (Armstrong’s line, 62,000–63,500 

catastrophic event feet). This event would cause ear barotrauma with 

attendant severe pain and disorientation and rapid loss

After the forebody separated from the midbody, rapid of consciousness due to hypoxia within 3 to 10 seconds.

depressurization occurred at an altitude greater than The transient differential between alveolar and ambient 

100,000 feet. This is well above the altitude at which pressure led to massive pulmonary barotrauma with

ambient pressure is less than the vapor pressure of water alveolar rupture and hemorrhage, and all respiratory 

Tissues Showing Bubbling 

After the forebody separated from the midbody, complete depressurization occurred over a maximum 

of 41 seconds and probably over much less time, with resulting cessation of respiration, hypoxia, and rapid 

loss of consciousness. With pulmonary and vascular tissues exposed to near vacuum, the phenomenon 

of ebullism ensued, with bubbling or vacuolation occurring in multiple tissues throughout the body. 

Along with the pulmonary barotrauma seen, this rapid depressurization may have caused ear barotrauma 

with attendant severe pain and 

disorientation. The micrographs 

illustrate the bubbling observed in 

multiple tissues in crewmembers: 

lung, brain, spinal cord, and 

bone marrow. Formation of vapor 

bubbles in body fluids occurs 

when the ambient pressure falls 

below the vapor pressure of 

water at 98.6°F (47 mm Hg) or 

applicable body temperature. 

Intra-alveolar hemorrhage in lung. Rupture of alveolar septa, the partitions 

dividing one alveolus from another. 

Bubbles in vasculature of the brain. Bubbles in spinal cord. Bubbles in lung tissue. 

Bubbles in bone marrow. Bone marrow embolus in pulmonary tissues. 
SECTION 4 – THE ANALYSIS 103 

 

exchange ceased. With pulmonary and vascular tissues 

exposed to near vacuum, the phenomenon of ebullism 

ensued, with bubbling or vacuolation occurring in 

multiple tissues throughout the body. One crewmember 

is known to have died from massive pulmonary 

barotrauma, as evidenced by lack of hemorrhage 

associated with subsequent tissue injuries, because of 

complete cessation of circulation. 

Although all crewmembers were wearing pressure 

suits, none managed to pull their visors down to form a 

protective pressure seal, an action that normally takes 

only a few seconds. The investigation team concluded 

that the depressurization event was sufficiently rapid 

to promptly incapacitate all crewmembers and preclude 

this response. 

Mechanical injuries incurred after the 

catastrophic event and before the crew 

module catastrophic event 

After the CE and depressurization occurred, the motion 

and acceleration dynamics rapidly became increasingly 

hostile. During this time the unconscious crewmembers 

sustained mechanical trauma and associated 

hemorrhage into soft tissues, with the exception of the 

individual who succumbed to pulmonary barotrauma. 

Active hemorrhage into injured tissue implies active 

circulation; therefore this is an important temporal 

marker for events occurring antemortem. 

An unconscious individual with an unsupported 

head-neck complex is vulnerable to head flail injury. 

The anterior and posterior hemorrhages found in the 

neck strap muscles of most crewmembers indicated 

that anterior, posterior, and lateral flail of their heads 

did occur along with atlanto-occipital separation. 

The unsupported head in association with the weight 

of the helmet and the helmet neck-ring geometry 

provided a fulcrum that caused cervical spine fractures 

together with neck injuries such as fractures of the 

hyoid bone and thyroid cartilage. 

Most crewmembers sustained head trauma from internal 

(head-to-helmet) and external (helmet-to-structure) 

impacts consistent with movement of the head within a 

non-conformal helmet. These injuries included softtissue scalp hematomas, depressed skull fractures, small 

hemorrhages into the subdural space, and petechial 

hemorrhages of the brain parenchyma. Also noted were 

subarachnoid hemorrhages of the spinal cord. 

Correlations between the injuries sustained and 

the restraint system contribute to understanding 

of safety system function. With one exception, all 

Tissues Showing Bleeding due to Mechanical Trauma 

Between the catastrophic event and the crew module catastrophic event, the unconscious crewmembers 

(with the exception of one crewmember who succumbed to pulmonary barotrauma) sustained mechanical 

trauma and associated bleeding into soft tissues. Active hemorrhage into injured tissue implies active 

circulation, as seen in these slides of crewmember neck muscles. This is an important temporal marker for 

events that occurred antemortem. 

Petechial hemorrhages in neck muscle. Streak hemorrhage in neck muscle. 
104 SECTION 4 – THE ANALYSIS

Head and Neck Injuries 

An unconscious individual with an unsupported head-neck complex is vulnerable to head flail injury. The 

unsupported head, in association with the weight of the helmet and the helmet neck-ring geometry, provided 

a fulcrum that caused cervical spine fractures together with neck injuries such as fracture of the hyoid bone 

and thyroid cartilage. The following illustrations show the effects of the helmet and the suit and harness on the 

cervical spine and the soft tissues of the head and neck complex. This illustration shows the atlanto-occipital 

dislocation (red arrows) and distraction fractures (yellow arrows) of the cervical spine. 

Head Injuries Caused by the Non-conformal Helmet 

Soft-tissue injuries in the area shown by the red circle on the manikin were caused by impacts with the 

helmet, which was non-conformal. The Advanced Crew Escape Suit helmet shown is not from STS-107 but 

is identical to the STS-107 helmets. 

Head strike within non-conformal helmet. 

Illustration provided by Biodynamic Research Corporation – BRC Illustration provided by Biodynamic Research Corporation – BRC 

Helmet 

neck ring 
SECTION 4 – THE ANALYSIS 105 

crewmembers were restrained in their entry seats by a 

standard five-point harness system. (One crewmember 

was incompletely restrained, suggesting that donning 

restraints was in progress at the time of CE.) A lap belt 

secured the lower torso and a crotch strap prevented 

“submarining,” keeping the occupant from sliding 

forward and beneath the lap belt. Two shoulder harnesses 

attached to an inertial reel via the inertial reel strap that 

was designed to secure the upper torso. Engineering 

analysis of the STS-107 restraints indicated that the 

inertial reel straps did not lock and were extended during 

dynamic motion, leaving the upper torso unsupported 

and free to move. As stated above, this happened because 

the strap velocity was lower than the locking threshold 

velocity of the inertia reel system, which was designed 

for higher velocity transient acceleration associated with 

impact. With the upper body functionally unrestrained 

and the lap belts secured, the crewmembers sustained 

lower spinal and pelvic fractures; these injuries were 

also noted to have a hemorrhagic component in most 

crewmembers. The lumbar spine injuries (Chance fracture 

or transverse vertebral body fracture) resulted from the 

sudden forward and downward rotation of the torso 

over the lap belts. This injury pattern is similar to those 

experienced by victims of automobile accidents who were 

secured with only a lap belt in a forward impact. 

Crew Restraints 

Crewmembers were restrained in their seats by a five-point harness system (diagram on the left). A lap belt 

secures the lower torso and a crotch strap prevents “submarining,” keeping the occupant from sliding forward 

and beneath the lap belt. The photo of a technician shows how the two shoulder harnesses attach to the 

restraint buckle. The drawing of the seat with restraints shows that the two shoulder harnesses attach to the 

inertial reel by means of the inertial reel strap which was designed to secure the upper torso. 

Illustration (left) and photograph (right) of five-point harness. 

Headrest 

Inertial 

reel strap 

Seatback 

Seat pan 

Shoulder 

belts 

Lap 

belts 

Buckle 

Crotch 

belt 

Five-point 

restraint 

Restraint buckle 

for the 5-point 

harness system 
106 SECTION 4 – THE ANALYSIS

-

Chance-type Fracture 

This is an illustration of the mechanism causing 

lumbar spine Chance-type fracture. With the 

upper body functionally unrestrained and the lap 

belts secured, the unconcious crewmembers’ 

lumbar spine injuries occurred from the sudden 

forward and downward rotation of the torso over 

the lap belts. 

Flail Injuries 

All crewmembers exhibited upper- and lower 

extremity fractures consistent with deceleration 

injury or aerodynamic flail. Using a model that 

analyzed the possible strike envelopes of the 

seated crewmembers, correlation was found 

between the possible injury locations and the 

actual sites found at autopsy. The static flail 

analysis predicted that most injuries would be 

located in the distal limbs and parietal skull, with 

some slight variations due to crewmember seat 

location. The shaded areas represent the common 

flail injury patterns found. The illustration is based 

on an analysis using a static strike envelope. 

Illustration provided by Biodynamic Research Corporation – BRC Illustration provided by Biodynamic Research Corporation – BRC 

All crewmembers had exhibited upper and lower 

extremity fractures consistent with deceleration injury 

(G flail) before CMCE and aerodynamic flail after 

CMCE and exposure to windblast. Using a model that 

analyzed the possible strike envelopes of the seated 

crew, correlation was found between the possible 

injury locations and the actual sites. The static flail 

analysis predicted that most injuries would be located 

in the distal limbs and parietal skull, with some slight 

variations due to crewmember seat location. 

Thermal injuries after the crew module 

catastrophic event and exposure to the 

atmospheric environment 

Forensic evidence supported exposure of the deceased 

crewmembers to at least two separate thermal events. 

The first was a directional thermal event that occurred 

while the crewmembers were suited and restrained 

in their seats. This first thermal event is consistent 

with a breach of the crew module pressure vessel in 

the vicinity of the starboard x-link when the forebody 

separated from the midbody at the CE. A breach in 
SECTION 4 – THE ANALYSIS 107 

The Initial Stages of the Destruction of the Crew Module with the Separation of the 

Forward Fuselage from the Body of the Crew Module 

Position and condition of starboard x-link. 
108 SECTION 4 – THE ANALYSIS

this location permitted thermal energy to enter the 

crew cabin after atmosphere evacuation had occurred. 

Analysis of thermal skin burn patterns suggested that 

the burns initially occurred within the crew cabin with 

crewmembers in their seats protected by relatively intact 

suits. As the thermal environment worsened, the suit 

material was weakened and failed, allowing secondand third-degree burns and thermal shadowing patterns 

consistent with thermal intrusion. 

The second thermal event occurred during the interval 

from the start of crew module disintegration at GMT 

14:00:53 through the total dispersal of the crew 

compartment structures at GMT 14:01:10. In this 

time interval the deceased crewmembers underwent 

additional mechanical trauma. As the remaining 

forward fuselage and crew module structures were 

disintegrating, exposure to windblast and possibly 

shock wave forces rapidly stripped the damaged 

Advanced Crew Escape Suits (ACES) from the 

deceased crewmembers. The denuded crewmember 

remains then passed through the surrounding hot gas 

and molten metal mist “cloud,” incurring additional, 

universal second-degree flash burns and molten metal 

Burns During the Thermal Events 

These graphics illustrate the thermal skin burn patterns that occurred during the thermal events with the 

breakup of the crew module and its dispersal. The crewmembers had 2nd- and 3rd-degree burns and 

patterns of thermal shadowing with molten metal deposition. The thermal event was severe enough to cause 

portions of the ACES material to adhere to the skin of one crewmember. 

All crewmembers exhibited some degree of 

increased thermal injury/metal deposition on 

their heads and necks consistent with exposure 

while wearing an ACES with helmet visors open. 

Some shadowing from the communications 

cap was visible on some crewmembers. It 

is therefore concluded, from the burn/metal 

deposition patterns, that the initial burns 

occurred with the crewmembers in the cabin, 

in their seats, helmet visors up and covered 

by a relatively intact ACES that afforded them 

some thermal protection. 

Burn and metal deposition patterns 

The shadowing is caused by some of the suit 

materials protecting the crewmembers from the 

thermal intrusion into the crew module. 

Burns on the feet 

The feet of several crewmembers exhibited 

thermal injuries in areas coinciding with the 

nylon panels of the boots vs. the leather 

portions. These injuries are consistent with 

initial failure of the nylon panels and boot 

soles. The feet of several of the crewmembers 

exhibited a greater degree of burn/material 

deposition on the forefoot consistent with 

failure of the boots at the mid-sole. All of these 

second-degree burns were associated with 

“molten metal mist” deposits. This illustrates the burn mapping of a deceased crewmember’s foot. 

Shadowing 

from 

communications 

cap 

Shadowing 

from ACES 

Area of 

burn/material 

deposition 

Area of adhered Maximum Absorbent Garment (MAG) material 

Shadowing from parachute harness 

Areas of third degree burn 

Area of second degree burn 
SECTION 4 – THE ANALYSIS 109 

No Evidence of Fire 

No deposition of foreign material or evidence of thermal injury was present in any of the respiratory tracts 

available for review. Forensic analysis showed no significant levels of carbon monoxide or cyanide 

(combustion by-products) in body fluids. These facts indicate that there was no fire in the crew module 

before breathing cessation and crew death. These micrographs show a representative section of a 

crewmember’s trachea with intact cilia, free of deposits and evidence of thermal injury. 

Thermal Injuries 

During the second thermal event, the crew module catastrophic event through total dispersal of the crew 

module, the unconscious crewmembers passed through a surrounding mist “cloud” of hot gas and molten 

metal, which caused additional 2nd-degree flash burns. 

These slides show examples of the superficial skin burns incurred by crewmembers. The left-hand image (20X) is stained with a 

trichrome stain and demonstrates a superficially burned epidermis in red and the spared deeper reticular dermis in blue (characteristic 

of a flash burn). The right-hand image is a higher magnification (40X) hematoxylin-eosin stained skin section showing the metallic 

deposits over the burned surface. 

Metallic Mist 

Deposition 
110 SECTION 4 – THE ANALYSIS

deposition caused by conductive and irradiative transfer 

of thermal energy. The FBI material analysis laboratory, 

using scanning electron microscopy and energydispersive x-ray spectrometry, identified the following 

elements present in the skin deposits: aluminum, 

calcium (normal component of skin), copper, iron 

(normal component of skin), manganese (normal 

component of skin), nickel, phosphorus (normal 

component of skin), silicon, sulfur (normal component 

of skin), and titanium. 

No deposition of foreign material or evidence of 

thermal injury was present in any of the respiratory 

tracts available for review in spite of the presence 

of superficial facial burning associated with the first 

thermal event while crewmembers were still suited and 

seated. Forensic analysis showed no significant levels of 

carbon monoxide or cyanide (combustion by-products) 

in body fluids. This is consistent with the complete 

cessation of respiration after depressurization, shortly 

after the CE and before the thermal intrusion. 

After these two thermal events, the crew remains 

were exposed to the atmospheric environment at 

an altitude above 100,000 feet. The remains were 

subjected to additional thermal injuries during the 

hypersonic to subsonic deceleration. The findings 

indicated exposure to near vacuum, aerodynamic 

heating, highly reactive monatomic oxygen, and 

subfreezing ambient temperatures during the free-fall 

descent. As human exposure to these environmental 

extremes is not well documented, the contribution 

of these environmental conditions to the pathology 

findings remains uncertain. 

Common injuries incurred during the crew 

module catastrophic event and ground impact 

The common injuries that occurred during the CMCE 

period were consistent with the application of high 

dynamic loading, from complex deceleration forces, 

to the seated, partially restrained and unconscious 

crewmembers. Engineering and ballistic analyses of 

the CMCE supports the scenario that the middeck floor 

and everything attached to it separated from the crew 

module structure first. When this lower half of the 

crew module separated from the flight deck “pod,” 

it is likely that a negative Gz

 load was imparted along 

the hinge line where the middeck floor was attached 

Mechanical Injuries During the Destruction of the Crew Module 

Mechanical injuries occurred during the destruction of the crew module. The high negative Gz translational 

and rotational decelerations at the time of module disintegration were thought to be the major cause of 

the most severe traumatic mechanical injuries sustained by the deceased crew. An example of these injuries 

is the basilar skull fracture depicted in this graphic. The fracture was probably caused by the neck ring on 

the Advanced Crew Escape Suit sticking the lower jaw as the neck ring departed the body due to windblast. 

All crewmembers but one exhibited these basilar skull fractures. 

Illustration provided by Biodynamic Research Corporation – BRC 

Illustration of the mechanism of basilar skull fracture. 
SECTION 4 – THE ANALYSIS 111 

 

Plot of Relative Range and Recovery Locations Based on the Ballistic Coefficients of the 

Principal Human Remains Found on the Ground 

to the aft bulkhead. Because of this negative Gz 

loading, the middeck floor and the Environmental 

Control and Life Support System bay would have 

quickly disintegrated together with the middeck floor 

panels. On the basis of structural design analysis, 

thermal damage, and position in the debris field, the 

flight deck “pod” and aft bulkhead are thought to 

have remained intact for a slightly longer time. 

At the time of disintegration, the high negative Gz 

translational and rotational decelerations were thought 

to be the major cause of the most severe traumatic 

mechanical injuries sustained by the deceased 

crewmembers. These mechanical injuries included 

hemi-transection associated with multiple flexiontype distraction fractures of the spine and separation 

fractures of the pelvis. In addition to the major 

traumatic injuries involving the pelvis and spine, all 

but one crewmember exhibited basilar skull fractures, 

which are thought to have been caused by the neck ring 

on the ACES striking the lower jaw as the neck ring 

departed due to windblast; all exhibited comminuted 

fractures of facial bone(s); and all exhibited 

other multiple skeletal fractures, disarticulations, 

dislocations, and amputations. Although some of the 

flail injuries were sustained while the crewmembers 

were restrained in their seats, other flail injuries 

were inflicted during a period of deceleration from 

supersonic to subsonic velocity, during free-fall descent 

and ground impact. Some crewmembers’ remains found 

later in the recovery process had evidence of insect and 

animal predation. 

Gross examination of the recovered remains revealed 

that the occupants on the starboard side of the vehicle 

incurred a greater degree of mechanical trauma than 

those on the port side, suggesting that more energy was 

imparted to these individuals. This is consistent with 

the calculated ballistic coefficients of the remains and 

where the crewmembers were found on the ground 

during the recovery operations. The ballistic analysis 

could not be used to determine the sequence and the 

release times of the crewmembers. 

Summary 

In summary, the forensic analysis of the Columbia 

accident led to the following conclusions regarding 

lethal events and lessons learned: 

1. The STS-107 crew died as a direct result of a rapid 

depressurization causing pulmonary barotrauma and 

ebullism, followed by blunt-force trauma. 

2. An off-nominal dynamic G environment, combined 

with a lack of restraint of the upper body and 

nonconforming helmets, contributed significantly 

to lethal trauma. 

3. A third traumatic event consisted of thermal intrusion 

into the crew cabin, causing extensive second- and 

third-degree burns on all crewmembers. 

4. A fourth traumatic event occurred when the 

crewmembers separated from the crew module 

and were subjected to restraint injuries, transonic 

velocity changes, windblast, aerodynamic flail, 

exposure to near vacuum, aerodynamic heating, 

monatomic oxygen, and subfreezing temperatures 

during free fall. 

5. The fifth traumatic event was ground impact. 
112 SECTION 4 – THE ANALYSIS

 

 

 

Aerospace Medical Forensic Findings 

and Recommendations 

Finding 1: Spacecraft accidents are rare; each event 

adds critical knowledge and understanding for 

future spacecraft designs and for improvement of 

operational procedures. 

Recommendation 1: As was executed with the 

Columbia mishap, spacecraft accident investigation plans 

must include provisions for debris recovery and storage, 

data preservation, and security. The investigators must 

catalog, store, and preserve all debris and data so it will 

be available for future study. 

Finding 2: Crewmembers exhibited injuries consistent 

with bracing, a conscious and volitional act. The loads 

associated with the CE, together with the lax shoulder 

harnesses and mass of the crew escape equipment, 

contributed to these injuries. 

Recommendation 2: The design of the restraint system 

should be integrated with the design of suit and seat, so 

that crewmembers are not required to use their arms and 

legs to brace against nominal and off-nominal loads. 

Finding 3a: The unprotected crewmembers (helmet 

visors open, some gloves off) were exposed to a 

depressurization event sufficient to cause severe 

barotrauma, hypoxic hypoxemia, ebullism, and death. 

Finding 3b: The depressurization incapacitated the crew 

so rapidly that they were not able to configure their crew 

survival equipment (e.g., lower their helmet visors). 

Finding 3c: When the ACES is properly deployed 

(visor down, gloves on, O2 flowing), it is incompatible 

with the Shuttle hazard controls for preventing cabin 

fires, impedes operation of user interfaces, and interferes 

with crew communications. 

Recommendation 3a: Future spacecraft and crew 

survival systems should be designed so that the 

equipment and procedures provided to protect the crew 

in emergency situations are compatible with nominal 

operations. Future spacecraft vehicles, equipment, 

and mission timelines should be designed so that a 

suited crewmember can perform all operations without 

compromising the configuration of the survival suit 

during critical phases of flight. 

Recommendation 3b: A feature should be incorporated 

into the suit helmet/O2 system that will automatically 

activate (lower the visor and turn on O2

) upon cabin 

depressurization. Operational and design changes must 

also be made so the integrity of the ACES is ensured and 

prolonged emergency “in suit” O2 breathing is permitted 

without exceeding the O2 cabin safety fire limits. 

Recommendation 3c: None. 

Finding 4: Ebullism or bubble formation was 

present in examined tissues (brain, spinal cord, lung, 

thyroid, myocardium, and bone marrow), indicating 

that the unprotected crew was exposed to a pressure 

altitude above 62,000 ft (Armstrong’s line, the altitude 

that produces an atmospheric pressure so low [0.0618 

atmosphere] that water boils at the normal temperature of 

the human body: 98.6°F [37°C]). 

Recommendation 4: None. 

Finding 5: Injuries of the lower lumbar spine, upper 

body extremity, and skull were consistent with 

crewmembers’ torsos flailing forward and downward 

while anchored by their seat belts. This evidence 

indicates that those so injured had their seat belts in 

place, but their inertial reel straps were extended. 

Recommendation 5: The use of inertial reels in future 

restraint systems should be redesigned to ensure that 

they are capable of protecting crewmembers during 

off-nominal situations (for example, seat belts should be 

wider, and extremity flail protection could be provided) 

without active crew intervention. 

Finding 6: The crewmembers had lethal injuries due to 

the seat restraint system. 

Recommendation 6: The design of the seat restraint 

systems should include considerations to preclude 

restraint-induced injuries during dynamic motion (e.g., 

NASCAR racing-type straps). 

Finding 7: Most crewmembers had hemorrhage into 

the anterior and posterior strap muscles of the neck 

and fractures of cervical vertebrae. The unsupported 

head (nonconformal helmet) in association with the 

helmet neck ring acting as a fulcrum contributed to the 

neck flail injuries. 

Recommendation 7: The suit-seat-restraint system 

should provide support for the head-neck complex (e.g., 

conformal helmets, head and neck restraint-type devices). 

Finding 8: All crewmembers had evidence of global 

second-degree burns with deposition of metallic particles 

and pyrolysis products on skin surfaces. 

Recommendation 8: Future crew cabin designs should 

protect the crew in the event of vehicle disintegration 

(e.g., crew encapsulation). 

Finding 9: The crewmembers’ body fluids had no 

significant levels of carbon monoxide or cyanide 

(combustion by-products), and they had intact ciliated 

columnar cells in their tracheas with no evidence of 

deposition or other thermal injury to the respiratory 
SECTION 4 – THE ANALYSIS 113 

 

tracts. This indicates that there was no cabin fire 

before depressurization and that the crew had ceased 

breathing before any thermal intrusion into the crew 

module occurred. 

Recommendation 9: None. 

Conclusion 

One of the legacies of the Columbia accident was 

the documentation of the catastrophic injuries of the 

crewmembers themselves. NASA, through the efforts 

of the Crew Survival Working Group, the Spacecraft 

Crew Survival Integrated Investigation Team, the Office 

of the Armed Forces Medical Examiner, the Armed 

Forces Institute of Pathology, the Federal Bureau of 

Investigation, and the Biodynamic Research Corporation, 

developed findings and recommendations about the 

effects of a high-altitude hypervelocity spacecraft 

accident on the crewmembers. These medical findings 

and recommendations provide the basis for improved 

systems design, engineering, and operations of human 

spacecraft to enable a crew to survive such a mishap 

in the future. We honor the Columbia crew for the 

significant aeromedical lessons learned from this mishap. 

Integrated Summary Timeline of Crew-related Events 

A high-level overview depicts the probable timeline of medically significant events, illustrating their temporal 

relationship with major environmental conditions. The illustration also emphasizes the short period of time over 

which these events occurred: about 35 seconds from the forward fuselage separation (catastrophic event or 

CE) to the crew module disintegration (crew module catastrophic event or CMCE). The cabin pressure profile 

presented is a reconstructed scenario based on debris analysis and ballistics. The rapid depressurization event 

started at GMT 14:00:18 with an uncertainty of up to +10 seconds. 

Illustration provided by Biodynamic Research Corporation – BRC 

Loss of Control Total Dispersal 
114 SECTION 4 – THE ANALYSIS

Legal Analysis and Issues 

from Recovery and Investigation 

of the Columbia Accident 

Donna M. Shafer and Amy V. Xenofos 

Immediate Response Phase 

Despite the extraordinary focus and perseverance of 

the personnel at NASA, the Columbia accident was not 

the first time NASA has lost a Space Shuttle orbiter 

and its crew—Challenger was tragically lost 73 seconds 

after lift-off from the Kennedy Space Center in 1986. 

NASA learned and applied many lessons from the 

Challenger accident, including a need for an overall 

contingency plan to be in place as well as a plan for an 

independent assessment. As a result, today at NASA, 

activation of an investigation board is required for any 

event involving serious injury or loss of life, other 

serious mishaps, or significant public interest. The plan 

to activate an investigation board was accomplished 

through the implementation of NASA Policy Directive 

8621.1, NASA Mishap and Close Call Reporting, 

Investigating, and Recordkeeping Policy. 

After the Columbia accident, NASA immediately 

established recovery and investigation teams. At 

10:30 a.m. on February 1, 2003, NASA Administrator 

Sean O’Keefe activated the International Space 

Station and Space Shuttle Mishap Investigation Board, 

naming retired naval Admiral Harold Gehman, Jr. as 

its chairman. The board renamed itself the Columbia 

Accident Investigation Board (CAIB). On the NASA 

side, we established the Space Shuttle Mishap 

Investigation Team (MIT) and the Columbia Task 

Force (CTF). The CTF served as the primary interface 

between the Agency and the CAIB. The MIT was 

responsible for gathering and preserving evidence to 

allow the CAIB to conduct its analysis and make a 

causal determination. By the evening of February 1, 

2003, the MIT arrived at Barksdale Air Force Base and 

began organizing its efforts. 

This chapter will focus on some of the matters addressed 

by the NASA legal community. First we cover the 

primary legal framework within which the recovery and 

investigation efforts were completed. Then we cover 

the methods used in the collection and control of the 

The Johnson Space Center Legal Office logo at the time of the 

Columbia Space Shuttle Accident. 

enormous amount of data involved in the aftermath 

of the accident. Next, we will look separately at the 

recovery and investigation phases and the unique legal 

questions raised by each. Finally, we will discuss the 

claims associated with the search and recovery efforts, 

survivor privacy issues, balancing assessments, the Crew 

Survival Investigation Report, and some lessons learned. 

Primary Legal Framework 

This section will describe some of the more important 

laws and legal frameworks within which NASA 

conducted activities related to the Columbia mishap. 

This framework is by no means all-inclusive. 

National Aeronautics and Space Act of 1958: The 

National Aeronautics and Space Act of 1958 (Space 

Act) created NASA to carry out US policy that 

“activities in space should be devoted to peaceful 

purposes for the benefit of all mankind.” From a 

legal perspective, the Space Act encompasses almost 
SECTION 4 – THE ANALYSIS 115 

any situation and is one of the most flexible pieces of 

organic legislation written for a federal agency. 

Under the Space Act, NASA may enter into 

and perform such contracts, leases, cooperative 

agreements, or other transactions as may be 

necessary in the conduct of its work and on such 

terms as it may deem appropriate. This provision 

gave NASA the ability to enter into agreements with 

some of the more than 100 state and local agencies 

and individuals in Texas, Louisiana, New Mexico, 

Nevada, and Utah, who assisted NASA in the search 

for debris. The Space Act was also used in making 

initial preparations for conducting investigative tests 

in support of the CAIB. 

Stafford Act and Emergency Assistance Act: 

Ultimately the Space Act did not play a significant 

role during the recovery efforts because the Federal 

Emergency Management Agency (FEMA) became 

involved. On February 1 and reiterated on February 

6, 2003, President Bush issued a declaration, under 

the Stafford Act and Emergency Assistance Act, of 

emergency conditions in certain areas of the United 

States relating to the loss of the Space Shuttle 

Columbia. The Stafford Act was drafted to provide 

an orderly and continuing means of assistance by the 

federal government to state and local governments 

in carrying out their responsibilities to alleviate 

suffering and damage resulting from disasters. The 

basis for this presidential declaration included the 

fact that the Space Shuttle and the space program 

are federal property and federal programs. The 

memo issued by the White House authorized FEMA 

to coordinate and direct other federal agencies and 

to fund activities not otherwise authorized. FEMA 

was instructed to consult with the governor of any 

affected state before providing assistance. This is 

because FEMA Public Assistance grants are given 

only to states, and the state distributes money to 

qualified applicants. 

Freedom of Information Act: The Freedom of 

Information Act (FOIA) was enacted in 1966 and 

generally provides that any person has the right 

to request access to federal agency records or 

information. Nine statutory exemptions authorize 

withholding of certain information, including 

information of a sensitive nature. FOIA exemptions 

found in 5 U.S.C. § 552(d) include (1) classified 

information, (2) internal personnel rules and 

policies, (3) information exempt under other laws, 

(4) confidential business information, (5) internal 

government communications, (6) personal privacy 

interests, (7) records or information compiled for 

law enforcement purposes, (8) records related 

to the regulation or supervision of financial 

institutions, and (9) geological information. For 

any exemption cited by an agency as a reason to 

withhold requested information, an administrative 

appeal process is described in NASA regulations 

available to the requestor. One of the lessons 

learned from the Challenger accident was that the 

Agency should release as much information as it 

is legally authorized to release without the need 

of a FOIA request. Even though the CAIB and the 

Agency learned this lesson and proactively released 

as much information as possible, without in any 

way disrupting or jeopardizing the integrity of the 

investigation, the number of requests specifically 

related to the accident still totaled nearly 500. 

Other Acts that played a significant role include the 

Privacy Act of 1974 and, to a much lesser degree, 

the Arms Export Control Act (and its implementing 

regulations: the International Traffic in Arms 

Regulations [ITAR] and the Export Administration 

Regulations) and the Federal Advisory Committee Act. 

Privacy Act: This Act is a companion to the FOIA. 

It allows individuals to seek access to agency 

records about themselves. The Act also restricts the 

disclosure of personally identifiable information by 

federal agencies. The essential feature of both the 

Privacy Act and FOIA is that they make agencies 

accountable for information disclosure policies 

and practices. If a record cannot be released, the 

requestor is entitled to be informed of the rationale 

for the denial and has a right to appeal the denial as 

well as challenge it in court. 

Export Control: The existing NASA export control 

process was used to facilitate public releases of 

information by the CAIB. The Space Shuttle 

Program Office Export Control Representative 

reviewed all NASA data turned over to the CAIB 

and made a written recommendation concerning 

releasability of that information. It was important to 

sensitize individuals unfamiliar with NASA data to 

the fact that much of the Shuttle data is controlled 

by ITAR. As the cognizant Agency, NASA had the 

authority to approve such data for public release. 
116 SECTION 4 – THE ANALYSIS

 

Guide to the Law 

NASA’s actions are governed by three levels of 

requirements: Federal Law, which defines what 

we must do; Federal Regulations, which define 

how we implement Federal Law; and Federal 

Policy, which defines how we will exercise our 

discretion under the Regulations. Below is a list of 

all the Federal laws and regulations discussed in 

the chapter, along with a citation, to aid readers 

interested in further research. 

Federal Law 

National Aeronautics and Space Act of 1958, 

51 U.S.C. § 201 

Robert T. Stafford Disaster Relief and Emergency 

Assistance Act, 42 U.S.C. §§ 5121-5206 

Freedom of Information Act (FOIA), 5 U.S.C. § 552 

Privacy Act of 1974, 5 U.S.C. § 552a, as amended 

Arms Export Control Act (AECA), 

22 U.S.C. §§ 2751-2799 

Federal Advisory Committee Act (FACA), 

5 U.S.C. apps. §§ 1-16, as amended 

Federal Regulations 

Availability of Agency Records to Members of 

the Public, 14 C.F.R. 1206 

International Traffic in Arms Regulations (ITAR), 

22 C.F.R. §§ 120-130 

Export Administration Regulations (EAR), 

15 C.F.R. §§ 730-774 

Federal Advisory Committee Act (FACA): The 

purpose of the FACA is to ensure that advice 

rendered to the executive branch of the US 

government is both objective and accessible to 

the public. All of the formalities required by the 

Act for record keeping and publications were 

not compatible with the broadly defined, timeintensive Columbia accident investigation or 

with the effective oversight of more than 100 

staff members and thousands of debris searchers. 

Because of a number of practical considerations, all 

CAIB members who were not already employees 

or officers of the United States were hired as 

full-time federal employees. However, (5 U.S.C. 

app. 3(2) provides that FACA does not apply to 

committees “comprised wholly of full-time officers 

or employees of the federal government.”) Even 

though the Act was therefore not applicable to the 

CAIB’s activities, the Board resolved to comply, to 

the maximum extent practicable, with its standards. 

Collection and Control Methods 

The recovery of human remains began immediately, 

and within only 10 days of the accident, February 10, 

2003, NASA Human Remains for Columbia Recovery 

Guidelines had been drafted and concurred on by 

NASA, FBI, FEMA, the Office of the Armed Forces 

Medical Examiners, and Air Force Mortuary Affairs. 

The objectives of the guidelines were to optimize use 

of resources available in the main search area and to 

deliver suspected human remains as soon as practical for 

definitive forensic examination. The guidelines outlined 

operations for material in the main search area near 

Lufkin, Texas, material outside the main search area, 

and late-phase operations for suspected human remains. 

Formal human remains efforts terminated on February 

13, 2003, with instructions to refer any suspected human 

remains located after that date to local law enforcement 

authorities, all of whom were instructed to contact 

USAF mortuary Affairs. NASA also provided points 

of contact within the Agency for questions concerning 

human remains, life support, or biohazards via the JSC 

Emergency Operations Center. 

With any investigation quickly comes the compilation 

of data. The CAIB soon realized that the sheer volume 

of available data involved with the technically complex 

Space Shuttle could quite easily overwhelm them 

if it was not properly cataloged. As a result, the US 

Department of Justice was enlisted to assist with the 

collection and control of the data for the CAIB. The US 

Department of Justice Office of Litigation Support was 

brought in because of their vast experience in collecting 

and controlling evidence for the US attorneys conducting 

litigation on behalf of the US government. Configuration 

management between the CAIB and NASA was 

accomplished through the Columbia Task Force. 

The CAIB Document Database contains over 35,000 

records created or received by the CAIB during 

its investigation. Records include testing reports, 
SECTION 4 – THE ANALYSIS 117 

interim recommendations, independent assessment 

team reports, presentations, photographic images, 

drawings, correspondence, and e-mail messages. These 

records are permanent government records that NASA 

transferred to the custody of the National Archives 

and Records Administration after the work of the 

CAIB was completed. 

NASA maintained its own database, known as the 

CTF Document Database. The CTF Database contains 

about 45,000 records that the CAIB requested, 

reviewed, and used during its investigation. It is 

important in noting the sheer volume of information 

that there is minimal duplication between the CTF 

and the CAIB databases. 

The CAIB created and controlled extensive witness 

testimonies in the formats of audio recordings, 

electronic transcripts, and interview notes. Consistent 

with longstanding practice in aircraft accident 

investigation, the CAIB granted confidentiality to 

individuals who were interviewed. The Archivist of the 

US, the chief official overseeing the operation of the 

National Archives and Records Administration, acceded 

to the CAIB’s request to restrict access to the statements 

for a period of 50 years. These statements have been 

found privileged with respect to pretrial discovery. 

The US Supreme Court has also recognized the 

privilege as exempting such statements from disclosure 

under FOIA. Also included in these records are copies 

of the written statements made by the staff of NASA’s 

Mission Control Center immediately after the accident. 

Other records were divided into permanent and 

temporary records and were archived or deleted/ 

destroyed according to the appropriate disposition for 

the record. Those records include interim and final report 

records, public affairs records, public comment records, 

CAIB World Wide Web content and Web management 

records, and e-mail and word-processing system copies. 

For more information, see the article “First Hand 

Account of Selected Legal Issues From the Recovery 

and Investigation of the Space Shuttle Columbia,” 

Journal of Space Law, Volume 30, Number 1 (2004). 

Right of Entry Agreements: NASA entered into an 

agreement with FEMA which included the stipulation 

that NASA would not remove debris from public 

and private property until the landowner signed an 

unconditional authorization termed a “Right of Entry 

Agreement.” The agreement included notification 

that the agreement’s execution did not obligate the 

government to clear the debris and contained a hold 

harmless agreement for claims arising from activities 

on the property. 

Recovery Phase Legal Issues 

As of May 5, 2003, ground, water, and air searches 

combined covered more than 2.28 million acres, and 

about 25,000 personnel took part in the Columbia 

recovery operations. The Texas operation was unique. 

Texas was the site of the majority of debris recovered 

and had by far the largest number of state and local 

agencies with which NASA coordinated. By one count, 

about 130 different agencies were involved. Debris 

reports came in daily from 28 other states and three 

foreign countries. 

Reimbursable and Tort Claims 

FEMA’s public assistance program projected 

reimbursable payments in Texas and Louisiana to total 

about $10.5 million; however, the parameters of the 

program were such that many groups were not eligible 

for FEMA support. Because FEMA’s funding efforts 

were not all-inclusive, NASA took the highly unusual 

step of soliciting claims. The many state agencies and 

individual entities assisting NASA were all happy 

to learn that NASA was being very proactive in our 

efforts to ensure that all entities providing assistance 

were being reimbursed by NASA. Generally, if 

NASA’s search and recovery efforts led to unintended 

expenses, NASA reimbursed those costs under Space 

Act authority. For example, NASA paid Nacogdoches 

County $4,000 for expenses incurred in moving the 

Texas Spring Classic Horse Show to Navarro County. 

NASA paid Stephen F. Austin State University $15,000 

for the mapping work they did, associated with human 

remains recovery. NASA paid Palestine Texas Regional 

Medical Center $6,000 for medical transportation and 

decontamination services. Carroway-Claybar Funeral 

Home was reimbursed for transportation of remains. In 

addition to claims from Texas and Louisiana, we paid 

claims from Utah and New Mexico. NASA reviewed 

about 70 requests for reimbursement from various 

entities and provided compensation totaling just over 

$1.2 million. NASA also provided about $90,000 

resulting from153 property-damage claims. 
118 SECTION 4 – THE ANALYSIS

   

   

       

     

   

       

For the processing of monetary claims against NASA 

under the Federal Tort Claims Act or under the Space 

Act, the claimant is required to submit a claims form 

which was furnished by NASA installations upon 

request. For example, a mounted patrol officer fell off 

of his horse and broke his leg and was required to seek 

reimbursement for medical expenses under the Federal 

Tort Claims Act. 

Controlling Theft of Debris 

In an attempt to curb the desire of any individual to 

retain any debris as a souvenir of an historic event, 

the US Attorneys for the Southern and Eastern 

Districts of Texas issued a 1-day moratorium from 

prosecution for anyone who had Shuttle debris and 

had not reported it or turned it in to authorities. The 

NEWS RELEASE 

Office of the United States Attorney

Eastern District of Texas 

FOR IMMEDIATE RELEASE Contact: Duncan Woodford 

DATE: February 6, 2003 Public Information Officer 

(409) 839­2538 

The United States Attorney's Office encourages residents of Texas to assist in the recovery

of debris from the wreckage of the shuttle Columbia.  Any person who is in possession or

finds debris from the space craft should immediately call the Columbia Shuttle Command

Center Debris Reporting Line at 936­699­1000 or the Johnson Space Center Emergency

Operations Center telephone  number  at  281­483­3388.  You may also  call  your local 

sheriff's office or police department to report any items.  Individuals are strongly cautioned

not to handle or touch the debris but to contact the appropriate authorities to secure the

objects. 

To assist in the recovery effort, the U.S. Attorney's Office is offering a grace period to

anyone who turns in debris until Friday, February 7, 2003 at  5:00 p.m.  Anyone having a

piece of debris from the wreckage is strongly urged to take advantage of this period of

leniency to avoid federal prosecution and hefty fines.  After Friday afternoon, the U.S. 

Attorney's  Office  will  resume  prosecuting individuals  who take  or  keep  pieces  of the 

wreckage. 
SECTION 4 – THE ANALYSIS 119 

moratorium was publicized in a press release (Press 

Release, US Department of Justice, US Attorney Eastern 

District of Texas, First Indictments in Shuttle Debris 

Recovery, Limited Prosecution Moratorium Announced, 

available at http://www.usdoj.gov/usao/txs/releases/ 

February2003/030205-columbiamoratorium.htm (Feb. 

5, 2003). During the moratorium quite a few individuals 

called about turning in property to NASA, including 

individuals who had debris from the Challenger accident. 

Texas Death Investigation System 

The Death Investigation System in the State of Texas, 

including the state’s 254 counties, has a mixed system 

of coroners and medical examiners. The preparation 

of certificates of death includes the direction that the 

provider pronouncing death prepares a death certificate 

and sends it to proper authorities according to state and 

civil requirements. Although human remains from the 

Columbia accident were originally located in Texas, 

they were initially transported to Louisiana and then 

to Delaware. The death certificates were issued by the 

State of Texas, Angelina County, and executed by Philip 

Stepaniak, MD, with certification by the Armed Forces 

Medical Examiner, Craig Mallak, MD. The immediate 

cause of death was “blunt force and thermal injuries in 

association with exposure to extreme altitude” with an 

underlying cause of “Spacecraft Mishap.” 

Investigation Phase Legal Issues 

Survivor Privacy Rights 

As an agency, NASA flies high-performance and 

experimental vehicles in mission-oriented operations 

like the military services, but it is a more public 

organization with relatively high-profile operators. 

As a result, NASA policy for the release of sensitive 

information is necessarily a hybrid of the two 

approaches, with points at which decisions are to be 

made by and at the discretion of identified personnel. 

The aim of making NASA aircraft and spacecraft 

mishap information available is to educate the aerospace 

medical communities and to inform the design and 

development processes of new spacecraft by the lessons 

learned about crew safety and survivability. 

The privacy of an individual and surviving relatives is 

a personal and fundamental right that must be respected 

and protected. Survivor privacy rights for families of 

government employees have been recognized by the 

United States government for more than 40 years. In 

the case of Hale v. United States Dep’t of Justice, 973 

F. 2d 894, 902 (10th Cir. 1992), the court ruled that 

there was “...no public interest in photographs of the 

deceased victim, let alone one that would outweigh 

the personal privacy interests of the victim’s family” 

(Exemption 6(C), cert. granted, vacated and remanded 

on other grounds, 509 U.S. 918 (1993). In KTVY-TV 

v. United States, No. 87-1432-T, slip op. at 9 (W.D. 

Okla. May 4, 1989), the court ruled that “The privacy 

rights asserted—those of the survivors and family of 

the victims in not having photographs of the bodies of 

the victims and clinical descriptions of their wounds 

being divulged—are patent and compelling and within 

the protections of the Act.” (Exemption 6(C), aff’d per 

curiam, 919 F. 2d 1465 (10th Cir. 1990)). 

The recognition of survivor privacy rights is primarily 

found in case law and government policy and 

memoranda, and stems from a long common law 

tradition of acknowledging a family’s control over the 

body and death images. After much litigation, spanning 

1987–1991, in New York Times v. NASA, 782 F. Supp. 

628, 631-32b (D.D.C. 1991), NASA’s recording of 

the voices of the Challenger crew was found properly 

withheld under FOIA exemption 6 on the basis that 

“exposure to the voice of a beloved family member 

immediately prior to death is what would cause pain... 

a disruption of their peace of mind.” 

This recognition of rights protects survivors against 

the clearly unwarranted invasion of personal privacy. 

Concern about family is well ensconced into 

investigation activities and information release. 

NASA is also obligated to distribute information, 

including investigational findings, to stakeholders 

involved in human space flight, both government and 

commercial, particularly to those who are integrating 

safety and survivability elements into new designs. 

The overarching goal is to prevent further losses of 

crew or vehicle by incorporating observations and 

lessons learned into new designs as well as ongoing 

flight operations. 

To best protect surviving families and also adequately 

inform communities involved in prevention, there must 

be a well-defined balance between privacy and the 

public need to know. 
120 SECTION 4 – THE ANALYSIS

Balancing Assessment for Survivor Privacy 

Determination 

To determine if information would be protected, a 

balancing assessment was made by considering the 

following factors: 

• Does disclosure violate a viable privacy interest? 

Privacy encompasses the identifiable living 

individual’s control of information concerning his/ 

her person. This interest extends to surviving family 

member(s) primarily under case law. 

• Is there a public interest in disclosure? Does it 

directly reveal operations or activities of the federal 

government? 

• Does public interest qualify for balancing? (Only if 

an identified public interest sheds light on NASA’s 

performance of statutory duties.) 

• Balance personal privacy against qualifying public 

interest. This involves assessment and comparison of 

the relative magnitudes of the two interests. 

A “public release” is any external release of data, 

including information given to the academic, 

engineering, and industrial communities involved 

in high-performance aircraft and spacecraft design, 

construction, and operation. The assessment to 

determine what information to release is informed by 

what the public needs to know. The basic guidelines of 

this assessment are as follows: 

What the public needs to know about crewmembers: 

• Fundamental causative factors 

• Factors contributing to the mishap (eye toward 

prevention), structural and medical 

• Circumstances of injury 

• Mechanism of injury
	

What the public does not need to know:
	

• Photographs, video, or other imagery of 

human remains 

• Audio of sensitive content 

• Medical information or levels of detail not germane 

to the understanding of the event 

• Information about family members or personal items 

not germane to the understanding of the event 

At the conclusion of the investigation, which can 

be defined as the release date of the investigative 

committee’s findings, NASA determined how best to use 

the sensitive information from the accident to improve 

medical care and vehicle performance and safety. A 

body of stakeholders consisting of representatives from 

the JSC Flight Crew Operations Directorate (astronaut 

management), Space Life Sciences Directorate 

(medical), Safety and Mission Assurance Directorate, 

and Office of Chief Counsel informally worked together 

to determine how to do the following: 

• Provide for long-term curation of the medical 

and biomechanical data used and generated by 

the investigation. 

• Ensure that this information is used for preparing and 

educating teams for timely and correct response to 

aircraft and spacecraft mishaps. 

• Ensure that this information is fed into the design of 

new vehicles, if the information is deemed applicable 

to a particular aspect of design that would influence 

crew safety or survivability. 

• Review and approve public release of information 

related to medical and human factors of a mishap 

including the following: 

Internal NASA reports 

Academic journal articles and other publications 

Academic meetings and symposia 

Presentation to industry 

NASA routinely tries to maintain all medical data in 

non-attributable form. However, the small number of 

crewmembers involved, the unique circumstances of 

the mishap, and the large number of people involved 

in aircraft and spacecraft operations may cause 

circumstances to arise in which data are attributable to a 

specific individual. 

NASA astronauts are public figures, but they do not 

surrender all rights to privacy by placing themselves 

in the public eye, though their expectations of privacy 

certainly may be diminished. Disclosure of sensitive 
SECTION 4 – THE ANALYSIS 121 

personal information contained in an investigative 

report about a public figure is appropriate only where 

exceptional interests militate in favor of disclosure. 

Although one’s status as a public figure might tip the 

balance in favor of disclosure, a public figure does 

not, by virtue of status, forfeit all rights of privacy. 

Redaction of all identifying information is possibly 

sufficient to protect privacy interests. 

If the information at issue is particularly well known 

or is widely available within the public domain, there 

generally is no expectation of privacy. In Nat’l W. 

Life Ins. Co. v. United States, 512 F. Supp. at 461, 

the court noted that names and duty stations of most 

federal employees are routinely published and available 

through the Government Printing Office. Nor does an 

individual have any expectation of privacy with respect 

to information that the individual has made public. On 

the other hand, if the information in question was at 

some time or place available to the public, but now is 

“hard-to-obtain information,” the individual to whom 

it pertains may have a privacy interest in maintaining 

its “practical obscurity.” See Dayton Newspapers, 

Inc., 257 F. Supp. 2d at 1010 (reasoning that although 

modern search engines might make even otherwise 

obscure personal information more widely available, 

that “does not mean that [individuals] have lost all traits 

of privacy” in that information); Linn v. United States 

Dep’t of Justice, No. 92-1406, 1995 WL 417810, at 31 

(D.D.C. June 6, 1995) (declaring that even if “some 

of the names at issue were at one time released to the 

general public, individuals are entitled to maintaining 

the ‘practical obscurity’ of personal information that 

is developed through the passage of time”). Public 

availability of information in question will disqualify 

it from privacy protection only where it fails the new 

“practical obscurity” standard. 

Columbia Crew Survival 

Investigation Report 

As in all mishap investigations, NASA was motivated 

both to understand the cause of the accident and to find 

ways to prevent future accidents. Although the Columbia 

accident was not survivable, the investigation looked 

into the survival aspects of the accident and published 

a report to recommend enhancements to equipment and 

operations, to improve survivability in future accidents. 

The most sensitive medical data from the accident were 

not publicly released; however, we needed to balance 

the protection of the privacy interests with the inclusion 

of sufficient data to support the report’s conclusions. We 

minimized the disclosure of medical information and 

endeavored to ensure that no injury could be definitively 

tied to a specific crewmember. 

One of the key recommendations from the Columbia 

Crew Survival Investigation Report is that medically 

sensitive and personal effects data should always be 

protected to preserve the privacy of the victims and their 

families. Additionally, issues surrounding public release 

of this type of sensitive information during a NASA 

accident investigation should be resolved and policies 

documented throughout the Agency to ensure that the 

recommendation is followed when future crew survival 

investigations are performed. The successful publication 

of the Columbia Crew Survival Investigation Report 

is in large part a result of the team’s tireless dedication 

to ensuring close and careful coordination with the 

surviving family members. 

Future Investigations 

In 1986 after the loss of Challenger, a Presidential 

commission was established to investigate the accident. 

This body, named the Rogers Commission, was chaired 

by William P. Rogers. In contrast, after the Columbia 

accident, the ISS and SSP Mishap Interagency 

Investigation Board, an external board, was established 

by the NASA Administrator. The positions on this 

board, renamed the Columbia Accident Investigation 

Board, were filled with employees who occupied 

specific government positions. 

To create more consistency, on December 30, 2005, 

Congress passed Public Law 109-155, the National 

Aeronautics and Space Administration Authorization 

Act of 1958 as amended. This law had two provisions, 

under which NASA now operates, that pertain to 

investigation of space flight mishaps. 

One provision established a Human Space Flight 

Independent Investigation Commission, an independent 
122 SECTION 4 – THE ANALYSIS

Presidential Commission to investigate loss of a Space 

Shuttle; loss of the International Space Station or its 

operational viability; loss of any other US space vehicle 

(owned or contracted); or loss of a crewmember or 

passenger in any of these types of space vehicle. 

Under the new law, the Commission shall, to the 

extent possible: 

• Investigate the incident 

• Determine the cause 

• Identify all contributing factors to the cause 

• Make recommendations for corrective action 

• Provide additional findings or recommendations 

deemed important whether or not they are 

related to the specific incident 

• Prepare a report to Congress, the President, 

and the public 

The other provision established recovery and 

disposition authority. Under this authority, the NASA 

Administrator may take control over human remains 

and order autopsies and other scientific or medical 

tests. Additionally, each crewmember shall provide his/ 

her preferences regarding the treatment accorded to 

their remains and the Administrator shall, to the extent 

possible, respect those preferences. 

This provision does not permit the Administrator to 

interfere with any federal investigation of a mishap or 

accident. A crewmember is defined as an astronaut or 

other person assigned to a NASA human space flight. 

A NASA human space flight vehicle is a space vehicle 

that is intended to transport one or more persons; is 

designed to operate in outer space; and is owned by 

NASA or a NASA contractor or cooperating party and 

operated as part of a NASA mission or joint mission 

with NASA. 

Summary 

Even though NASA understood the cause of the 

Challenger accident fairly early on, we were not 

proactive in getting information out to the public. 

After the Columbia accident, the lengthy investigation 

into the cause of the accident was conducted in an 

open and thorough manner, and records were released 

to the public as quickly as possible. Improvements that 

can be made include formalization of policies relating 

to the public release of sensitive information during 

a NASA accident investigation and documentation of 

these policies throughout the Agency, to ensure that 

future crew survival investigations are performed; 

documentation of authority for the payment of claims; 

documentation of methods for obtaining complete and 

accurate witness statements; and review of internal 

guidance on existing regulations and how those 

regulations may need to be altered with the emergence 

of commercial space flight. 

Including attorneys as an integral part of the Columbia 

accident teams as they were formed enabled proactive 

legal advice to be given in the areas of FOIA and 

its exemptions, payment of reimbursable claims, 

and protection of survivor privacy rights. The work 

performed by the NASA legal team, though less visible 

to the public than that of recovery teams, made possible 

the expeditious recognition and resolution of legal 

issues that might otherwise have encumbered progress. 

One thing that was evident on February 1, 2003, 

was a strong commitment and dedication among the 

employees in the Agency to the mission and goals of 

space exploration. 
Section 5 – The Future
 

Human Space Flight Incidents and 

Crew Survival Lessons Learned 

The Future: Crew Survival Investigations 
124 SECTION 5 – THE FUTURE

Human Space Flight Incidents and 

Crew Survival Lessons Learned 

Jonathan B. Clark 

This section describes human space flight incidents 

and historic lessons learned related to occupant 

protection and crew survivability in space exploration. 

Mishaps, incidents, and close calls often serve as a 

basis for making improvements in system designs, 

mission architecture, and operations. 

Challenges 

Crew survivability is the collective implementation of 

abort, escape, emergency egress, safe haven, emergency 

medical, and rescue capabilities throughout all phases 

of a mission. The survivability concept of operations 

includes the autonomy of systems, size of the crew, 

duration and type of life support measures, and systems 

protecting individual crewmembers. The challenges of 

developing a crew survival system include predicting 

its effect on vehicle design and performance, and 

such systems are limited in that they should not create 

added risks to the crew or significantly limit spacecraft 

capability, affordability, and sustainability. Survival and 

escape systems that jeopardize nominal operations may 

defeat overall mission success. The main challenges 

are to strengthen the ability to keep the crew alive and 

return them to Earth safely in response to an imminent 

catastrophic condition. 

Major Historical Mishaps 

Human space flight is extremely risky, and threats 

to crew health have happened in all mission phases 

including ground testing, launch pad aborts, ascent, orbit, 

reentry, landing, and post-landing. Fatalities related to 

space operations include 5 Russian fatalities: 1 during 

an altitude chamber oxygen (O2) fire and 4 on reentry 

and landing (Soyuz 1 and Soyuz 11). The US has had 

18 fatalities: 3 during ground testing (Apollo 1 crew 

cabin fire), 7 on ascent (Challenger accident), and 8 

on reentry (7 in the Columbia accident and 1 during a 

high-altitude X-15 flight). Catastrophic loss of crewed 

launch vehicles has occurred on the pad (Soyuz 18A) 

and on ascent (Soyuz T10A); both of the Soyuz crews 

survived. Reentry anomalies have occurred frequently 

and are often due to vehicle configuration or faulty 

separation from modules. Landing and post-impact 

issues also occur, including hard-impact injuries and 

inability of rescue forces to reach a crew in a timely 

fashion. On-orbit space flight emergencies have included 

cabin pressure loss, fire, and toxic environment. Also, 

evacuations from space have occurred due to intractable 

headaches following combustion event (Salyut 5/1976), 

for fever and urinary infection (Salyut 7/1985), and 

for a cardiac irregularity (Mir/1987). Space flyers and 

ground controllers have made human errors to which 

near-catastrophes and effects on mission milestones were 

attributed in the following programs: Mercury, Gemini, 

Apollo, Space Shuttle, and Russian Mir. 

Ground System and Vacuum Chamber 

Test Incidents 

Accidents have also occurred during vacuum chamber 

tests, used to evaluate equipment at high altitude. 

During a chamber ground test in 1961, a Russian 

crewmember died when an alcohol wipe hit a hot plate 

and started a fire in the oxygen-rich chamber. 

In 1966 a spacesuit technician experienced rapid 

decompression to 120,000 ft altitude equivalent, and 

recalled the saliva boiling off his tongue as he passed 

out. He regained consciousness once the chamber 

pressure increased to that of 14,000 ft altitude equivalent 

and suffered no neurological sequelae and was not 

hospitalized. In another case occurring in an industrial 

vacuum chamber in 1982, a technician was accidentally 

decompressed to greater than 74,000 ft, and remained 

above 63,000 ft for 1 to 3 minutes. He underwent 

hyperbaric recompression for 5 hours, and by 24 hours 

he was awake and alert. At a 1-year follow-up he was 

neurologically normal. The lessons from these vacuum 

chamber events are that exposure to near-vacuum for 

seconds is survivable with no medical care, and exposure 

to near-vacuum for a minute or two is survivable with 

aggressive medical care. A field treatment protocol for 

ebullism and vacuum exposure is now available. 

On January 27, 1967, the three US Apollo 1 

crewmembers died in a cabin fire when an electrical 

short circuit occurred during a test in a high-O2 
SECTION 5 – THE FUTURE 125 

 

On January 27, 1967, a flash fire swept through the Apollo 1 Command 

Module during a launch rehearsal test. Astronauts Virgil “Gus” Grissom, 

Ed White, and Roger Chaffee perished in the fire. 

atmosphere. An accident board listed findings, 

determinations, and recommendations. The conditions 

leading to the disaster were summarized as follows: 

• Failed to identify the test as hazardous – 100-percent 

pure oxygen cabin atmosphere at 16.7 psi. 

• Spacecraft inward opening hatch required at least 

90 seconds for either internal or external removal and 

crew egress. 

• Ground safety procedures were completely inadequate. 

• Operational test procedures were subjected to lastminute changes. 

• Communications were overall unsatisfactory. 

• Control of combustible material standards 

established for nonmetallic materials were too low 

and the criteria for selection and approval of 

spacecraft material were inadequate. 

• Engineering, workmanship, and quality 

control deficiencies created an unnecessarily 

hazardous condition. 

The rapid spread of the fire caused an increase in cabin 

pressure and temperature and filled the cabin with toxic 

gases. The increased pressure prevented the rescue 

crew from being able to open the inwardly opening 

hatch. Rescuers were only able to open the hatch after 

the Command Module pressure shell ruptured and 

the pressure equalized. Death of the crew was from 

asphyxiation due to inhalation of toxic gases caused 

by fire. The fire melted the hoses that connected the 

crewmembers’ spacesuits to their life-support system. 

It was estimated that the crewmembers lost 

consciousness between 15 and 30 seconds after the 

first suit failed. A contributory cause of death was 

thermal burns. NASA implemented changes including 

limitations on oxygen levels, reduction in flammable 

materials, spacecraft designs to improve crew egress, 

and increased crew and personal emergency training. 

Parachutes and Aviation High-Altitude 

Mishap Incidents 

In preparation for sending humans to space, both the 

former Soviet Union (Russia) and the US military 

tested life support and survival systems with human test 

subjects using high-altitude balloon parachute jumps. 

The US Air Force conducted high-altitude balloon 

studies on humans in programs such as Project Excelsior, 

which consisted of a series of high-altitude balloon 

flights and bailouts, with free fall and descent under 

canopy. These flights were fraught with difficulties, but 

many lessons were learned about survivability at high 

altitudes. In 1959, on the Excelsior I jump, Joe Kittinger 

became entangled with the drogue and went into a highspeed spin and lost consciousness. On the third flight in 

Project Excelsior in 1960, Kittinger, wearing the David 

Clark MC-3 partial pressure suit, parachuted in free 

USAF Captain Joe Kittinger begins his historic free fall in August 1960. 
126 SECTION 5 – THE FUTURE

 

 

 

fall with a small stabilizing drogue chute from an open 

gondola at 102,800 ft for 4 minutes, 36 seconds until 

the main parachute opened at 17,500 ft. His right glove 

lost partial pressure during the final ascent phase and 

his hand became swollen, causing extreme pain, but the 

hand had completely returned to normal by 3 hours after 

landing. The lesson learned was that a localized suit leak 

may result in focal tissue swelling from exposure to near 

vacuum and can completely recover in hours. 

The Russian Volga stratospheric balloon parachute 

test program evaluated the pressure suit for the Vostok 

space program in a pressurized gondola in 1962. 

Evgeny Andreev exited at 83,524 ft and free-fell 

80,360 ft, setting the record at that time for highest 

free fall without a drogue parachute, a record that 

stood for 50 years. In the same program, Pyotr 

Dolgov intentionally opened his parachute as he 

exited at 86,156 ft above the Earth, but as he exited, 

his helmet visor hit the capsule and cracked, and 

his suit depressurized. Because of the high altitude 

and prolonged descent, he was unable to survive the 

depressurization and was found dead on landing. 

An American civilian high-altitude parachute test 

(Project Strato Jump) was conducted in 1966, with 

parachutist Nick Piantinata. While Piantinata was 

ascending through 57,600 ft, his visor inadvertently 

opened and the suit depressurized. Ground controllers 

recognized the emergency and cut the balloon from the 

gondola. Piantinata landed 25 minutes later. The rescue 

team was on the scene within 30 seconds, and found him 

unconscious; he died 4 months later in a hospital. 

On Soyuz 1 in 1967, both the main and reserve 

parachutes failed, leading to the death of the crewman. 

On Apollo 15 in 1971, one of the three main chutes 

failed, resulting in a slightly harder splashdown landing 

than normal (32 feet per section (fps) vs. 28 fps), but the 

seat stroking (load-limiting) mechanisms did not reach 

The Soyuz 1 parachute failures in 1967 resulted in loss of the sole 

crewman aboard the spacecraft. 

The Apollo 15 Command Module, with astronauts David R. Scott, 

commander; Alfred M. Worden, command module pilot; and James 

B. Irwin, lunar module pilot, aboard, nears a safe touchdown in the 

mid-Pacific Ocean to conclude a highly successful lunar landing mission. 

Although causing no harm to the crewmen, one of the three main 

parachutes failed to function properly. The splashdown occurred at 

3:45:53 p.m. (CDT), August 7, 1971, some 330 miles north of Honolulu, 

Hawaii. The three astronauts were picked up by helicopter and flown to 

the prime recovery ship USS Okinawa, which was only 6 1/2 miles away. 

activation threshold and no injuries occurred. Possible 

causes of the parachute failure were 

• damage from the jettisoned forward heat shield, which 

was in close proximity to the spacecraft flight path; 

• a broken riser/suspension line connector link, which 

was found on the recovered parachute; 

• damage from firing of the propellant in the command 

module reaction control system and fuel dump from 

the same system. 

The most probable cause of the anomaly was the 

burning of raw fuel (monomethyl hydrazine) being 

expelled during the latter portion of the depletion firing, 

and this resulted in exceeding the parachute riser and 

suspension-line temperature limits. 

Red Bull Stratos was a privately funded manned 

stratosphere balloon flight test; its free-fall parachute 

jump program was completed in 2012. The test program 

included unmanned balloon and capsule tests, vertical 

wind tunnel and high troposphere tests of the drogue and 
SECTION 5 – THE FUTURE 127 

main parachutes and the spacesuit, low-pressure chamber 

tests of the spacesuit, and integrated thermal and vacuum 

chamber tests of the capsule, spacesuit, and parachute 

and life support systems. These tests ultimately led to 

incremental stratosphere free-fall parachute jumps. A 

team was formed to develop and implement medical and 

physiological support for this program. Issues addressed 

included development of a protocol for oxygen 

prebreathe to reduce the risk of decompression sickness, 

briefing crewmembers on medical and physiological 

threats, medical and physiological monitoring for 

the thermal vacuum test phase and stratospheric 

flights, launch and recovery medical planning, and 

contingency planning. Contingency planning included 

the development of protocols against two serious known 

threats during a stratospheric bailout. The Red Bull 

team developed a protocol for treatment of ebullism in 

response to the potential threat of exposure to vacuum 

from a suit depressurization. Also the team addressed 

another serious threat, flat spin with negative acceleration 

in the vertical direction (-Gz

). 

Manned Balloon Flight (MBF) 1 occurred on March 15, 

2012, with test parachutist Felix Baumgartner ascending 

to 71,581 ft in a 1.22-million cubic foot (MCF) balloon, 

from which height he free-fell 63,691 ft, reaching a 

maximum speed of 364.4 mph. For MBF 2 on July 25, 

2012, Baumgartner ascended to 97,146 ft in a 5.3-MCF 

balloon from which he free-fell 84,357 ft, reaching 

546 mph. For the last test, MBF3 on October 14, 2012, 

Baumgartner ascended to 127,852 ft in a 29-MCF balloon 

and free-fell 119,431 ft, reaching 843.6 mph (Mach 1.25). 

The parachutist was in free fall for 3 minutes 40 seconds 

on MBF1, 3 minutes 48 seconds on MBF2, and 4 minutes 

20 seconds on MBF3. He was weightless (< 0.1g) until 

he reached terminal velocity, for 6 seconds on MBF1, 9 

seconds on MBF2, and 25 seconds on MBF3. During the 

weightless phase the jumper had no aerodynamic control. 

A manually or automatically deployed drogue chute was 

available if the jumper became significantly unstable. A 

multiaxis, dynamically unstable spin occurred on MBF3, 

reaching a maximum of 60 rpm for 10 seconds, which 

was below the automatic drogue trigger set for 3.5 G 

for 6 seconds. Aerodynamic control was regained by 

the test parachutist, but the spin, which was multiaxis 

and approached -2.5 Gz

, approached human physical 

performance (but not injury) limits. The conclusion was 

that stratospheric free fall should include stabilization 

with a drogue parachute. 

Aviation accidents have also tested human exposure to 

high altitudes. In 1966 an SR-71 Blackbird traveling at a 

speed of Mach 3.18 at 78,800 ft became unstable, broke 

Photo credit: Red Bull Stratos 

On October 14, 2012, Red Bull Stratos team member Felix 

Baumgartner jumped from a helium balloon at 127,851 ft into the 

stratosphere over New Mexico, before free-falling in a pressure suit 

and then parachuting to Earth. 

up, and disintegrated in flight because of an engine 

unstart. The pilot and system operator were torn from 

the aircraft and both parachutes deployed automatically. 

The pilot suffered only minor injury, but the system 

operator in the back seat sustained a fatal neck injury. 

The pilot attributed his survival to the protection 

afforded by his inflated pressure suit from the intense 

buffeting and g forces during the supersonic transition. 

A second SR-71 breakup at a similar airspeed and 

altitude occurred in 1966 during a drone release. Both 

crewmembers survived the breakup and successfully 

ejected, although one died from drowning after landing. 

Acceleration Risks Associated 

with Ejection Seats 

Ejection seats were used in the US Gemini capsule, 

the first 4 Space Shuttle missions, and the Russian 

Vostok capsule. All 6 of the cosmonauts on the Vostok 

series ejected before the capsule landed. Ejection seats 
128 SECTION 5 – THE FUTURE

were considered in a Shuttle escape study. The injury 

potential with ejection seats is related to ejection seat 

G forces, fouling with seat/cockpit structure, windblast, 

flail and wind drag deceleration, and parachute opening 

shock. Major injuries and fatalities, mainly from flail, 

rise sharply at ejection speeds over 600 knots airspeed. 

For the first four flights, the Orbital Flight Test phase, 

the Space Shuttle program used a modified SR-71 seat 

and pressure suit. 

Challenger Accident and 

Lessons Learned 

In 1986 the Shuttle flight 51L (Challenger mishap) 

broke up on ascent while traveling at Mach 1.92 at 

48,000 ft, and the crew module lofted to 65,000 ft and 

then fell back to the ocean. The vehicle breakup forces 

were estimated to be 12 to 20 G and were short-term 

and survivable. The crew at this time wore standard 

Nomex® flight suits accompanied by a launch and entry 

helmet that interfaced with a personal egress air pack 

that provided breathing air. The external investigation 

body for this accident, called the Rogers Commission, 

recommended that a system be developed to ensure 

On January 28, 1986, the Space Shuttle Challenger broke apart on 

ascent while traveling at Mach 1.92 at 48,000 ft. 

crew egress and escape: “The crew egress and escape 

(CEE) together with other elements of the egress/escape 

system, shall enhance the capability for all crewmembers 

to safely escape from a disabled orbiter on the pad, in 

subsonic flight, or on the ground. Controlled subsonic 

gliding flight conditions shall be required for in-flight 

use of the CEE. The CEE shall provide the necessary 

protective and survival equipment to sustain the crew 

Portrait of the Space Shuttle Challenger crewmembers holding their launch and entry helmets and wearing their standard Nomex® flight suits. 

Back row, left to right: Ellison Onizuka, Christa McAuliffe, Gregory Jarvis, and Judith Resnik; front row: Michael Smith, Francis Scobee, and 

Ronald McNair. 
SECTION 5 – THE FUTURE 129 

at or below 100,000 ft altitude and to ensure the crew’s 

safety after vehicle egress until such time as the danger is 

past and/or they are removed to a safe area.” 

NASA has considered various crew escape systems that 

provide coverage during ascent and reentry, including 

bailout, ejection seats, extraction rocket systems, 

encapsulated seats, modular separation, and hybrid 

combinations of these systems. However, implementing 

modifications after a vehicle has been designed could 

dramatically affect other operational parameters. The 

Space Shuttle Program performed several escape 

studies during its 30-plus years of existence. Initial 

design considerations in 1971 (the first shuttle flight 

was in 1981) determined that the only system that could 

provide protection for more than the two crewmembers 

on the experimental flights was the separable crew 

compartment, which would add substantial weight and 

developmental cost. 

The National Space Transportation System Crew Egress 

and Escape Study, conducted after the Challenger 

accident in 1986, reviewed past studies to identify new 

and innovative concepts. Low-cost options provided less 

coverage, whereas more costly concepts would have 

had a severe impact on the performance capability of 

the Shuttle orbiters. In 1989 the Crew Escape Module 

Study assessed the impacts of retrofitting a crew escape 

module into the orbiters that would be equivalent to a 

“new” orbiter program. The Shuttle Evolution II Crew 

Escape Study, done in 1991, assessed the impacts of 

incorporating ejection seat and extraction seat concepts 

into the existing orbiters. 

The ejection seat concept was the option having the 

lowest risk, and it provided for the escape of five or 

fewer crewmembers (the Space Shuttle routinely had six 

or seven crewmembers for complicated payloads). The 

high cost of incorporating additional escape capabilities, 

combined with the significant impact on vehicle 

capabilities, did not warrant the addition of escape seats 

or an escape pod. 

However, after the Challenger accident, the program 

implemented a Crew Escape System (CES) suit and 

supporting equipment. The CES includes a pressure 

suit, personal parachute assembly, emergency oxygen 

system, survival kit, and flotation system. The original 

CES suit was a partial pressure suit (David Clark 

Company Model S1032) called the Launch Entry Suit. 

In 1994 the Advanced Crew Escape Suit Model S1035 

full pressure suit began replacing the Launch Entry 

Suit. The Shuttle CES was certified to an atmospheric 

altitude environment up to 100,000 ft. Bailout scenarios 

were developed for the CES. A bailout below 30,000 ft 

required stable gliding flight below Mach 1. The plan 

was for the crew to jettison the Shuttle hatch below 

30,000 ft, using the crew escape pole, which allowed 

them to clear the left wing on exit. Jettisoning the hatch 

and using the crew escape pole initiated the automatic 

parachute opening sequence that would deploy the 

parachute at 14,000 ft. 

The scenario for a bailout at or above 30,000 ft was 

egress from a loss-of-control breakup from a detached 

crew module, the situation in the Challenger accident. 

As there was no wing to clear, the crew would jettison 

from the hatch without deploying the escape pole, and 

this action eliminated the automatic parachute-opening 

sequence. Hence each crewmember was required to 

manually deploy their parachute. If crewmembers 

became disabled or unconscious during the bailout or 

descent, they would not be able to manually deploy 

their parachute. Consequently, astronauts William 

In 1994 the David Clark Company Model S1035 Advanced Crew 

Escape Suit began replacing the S1032 Launch Entry Suit. 
130 SECTION 5 – THE FUTURE

 

Test of Space Shuttle bailout using the crew escape pole to allow crewmembers to clear the left wing. 

Shepherd and Michael Foale reviewed the feasibility 

of using the Shuttle CES equipment for egress during 

a loss of control or breakup. They examined the forces 

leading to vehicle breakup, crew module dynamics 

following a breakup, crew module survivability, crew 

module stable attitudes, and time available to egress. 

The primary egress concern was when to leave the 

orbiter. Shepherd and Foale recommended crew egress 

procedures and techniques. 

Vehicle egress should begin once the crew module 

was below 40,000 ft. Cues to egress should be G 

forces diminishing and suit depressurizing; use of 

this guideline would allow about 80–90 seconds to 

egress. The contingency egress during a loss of control 

following vehicle breakup was not a defined egress 

mode, but a bailout. Shepherd’s and Foale’s conclusion 

was that the crew module could withstand reentry 

heating for an ascent breakup occurring at 280,000 ft 

and below. The forces causing breakup of the Challenger 

were estimated to be <12–20 G and were short-duration 

and non-lethal. For vehicle breakup during ascent below 

100,000 ft, drag would cause initial rapid deceleration. 

Then G forces on the crew module would be low while 

it was lofting, followed by a 1-G force while the module 

was nose down in free fall. 

After a high-altitude breakup (>100,000 ft), no initial 

deceleration would occur. The module would travel in 

a low-G-force ballistic arc while lofting, then below 

70,000 ft it would be subject to a deceleration of 3 G to 

8.5 G from aerodynamic drag, then to 1 G while nose 

down in free fall below 50,000 ft. 

Columbia Accident Lessons Learned 

After the Columbia accident, NASA Associate 

Administrator Bill Readdy said “.... I do not anticipate 

that the next system will talk about ‘crew escape’ – 

but rather ‘crew survival’....” The Columbia 

Accident Investigation Board (CAIB) asked NASA 

to form the Crew Survival Working Group (CSWG) 

to evaluate life-support concerns related to the 

disaster. The CSWG report was summarized in the 

original CAIB Report in August 2003. The CAIB, in 

Observation O 10.2-1, stated, “Future crewed-vehicle 

requirements should incorporate the knowledge 

gained from the Challenger and Columbia accidents 

in assessing the feasibility of vehicles that could 

ensure crew survival even if the vehicle is destroyed.” 

Clearly, designing for crew survivability early is more 

effective than post-production modification. Escape 

systems must also consider human factors and the 

deconditioning effects of space flight. 

NASA then appointed an independent team, called 

the Return to Flight Task Group, to assess NASA 

actions to implement the 15 CAIB return-toflight recommendations. NASA met 12 of these 

recommendations before the STS-114 Shuttle mission 

in 2005. NASA could not completely comply with the 

three more challenging recommendations, but conducted 

further work to improve safety, as documented in the 

report NASA’s Implementation Plan for Space Shuttle 

Return to Flight and Beyond. 
SECTION 5 – THE FUTURE 131 

 

 

NASA commissioned a more complete report, 

Spacecraft Crew Survival Integrated Investigation 

Teams (SCSIIT), which was published in December 

2008. This report confirmed that the crew of Columbia 

died as a result of an unprotected rapid decompression 

and blunt force trauma at an altitude of between 

181,000 and 140,000 ft, resulting in severe hypoxia, 

pulmonary injury, and cardiovascular collapse. Post 

mortem, the crew was exposed to acceleration-induced 

in-seat flail, third-degree skin burns from thermal 

intrusion, aerodynamic flail at the time of crew module 

disintegration, lack of protection from high-altitude 

conditions (low pressure, monoatomic oxygen, 

subfreezing temperatures), and ground impact. 

Crew Survival Enhancements after 

the Columbia Mishap 

The SCSIIT report concluded that significant failures 

occurred in the crew restraint system. Specifically, inertial 

reels on the Shuttle seat belts were found to be unlocked 

during exposure of the crew to acceleration forces during 

the orbiter destruction. As a result of these findings, the 

Space Shuttle Program upgraded the inertial reels that 

lock with absolute load and differential acceleration 

in any direction. The specifications for crew escape 

equipment were changed to add a fail-safe parachute 

capability for crew bailout from a detached crew module, 

as well as adding an upgraded survival radio with 

Global Positioning System (GPS) location reporting. 

An improved portable O2

 system was added to enhance 

survivability in launch pad and landing emergencies. 

Shuttle training for loss of control was modified to 

emphasize transition between problem-solving (flying 

the vehicle) and survival (lock inertial reels, close visors, 

and activate personal O2 system). Training in Shuttle 

unusual attitudes was incorporated (by using nose-down 

mockups) to develop egress paths in unusual attitudes. 

Closing the Survival Gap for 

Columbia Crew 

In the course of the Columbia mishap analysis, 

considerable discussion occurred about how close 

the crew was to a survivable state. Survival has 

occurred after free fall from stratospheric balloons 

at 102,800 and 127,852 ft and from aerodynamic 

aircraft breakups at Mach 3.18 and 78,800 ft. 

During the Columbia debris recovery, live worms 

were found in four of five experiment canisters, 

demonstrating that primitive animals can survive 

a relatively unprotected reentry into the Earth’s 

atmosphere. However, given that a rescue was not 

feasible, the only other option that might have been 

possible for the Columbia crew was repair of the wing 

breach, payload jettison, pre-entry cold soak, and 

modified reentry profile. 

The repair would have required complex, unproven 

extravehicular activity (EVA) procedures. Perhaps 

contingency water containers could have been 

placed into the hole in the wing leading edge and 

some other heat-and cold-resistant material could 

have been applied. This would have presented 

substantial difficulties, however. Another complex, 

unproven EVA procedure could have been performed 

to detach and jettison consumables and the Spacehab 

Research Module in the Shuttle payload bay, which 

could have reduced landing weight by over 30,000 

pounds from a nominal 250,000-pound vehicle. 

Although these measures might have reduced wing 

dynamics and thermal loading, they could have 

adversely altered the delicate wing boundary layer 

and vehicle aerodynamics. Optimistically this could 

have provided more time for the crew module to 

reach a lower altitude and airspeed. The Columbia 

mishap analysis showed that the detached crew module 

probably did not attain a stable aerodynamic trim 

condition that would have been necessary for a bailout. 

Video footage of the Challenger breakup showed a 

relatively stable nose-down crew module, with trailing 

wires acting as an aerodynamic decelerator, making 

bailout in this scenario at least possible. The Challenger 

breakup was transonic/low supersonic and lofted to a 

point where airspeed would have been close to zero, 

while the Columbia mishap was hypersonic. Any 

trailing wires on Columbia would have likely been 

destroyed from thermal or shock waves. The vehicle 

state of Columbia at the time of the catastrophic 

event (initial breakup and cabin depressurization) 

was estimated on the basis of modeling to be altitude 

181,000 ft, Mach 15, and the final crew module breakup 

was estimated to have occurred between 148,000 ft and 

138,000 ft and Mach 10–12. 
132 SECTION 5 – THE FUTURE

Survival Enhancements for the Crew 

Exploration Vehicle for Commercial 

Crew and Exploration 

The lessons learned from the Columbia mishap have 

had a significant impact on both commercial and NASA 

crew vehicle designs, including vehicles, such as Orion, 

that leave low Earth orbit but return to Earth for a water 

landing. These vehicle designs must address the threats 

to human health, listed with proposed countermeasures, 

in the accompanying table. 

NASA contracted for several studies to be done, using 

manikins and three cadavers for impact studies, to better 

understand occupant protection. These studies have led 

to major design changes in requirements for helmets, 

suits, and seat restraints. For example, pressure suits, 

restraints, and the seats themselves must be integrated 

into the vehicle. The restraint belt size and position were 

modified to improve limb mobility to maintain vehicle 

control under high acceleration. An autonomously 

activated GPS personal locator beacon was added to 

the NASA Launch Entry Suits, as was a survival kit for 

post-landing contingencies. To better understand the 

mishap environment, a requirement for a crashworthy 

data recorder for NASA capsules was established. 

The crew of the Orion space exploration vehicle 

will be recumbent, and thus some of these additional 

recommendations, such as inertia reels, will not be 

needed for that spacecraft. 

A mockup of the Orion Multi-purpose Crew Vehicle at the Johnson Space Center shows NASA’s next-generation spacecraft, designed to carry 

humans beyond low Earth orbit to the moon, asteroids, and Mars. 
SECTION 5 – THE FUTURE 133 

Human Health Threats and Countermeasures 

Entry Phenomenon Physical Characteristics Altitude/Speed Biological Effect Countermeasure 

Plasma Ionized molecular O2 > 130,000 ft Chemical/thermal burn Thermal protection system 

Excessive Delta G (dG/dT) Below entry Organ/skeletal damage, Crew compartment 

acceleration x, y, z linear/ interface body fragmentation stability system, axial 

gradients angular planes (<400,000 ft) restraint system 

Shock-shock Blast wave pressure NA/supersonic Organ damage, body Aerodynamic design, crew 

interaction speeds fragmentation compartment integrity 

Dynamic heating Temperature > 150,000 ft Thermal burn Thermal protection system 

Dynamic pressure Q = measure of Organ/skeletal damage, Crew protection system 

dynamic pressure body fragmentation 

Atmospheric Atmosphere absolute > 63,000 ft Tissue water vaporized to Pressure vessel, 

pressure (ATA) (<0.06 ATA) gas resulting in ebullism pressure suit, pressure 

breathing mask 

Atmospheric Atmosphere absolute > 18,000 ft Evolved tissue nitrogen Pressure vessel, 

pressure (ATA) (<0.5 ATA) resulting in decompression pressure suit, pressure 

sickness breathing mask 

Pressure differential Delta pressure (dP) Barotrauma in gasfilled spaces (lung, ear, 

gastrointestinal) resulting 

in arterial gas embolism 

Pressure vessel, 

pressure suit 

Oxygen partial 

pressure 

ppO2 > 10,000 ft Hypoxia and asphyxiation Pressure vessel, 

pressure suit, mask, 

supplemental oxygen 

Intrusion of Physical trauma NA Fatal or severe organ Crew compartment 

habitable space damage due to penetration protective system 

Terrain impact Delta G (dG/dT) 

x, y, z linear planes 

Surface Injury due to rapid 

deceleration 

Parachute, ballute, lifting 

body, airbag, braking 

rocket, automated and 

crew initiated 

NA, not applicable 

Conclusions and Recommendations 

Crew survivability should be considered the primary 

mission success criterion and should be the main 

driver in vehicle design and mission architecture. Crew 

survivability should incorporate advanced technologies 

where feasible and should be simple, reliable, and 

attainable to address catastrophic failure modes. Lessons 

learned from related high-risk operations, as well as 

space mishaps, incidents, and close calls, can enhance 

crew survival by providing insight into failure modes, 

and improving procedures, design requirements, and 

occupant protection strategies. 

Survival systems should be designed so that the 

equipment and procedures provided to protect the crew 

in emergency situations are compatible with nominal 

operations. A pressure-suited crewmember should be 

able to perform all operations without compromising 

the configuration of the survival suit during critical 

phases of flight. The design of personal protective 

equipment needs to adequately address anticipated 

catastrophic failure modes, and compliance with 

protective equipment and procedures is essential. 

Our current knowledge of injury mechanisms at high 

Mach numbers and altitudes over 100,000 ft has 

significant limitations, and crew survivability could be 

enhanced by advanced technologies. Occupant protection 

and crew survivability studies should be conducted 

to fill these gaps. Although NASA has recognized the 

importance of capturing lessons learned, it has often 

been criticized for not following that principle. However, 

NASA learned important lessons about crew survival 

from the Columbia mishap, and these lessons hold great 

benefit for all future human space exploration. 

“The only thing we learn from history is that we learn 

nothing from history.” 

Georg Wilhelm Friedrich Hegel (1770-1831) 
134 SECTION 5 – THE FUTURE

The Future: Crew 

Survival Investigations 

Karon Woods 

“Those who don’t know history are destined to 

repeat it.” 

Edmund Burke (1729-1797) 

One of the lessons learned from the loss of the Space 

Shuttle Columbia was that root-cause investigations 

do not dig deep enough to trace the individual 

crewmember experiences to determine the successes 

and failures of protective measures. Past mishap 

investigations focused on determining the root cause 

of the mishap and preventing recurrence. However, 

if the crewmembers were not identified in the causal 

chain of events, their experiences were not analyzed 

and lessons were lost. 

Until NASA’s Constellation Program1

 vehicle, crew 

survivability under emergency conditions was not 

assessed. By postulating the outcomes of system and 

operational failures that would result in potentially 

catastrophic conditions, and analyzing those chains 

of events, it was possible to identify credible crew 

responses under emergency conditions. In each scenario, 

the must-work functions and equipment are evaluated 

for their ability to prevent crew injury or death. 

NASA documented a process for performing crew 

survival investigation by integrating an understanding 

of historical and potential spacecraft accidents with 

an understanding of mishap investigation practices. 

By understanding which emergency scenarios can 

happen, how they may manifest, and anticipating 

crew actions; we can predict potential mishap causes 

and outcomes. This process adds space flight-unique 

information to the aviation mishap knowledge base 

and creates common language between the medical and 

engineering team members. 

The crew survival in-depth investigation process 

supplements the root-cause investigation. The crew 

1 NASA Constellation Program goals included vehicles that could have rocket and 

crew module capability to leave low Earth orbit. 

Johnson Space Center Safety & Mission Assurance Directorate logo. 

survival investigation focus is different from that 

of the usual mishap investigation. Specifically, the 

crew survival investigation team investigates the 

performance of the crew, crew protective equipment, 

crew-vehicle interfaces, emergency and crew survival 

systems, training, and procedures that are intended to 

protect the crew. 

The outcomes of the crew survival investigation are 

the awareness of factors and events that affected crew 

survivability and recommendations for improving crew 

survival for future human space flight. This chapter 

provides an overview of investigation elements including 

data and information management; imagery; debris 

recovery and reconstruction; timelines; and assessments. 
SECTION 5 – THE FUTURE 135 

Space Flight Considerations 

The starting point for spacecraft mishap investigation 

is the wealth of experience from aviation mishap 

investigations. Using aviation mishap investigation 

processes, analytical tools, and historical results, space 

flight specialists apply their understanding of the 

dynamic mission envelope and the hazards of space 

flight to the investigation. Some aspects of space flight 

that make crew survival investigation different from 

aviation mishap investigation are these: 

• Large quantities of fuels, presence of oxidizer, 

cryogenic temperatures 

• Severe vibroacoustic environment, high kinetic and 

potential energy, high acceleration loads, dynamic 

separation events, constrained flight trajectory 

• Extreme aerodynamic heating, plume heating, thermal 

cycling (extreme heat and cold), entry heating and hot 

gas intrusion, reactivity of heated gases 

• Consequences of depressurization, radiation, vacuum, 

plasma charging, atomic oxygen, collision with 

micrometeoroids or orbital debris 

• Orbital mechanics, abort modes, plume impingement, 

shock-shock interaction, hypersonic environment, 

absence of aerodynamic effects 

• Limited energy or capability for downrange 

correction; reliance on parachute, flotation, and 

uprighting systems 

• Limited egress paths, sea conditions at landing, crew 

deconditioning, crew suits that limit mobility, limited 

visibility and visual cues 

• Complex and constrained timeline, critical time 

sequencing, critical event timing 

The crew survival investigation process lends itself 

to a full range of investigations, from the destruction 

of a spacecraft to a crewmember injury during a 

spacewalk to an electrocution while interacting with 

onboard hardware. 

Team Member Selection 

Crew survival investigation team member selection 

is determined by the mission phase of occurrence, the 

systems involved, and the likely cause of the mishap. 

In all cases, a crew survival specialist, with extensive 

mishap investigation and human factors training, leads 

the team. Typical team members are a medical doctor, 

a pathologist, a legal representative, and specialists 

in structures, environmental control and life support 

systems, flight performance, and crew equipment 

(crew survival and emergency equipment and crew 

suits). Depending on the scenario, communications, 

mission operations, or ground operations specialists, 

as well as other technical specialists, may supplement 

the investigation team. 

Management of Data and Information 

All information generated by the investigation and 

collected from other sources must be documented, 

organized, and uncompromised to be useful to teams 

performing current and future investigations. Because of 

the high volume of information collected and analyzed 

during a crew survival investigation, much of which 

may be sensitive, organization and information control 

are important features of the crew survival investigation 

plan. Medical forensics data are graphic and highly 

sensitive, so “need to know” criteria must be established 

before any information is distributed. 

Data and information exist in many forms including 

presentations, spreadsheets, diagrams, user manuals, 

analysis reports, photographs, operating manuals, 

models and simulations, written notes, videos, and 

audio recordings. Improper cataloging practices make 

organizing or retrieving the information difficult. All 

items should be marked with a title, date, version, 

source or author’s name, and any other pertinent 

information. Information sources include mishap-site 

records (diagrams, maps, notes, and photographs), 

vehicle telemetry, analytical results, vehicle processing 

records, crew medical and training records, interviews, 

and debris and remains. 
136 SECTION 5 – THE FUTURE

This information is used in analyses, tests, and 

reconstructions to identify the sequence of events 

that resulted in the mishap, to identify the cause(s) 

of crewmember injury or death, and to justify the 

recommendations. Once the investigation is complete, 

a crew survival investigation report captures the 

investigation results, recommendations, and investigation 

lessons learned. Not only is the information used in the 

current investigation, but it may identify trends or justify 

improvements in vehicle design, crew equipment, or 

operations to improve crew survival. A data retention 

plan should identify where, how, and for how long the 

investigation information will be kept. 

Imagery 

It is likely that other response teams will document 

the initial scene before the crew survival investigation 

team arrives, so it is important to collect copies of 

their photographs and video. Imagery documents the 

locations of crewmembers relative to the vehicle and 

to crew protective equipment, and captures evidence of 

crew actions. Videos and photographs help determine 

the breakup sequence, and videos reveal the conditions 

the crew experienced during the mishap. Regardless 

of the imagery medium, it is important to catalog and 

store all collected images for quick, reliable access. 

Because of the sensitive nature of some images, not all 

imagery may be accessible by all team members. For 

this reason, protocols should be established to manage 

release of crewmember photographs, videos, and 

advanced imagery. 

Photographs 

The adage that a picture is worth a thousand words 

holds true in mishap investigation as well. NASA 

routinely takes photographs throughout vehicle 

processing and the mission. During processing, 

closeout photographs capture the final (or “asflown”) configuration of the vehicle, payloads, and 

equipment. Launch and ascent photographs document 

the performance of the launch vehicle. On-orbit 

photographs, transmitted throughout the mission, 

document the latest vehicle configurations and onboard 

conditions. Photographs also capture the operation and 

performance of the returning vehicle. A further benefit 

to a crew survival investigation is photographs of the 

interactions of crewmembers with each other and with 

the vehicle and equipment throughout the mission. 

Photographs of a spacecraft mishap come from 

many sources (including amateur photographers and 

astronomers, the news media, and mission photographs) 

and in some circumstances capture the mishap as 

it unfolds. “As-found” photographs are taken of 

the mishap scene or where the debris is located, as 

applicable. Aerial photographs may capture such 

features as spatial relationships, vehicle components, 

ground fire damage, and fuel spills. Reconstruction 

photographs are taken of reassembled vehicle wreckage 

or only the portion of recovered wreckage that is 

of interest to the investigation. Images of the crew 

protective equipment and systems and the hardware 

closest to the crew help the team relate the vehicle and 

equipment condition to crew injuries. 

Similar to the vehicle “as-found” photographs, “asfound” crew photographs capture the human remains 

as they are discovered. These photographs are used 

to understand the relationship of the body or remains 

to the vehicle and the environment. “As-received” 

photographs are taken when the human remains are 

received at the facility for autopsy. The purpose of these 

photographs is to rule out confounding information, 

injuries induced during transport, or other noted changes 

in the remains. Autopsy photographs document the 

condition of the human remains to establish injury 

patterns and/or causes. 

Videos 

Videos are also important to an investigation. Onboard 

video provides insight into the status of the crew and of 

the crew protective measures, and the sights, sounds, 

and configuration of the vehicle. Depending on the 

type of mishap, the onboard video may provide critical 

information about the environmental conditions and 

timing of key events, capture crew communications 

and crew actions, record audible caution and warning 

alarms, or document damage to the vehicle. In addition 

to onboard video sources, ground-based or radar video 

can show deviations of the mission profile, capture a 

debris trail, reveal indications of leakages from vehicle 

systems, document events with their associated times, 

and document recontact of spacecraft elements or 

contact with foreign bodies or terrain. 
SECTION 5 – THE FUTURE 137 

STS-107 Columbia Commander/Seat 1 visor down and latched for 

suit pressure integrity check (blue dashed circle) and Mission Specialist 

2/Seat 4 with helmet on and left glove off (red dashed circle). Upon 

completion of the pressure integrity check the visor is raised for reentry. 

Advanced Imaging 

In addition to photography and videos, other imaging 

methods (including magnetic resonance imaging [MRI], 

radiology, computed tomography [CT], and electron 

microscopy) can document the current condition of the 

debris, body, and remains to further develop cause-andeffect relationships. 

As a practice, imagery should be reviewed at the start 

of the investigation, then periodically reviewed as the 

analyses progress and scenarios develop. As with all 

other analyses, images can support or refute findings. 

Debris Recovery and Reconstruction 

Debris recovered from a spacecraft mishap provides 

tangible evidence that can be used to determine failure 

mechanisms, failure modes, fracture dynamics, and 

thermal exposure. It can also provide insight into 

crewmembers’ injuries and the environmental conditions 

the crew experienced. The focus of the crew survival 

investigation is on the bodies and remains on the crewvehicle interactions (the crew cabin, windows, vehicle 

systems, crew-worn equipment), and on crew emergency 

and survival equipment and systems. One relevant 

vehicle system is the environmental control and life 

support system; this system provides the atmospheric 

pressure, oxygen, humidity, and temperature, along 

STS-107 Columbia Mission Specialist 2/Seat 4 donning left glove; 

Commander/Seat 1 and Pilot/Seat 2 with gloves ON and MATED. 

with water for sanitation and potable water. The 

evidence collection techniques described in this section 

are applicable to both spacecraft debris and bodies or 

remains. For example, instead of collecting debris to 

reconstruct the spacecraft for analysis, the crew survival 

investigation team can collect remains to virtually 

reconstruct a crewmember. Of course, the timeliness and 

sensitivity when dealing with crew remains or injuries 

differ greatly from such considerations when dealing 

with spacecraft debris. 

The amount and type of evidence generated during the 

mishap will vary, depending on the mishap and when 

it occurs during the mission. The amount of recovered 

debris depends on the size of the recovery effort, 

location of the debris (e.g., on board a vehicle, in rugged 

or remote terrain, in water), and when the mishap 

occurred in the mission profile. 

Site Documentation and Debris Recovery Plan 

The first step in a debris recovery plan is to observe 

the site and document the scene. The major components 

of the spacecraft and the flight path should be located 

as references to crew-relevant debris. Specifically, the 

relative locations of the crew and crew protective and 

survival equipment and systems should be diagrammed. 

When a crewmember is rescued or remains are 

recovered, their condition should be documented 

along with their relationship to their crew equipment, 
138 SECTION 5 – THE FUTURE

the vehicle, prominent terrain features, and areas 

of post-impact fire. These “as-found” records (e.g., 

descriptions, photographs, videos) provide clues for 

interpreting injury patterns and comparing conditions 

of crewmembers. Mechanisms at the scene that could 

explain the injuries and any protective equipment 

accessed by the crew should be documented. For a 

crew survival investigation, the highest priority is 

locating and retrieving the vehicle components that 

were closest to the crew during the mishap and at 

the mishap site, emergency or protective equipment 

and systems that were activated or should have been 

activated, and crew remains. It is also important to 

document what debris is missing or out of place given 

the circumstances of the mishap. 

Crew survival investigation teams should consider 

indications of intrusion into the cabin, of seat restraint 

failures or separation of the seat from the vehicle, 

of ejection from the cabin, of impacts with interior 

surfaces or equipment, that the crew was not seated, and 

that crewmembers were executing procedures such as 

indications of deployed emergency hardware and switch 

or lever positions. They should look for indications 

that the crew survived the initial mishap but could not 

escape the ensuing conditions inside the vehicle (such as 

an obstruction or fire) or the hazards of the post-impact 

external environment. 

Many samples may be taken at the scene including 

medical samples, environmental samples (water, soil, 

foliage), and spacecraft samples (fuels, coolants, fire 

or toxic release products). For example, a pre- or 

postmishap toxic environment may be indicated by 

samples taken at the scene. Samples for crewmemberto-crewmember comparisons should be collected at a 

consistent sampling site. 

It is important to distinguish damage related to recovery 

and transportation of evidence from damage related to 

the mishap. If the scene is not thoroughly documented 

before the crewmembers are removed, evidence on 

the crewmembers may be lost, further damage to the 

vehicle-related evidence may occur, or positions of 

controls or switches may be altered during removal 

of the crewmembers from the scene. At the collection 

location, by comparing the debris to photographs or 

video taken in the field, the crew survival investigation 

team can document any changes in the debris that are 

incurred during handling or transportation. After the 

recovered debris has been cataloged and stored, specific 

items of interest can be identified for reconstruction, 

testing, or analysis. 

Debris Reconstruction 

Reconstruction provides the team an opportunity to 

see how the debris pieces fit together and the final 

positions of parts such as switches, valves, and levers, 

to determine the sequence of events. Reconstruction of 

all or a portion of the vehicle involves assembling the 

vehicle in the as-flown configuration using physical 

or virtual recovered debris. Physical reconstruction 

is the reconstruction of the vehicle using recovered 

debris, usually on a constructed grid or frame. Virtual 

reconstruction is the electronic reconstruction of the 

recovered debris, creating an as-flown configuration 

using specialized software and debris photographs 

to simulate the debris. It can also be an interactive, 

three-dimensional simulation of the flight dynamics 

and failure sequence. 

The focus of reconstruction is to observe the damage 

characteristics, or patterns, among the debris. The 

reconstructed wreckage may include only the portion of 

wreckage of interest to the crew survival investigation, 

such as the crew cabin, seats, and crew-protective 

emergency equipment and systems, which can assist 

the team in relating the hardware to the crew actions, 

conditions, and injuries. The recovered debris is 

tracked to a specific location on the vehicle, or in the 

Virtual reconstruction of the recovered Columbia flight deck panels. 
SECTION 5 – THE FUTURE 139 

Identified Debris from the Flight Deck Seats from the Columbia Accident 

More than 68 pieces of seat structure debris were recovered. The blue items in these figures represent pieces 

of seat structure that were positively identified to a seat location. The green items are those pieces that could 

be from one of two seats. 

case of the crew equipment, to a specific crewmember. 

Part numbers and serial numbers provide definitive 

proof of the as-flown location. For debris without part 

numbers, comparing the material composition of the 

recovered debris to vehicle drawings may determine the 

origin of the debris. 

Reconstruction also provides an opportunity to identify 

missing pieces of the vehicle and determine if additional 

debris recovery is necessary. It is unlikely that the 

team will recover the entire vehicle or match all debris 

to a definitive position on the reconstructed vehicle, 

so uncertainty is associated with reconstruction. 
140 SECTION 5 – THE FUTURE

Analysis of the Evidence and • Materials (deterioration of paint or primer, sources 

Reconstruction Results and patterns of material deposits, deformation, 

The purpose of analyzing physical evidence is to 

develop scenarios or sequences of what may have 

taken place that caused the crew to incur the observed 

injuries. From a crew survival investigation perspective, 

reconstruction provides insight into the performance 

of the crew cabin and the surrounding structure, 

crew-vehicle interactions, initial and subsequent 

system or structural failures, toxic releases, fire, and 

other circumstances. To begin with, secondary, 

debris-debris, and ground-impact damage should be 

identified and excluded from consideration. Then, the 

collected evidence should be analyzed for indications 

of failure progression and crew actions. Team members 

should note outliers, anything that does not follow 

logic. The relative locations of debris (what departed 

first or last, emergency equipment in proximity to 

each crewmember, and so on), equipment settings 

and configurations, and other relevant evidence should 

be considered. 

In identifying the cause of the mishap, system or 

structural failures, the environment, crew actions, 

and anything else that might be relevant should be 

considered. Observations may include these categories: 

• Thermal (directional heating, random heating, 

thermal erosion or degradation, hot gas flow, shockshock interaction, combustion/oxidation, melting, 

fire, freezing) 

• Structural (fractures, breach, rupture, weakening, 

shadowing, warping, fragmentation, tearing) 

degradation caused by exposure to the environments, 

flow redirection, properties) 

• Loads (mechanical, structural overloading, impact) 

• Chemical (residue deposit, discoloration, residual 

fuels, fluids or coolants) 

• Configuration (switch, handle, control surface or 

gimbal, and valve positions; deviations of settings, 

positions, or locations from nominal; configuration of 

deployed equipment and crew restraints) 

• Foreign material or debris 

• Premishap system failures 

This analysis may encompass a broad range of activities 

that include observing the physical evidence, conducting 

an engineering analysis of the debris, identifying 

the role of any system failures or crew actions, and 

determining the origin and progression of the failure(s). 

Timelines 

Timelines are one of the most effective tools used 

to build scenarios and to document the sequence of 

events. Timelines are graphical representations of the 

sequence of events based on collected information and 

analytical results. Developing scenarios and sequencing 

events is an iterative process as evidence and analytical 

results are integrated, eventually converging on a 

scenario supported by all of the available information. 

Using timelines, a team can visualize the progression 

of the events that led to crew injuries or death. 

Deorbit Preparation to Entry Interface from the Columbia Timeline 

This timeline illustrates key events from the beginning of deorbit preparation to entry interface. Green bars 

represent times when video data were available. The blue bar represents times when voice and telemetry 

transmissions were available (throughout this phase). Times shown are GMT. 
SECTION 5 – THE FUTURE 141 

When determining where the timeline starts, an 

event occurring before the mishap may be relevant. 

For instance, a change to a crew procedure for which 

the crew was not trained may be a significant event 

on a timeline. Typically, a good starting point is 

the start of the mission. In most cases, the timeline 

ends with the mishap. An example of an exception 

is one where the crew survives a parachute failure 

at landing, but succumbs to exposure because the 

emergency equipment was not available or suited for 

the environment. 

The task of determining what is and is not relevant is 

different for each investigation. When constructing a 

crew survival investigation timeline, one should begin 

with events that have established confirmed times; 

those without uncertainty. These events are based 

on telemetry, video, air-to-ground communications, 

or some other source that provides a time stamp for 

events. Next, add events that occurred in conjunction 

with a specific mission event or crew action, but 

with associated uncertainty, such as a crewmember 

lowering their visor during entry preparations. Include 

events that would produce a crew action or reaction, 

system response, or known injury. If possible, verify 

individual crew-related milestones on the timelines with 

survivor interviews or substantiate with engineering 

or medical evidence. Assess all timelined events for 

significance as contributors to the survival or injury of 

the crewmembers. 

A separate medical timeline allows the crew survival 

investigation team to capture relevant medical 

events and develop an injury event sequence. A 

separate timeline permits limited dissemination of 

sensitive information. When sequencing the events, 

associate the incidence of crewmember injuries 

with the timelines. Remember that fire precedes burns, 

impacts precede fractures, loss of pressure integrity 

precedes decompression sickness, and so on. When 

correlating injuries with an event on a timeline, 

account for all injuries experienced by the individual 

crewmembers. It is unlikely that all crewmembers 

experienced identical injuries, so consider constructing 

an individual medical timeline for each of the 

crewmembers, and then add the significant events to 

the crew survival investigation timeline. Before 

finalizing the crew survival and medical timelines, 

reconcile any conflicts and confirm the times of as 

many events as is practical. 

Assessments 

Crew Survival Investigation Assessments 

The material presented in this section is not allinclusive, but provides general information and 

insight regarding the assessments and analyses that 

may be performed by a crew survival investigation 

to bound the crew experience during the mishap. 

The crew survival investigation assessments focus on 

(1) the failure of the vehicle, especially the portion 

of the vehicle closest to the crew at the time of 

the mishap; (2) the performance of equipment and 

systems designed to protect the crew; and (3) the 

medical forensics to identify each crewmember’s 

experience during the mishap. Both objective (e.g., 

air-to-ground communications, vehicle forensics) and 

derived (e.g., ballistics analysis, thermal analysis) data 

are used. The assessment results are used to develop 

failure scenarios, place events in the proper sequence, 

confirm times, and support or refute findings. The 

crew experience is defined by mapping analytical 

results to specific seat locations and/or crewmembers, 

then correlating vehicle or system failures and crew 

actions with the injuries observed in the crew. These 

results are essential for identifying the successes and 

failures of the protective measures of the vehicle 

and crew equipment and systems, and improvements 

for future missions. 

Spacecraft Assessments 

Typical spacecraft-related analyses include, but are 

not limited to, aerodynamic and propulsive loading, 

ballistics, motion, thermal, aero-thermal, structural, 

environmental, and materials analysis; and evaluation 

of debris, vehicle systems performance, and vehicle 

telemetry. Depending on the type of mishap and 

the phase in which it occurs, the team may include 

evaluations of ground operations, mission operations, 

and communications. Knowledge of the relevant phase(s) 

of flight helps to determine the scope of the analyses 

and bounds the likely velocities, trajectories, altitude, 

environmental factors, and potential aerodynamic, 

propulsive, and thermal loads. The phase of flight in 

which destruction occurs (e.g., prelaunch, ascent, orbit, 

rendezvous, reentry into Earth’s atmosphere, landing, or 

post-landing) may be obvious. However, the mishap may 

result from latent damage, failures, or events occurring 

in a previous mission phase, so the initial cause and 

timing of the mishap may be difficult to discern. 
142 SECTION 5 – THE FUTURE

Human Performance Limits of the Columbia Crew 

This graphic illustrates representative loads based on modeling in all three axes, including the effects of 

increasing rotational loads. Models showed that accelerations were initially low, and peaked between 2 G 

and 3.5 G by the time of the catastrophic event (separation of the forebody from the midbody). The dashed 

black lines (upper and lower) on the chart indicate human performance limits based on NASA-STD-3000.* The 

representative loads, which are based on modeling, were well within these human performance limits. 

* NASA-STD-3000, Man-Systems Integration Standards, Volume I, Section 5, Revision B, 1995. 

LOC – Loss of Control of Columbia 

CE – Catastrophic Event 
SECTION 5 – THE FUTURE 143 

 

Analyses for Spacecraft Assessments 

• Flight Dynamics 

• Ballistics 

• Motion 

• Thermal 

• Aero-Thermal 

• Structural 

• Materials 

• Environmental 

The results of analyses conducted on the vehicle can 

be used to calculate the resulting loads applied to 

the crew cabin and to the crew. The loads and forces 

acting on the vehicle can be mapped to the individual 

crewmembers. Through understanding of the mission 

phases, altitude, ballistic coefficient, and other factors, 

engineers can calculate loads and other relevant 

information vital to the crew survival investigation 

medical team. The medical team uses this information 

to determine the causes of the crew injuries and 

fatalities, and the sequence of the medical events. 

In addition to conducting engineering analyses, a crew 

survival investigation team should review historical 

records to identify any potential contributors to the 

mishap. Begin with the subset of vehicle records 

applicable to the crew protective equipment and systems, 

environmental systems, and the crew-vehicle interface. 

These records include relevant design and manufacturing 

drawings, and the subject spacecraft and fleet 

manufacturing, assembly, and maintenance histories, 

including any problem reports and corrective actions, 

non-conformances, or design changes resulting from past 

issues. In addition, capture any crew and safety concerns 

with operational (human) factors, such as cabin layout; 

emergency hardware quantity, accessibility, and stowage 

locations; and situational awareness (annunciation, 

indications, visibility, auditory levels, and so on). 

Flight Dynamics Analysis 

The spacecraft is subjected to thrust, drag, gravitational, 

and lifting loads of varying magnitudes throughout the 

mission. Together, the aerodynamic and propulsive loads 

define the flight dynamics. Analyses of aerodynamic 

and propulsive loads provide insight into the vehicle’s 

trajectory, motion, and loads, and provide the reference 

data necessary for other analyses such as thermal analysis. 

Also, the vehicle’s trajectory provides information on 

the gross vehicle motion, velocities, and acceleration 

forces acting on the vehicle. An aerodynamics analysis 

is done to study the interaction of aerodynamic forces on 

an object. For mishaps that occur during flight through 

the atmosphere (as during launch, reentry to Earth’s 

atmosphere, and landing), the analysis of aerodynamic 

stability data provides the relative motion of the vehicle. 

A propulsive loads analysis is used to study the loads 

imparted by the propulsive thrust of the engine, motor, 

and thruster propulsion systems. Other sources of loading 

events include collision of spacecraft elements, actuation 

of the pyrotechnic system, inputs to directional flight 

control, parachute deployment, landing, and braking. 

These vehicle motions and forces are translated into the 

motions and loads experienced by crewmembers. 

Types of accelerations experienced by crewmembers 

include sustained, oscillatory, impulse, and instantaneous 

(impact) accelerations. Acceleration loads, whether 

positive or negative, can affect human performance, 

and can lead to loss of consciousness and/or physical 

injuries. The degree of injury is related to the magnitude, 

duration, and direction of the acceleration forces. The 

human body is more able to withstand accelerations in 

the fore-aft direction than in the up-down or side-to-side 

directions. Also, deconditioned crewmembers have a 

reduced tolerance for acceleration loads. 

Ballistics Analysis 

In cases of spacecraft breakup occurring during ascent 

or reentry to Earth’s atmosphere, a ballistics analysis 

can provide the order in which the crew, equipment, 

and debris were shed during the mishap and determine 

debris trajectories. This analysis uses the ground location 

of the recovered debris (latitude and longitude) and the 

debris properties (size, shape, and mass) to characterize 

the breakup sequence. The ballistics analysis makes use 

of the ballistic trajectory, controlling forces, ballistic 

number, reference trajectory, and any cascading failures. 

Motion Analysis 

Motion analysis determines the gross movements of the 

spacecraft during the mishap. Data to support the motion 

analysis comes from telemetry, a flight data recorder, 

radar, and video. In the absence of any recorded data, 
144 SECTION 5 – THE FUTURE

flight dynamics and ballistic analyses can provide 

information on the representative loads and motions 

experienced by the vehicle. Through understanding the 

motion of the vehicle, it is possible to combine these 

data with the flight dynamics and ballistic analysis 

to determine the loads the crew experienced through 

the evolving conditions. This information assists 

the medical team in evaluating the crew injuries and 

determining possible mechanisms of injury. 

Thermal Analysis 

Thermal analysis identifies the thermal loads imposed 

on the vehicle, the crew equipment, and crewmembers. 

The spacecraft and crew are subjected to an induced 

thermal environment managed by flight profiles, 

vehicle orientation, and onboard thermal systems. 

When induced heating exceeds the design limits of the 

spacecraft materials, material failure may lead to the 

destruction of the vehicle. This analysis considers the 

source of the thermal energy, the transfer mechanisms 

(e.g., conduction, convection, or radiation), thermal 

effects, the ambient thermal environment, and the 

duration of exposure. The temperatures resulting 

from the thermal loads can affect the properties of 

the materials (e.g., strength, toughness, chemical 

composition, and phase state). Thermal injuries to the 

crew can also provide information on the sequence of 

the thermal event relative to any other traumas and/or 

death, and on the intensity, duration, and directionality 

of the event and the state of any crew protective 

equipment and surrounding structures at the time of 

the thermal exposure. 

If thermal systems fail to maintain a habitable 

environment, the crew may experience heat- and 

cold-related injuries, or conditions may affect their 

ability to function. Temperature-related injuries include 

hypothermia, frostbite, cryogenic burns (caused by 

contact with cryogenic materials), contact burns, heat 

stroke, heat exhaustion, and dehydration. The extent 

and severity of the injuries depend on the source and 

exposure time. Burns from radiant heat sources may 

show signs of shadowing, deposition, and/or adhered 

material and appear only on the side of the body 

exposed to the heat source. Sources of radiant heating 

are fire, materials heated to high temperatures, and 

exothermic chemical reactions. At high Mach numbers, 

shock-shock interactions result from an amplification 

of energy at the point where two shock waves intersect, 

and these interactions can result in laser-like damage to 

exposed tissue; cases exhibit areas of focal burning and 

cauterization injuries. 

Aero-Thermal Analysis 

Aero-thermal analysis is performed on the spacecraft 

to identify probable failure sequences for launch, 

launch abort, and reentry mishaps. When considerable 

heat is generated, the high temperatures can affect the 

properties of the spacecraft materials and contribute 

to structural failure. Such high temperatures can result 

in combustion and chemical reactions unique to space 

flight. The aero-thermal analysis considers atmospheric 

reentry conditions, maximum survivable altitude 

analysis, reentry heating thermal analysis, vehicle 

orientation, and ablation. 

Structural Analysis 

Structural analysis studies the behavior of the 

spacecraft structure under various loading conditions. 

Structural analysis performed in support of the crew 

survival investigation is focused on the crew cabin and 

the structure surrounding it for understanding of the 

crew-to-vehicle load paths and how this hardware is 

attached to the vehicle, and to determine when and how 

it failed. The many types of structural, or mechanical, 

failures include deflection, ductile fracture, brittle 

fracture, impact, creep, thermal loading, buckling, 

corrosion, stress corrosion, wear, and fatigue. Each type 

of failure produces unique indicators near the fracture 

surface. A crew survival investigation should consider 

vehicle design margins, vehicle stresses, environmental 

conditions, structural loads, translational loads from 

aerodynamic drag, propulsive loads, rotational loads 

from vehicle rotation, linear moments from motion 

in roll, pitch, and yaw, and loads caused by differences 

between internal cabin pressure and external static 

and dynamic pressures. 

It is important to distinguish each of the indicators 

on the debris as either a cause of the initial failure, a 

consequence of a subsequent failure, or an impact. 

Materials Analysis 

The mishap may expose spacecraft materials to 

conditions beyond their design limits and cause the 

materials to fracture, degrade, melt, and deform. 

Materials analysis can determine the sequence of the 
SECTION 5 – THE FUTURE 145 

failures by identifying the progression of changes 

in the properties of the materials (e.g., strength, 

hardness, toughness, chemical composition, phase 

state) and provide insight into the origin of any material 

deposits found on the vehicle structure or crew. Also, 

comparisons of the materials properties to the debris 

attributes may identify the origin of a piece of debris 

when other methods cannot. 

Environmental Analysis 

The environmental conditions affecting a spacecraft 

and crew are both natural and induced, and affect crew 

health and performance. Environmental factors may be 

direct causes for injury or death, or contributors that 

compromised the ability of the crew to function. When 

determining whether the environment contributed to the 

crew condition, a crew survival investigation should 

consider human factors and environmental hazards in 

microgravity, space, and terrestrial environments. 

Inadvertent actions and crew errors can result from 

human factors such as overly complex procedures, 

insufficient lighting, unguarded switches, or excessive 

background noise, and contribute to a mishap. In 

a microgravity environment, translation corridors 

obstructed by stowage and unrestrained equipment 

can entangle the crew or the crew can be entrapped 

while moving or rotating equipment. Sharp corners and 

edges, pinch points, protrusions, and rough edges can 

snag clothing and impede crew actions or result in head 

trauma, lacerations, or broken bones. 

In a space environment and in the spacecraft design, 

ionizing and nonionizing radiation and electric 

shock hazards can contribute to a mishap. Ionizing 

radiation from the natural environment, radioactive 

power and heat sources, and some equipment may 

produce short-term effects including nausea, vomiting, 

headache, diarrhea, burns, and cognitive impairment. 

Non-ionizing radiation sources, such as lasers, 

radiofrequency transmitters, or the sun viewed through 

unprotected windows, can result in eye irritation 

or damage, temporary blindness, increased body 

temperature, or burns. Electric shock can interfere 

with nerve control or result in burns, ventricular 

fibrillation, loss of consciousness, or death. 

The environment at the landing site poses hazards to 

the crew including natural predators (e.g., fish, birds, 

mammals), lightning strikes, exposure, drowning, and 

entanglement. Although recovery forces and onboard 

emergency equipment may mitigate the hazards at the 

nominal landing site, recovery forces may be delayed 

or the emergency equipment may be inadequate or fail 

to function. Launch aborts and aborts from orbit may 

place the crew in an undesirable location without the 

necessary survival equipment. In some cases, wellmeaning Samaritans may extract the crew from their 

spacecraft and cause or exacerbate injuries. 

Crew Cabin Environment Assessments 

The cabin environment analysis determines whether 

conditions within the crew cabin affected the crew’s 

ability to respond under mishap conditions and/ 

or caused injury. For example, a crew survival 

investigation should 

• determine whether the vehicle structure invaded the 

space necessary for each crewmember; 

• evaluate the performance of the restraint system that 

secured the crewmembers to their seats and ultimately 

to the vehicle; 

• determine whether the energy-absorbing mechanisms 

in the design reduced the loads to within the tolerance 

limits for human survival; 

• determine whether and when a crewmember was 

unable to perform a response action, became 

permanently compromised, or lost consciousness 

due to loss of a habitable environment, toxic material 

release, or fire; 

• determine if postmishap conditions contributed to crew 

injuries by limiting egress, exposure to fire or toxic 

materials, or landing in a hostile environment or under 

hazardous conditions. 

Conditions in the crew cabin can produce in-flight or 

postflight incapacitation, decrease visibility, hinder 

egress and rescue efforts, or contribute to crew injuries, 

all of which reduce survival chances. 

Impact injuries 

When investigating the cause of impact injuries, a crew 

survival investigation starts by assessing the cabin 

area in proximity to the crew for evidence of contact 
146 SECTION 5 – THE FUTURE

with equipment or stowage. Impact injuries occur when 

a crewmember collides with an object or an object 

collides with a crewmember, such as when injuries 

result from forceful contact with equipment liberated 

during the mishap. Intrusion is also a type of impact 

injury. In this case, a deformation of the crew cabin 

reduces the available volume surrounding the crew and 

constricts respiratory function; this may be a momentary 

or permanent condition. Other consequences of impact 

are fracture, penetration, lacerations, contusion, blood 

loss, eye damage, and loss of consciousness due to head 

trauma or constriction. 

Toxicological injuries 

Toxicological injuries result from exposure to 

toxic substances (e.g., combustion products, fuels, 

coolants, airborne microbes, contaminated water, fire 

extinguishing gases) that damage tissues. Although 

spacecraft designers attempt to eliminate these 

substances from the crew environment, toxic substances 

can be introduced during a fire or enter the crew cabin 

on a contaminated spacesuit. Also, faulty environmental 

control and life support systems can fail to remove 

carbon dioxide, water can become contaminated, 

batteries can rupture, and solutions used to pretreat 

urine can leak out of their containers. Depending on 

the level of toxicity, exposure time, and concentration, 

exposure can result in burns, an inflammatory response, 

eye and mucosal irritation, visual disturbances, liver 

damage, gastrointestinal toxicity, central nervous system 

depression, and other effects. In microgravity, without 

forced airflow and the subsequent mixing of gaseous 

constituents, toxic accumulations of gases can lead to 

lung, eye, and skin damage; burns; unconsciousness; or 

death by poisoning or asphyxiation. 

Thermal injuries 

Thermal injuries result from failure to maintain a 

temperature-controlled environment or from thermal 

sources including radiation and combustion events. 

These injuries result from exposure to environmental 

temperatures and/or objects at temperatures that can 

harm the crew. The principal effect of a microgravity 

environment on heat transfer in the crew cabin is the 

loss of natural convection; that is, warmer air will not 

naturally rise. All convection under these conditions 

must be forced through the use of fans or blowers. 

Pressure injuries 

Pressure injuries result from excessive or insufficient 

atmospheric pressure conditions, barotraumas, and from 

exposure to high airflow. Changes in pressure generated 

by explosions, failed systems, cabin breach, leaks, failed 

overboard vents and valves, or ejection of the crew from 

a pressurized environment can cause incapacitation, 

injury, or death. An overpressure condition (e.g, 

explosion) that exceeds the pressure relief capability 

of the cabin can damage the ears, lungs, sinus cavities, 

circulatory system (pressure waves transmitted through 

blood), and teeth. Injuries to the lungs and ears due to 

overpressurization are similar to those observed from 

a rapid depressurization. Without sufficient venting, an 

overpressure condition may result from the unmitigated 

introduction of gases from failed environmental control 

and life support systems, or a cabin fire may increase 

pressure. Long-term exposure to elevated pressures can 

result in oxygen toxicity and increase the amount of 

nitrogen saturation. Ultimately, overpressurization of the 

crew cabin may result in a cabin breach. 

Depressurization occurs when the crew cabin is 

breached by structural failure, penetration, inadvertent 

hatch opening, a cabin leak (hatch, seal, or window), 

or failed overboard vent or valve. At pressure altitudes 

above 10,000 feet, as the pressure altitude increases, the 

oxygen partial pressure in the arterial blood decreases, 

which affects eyesight and cognitive abilities. The 

amount and pressure of oxygen delivered to the tissues 

is determined by arterial oxygen saturation, by the 

total oxygen-carrying capacity of the blood, and by the 

rate of oxygen delivery to the tissues. When the body 

is deprived of sufficient oxygen, hypoxia occurs. The 

four types of hypoxia are hypoxemic hypoxia, anemic 

hypoxia, stagnant hypoxia, and histotoxic hypoxia. 

In general, at pressure altitudes above 18,000 feet, 

decompression sickness occurs during depressurization 

when dissolved gases come out of solution and create 

bubbles inside the body. Symptoms include joint 

pain, rashes, paralysis, and death. Barotraumas are 

damage to the body’s tissues caused by the pressure 

differences between internal air cavities (e.g., sinus 

cavities, ears, dental fillings, lungs, and digestive tract) 

and the surrounding tissue when the body moves to 

or from higher pressures. Barotrauma effects include 
SECTION 5 – THE FUTURE 147 

pain, tearing or rupture of tissue, retarded breathing, 

disorientation, unconsciousness, and shock. 

Arterial gas embolism occurs when the depressurization 

rate overpressurizes the lungs, forcing gas into the 

arterial circulation, which disperses it throughout the 

body. The onset of arterial gas embolism is usually 

sudden, dramatic, and life-threatening. At higher 

altitudes, even while a person is breathing pure oxygen, 

the arterial oxygen partial pressure falls to a level that 

cannot support consciousness. Above 62,000 feet, 

the ambient pressure is low enough that the water in 

the body begins to boil at normal body temperature 

and ebullism occurs. Symptoms include bubbles 

forming in the blood, eyes, and mouth; tissue 

swelling and hemorrhaging; impaired breathing and 

circulation; and death. 

Acceleration injuries 

During atmospheric flight phases, breaches of the 

cabin or ejection of the crew from the vehicle expose 

the crew to the aerodynamic effects of high-velocity 

airflows, or windblast, and acceleration loads. The 

effects of windblast vary with the density of the air 

and are proportional to the surface area exposed to the 

flow. The atmosphere can exert significant loads on 

exposed crewmembers even at high altitudes. During 

ejection, the body can be subjected to substantial loads 

from various sources (e.g., maneuvering loads, escape 

system-induced loads, windblast) and may experience 

torsional and shearing forces that produce internal 

tears. The compressive loads acting on the body can 

result in vertebral fractures and compress the chest 

and abdomen. Injuries can be produced by windblast, 

including petechial and subconjunctival hemorrhage, 

and flail. Flail injuries occur when inadequacy of body 

restraints for the vehicle’s dynamic environment causes 

differential acceleration between the extremities and 

the torso, terminating at the range of motion limit or 

contact with surrounding structure. The effects of a 

load on the crew are determined by its direction, onset, 

magnitude, frequency, and duration. This information 

may be available from video, radar, modeling, and 

engineering analysis. Aircraft pilot ejection data 

are relevant for many conditions experienced by a 

spacecraft crewmember ejected from the crew cabin 

during atmospheric flight. 

Crew Equipment Assessment 

Crew equipment assessments focus on the utilization 

and performance of the individual crewmember seats, 

on crew protection and crew survival emergency 

equipment and systems, and on the analysis of each 

crew-vehicle interface. Data sources are audio and 

video recordings and the results of debris analysis. The 

as-found location of an equipment item can indicate 

when it was released from the vehicle. Because of 

their proximity to the crew, the condition and as-found 

locations of the seats, items worn by crewmembers, 

crew emergency and crew survival equipment and 

systems indicate the conditions experienced by the 

individual crewmembers during the mishap. Members 

of the crew survival investigation team should visually 

examine crew equipment for witness marks, thermal 

effects, materials effects, potential loads, hardware 

failures, and debris-debris impacts resulting from the 

mishap. The postmishap configuration of the equipment 

and systems, such as switch positions, provides insight 

into possible crew actions (e.g., activation of emergency 

breathing supplies, raft deployment, and activation of 

nitrogen purge). Analysis of the crew equipment and 

systems indicates whether individual crewmembers 

used or attempted to use the equipment and/or systems, 

how accessible the equipment was, and how well it 

performed. This analysis also provides insight into 

crew awareness of a hazardous condition and which 

hazardous conditions the crew experienced. 

Analysis of the crew seat-vehicle interface derives 

the loading events experienced by the crew. The 

investigation of recovered seat debris provides insight 

into injuries resulting from loss of restraint. Injuries 

resulting from restraint failures include bracing and 

flail injuries, transections, fractures, disarticulations, 

dislocations, and amputations. Bracing injuries, usually 

noted on the lower legs and feet or lower arms and hands, 

are a result of inadequate upper-body restraint against 

the vehicle motion (e.g., tumbling, spinning). Bracing is 

a deliberate act by a conscious crewmember to counter 

loads imposed on them or to respond to ineffective or 

failed restraints. Flail produces fractures, dislocations, or 

total disarticulations. Transecting (or shearing) fractures 

of the vertebral column result when extremely high 
148 SECTION 5 – THE FUTURE

loads imposed on the crewmember react against the 

restraint in such a way that the restraint transects the 

body. Fractures, disarticulations, and dislocations may be 

caused by overloading of the seat structure or the loss of 

restraint. Fractures of the extremities are consistent with 

deceleration injury or aerodynamic flail. Amputations 

may result from impact, flail, or exposure to high 

pressures or inertial forces. They may not occur at a joint 

but may be coincident with a restraint. 

Crew-worn or crew-donned equipment may cause 

injuries at the crew-equipment interface. Injuries can 

result when the weight of equipment under inertial 

loads is imposed on a crewmember by crew-worn or 

crew-donned protective equipment. The types of injuries 

include head and neck injury and mass augmentation 

injuries. Head injuries may result from the failure of 

helmets or head/neck devices to support the head and 

neck. Equipment worn or donned by a crewmember 

augments the crewmember’s mass properties (such 

as center of gravity and moment of inertia), and this 

augmentation may exacerbate the loads imposed on the 

crewmember and result in injuries such as a neck injury 

to a crewmember wearing a portable breathing apparatus 

during an acceleration event. 

Medical Forensics Assessment 

Medical forensic assessments are sensitive in nature 

and encompass medical factors, types of injuries, 

autopsy, crew involvement, and mechanisms of crew 

injury and crew death. These assessments also include 

evaluation of the crew’s awareness of and responses 

to timeline events, including any that were potentially 

lethal to the crew. Through review of medical and 

training records, autopsies, survivor examinations and 

interviews, and examination and analysis of data and 

physical evidence, the crew survival investigation team 

systematically creates and substantiates the mishap 

scenario for each crewmember. This assessment 

considers each crewmember’s awareness, response, 

and involvement from the start to the end of the 

mishap, the mechanisms and sequence of injuries and/ 

or death, and any conditions limiting the crewmember’s 

awareness or response, including human physiological 

limits under mishap conditions. The team considers the 

mishap conditions, injury patterns, and other potentially 

lethal conditions relative to each of the crewmembers, 

and determines why some crewmembers sustained 

injuries and others did not, and why some crewmembers 

survived, or survived longer, while others did not. 

Detailed documentation of all injuries and medical 

conditions is important when assessing the safety 

of the spacecraft design and the effectiveness of the 

protective equipment. 

The Crew Condition 

The investigative team should develop the medical 

sequence of events by first differentiating between 

premishap, mishap, and postmishap contributors to the 

condition of the crew. It is possible that an event that 

occurred before the mishap may be relevant. So review 

preflight psychological evaluations and medical records 

for evidence of preexisting conditions, injuries, or 

diseases of crewmembers, their psychological state (e.g., 

stress, family events, sleep, significant emotional events), 

and each crewmember’s performance during training 

and on previous missions, if applicable. Consider 

any conditions that might make a crewmember more 

sensitive to mission conditions, such as reduced sensory 

or motor capacities. Identify any injuries or illnesses the 

crewmember incurred before the flight that are relevant 

to the crewmember’s circumstances. Determine the role, 

if any, that preflight conditions played in the mishap or in 

contributing to the crewmember’s injuries or death. 

For conditions occurring during the mission, assess 

the crewmember’s workload, interactions, performance, 

and human factors issues immediately before and 

throughout the mission. Identify the roles and 

responsibilities of each of the crewmembers as well 

as any indications of their performance throughout 

the mission. Changes to mission timelines (e.g., sleep 

schedules, reprioritization of tasks, added activities 

such as extravehicular activities, isolation of the crew, 

and mission termination, extension, or delays) and offnominal or contingency operations or system failures 

can affect the crew. The duration of the flight may also 

be a factor because of the short- and long-term effects 

of microgravity on body functions and capabilities; 

consider the consequences of bone loss and morphology 

changes, immune system suppression, intracranial and 

eye pressure changes, and psychological alterations. 

Also, injuries may have occurred during the mission 

that impair crew performance during the mishap. 
SECTION 5 – THE FUTURE 149 

Payload specialist Ilan Ramon (left), astronauts Laurel B. Clark, mission specialist, and Michael P. Anderson, payload commander, participate in 

mission training in one of the high fidelity trainers/mockups in the Space Vehicle Mockup Facility at the Johnson Space Center (JSC). The three, 

attired in training versions of the full-pressure launch and entry suit, are seated on the middeck for an emergency egress training session. Ramon 

represents the Israeli Space Agency. 

Next, assess all of the areas mentioned earlier, including 

human factors and psychological, physiological, and 

environmental conditions, but only the findings specific 

to the time of the mishap event. For instance, if a 

crewmember was incapacitated by motion sickness, 

this may have affected their actions. Evaluate the 

crewmember’s exposure to potential environmental 

conditions resulting from the mishap, in light of 

their injuries. Mishaps occurring in a microgravity 

environment make the analysis of fluid splatter patterns 

more challenging because the fluid may have floated 

free or pooled on a surface, then been transferred when 

conditions changed. In microgravity, blood and other 

fluids can cross-contaminate crewmembers. DNA 

analysis and blood serology may be needed to trace 

blood to the source crewmember. After a mishap, the 

contributors to the crew condition are exposure (which 

could lead to decomposition or artifacts), environment 

(e.g., weather, temperature, humidity, season), and 

predation (causing, for example, alteration of evidence 

due to insects, mammals and plant life), or sometimes 

dispersal of remains. Environmental conditions 

influence the effects of delayed recovery. Evidence can 

be lost and artificial evidence introduced if a significant 

amount of time passes before remains are recovered. 

Awareness of postmishap contributing factors allows the 

team to rule out any postmishap injuries. 

Medical Examinations and Autopsies 

The medical examinations of the crewmembers should 

follow a systematic and well-organized plan. The 

objectives of the pathology inquiry are the diagnosis of 

preexisting disease or injury conditions, documentation 

of all injuries and analysis of the injury pathogenesis, 

and cataloging all observations, to substantiate the 

mishap cause and sequence. During the medical 

examination of a survivor or autopsy of human remains, 

record all injuries and document all evidence that can 

be used to identify potential sources of injury and to 
150 SECTION 5 – THE FUTURE

sequence the injuries. Many methods are available, 

such as thorough descriptions, photographs, diagrams, 

sketches, X-rays, MRI, and CT, to reveal various aspects 

of the injuries. Full-body radiographs with special 

emphasis on the head, neck, and extremities are useful 

in the clarification of injury mechanisms, particularly 

when the radiographs are correlated with photographs 

and diagrams. Describe and interpret all observed 

injuries in sufficient detail to identify possible causes 

in the context of the mishap, the time and/or sequence 

of injury, and the nature of the injurious event, and to 

differentiate mishap injuries from postmishap injuries. 

The pathologist performing the postmortem exam 

should be familiar with the spacecraft, the mission 

phase of the mishap, the environmental factors that were 

present from the time of the mishap until the time of the 

autopsy, and any handling errors. 

When you are interpreting medical evidence, 

relationships are important. These include the locations 

and conditions of the crew equipment relative to 

the crewmembers or remains, of the crew relative 

to hardware, and of injured crewmembers and their 

injuries relative to other crewmembers. It is ideal if all 

of the crew-worn or crew-protective equipment on the 

crewmember is documented before it is removed, or if 

it is left in place until the time of the autopsy. Assess 

whether any equipment limited the crewmember’s 

ability to respond (e.g., by impairing vision) or 

shows evidence of an impact that was translated to 

the crewmember. When analyzing the location of 

crewmembers relative to that of hardware, consider 

the events that resulted in the final configuration and 

identify supporting evidence found during the medical 

examination or autopsy. An example of an important 

relationship would be a fire extinguisher or breathing 

mask located next to a crewmember exhibiting 

evidence of smoke inhalation. Patterns of injuries may 

define events and injury mechanisms. Document each 

crewmember’s injury patterns, and then compare them 

to the injury patterns of the other crewmembers. A 

suggested technique is mapping the injuries onto virtual 

crewmembers. The virtual crew can be placed into a 

virtual model of the spacecraft to aid in visualizing 

injury patterns relative to potential sources. 

Mechanisms of Injuries 

Typical causes of crew injury are categorized as 

impact, loads, pressure, toxicological, thermal, and 

those from other environmental causes. This is not 

a comprehensive list, and a mishap may not involve 

all of these mechanisms of crew injury. To determine 

the mechanisms of crew injury, identify the crew’s 

injury patterns, reconstruct the mishap scenario, and 

correlate the injuries to a cause. This is an iterative 

process between examining the vehicle for evidence 

of interaction with the crew and mapping any 

interaction to a crew response or injury, and examining 

the crewmembers and correlating the source of an 

injury with the physical evidence on the vehicle or 

with analytical results. During this iterative process, 

eliminate postmishap injuries from consideration. The 

medical interpretations must be consistent with the 

circumstances of the mishap and findings from other 

lines of the investigation. 

Mechanisms of Survival 

The goal of the crew survival investigation is to identify 

ways to eliminate the mechanisms of injury and death 

and enhance crew survival. The injury potential must 

be reduced to a level that would not impede life-critical 

actions. Life-critical actions are actions the crew must 

take to protect themselves from serious harm or death 

(e.g., being able to release their harness and exit a 

sinking capsule). Once the mechanisms of injury and 

death are identified, the team can identify ways to 

prevent or mitigate them. Items that may be needed for 

crew survival include these: 

• Energy-attenuation systems to maintain loads within 

a tolerable range 

• A life-compatible environment (i.e., pressure, 

breathable atmosphere, temperature, and humidity that 

are compatible with life) 

• Adequate post-event factors such as escape paths, 

removal of fire or toxic event byproducts, secondary 

flotation methods, and availability of portable 

breathing apparatus 
SECTION 5 – THE FUTURE 151 

The Crew Survivability logo. 

• Structural integrity of the crew cabin sufficient to 

preclude intrusion 

• Adequate head and body restraint 

• Clear translation paths and control of stowage 

• Elimination of contact surfaces or rigid structures in 

close proximity to a seated crew 

• Elimination of hazards in the crew cabin such as 

sharp edges, surfaces exceeding touch temperatures, 

or pinch points 

• Protective measures that effectively mitigate the 

hazards without inhibiting mobility or the senses 

Ultimately, the purpose of the crew survival 

investigation is to identify the successes and failures 

of the crew protective equipment and systems in 

order to make recommendations for future spacecraft. 

This is accomplished by identifying the sequence of 

events; the attempted, unsuccessful, and successful 

crew actions; the performance of the crew protective 

equipment and systems; and the resulting outcome for 

each crewmember. If equipment or systems failed to 

provide a habitable environment for the crew for the 

duration of the mishap, the crew survival investigation 

team must understand why they failed. To answer 

this question, they must determine whether the 

failure occurred within certified capabilities or if the 

conditions exceeded the design specifications. If the 

conditions exceeded the design specifications, they 

should attempt to determine the amount by which the 

design specifications were exceeded so that they can 

recommend changes to improve survival in a future 

spacecraft mishap. 

Crew Survival Investigation — 

Process of Discovery 

The crew survival investigation is an iterative 

process of discovery. By examining the hardware 

and cross-matching the crew injuries to the hardware, 

the crew survival investigation team substantiates 

the mishap scenario. Once the mishap scenario is 

understood, the crew survival investigation team can 

recommend changes to spacecraft design, equipment, 

or operations to improve crew survivability. These 

are the lessons learned that improve the safety of 

human space flight. 
152
 SECTION 5 – THE FUTURE
Section 6 – Appendix
 

Abbreviations and Acronyms 

Selected Readings 

Recognition and Acknowledgments 

Contributors’ Biographies 

Index 
154 SECTION 6 – APPENDIX

	 	 	

	 	 	

	 	 	 	

 

	 	 	

 

 

	 	 	 	

	 	

 

 

	 	 	 	 	 	

 

Abbreviations and Acronyms
 

GMT Greenwich Mean Time 

GPC general purpose computer 

GPS global positioning system 

ISS International Space Station 

ITAR	 International Traffic in Arms Regulations

JSC Johnson Space Center 

KSC Kennedy Space Center 

LOC loss of control 

LOS loss of signal 

MBF	 manned balloon flight

MCC Mission Control Center 

MCF million cubic feet 

MEIDEX Mediterranean-Israeli Dust Experiment 

MILA Merritt Island Launch Annex 

MIT Mishap Investigation Team 

MMACS maintenance, mechanics, and crew systems 

MMT Mission Management Team 

MPCV Multi-Purpose Crew Vehicle 

MRI magnetic resonance imaging 

MS mission specialist 

NTSB National Transportation Safety Board 

OAFME	 Office of the Armed Forces Medical Examiner

ORSAT object reentry survival analysis tool 

PLT pilot 

PLBD payload bay doors 

POC point of contact 

PPE personal protective equipment 

PS payload specialist 

SCSIIT Spacecraft Crew Survival Integrated 

Investigation Team 

SLF shuttle landing facility 

SLSD Space Life Sciences Directorate 

SO space operations 

STS Space Transportation System 

TAEM terminal area energy management 

TD total dispersal 

TPS Thermal Protection System 

UTC Coordinated Universal Time 

VITT Vehicle Integration Test Team 

ACES 

AFB 

AFIP 

AFMES 

AsMA 

ATA 

BRC 

CACO	

CAIB 

CAP 

advanced crew escape suit 

Air Force Base 

Armed Forces Institute of Pathology 

Armed Forces Medical Examiner System 

Aerospace Medicine Association 

atmosphere absolute 

Biodynamic Research Corporation 

casualty assistance calls officer

Columbia Accident Investigation Board 

contingency action plan 

CAPCOM capsule communicator 

CDR 

CE 

CEE 

CES 

CFS	

CISD	

CMCE 

CMG 

CSI 

CSWG 

CT 

CTF 

DDMS 

DNA 

DOD 

EAP 

ECLSS 

EI 

EMS 

EPA 

ERT 

ET 

EVA 

FACA 

FBI 

FEMA 

FOIA 

G 

g 

commander 

Catastrophic Event 

crew egress and escape 

crew escape system 

chief flight surgeon

critical incident stress debriefing

Crew Module Catastrophic Event 

Contingency Medical Group 

crew survival investigation 

Crew Survival Working Group 

computed tomography 

Columbia Task Force 

Department of Defense Manned Space 

Flight Program Support Office

deoxyribonucleic acid 

Department of Defense 

employee assistance program 

environmental control and life support system 

entry interface 

emergency medical services 

Environmental Protection Agency 

Evidence Response Team 

external tank 

extravehicular activity 

Federal Advisory Committee Act 

Federal Bureau of Investigation 

Federal Emergency Management Agency 

Freedom of Information Act 

acceleration acting on objects or 

crewmembers, in units of the Earth’s 

gravitational acceleration 

acceleration due to gravity (1g = Earth gravity) 
SECTION 6 – APPENDIX 155

	 	 	

	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	

	 	

	 	 	

	 	 	 	

	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	

	 	

	 	 	 	

	 	 	 	 	

	 	 	

	 	 	 	

	 	 	 	 	 	 	

	 	

Selected Readings
 

Section 1 – The Mission 

Biomedical Results of the Space Shuttle Program; Risin, 

Diana and Stepaniak, Philip C., editors. US Government 

Printing Office, 2013. NASA/SP-2013-607.

Wings in Orbit: Scientific and Engineering Legacies of 

the Space Shuttle, 1971–2010; Lane, Helen, editor in 

chief. US Government Printing Office, 2010. NASA/

SP-2010-3409. Electronic version is available at: http:// 

www.nasa.gov/centers/johnson/wingsinorbit/index.html 

Section 2 – The Response 

A Practical Approach to Occupational and 

Environmental Medicine, 3rd ed.; McCunney, Robert J.,

editor. Philadelphia: Lippicottt, Williams & Wilkins,

2003.

Occupational Medicine, 3rd ed.; Zenz, Carl, editor.

St. Louis: Mosby, 1994.

“Defining Normal Psychological Reactions to Disaster”;

Flynn, B.W., Norwood, A.E.; Psychiatric Annals 2004;

34:597–603.

“Natural Disasters and Stress Response Syndromes”;

Horowitz, M.J., Stinson, C., Field, N; Psychiatric Annals

1991;21:556–562.

“Psychiatric Dimensions of Disaster: patient care,

community consultation and preventive medicine”;

Ursano, R.J., Fullerton, C.S., Norwood, A.E.; Harvard 

Rev Psychiatry 1995;3:196–209.

On Death and Dying; Kubler-Ross, E.; New York, 

Macmillan, Inc. 1969.

“Psychological First-Aid: A Practical Aide-Memoire”;

Leach, J.; ASEM 1995;66:668–674 http://www.asma. 

org/publications/asem-journal/read-the-journal 

“Assessing the impact of a traumatic community event 

on children and assisting their healing”; Allen S.F.,

Dlugokinski E.L., Cohen L.A., Walker J.L.; Psychiatric 

Annals 1999;29:93–98.

“Psychiatric disorders among survivors of the Oklahoma 

City bombing”; North C.S., Nixon S.J., Shariat S., et al.;

JAMA 1999;282: 755–762.

“The Huntsville tornado of 1989: A psychiatrist’s

perspective”; Thaggard S.L.; Psychiatric Annals 1991;

21:553–555.

Section 3 – The Investigation 

Columbia Accident Investigation Board Report:

http://www.nasa.gov/columbia/caib/html/start.html 

Columbia Crew Survival Investigation Report, NASA/

SP-2008-565: http://history.nasa.gov/columbia/ 

columbiacrewsurvival.pdf 

Section 4 – The Analysis 

“First Hand Account of Selected Legal Issues From 

the Recovery and Investigation of the Space Shuttle 

Columbia”; Shafer, D.M., LeConey, A.V.; Journal of

Law, Vol.30, Number1 (2004).

Section 5 – The Future 

“Crew Survival Lessons Learned From the Columbia 

Mishap”, Clark, Jon B.; Journal of the British

Interplanetary Society, 2009:62:246–51.

Apollo 204, History of the Accident; Events From

Initiation of Fabrication Until the Initiation of the Plugs 

out Test: http://history.nasa.gov/Apollo204/content.html 

Wendt, Guenter, and Still, Russell. The Unbroken Chain. 

Ontario: Apogee Books, 2001.

Merlin, Peter W.; Bendrick, Gregg A.; and Holland, 

Dwight A. Breaking the Mishap Chain: Human Factors 

Lessons Learned From Aerospace Accidents and 

Incidents in Research, Flight Test, and Development. 

US Government Printing Office, 2012.

Principles of Clinical Medicine for Space Flight; 

Barratt, Michael R. and Pool, Sam L., editors. New 

York: Springer, 2008.
 

Fundamentals of Aerospace Medicine. 4th ed.; Davis,
 

Jeffrey R.; Johnson, Robert; Stepanek, Jan; and Fogarty, 

Jennifer A., editors. Philadelphia: Lippincott Williams &

Wilkins, 2008.
156 SECTION 6 – APPENDIX

	 	

	 	 	

	 	

Recognition and Acknowledgments
 

JSC Space Life 

Sciences Directorate 

Craig L. Fischer, MD 

Sam Pool, MD 

Charles Stegemoeller 

Craig Stencil 

JSC Space Medicine 

Division 

Nitza Cintron, MD

J. Michael Duncan, MD 

JSC Flight Medicine 

Clinic 

Tamara M. Bradley 

Joseph P. Dervay, MD 

Rainer Effenhauser, MD 

Stephen F. Hart, MD 

Thomas H. Marshburn, MD 

Carole G. Porcher, RN 

Brenda Rouse, RN 

Josef F. Schmid, MD 

Paul Stoner Jr., MD 

Terrence A. Taddeo, MD 

Amy L. Trabue 

JSC Clinical 

Laboratories 

Kathleen Mcmonigal, MD 

Joan Robertson 

JSC Toxicology 

John T. James, PhD 

JSC STS-107 Astronaut 

Casualty Assistance 

Calls Officers 

Clayton C. Anderson 

Yvonne D. Cagle, MD 

Tracy Caldwell 

Robert L. Curbeam 

Takao Doi 

Joan E. Higginbotham 

Janet L. Kavandi 

James M. Kelly 

Steven W. Lindsey 

Steven G. MacLean 

Michael J. Massimino 

Leland D. Melvin 

Lee M. Morin, MD 

Carlos I. Noriega 

Lisa M. Nowak 

Scott E. Parazynski, MD

Julie Payette 

Heidemarie M. Stefanyshyn-Piper 

Garrett E. Reisman 

Stephen K. Robinson 

Daniel M. Tani 

Joseph R. Tanner 

Andrew S. Thomas 

Terry W. Virts, Jr. 

Sunita L. Williams 

Stephanie D. Wilson 

JSC Flight Crew 

Operations Directorate 

and Astronaut Office 

Ellen S. Baker, MD 

Stephen G. Bowen 

Robert D. Cabana 

Kenneth D. Cockrell 

Nancy J. Currie 

C. Michael Foale 

Dominic L. Gorie 

John M. Grunsfeld 

Kenneth T. Ham 

Scott J. Horowitz

Marsha S. Ivins 

Brent W. Jett 

Gregory C. Johnson 

Mark E. Kelly 

Scott J. Kelly 

Sandra H. Magnus 

Ellen Ochoa 

Kent V. Rominger 

Jerry L. Ross 

Rex J. Walheim 

Jeffrey N. Williams 

David R. Williams, MD 

Barry E. Wilmore 

David A. Wolf, MD 

JSC Public Affairs Office 

Kelly Humphries 

Steve Nesbitt 
SECTION 6 – APPENDIX 157

	 	 	 	 	

	 	

JSC Aircraft 

Operations Division 

Kenneth J. Baker 

Arthur Beal 

Richard Clark 

William A. Ehrenstrom 

Michelle Gore 

Charlie Hayes 

Richard Hull 

Charlie Justice 

Frank J. Marlow 

David Mumme 

Steven R. Nagel 

Charlotte Ober 

Scott D. Reagan 

Andy Roberts 

Edward Schneider 

Robert W. Smith 

Roger Zweig

JSC Medical Operations 

Contingency Team 

Colonel Peter Bauer, MD 

Richard McCluskey, MD 

Mark Swann 

Rick Pettys 

JSC Crew and Thermal 

Systems Division 

Ketan S. Chhipwadia 

Mark Greeley 

JSC Engineering Directorate 

Lauri N. Hansen 

JSC Safety and Mission 

Assurance Directorate 

Gregory C. Hite 

KSC Medical 

Operations Team 

NASA 

David Tipton, MD 

Sandy Reed 

Bionetics Corp. and 

Comprehensive Health 

Services 

Arthur Arnold, MD 

John Darwood, MD 

Catherine Dibiase, RN 

Ivonne Garcia, RN 

Luis Moreno, MD 

Mimi Shao 

Duane Ratliff 

Charles Smallwood, MD 

Janet Tate, RN 

Daniel Woodard, MD 

Office of the Armed 

Forces Medical Examiner 

and Armed Forces 

Institute of Pathology 

Colonel Eric Berg, MC, USA 

Captain Doug Knittel, MC, USN (FS) 

Colonel Steve Williams, DC, USA 

Colonel Robert Worley, USAF 

Lt Col Mark Vojtecky, MSC, USAF 

CDR James Caruso, MC, USN (FS) 

(DMO) 

CDR Jerry Hodge, MC, USN (FS) 

Major Lisa Pearse, MC, USA 

Major Elizabeth Rouse, USAF, MC, FS

LTJG Bobbie Turner, MSC, USN 

Chief Paul Kerr, USN 

David A. Boyer 

William Rodriguez, PhD

SA Russ Strasser, OSI 

Robert Veasey 

Numerous other support personnel 

from the Office of the Armed Forces 

Medical Examiner and Armed Forces 

Institute of Pathology 

Dover Port Mortuary – 

Delaware 

Roy Vaughn 

Bill Zwicharowski

USAF Mortuary Affairs 

Personnel – 

San Antonio, Texas 

Mark Blair 

Trevor Dean 

Garold Huey 

Jim Taft 
158 SECTION 6 – APPENDIX

	 	

	 	

	 	

	 	

	 	 	 	

	 	 	 	

Barksdale Air Force Base – 

Shreveport, Louisiana 

Colonel Marion Harned 

Colonel Charles H. McGuirk 

Colonel Jerry Owens 

Colonel John Ramer 

Colonel Robert Zalme

Lt Col Charles Williamson 

Major John Ogden 

1LT Michael Biles 

1Lt Michael Theeck 

2Lt Andres Duran

Lt Shaun Meadows 

CMSgt Jack Skaggs 

SMSgt Kenneth Dunn 

MSgt Art Carino 

MSgt Julia Broadway 

MSgt John Eiland 

MSgt Kevin Fuhrman 

MSgt Roger Veuthey 

TSgt Eric Dugger 

TSgt David Dunlap 

TSgt Sabrina Johnson 

TSgt Wendell Toliver 

SSgt Sharhonda Anderson 

SSgt Brian Cauley 

SSgt Cynthia Contreras 

SSgt Jeffery Fowlkes 

SSgt Carolyn Gray 

SSgt Christopher Houde 

SSgt Kimyetta Johnson 

SSgt Julian Moore 

SSgt Sheila Robinson 

SSgt Jose Salcedo 

SSgt James Smith 

SSgt Wesley Walker 

SrA Wensly Bedoya 

SrA Roger Arney 

SrA Jason Bishoff 

SrA Blake Duet 

SrA Charles Greene 

SrA Troy Hartman 

SrA Justin Hebert 

SrA James Hooter 

SrA Joel Ives 

SrA Kent Kaisaki 

SrA Johnny Kiefer 

SrA Albert Loder 

SrA Jerry Marmaduke 

SrA Samuel McNair 

SrA Viviana Merino 

SrA April Moss 

SrA William Patterson 

SrA Scott Stesney 

SrA Daniel Taylor 

SrA Jeffery Tomkiewicz

SrA Daniel Ruiz

SrA Amy Vang 

SrA Bret Workman 

A1C Jose Batista 

A1C Leah Crafard 

A1C Daniel Endris 

A1C James McGarrity 

A1C Melinda Padilla 

A1C Robert Sankey 

A1C Carlos Sauceda 

A1C Roy Shears 

A1C Chad Talbot 

A1C Cedric Taylor 

A1C Dustin Thomas 

A1C Ryan Verner 

A1C Ebony Walker 

Department of Defense 

Manned Space Flight 

Support Office – Patrick 

Air Force Base, Florida 

Colonel Sanford D. Zelnick, DO

Lt Col Timothy F. Lee 

Lt Col John R. Youngs 

CMSgt (Ret.) Donald W. Shelton 

United States Air Force 

Lt Col Donald White 

Major Hernando (Joe) Ortega 

United States Navy 

Captain Harold Robinson 

Israel 

Colonel Ahron Zwi Black, MD

Wyle 

Eugenia A. Bopp 

Kathleen P. Houser 

Mark A. Volpe 
SECTION 6 – APPENDIX 159

 

 

 

 

Federal Emergency 

Management Agency 

Justo Hernandez

Mark Wallace 

National Transportation 

Safety Board 

Frank A. Ciaccio, MD 

Federal Bureau of 

Investigation 

Sue Hillard 

Ann Hinkle 

Mike Sutton 

Medical Examiner – 

Lufkin, Texas 

James R. Bruce, MD, FCAP 

Michelle McGee 

Carroway-Claybar 

Funeral Home – 

Lufkin, Texas 

Roy Carroway, Jr. 

Batesville Casket 

Company – 

Batesville, Indiana 

Ken Camp 

There are many others whose 

names are not listed here 

who also contributed to the 

Columbia crewmember search, 

recovery, and investigation 

efforts. To all who helped— 

your willingness to contribute 

to this honorable effort with 

a higher purpose will always 

be inspiring and humbling. 

Out of tragedy came greatness. 

Loss of Signal 

Book Production 

Co-editor 

Robert Patlach, 

Wyle, Science, Technology 

and Engineering 

Technical Editors 

Jane Krauhs, 

Wyle, Science, Technology 

and Engineering 

Rebecca S. Blue, MD, 

University of Texas Medical 

Branch, Galveston, Texas 

Indexing 

Joanne E. Sprott, 

Potomac Indexing, LLC 

Data Management 

Liliana Ochoa, 

Wyle, Science, Technology 

and Engineering 

Design and Graphics 

Perry Jackson, 

DB Consulting Group 

Cynthia Bush, 

DB Consulting Group 

Funding 

JSC Space and Clinical 

Operations Division 

NASA Human Research Program 
160 SECTION 6 – APPENDIX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 		 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

Contributors’ Biographies 

Bagian, James P., Colonel, USAFR (Ret.), BSME, MD, PE 

Dr. James P. Bagian has extensive experience in the fields of human factors, aviation, and patient safety and is the

Director of the Center for Healthcare Engineering and Patient Safety and a Professor in the Medical School and 

the College of Engineering at the University of Michigan. Previously he served as the first and founding director

of the US Department of Veteran Affairs (VA) National Center for Patient Safety and as the VA’s first Chief Patient

Safety Officer where he developed numerous patient safety related tools and programs that have been adopted

nationally and internationally. He was a NASA astronaut for over 15 years and is a veteran of two Space Shuttle

missions including as the lead mission specialist for the first dedicated Life Sciences Spacelab mission. Following

the 1986 Challenger Space Shuttle mishap he dove and supervised the capsule’s recovery from the ocean floor,

co-led the medical investigation and was one of the leaders of the development of the Space Shuttle Escape System. 

He also served as the Chief Flight Surgeon and Medical Consultant for the Space Shuttle Columbia Accident 

Investigation Board. Dr. Bagian holds a BS degree in Mechanical Engineering from Drexel University and a 

Doctorate in Medicine from Thomas Jefferson University. He is a Fellow of the Aerospace Medical Association, 

a member of the National Academy of Engineering, the Institute of Medicine, and has received numerous awards 

for his work in the field of patient safety and aerospace medicine.

Banks, Robert, Lieutenant Colonel, Canadian Air Force (Ret.), BEng, MD 

Dr. Robert Banks is a graduate of the Royal Military College of Canada in Civil Engineering, the University of 

Toronto in Medicine, and the US Navy Residency of Aerospace Medicine. His military career included 28 years with

the Canadian Air Force as a pilot, flight surgeon, and senior aerospace medicine specialist. Dr. Banks’research on the

“push-pull effect” earned him the Arnold D. Tuttle Award in 1996 for the most significant contribution to aerospace

medicine. He has published over 40 papers, articles and scientific presentations. He is a Fellow of the Aerospace

Medical Association. Dr. Banks has applied the principles of impact biomechanics and injury causation analysis 

to over 2000 crashes involving traumatic injury. This work includes major aviation disasters, amusement industry

mishaps, and motor vehicle crashes. He is the lead author of the chapter entitled “Human Response to Acceleration”

in the fourth edition of Fundamentals of Aerospace Medicine. Dr. Banks investigated the causes of injuries and death 

experienced by the crew of the STS-107 Space Shuttle Columbia crash that occurred over Texas in 2003.

Barratt, Michael R., BS, MD, MS 

Dr. Barratt is a physician astronaut in the Flight Crew Office at the Johnson Space Center (JSC). He holds a BS

degree in Zoology from the University of Washington. He received his MD degree and completed his residency

in Internal Medicine at Northwestern University. Dr. Barratt came to JSC in 1991 after completing an additional

residency in Aerospace Medicine at Wright State University. He began working for Krug Life Sciences as a project 

physician for the Space Station Freedom program, and then transitioned to an operational flight surgeon role in the

JSC Flight Medicine Clinic. Dr. Barratt was selected as an astronaut in 2000. He served a 6-month tour of duty

on the International Space Station in 2009 as a member of Expeditions 19 and 20, and flew on STS-133, the final

mission of the Space Shuttle Discovery. Dr. Barratt serves as Associate Editor for Space Medicine for the journal 

Aviation Space and Environmental Medicine and is senior editor of the textbook Principles of Clinical Medicine for 

Space Flight. In response to the STS-107 accident, Dr. Barratt deployed to the Lufkin, Texas, disaster field office

and participated in the Columbia crewmember recovery operation. 
SECTION 6 – APPENDIX 161

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

Campbell, Charles H., BS, MS, PhD 

Dr. Campbell has 25 years of experience in hypersonic entry systems supporting the Space Shuttle, the X-38,

and recent Mars technology development efforts. This includes significant contributions to understanding the

hypersonic entry environments which contributed to the STS-107 accident. After completing a BS in Aerospace

Engineering at the University of Minnesota, he also completed an MS in Mechanical Engineering at the University 

of Houston. In 2007, a PhD in Aerospace Engineering was conferred upon him by the University of Minnesota.

Awards received by Dr. Campbell include the NASA Exceptional Achievement Medal, the Rotary National Award 

for Space Achievement – Mid-Career Stellar Award and an AIAA Thermophysics Conference Best Student Paper

Award. Dr. Campbell has also been recognized as an Associate Fellow of the AIAA for his technical contributions.

Chandler, Michael R., Major, USAF (Ret.), BS, MBA 

Mr. Chandler is the Chief, Human Space Flight Operations Branch at the NASA Johnson Space Center (JSC). 

He has a BS from Tarleton State University in Texas and an MBA from Embry-Riddle Aeronautical University 

in Florida. He was a fixed-wing and rotary-wing pilot while in the Air Force. Mr. Chandler supported Space

Shuttle missions at Northrup Strip (White Sands Space Harbor) and later supported the STS-3 landing there.

As a member of the Department of Defense STS Contingency Support Office at Patrick AFB, he supported the

Space Shuttle Challenger accident recovery operations. At JSC, Mr. Chandler was selected as a member of 

the medical contingency team in 1998 and helped develop response plans and procedures. He was requested

by the NASA Space Life Sciences Directorate to be one of the two primary medical representatives on the 

STS-107 Mishap Investigation Team. He assisted the NASA Medical Operations Branch in the development of

landing augmentation plans for the Soyuz in May 2003 following the STS-107 accident.

Charles, John B., BS, PhD 

Dr. Charles earned his BS in Biophysics at The Ohio State University and his Doctorate in Physiology and 

Biophysics at the University of Kentucky. He has been at the Johnson Space Center since 1983, where he

investigated the cardiovascular effects of space flight on Space Shuttle astronauts and on crewmembers of the

Russian space station Mir. He was Mission Scientist for the NASA research on American astronauts on Mir, 

on John Glenn’s Space Shuttle flight STS-95 and on STS-107, Columbia’s last mission in January 2003.

He co-chaired the 18th “Humans in Space Symposium” of the International Academy of Astronautics in Houston,

Texas, in 2011. Dr. Charles is now the chief of the International Science Office of NASA’s Human Research

Program and leads space life sciences planning for the joint US/Russian one-year mission on ISS. He is a Fellow

of the Aerospace Medical Association and a Full Member of the International Academy of Astronautics, has 

published over 60 scientific articles, and has received several professional awards.
162 SECTION 6 – APPENDIX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	

Clark, Jonathan, Captain, USN (Ret.), BS, MD, MPH 

Dr. Jonathan Clark is an Associate Professor of Neurology and Space Medicine at Baylor College of Medicine 

(BCM) and teaches operational space medicine at BCM’s Center for Space Medicine. Dr. Clark received his 

BS in Biology from Texas A&M University, MD from the Uniformed Services University of the Health Sciences,

and MPH from the University of Alabama. He completed his residency training in neurology at the Naval Hospital, 

Bethesda. Dr. Clark was a member of the NASA Spacecraft Crew Survival Integrated Investigation Team from 

2004 to 2007 and Constellation EVA Systems Project Standing Review Board from 2007 to 2010. Dr. Clark

worked at NASA from 1997 to 2005 as a Space Shuttle Crew Surgeon. He served 26 years active duty in the US

Navy as a Naval Flight Officer, Flight Surgeon and Military Freefall Parachutist. Dr. Clark is Medical Director of

the Red Bull Stratos Project. His professional interests focus on the neurological effects of extreme environments 

and crew survival in space. 

Davis, Jeffrey R., MD, MS 

Dr. Davis is the Director, Human Health and Performance and Chief Medical Officer at the NASA Johnson

Space Center (JSC), Houston, Texas. He joined NASA as an operational flight surgeon in 1984 and subsequently

served as Chief, of the JSC Flight Medicine Clinic and Chief of JSC Medical Operations. Dr. Davis has served as 

Corporate Medical Director of American Airlines and Professor of Preventive Medicine and Community Health 

at the University of Texas Medical Branch, Galveston, Texas. He received his BS in Biology from Stanford 

University and MD from the University of California at San Diego. He also holds a Master of Science (MPH 

equivalent) degree from Wright State University, Dayton, Ohio. Dr. Davis’ residency training included internal 

medicine at University of California, Davis and aerospace medicine at Wright State University. He is certified

by the American Board of Preventive Medicine. Dr. Davis is the senior editor of Fundamentals of Aerospace 

Medicine, Fourth Edition. After the Columbia accident Dr. Davis established the Crew Survival Working Group. 

Flynn, Christopher F., Lieutenant Colonel, USAFR, BA, MD 

Dr. Flynn is an Associate Professor of Psychiatry and of Space Medicine at Baylor College of Medicine and 

currently the Director, Assessment Service at the Menninger Clinic. He received his BA from Berry College, 

Rome, Georgia and MD at the Medical College of Georgia. Dr. Flynn completed his residency in psychiatry at the 

University of Colorado (Denver), and studied aerospace medicine at Brooks Air Force Base in Texas. He is board 

certified in Psychiatry by the American Board of Psychiatry and Neurology. Dr. Flynn has over 20 years’ practice

caring for those who serve in difficult or dangerous environments. He deployed from 2005 to 2009 to assist US

Department of State officers and families serving in the Middle East and West Africa—later becoming Director,

Mental Health Services from 2010 to 2011. From 1996 to 2005, he served as Chief, Psychiatry and also as a flight

surgeon at the NASA Johnson Space Center. While there, Dr. Flynn helped develop NASA’s behavioral health 

program for long duration space flight; cared for astronauts and families and was crew surgeon for two space flight

missions. He is a Senior Flight Surgeon and Lieutenant Colonel in the USAF Reserves with 26 years’ experience

working with aircrews in multiple types of military aircraft. 

Gilmore, Stevan M., MD, MPH 

Dr. Gilmore has been a flight surgeon with NASA since 2002 and has been a crew surgeon for multiple Space

Shuttle and International Space Station missions. He is also assigned to support the medical operations contingency 

group providing contingency planning, training, and mission support. Dr. Gilmore studied Chemistry at Grinnell 

College prior to attending Wake Forest Bowman Gray School of Medicine. He completed clinical residencies in 

Emergency Medicine and Aerospace Medicine at Wright State University and the University of Texas Medical 

Branch respectively. Dr. Gilmore is board certified by the American Board of Emergency Medicine (ABEM).
SECTION 6 – APPENDIX 163

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

Johnston, Smith L., MD, MS 

Dr. Johnston is the Medical Director of NASA Johnson Space Center (JSC) Aerospace and Occupational Medicine 

Clinics and also the lead physician, for the JSC Wellness and Fatigue Management Programs. He received his BS in 

Biology in 1976 and his MD in 1981 from Emory University in Atlanta, Georgia. From 1984 to 1990, Dr. Johnston

completed his residencies in Internal and Aerospace Medicine from Wright State University. He is board certified

in Aerospace Medicine from the American Board of Preventive Medicine and a Fellow of the Aerospace Medical 

Association (AsMA). Dr. Johnston joined NASA in 1994 as a flight surgeon in the Medical Operations Branch of

the NASA Johnson Space Center. Over the past 20 years he has supported the medical care of the Astronaut Corps

and dependents, and served as the crew surgeon for numerous missions of NASA’s Space Shuttle and International 

Space Station (ISS) programs. Dr. Johnston has served AsMA on numerous committees over the last two decades 

and recently as the President of the Space Medicine Association in 2005, and the President of the Society of NASA

Flight Surgeons in 2006. He is a member of the clinical faculties, at the University of Texas Medical Branch,

Department of Preventive, Occupational and Environmental Medicine in Galveston, Texas, and the Wright State 

University Department of Aerospace Medicine at Dayton, Ohio. Dr. Johnston presently serves on the Board of 

Directors for Houston Medical Centers Hospice and Palliative Care System. He has served on the Advisory and 

Oversight Committees for the National Science Foundation’s American Polar Medicine Program, Washington, 

DC and has held staff positions with the Veterans Administration Medical Center Emergency Department and 

Department of Internal Medicine, Kelsey-Seybold Clinic, Inc., in Houston, Texas. Dr. Johnston was the crew 

surgeon for the STS-107 Space Shuttle Columbia crewmembers.

Lane, Helen W., BS, MS, PhD, RD 

Dr. Lane is a Senior Scientist for Biological Sciences and Applications with the Human Health and Performance 

Directorate at the Johnson Space Center, Houston, Texas. She received her BS from the University of California, 

Berkeley, MS from the University of Wisconsin, Madison, and PhD in Nutritional Biochemistry from the University 

of Florida, Gainesville. Dr. Lane was trained in dietetics at Veterans Health Administration hospitals in Madison, 

Wisconsin, and Gainesville, Florida. She was an associate professor at the University of Texas Health Science 

Center, Houston, Texas and a professor at Auburn University, Alabama. Dr. Lane joined NASA in 1989 and has

served as branch chief of biomedical laboratories, chief nutritionist, assistant to the director, and manager of 

university affairs at the Johnson Space Center. She has edited three previous books including the 2010 Wings in 

Orbit. She has published over 100 peer reviewed papers related to space flight. Dr. Lane has received many NASA

honors and was a principal investigator on Space Shuttle and Shuttle–Mir spaceflights.

Mallak, Craig T., Captain, USN (Ret.), BS, JD, MD 

Dr. Mallak received his BS in Criminalistics from Michigan State University and his JD and MD from Creighton 

University. During his career in the US Navy he has served as a General Medical Officer, Regional Armed Forces

Medical Examiner and Director of Ancillary Services, and Medical Corps Detailer. At the time of his retirement 

from the Navy, Dr. Mallak was the Armed Forces Medical Examiner. Throughout the conflicts in Iraqi and

Afghanistan he initiated the first ever complete forensic investigation of every fatality from a declared conflict. Data

gathered has been used to improve body armor, helmets, vehicles, and enhance battlefield medical care. Dr. Mallak

directed the medical investigation and analysis of NASA crewmembers following the Space Shuttle Columbia 

mishap. He is board certified by the American Board of Pathology in Anatomic and Clinical Pathology and Forensic

Pathology. Dr. Mallak is currently the Broward County Medical Examiner, Fort Lauderdale, Florida. 
164 SECTION 6 – APPENDIX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

Melroy, Pamela A., Colonel USAF (Ret.) BA, MS 

Ms. Melroy is Deputy Director, Tactical Technology Office at the Defense Advanced Research Projects Agency

(DARPA). Prior to joining DARPA she was the acting Deputy Associate Administrator and Director of Field 

Operations in the Federal Aviation Administration’s Office of Commercial Space Transportation. Ms. Melroy served

as a pilot in the USAF from 1983 to 2007 and is a veteran of Operation Just Cause and Operation Desert Shield/

Desert Storm, with more than 200 combat and combat support hours. Ms. Melroy also served as a USAF test pilot

and has logged more than 6,000 hours flight time in more than 50 different aircraft. Ms. Melroy was selected by

NASA as an astronaut candidate in 1994. She served as pilot on two Space Shuttle missions, STS-92 and STS-112.

Ms. Melroy was the Mission Commander on STS-120 in 2007. She was the second woman to command a Space

Shuttle mission. She held several key positions within the NASA Space Shuttle Program from 1994 until 2009,

including Crew Module Lead on the Columbia Reconstruction Team, Deputy Project Manager for the Columbia 

Crew Survival Investigation Team, and Branch Chief for the Orion Branch of the Astronaut Office. Ms. Melroy

holds a BA in Physics and Astronomy from Wellesley College and an MS in Earth and Planetary Sciences from 

Massachusetts Institute of Technology. 

Packham, Nigel, BS, PhD 

Dr. Packham is the Associate Director, Technical, Safety and Mission Assurance at the Johnson Space Center. He 

received his BS in Chemistry and Biology from City of London Polytechnic and PhD in Physical Electrochemistry, 

from Texas A&M University. Dr. Packham has been awarded the NASA Exceptional Achievement Medal, the

NASA Outstanding Leadership Medal, the NASA Silver Snoopy Award and numerous other JSC and Agency 

awards. Dr. Packham was a member of the Spacecraft Crew Survival Integrated Investigation Team and Project 

Manager for the Columbia Crew Survival Investigation Report. 

Patlach, Robert, Lieutenant Colonel, Texas ANG (Ret.), BS 

Mr. Patlach is a Space Flight Medical Contingency Coordinator with Wyle, Science, Technology & Engineering

Group where he supports the Human Space Flight Operations Branch, NASA Johnson Space Center. He received a 

BS degree in Electrical Engineering from The Citadel in South Carolina. Mr. Patlach was a C-130 instructor pilot

in the US Air Force and C-26 evaluator pilot in the Texas Air National Guard. During his career supporting NASA

he served as a Space Shuttle simulator instructor, a Space Shuttle payload integration engineer and a project engineer 

with the Boeing International Space Station Project Engineering Group. Mr. Patlach was a member of the Space 

Shuttle Mishap Investigation Team and was deployed to the Lufkin, Texas, disaster field office during the STS-107

Columbia crewmember recovery operation. 

Pogue, David J., BS, M. Eng. 

Mr. Pogue is an engineer with the Extravehicular Activity, Robotics and Crew Systems Operations Division within 

the Mission Operations Directorate (MOD) at the Johnson Space Center. He has served MOD as the International 

Space Station Crew Systems Lead, the Space Shuttle Crew Escape Lead, the Technical Lead of the Crew Systems 

Group, and the Lead for Exploration Crew Systems and Crew Survival Operations. He received his BS and Masters 

of Engineering in Biomedical Engineering from Texas A&M University. Mr. Pogue has been awarded the NASA

Exceptional Engineering Achievement Medal, NASA Silver Snoopy, and numerous NASA Group Achievement 

Awards. Mr. Pogue was the Crew Equipment Team Lead for the Spacecraft Crew Survival Integrated Investigation 

Team and was a major author of the Columbia Crew Survival Investigation Report. 
SECTION 6 – APPENDIX 165

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

Scarpa, Philip J., MD, MS 

Dr. Scarpa is the Deputy Chief Medical Officer at the NASA Kennedy Space Center in Florida. He received his

BS in Biology from Rutgers University and MD from Rutgers Medical School. He also holds a Master of Science 

(MPH equivalent) degree from Wright State University in Dayton, Ohio. Dr. Scarpa completed residency training in 

Internal Medicine at the University of Medicine and Dentistry of New Jersey and in Aerospace Medicine at Wright 

State University. He is currently certified by the American Board of Preventive Medicine in Aerospace Medicine and

Occupational Medicine. Dr. Scarpa led the biomedical management of the Space Shuttle Columbia reconstruction 

and analysis activities conducted at the Kennedy Space Center. 

Shafer, Donna M., BS, JD 

Ms. Shafer is the Deputy Chief Counsel at the NASA Johnson Space Center. She earned a BS in Criminal Justice 

from Midwestern State University in 1987 and a JD from the University of Houston in 1994. Ms. Shafer began her

career at JSC in 1989 as a security specialist, and joined the Office of Chief Counsel in 1997 where she has held

progressively more responsible positions. She has experience in all legal practice areas, and served as the Assistant 

Chief Counsel for Procurement matters, Assistant Chief Counsel for International matters, and the Assistant Chief 

Counsel for General Legal matters. Ms. Shafer served as the legal advisor to the Columbia Task Force. She has 

received numerous awards and recognition for her work, including being named NASA Attorney of the Year in 

2004, a NASA Space Flight Awareness award in 2008, the NASA Silver Snoopy in 2010, the Michael Taylor Shelby

Award in 2011, the NASA Legal Leadership award in 2012, and a NASA Outstanding Leadership Medal in 2013.

Stepaniak, Philip C., MD, MS 

Dr. Philip C. Stepaniak currently serves as a NASA operational flight surgeon for the International Space Station

Program at the Johnson Space Center (JSC), Houston, Texas. He is also the lead medical operations flight surgeon

to the JSC Contingency Medical Group for NASA aircraft and spacecraft accidents. Dr. Stepaniak received his MD 

from the Northeast Ohio Medical University. He is residency trained in Aerospace and Emergency Medicine from 

Wright State University and is board certified in Emergency Medicine. Past positions include the lead Medical

Operations Branch flight surgeon for the Space Shuttle Program and Medical Operations Training Group. Since

1986 Dr. Stepaniak has supported crews for 29 Space Shuttle flights as their flight surgeon. These flights included

STS-71, the first Shuttle-MIR docking in 1995; STS-95, which flew Senator and former astronaut John Glenn in

1998; STS-96, the first Space Shuttle and International Space Station docking mission in 1999; STS-125, the final

Hubble Space Telescope repair mission in 2009, and STS-135, the final flight of the Space Shuttle Program in 2011.

Dr. Stepaniak has achieved numerous NASA service awards including the Stellar Award from the Rotary National 

Space Foundation presented in 1999 for operational excellence in aerospace medicine. He is a former major and

flight surgeon with the United States Air Force Reserve and is a member of the Society of NASA Flight Surgeons.

During the Columbia STS-107 accident Dr. Stepaniak served as the medical lead for the Mishap Investigation Team

(MIT) at Barksdale AFB, Louisiana, during crewmember recovery and identification operations.
166 SECTION 6 – APPENDIX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

Wetherbee, James D., Captain, USN (Ret.), BS 

Mr. Wetherbee received a BS in Aerospace Engineering from the University of Notre Dame in 1974. He is a former

NASA astronaut, selected in 1984. Mr. Wetherbee flew six flights aboard the Space Shuttle, including docking

missions to the International Space Station and the Russian Space Station, Mir. He is the only American to have 

commanded five missions in space. During his 20-year career at NASA, Mr. Wetherbee held the management

positions of Deputy Director, Johnson Space Center, and Director, Flight Crew Operations. Mr. Wetherbee 

was a US Naval Aviator and test pilot, and has logged 7,000 flight hours in 20 types of air and space vehicles,

with 345 carrier arrested landings. In 2009, Mr. Wetherbee was inducted into the US Astronaut Hall of Fame.

During his military career, Mr. Wetherbee was awarded a Distinguished Flying Cross, Navy Achievement Medal, 

two Meritorious Unit Commendations, six Space Flight Medals, two Outstanding Leadership Medals, and four 

Distinguished Service Medals. He is a lifetime member of the Society of Experimental Test Pilots, and an 

honorary member, Musicians’ Union, Local 47, American Federation of Musicians, Los Angeles, California.

From February 1 through February 13, 2003, Mr. Wetherbee was the Operational Search Director for the human

remains of the Columbia crew in Lufkin, Texas. 

Woods, Karon S. B., BS 

Ms. Woods is the crew survival and operations specialist for the Safety and Mission Assurance Directorate at the 

Johnson Space Center. She has also served as an International Space Station Safety Risk Analyst and Emergency 

Response Strategy Specialist, and Space Shuttle Probabilistic Risk Assessment Lead for the Safety and Mission 

Assurance Directorate and as the Shuttle Training Aircraft Project Engineer for the Flight Crew Operations 

Directorate. She has authored numerous technical papers on the subjects of damage-tolerance of aging aircraft and 

on Space Shuttle mission integrated probabilistic risk assessment, and a reference manual for performing a crew 

survivability investigation. Ms. Woods has a BS in Aeronautical and Astronautical Engineering from The Ohio 

State University. She is the recipient of the NASA Flight Safety Award, NASA Silver Snoopy, NASA Exceptional 

Service Medal and numerous NASA Group Achievement Awards. 

Xenofos, Amy Voigt, JD 

Ms. Xenofos is the Assistant Chief Counsel for General Law and External Partnerships at NASA’s Johnson 

Space Center in Houston, Texas, and has been with NASA since August 2000. Her areas of responsibility include

government ethics, personnel/equal employment opportunity matters, environmental and real property matters, tort

claims and litigation, internal NASA policies and processes, fiscal law, Freedom of Information Act/Privacy Act

matters, and agreements and partnerships using NASA’s “other transaction” authority. Ms. Xenofos served as the

legal advisor to the NASA Mishap Investigation Team during the Space Shuttle Columbia investigation in 2003.

She spent 2 years working at NASA Headquarters serving as lead counsel for the Exploration Systems Mission

Directorate and 6 months in the Office of Procurement working on procurement policy matters. She received her

juris doctorate, cum laude, from The Florida State University College of Law in 2000 and is an active member of

the Florida Bar and the American Bar Association. 
SECTION 6 – APPENDIX 167

	 	 	

	 	 	

	 	 	

	 	 	 	 	

	 	 	 	

	 	 	 	

	 	 	 	 	

	 	 	

	 	 	 	 	 	

				 	 	 	 	 	

	 	 	 	

				 	

				 	 	 	

				 	 	

								 	

	 	

	 	 	 	

	 	 	 	 	

				

	 	

	 	 	 	

	 	

				

				 	 	

	 	 	 	 	

	 	 	 	 	

	 	 	 	

	 	

	 	

	 	 	 	 	

	 	 	

				 	

	 	 	

	 	

	 	 	 	

	 	 	 	 	 	

				 	 	

	 	 	 	

	 	 	 	

				 	

	 	 	 	

	 	 	

	 	 	

	 	 	 	 	

				 	

	 	 	

				 	 	 	 	

	 	 	 	 	

				

	 	 	 	

	 	 	 	

	 	 	 	 	 	

	 	 	 	 	

				

				

	 	

	 	 	 	 	 	 	

				 	

	 	 	

	 	 	

	 	

	 	 	

 

	 	

	 	 	 	 	 	

				 	

	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	

	 	

	 	

	 	

	 	 	 	 	 	

	 	 	

				 	

	 	

				

	 	 	 	 	 	 	

	 	 	 	

	 	 	

				 	 	

	 	

	 	

	 	 	

				

	 	 	 	

	 	 	 	

	 	 	

				 	 	

				

				

	 	 	 	 	

				

	 	 	 	 	

	 	 	

	 	 	 	 	

				 	 	

	 	 	 	

				 	 	

	 	 	

	 	 	

	 	 	 	

				 	 	 	 	 	 	

				 	

	 	 	 	

				 	

	 	 	 	

	 	 	 	

				

				 	

	 	 	

				 	

	 	 	

	 	 	 	

				 	

	 	 	 	 	 	

Index
 

A 

acceleration forces 

analyzing injuries from, 147
 

ejection seat risks, 127–128
 

during forebody separation, 91
 

and human performance limits, 142, 143
 

and life-support equipment losses, 36
 

post-CMCE effects on crew, 93
 

windblast effects, 93, 106, 108, 110
 

accident investigation, importance of, x–xi
 

ACES (Advanced Crew Escape Suit), 32,
 

98, 108, 111, 112, 129, 137
 

aerodynamic flail injury, 106, 148
 

Aerospace Medical Association (AsMA), 

32, 42
 

Aerospace Medicine and Occupational 

Health Branch, KSC, 42
 

aero-thermal analysis, crew survival 

investigation, 133, 144
 

AFIP (Armed Forces Institute of 

Pathology), 133
 

capabilities of, 42
 

cause of death analysis, 81
 

contingency planning with NASA, 39,
 

42
 

DDMS coordination with, 50
 

forensic support to CSWG, 80
 

location of, 42
 

and reconstruction hangar specimens, 

58–59

reporting of specimens collected after 

recovery termination, 30
 

transfer of human remains to, 29
 

TWA 800 accident forensic analysis, 32
 

Air Operations Officer, recovery, 21
 

Anderson, Michael P. 

during mission, 7
 

official photo, ix
 

profile and role in mission, 4–5
 

and team cohesion, 69
 

at Terminal Countdown Demonstration 

Test, 66
 

in training module, 149
 

Andreev, Evgeny, 126
 

Apollo 1 fire, 5, 124–125
 

Apollo 15 command module with one
 

unopened parachute, 126
 

approach through landing phase, 10
 

Archivist of the US, 117
 

Armed Forces Institute of Pathology 

(AFIP). See AFIP 

Armed Forces Medical Examiner System, 

41. See also OAFME
 

Armstrong’s line, 102, 112, 147
 

Army Medical Museum, 42
 

arterial gas embolism, 147
 

astronauts. See also crewmembers 

briefing for assignees in recovery
 

process, 22–23
 

egress training for, 32
 

psychological challenges and support for 

recovery teams, 22–23, 30–31, 84
 

SLSD’s mission of support to, 49
 

atomic oxygen (O2

), 92
 

autopsies, guidance for crew survival 

investigation, 149–150
 

aviation vs. space flight environments, 135
 

awareness, crew, 89, 97, 100–102
 

B 

Bagian, James, 29, 35, 50, 51, 76
 

bailout equipment and procedures, 32,
 

129–130
 

ballistics analysis, crew survival 

investigation, 143
 

Banks, Robert, 51–52
 

Barksdale AFB, Louisiana, 14, 19, 33, 34,
 

35, 43
 

barotraumas, 97, 102, 146–147
 

Batesville Casket Company, 35
 

Bauer, Peter, 37
 

Baumgartner, Felix, 93, 127
 

behavioral health team (JSC). See

 psychological and medical support 

operations 

Benz, Frank, 79
 

biological payloads, recovery of, 51, 60,
 

64, 131
 

Black, Col Rabbi Ahron Zwi, 37, 44
 

Blue Team, 4–5, 10, 67
 

bracing injuries at CE, 100, 101, 147
 

Brown, David M. 

flight surgeon qualifications, 70
 

during mission, 7
 

official photo, ix
 

profile and role in mission, 4–5, 6
 

and team cohesion, 69
 

at Terminal Countdown Demonstration 

Test, 66
 

Bruce, James, 34
 

burn injuries during thermal events, 

108–110
 

Bush, President George W., 13, 15, 44, 115
 

Bush, Governor (Florida) Jeb, 15
 

C 

cabin depressurization, 88–91, 97,
 

101–103, 112, 146
 

CAIB (Columbia Accident Investigation 

Board) 

background of organization, 77
 

challenges of investigation, 76
 

crew recovery operations, 78–80
 

crew-vehicle requirement 

recommendations, 86
 

CSWG organization and analysis, 80–83
 

findings, 82
 

formation of, ix, 50, 114
 

Gehman’s leadership of, 13
 

importance of independence from 

NASA, 84, 85
 

information control and record keeping, 

116–117

lessons learned and recommendations, 

84
 

medical operations CMG’s briefing of,
 

35
 

members, 79
 

return to flight recommendations, ix, 130
 

CAIB Document Database, 116–117
 

CAP (Contingency Action Plan), SLSD, 13,
 

50, 53, 77
 

carbon-carbon panels, 9, 11, 131
 

car racing protective systems technology 

for spacecraft, 91
 

Carroway–Claybar Funeral Home, 35
 

Caruso, CDR James, 35
 

Casualty Assistance Calls Officers
 

(CACOs), 37, 46, 51, 69, 70, 72
 

cataloging procedures for investigation 

data, 135
 

causal investigation 

crew death, 36, 80, 111
 

early focus of CAIB on overall cause of 

mishap, 79
 

overview for entire mishap, ix–x
 

CE (Catastrophic Event) 

breakup sequence representation, 86–87,
 

100
 

CSWG’s conclusion on orbiter 

separation, 82
 

impact on crew, 97
 

injuries after but prior to CMCE, 

103–106, 108
 

injuries during, 100–101, 147
 

photographic recording of, 87, 136
 

points of separation representation, 

67, 107
 

CEE (crew egress and escape), iv, 128–130
 
168 SECTION 6 – APPENDIX

	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	

				

	 	

				 	 	

	 	 	

	 	 	

	 	

	 	 	 	 	 	

	 	 	 	 	

	 	 	

				 	 	

				 	

	 	 	 	 	 	

	 	 	

	 	 	 	

				 	

	 	 	

	 	

	 	

	 	 	 	 	 	

	 	 	

				 	

	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

				

	 	 	 	

	 	 	 	 	

				 	

	 	 	 	

	 	

	 	 	

	 	

	 	

	 	 	 	 	 	

	 	 	

				 	

	 	 	

	 	 	 	

				 	 	

				 	 	 	 	 	 	

									 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

				 	

	 	 	 	

	 	 	 	 	

	 	 	

	 	 	 	

				 	 	 	

				 	 	 	

				 	 	

				 	

	 	 	 	

	 	 	 	

	 	 	

	 	 	

	 	

	 	 	 	 	

				

	 	 	 	 	

	 	 	 	

	 	 	 	 	

				 	 	

				 	

	 	 	 	 	 	

				

	 	

				 	

	 	 	

	 	 	

				 	

	 	

	 	 	 	 	 	 	 	

	 	 	

				 	 	 	 	 	

	 	 	 	 	

				 	

	 	 	 	 	 	

				

	 	

	 	 	 	 	 	

				 	 	

				 	

				 	 	 	 	

	 	 	 	 	

				 	 	 	 	

	 	 	

				 	 	

	 	 	 	

				 	 	

				 	

				 	

	 	 	 	

	 	 	 	 	 	

				 	

	 	 	 	

	 	 	 	

	 	 	 	

	 	 	 	 	 	

				

	 	 	 	 	 	 	

				 	 	

	 	 	 	 	

				 	

	 	 	 	 	 	

				 	

	 	 	 	

				 	 	 	

	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

				 	

 

	 	 	

	 	

	 	 	 	 	

				 	 	 	 	 	 	 	

	 	 	 	

				 	 	 	

	 	 	 	 	 	 	

				 	

				 	 	

	 	 	 	 	 	

				

				 	 	 	 	

	 	 	 	 	 	

				

				

	 	

	 	 	

	 	 	 	 	

				

	 	

cell phone coverage challenge, 20, 62, 76
 

ceremonial last rites, 28
 

CFS (chief flight surgeon), 76, 78, 79,
 

80–81
 

Chaffee, Roger, 125
 

chain-of-custody procedures for handling 

crew remains, 39
 

Challenger mishap 

AFIP’s work on, 81
 

Bagian’s work on, 29
 

vs. Columbia, 131
 

contingency plan result of, 28, 32, 114
 

crew egress and escape system, 128–130
 

forces causing breakup, 130
 

and importance of independent 

investigation board, 121
 

and psychological effects of recovery 

operation, 31
 

STS-107 crew’s honoring of those lost, 5
 

Chance-type fracture, 105, 106
 

Chandler, Michael, 33, 34, 50
 

Charles C. Carson Center for Mortuary 

Affairs, 48
 

Chawla, Kalpana 

in middeck sleep compartments, 67
 

during mission, 7
 

official photo, ix
 

profile and role in mission, 4–5, 6
 

and team cohesion, 69
 

at Terminal Countdown Demonstration 

Test, 66
 

chemical toxicity 

in crew survival analysis, 140, 146
 

hazards with Shuttle debris, 19, 41, 50
 

chief flight surgeon (CFS), 76, 78, 79,
 

80–81
 

circadian adjustment lighting schedule, 68
 

CISD (Critical Incident Stress Debriefing),
 

56, 57
 

Clark, Jonathan, 70, 81, 83
 

Clark, Laurel B. 

flight surgeon qualifications, 70
 

in middeck sleep compartments, 67
 

during mission, 7
 

official photo, ix
 

profile and role in mission, 4–5, 6
 

and team cohesion, 69
 

at Terminal Countdown Demonstration 

Test, 66
 

in training module, 149
 

climate change, STS-107’s onboard
 

research on, 4
 

CMCE (Crew Module Catastrophic Event) 

cause of crew module breakup, 82,
 

86–87, 89, 92
 

CSWG’s assessment of timing of, 80
 

effect on crew (injuries), 92, 93, 97, 100,
 

106, 108–111
 

flight deck disposition at, 111
 

lack of fire evidence, 109, 113
 

photographic record of, 89
 

CMG (Contingency Medical Group), 14,
 

32–40, 42, 51. See also MIT
 

cold temperatures, effect on crew bodies 

after CMCE, 93, 110
 

Columbia Accident Investigation Board 

(CAIB). See CAIB 

Columbia Crew Survival Investigation 

Report, 86–94, 121
 

Columbia Space Shuttle. See also debris 

recovery; STS-107
 

carbon-carbon panels, 9, 11, 131
 

chemical toxicity hazards, 41, 50
 

at first launch, 2
 

history of operations, 3
 

name origin, 2
 

reconstruction of, 14, 58–61, 63–64,
 

138–140
 

Columbia Task Force (CTF), 114, 116–117
 

command centers, 19–20, 34, 35
 

commercial space flight, Columbia lessons
 

applied to, 132
 

communications 

CACOs’ role in providing for families, 

38, 72
 

cell phone challenges, 20, 22, 62, 76
 

contribution to recovery mission success, 

53
 

establishing radio, 20
 

etiquette and security for recovery 

personnel, 23
 

KSC’s lessons learned, 62
 

MIT’s lessons learned, 40
 

need for improved mishap response and 

recovery, 84
 

recovery overview, 20
 

security of, 22, 29, 34, 35, 76, 78, 84
 

compartmentalization strategy for
 

psychological stress, 30, 58, 70, 73
 

confidentiality and sensitivity issues, xi,
 

29, 80
 

confirmation bias issue for crew survival
 

investigation, 80–81
 

Constellation Program, 134
 

contamination of debris, assessment of, 19,
 

41, 50, 58
 

Contingency Action Plan (CAP), 

agency, 77
 

SLSD, 13, 34, 50, 53
 

Contingency Medical Group (CMG), 14,
 

32–40, 42, 50–51, 114. See also MIT
 

contingency planning
 

AFIP–OAFME’s contribution to
 

NASA’s, 39, 42
 

JSC’s activation of plan, 13
 

post-Challenger mishap recognition of 

need for, 114
 

crashworthy data recorder for future 

spacecraft, 132
 

Crew and Thermal Systems Division, JSC, 

38, 46
 

crew cabin environment analysis, 145–146
 

crew egress and escape (CEE), 89, 128–130
 

crew equipment analysis, 89, 92–93, 112,
 

137, 147–148
 

Crew Escape Module Study, 129
 

crew escape pole, 129, 130
 

crewmembers. See also crew recovery; 

crew survival investigation; individual 

crewmembers by name 

actions prior to CE, 97
 

awareness levels during mishap, 89, 97,
 

100–102
 

cause of death investigation, x, 78, 82,
 

111, 119, 131
 

disposition of remains, 35, 44, 46
 

as experimental subjects during mission, 

4, 67–68
 

hazards of space environment for, xi,
 

124, 135
 

information sensitivity and control, xi
 

life-support equipment (See life-support 

equipment)
 

medical examiner findings, 47, 81
 

normal disposition upon successful 

landing at KSC, 55
 

qualifications and roles, 4–7
 

training for STS-107, 3, 4
 

crew module, 89, 92, 93, 97–98, 100, 110,
 

131, 139
 

Crew Module Catastrophic Event (CMCE). 

See CMCE 

crew recovery 

AFIP–OAFME’s role in, 42–46
 

CAIB’s perspective, 78–80
 

care of crew remains during, 28–29
 

dignity, honor, and reverence imperative, 

18, 23, 24–25, 28, 35, 37–38, 39, 46
 

disposition plan for remains, 35
 

geographic distribution of remains and 

associated equipment, 36, 111
 

MIT’s role in, 14, 32–40, 50–51, 76, 114
 

reconstruction of Shuttle, screening for 

remains, 58–60

search and recovery team operations, 

18–31, 38, 78
 

transfer of crew remains, 28–29, 37–38,
 

45
 

Crew Survivability Working Group 

(CSWG), ix–x, 51, 80–83, 130
 

crew survival investigation. See also

 forensic pathology analysis; injury 

analysis; SCSIIT 

awareness levels during mishap, 89, 97,
 

100–102
 

Challenger mishap lessons learned, 

128–130
 

challenges of, 124
 

closing survival gap, 131
 

Columbia accident as not survivable, 88
 

Columbia mishap lessons learned, 

130–131
 

conclusions and recommendations, 133
 
SECTION 6 – APPENDIX 169

	 	 	 	 	

				 	

	 	 	

				 	

	 	

	 	

	 	 	 	

	 	

	 	

				 	 	 	 	

	 	 	 	 	

	 	 	

	 	 	 	 	 	

				

	 	 	 	 	 	

				 	

	 	 	 	

	 	 	 	 	 	

	 	 	

	 	 	 	 	

	 	 	 	

				 	 	 	 	 	 	

	 	 	

	 	 	

	 	 	 	 	 	

				 	

	 	 	 	 	

	 	 	 	 	

	 	 	 	 	

				

	 	 	

				 	 	 	

	 	 	 	 	

				 	

	 	 	 	

				 	 	

				

	 	

	 	 	

	 	 	 	 	 	

	 	 	 	 	

				

				 	 	 	 	 	 	 	

								 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

				

				 	 	 	 	 	 	

	 	 	 	 	

	 	

	 	 	

	 	 	 	 	 	 		

				 	 	

	 	 	 	

				 	

	 	

	 	 	 	 	 	 	

	 	 	

	 	 	 	

	 	 	

	 	 	

				 	

				

	 	 	

	 	 	

	 	 	

				 	 	

				 	

	 	 	 	

				 	 	

	 	 	 	

	 	 	

				 	 	

	 	 	

				

	 	

	 	 	 	

	 	 	 	 	

				

	 	

				 	

	 	 	 	 	 		

				 	

	 	 	 	

	 	 	

	 	 	

				 	 	 	

	 	 	 	 	

				 	 	 	

	 	 	 	 	 	

				 	 	

				

	 	 	 	

				 	 	 	 	

	 	 	 	 	

				 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

				

	 	 	

	 	 	

	 	 	 	 	 	

				 	

	 	 	 	 	 	

	 	 	 	 	

	 	

	 	 	 	 	

				

	 	 	 	 	

	 	 	

				 	 	

				 	

	 	 	 	 	 	

	 	 	 	 	 	

				

	 	 	

				

	 	

	 	

	 	 	 	 	 	

				

				

	 	

	 	 	

	 	

	 	 	

	 	 	

	 	 	 	 	 	 	

				 	

early evidence from STS-107 applied
 

to, 79
 

ejection seats, 127–128, 129
 

future considerations for lessons learned, 

132–133, 134–151
 

historical mishaps, 124–127
 

importance of, 84
 

SLSD role, 51, 53, 79
 

crew-worn/crew-donned life-support

 equipment. See life-support equipment 

Crippen, Robert, 15
 

CSWG (Crew Survivability Working 

Group), ix–x, 51, 80–83, 130
 

CTF (Columbia Task Force), 114, 116
 

CTF Document Database, 117
 

D 

damage to orbiter from launch, 10–11, 56
 

databases for investigation documentation, 

116–117

data collection and information control 

communications security, 22, 29, 34, 35,
 

76, 78
 

future recommendations, 135–136
 

impact on families, 51, 71–72
 

information security, xi, 29, 38, 40, 80
 

legal aspects, 115–117, 119–122
 

news sources issue for KSC, 62–63
 

Davis, Jeffrey, 34, 51, 79
 

DDMS (DOD Manned Space Flight 

Program Support Office), 32, 42, 46, 50
 

death certificates, 46, 119
 

Death Investigation System, Texas, 119
 

debris damage at launch of STS-107,
 

10–11, 56
 

debris recovery and analysis 

accessibility of debris after recovery, 61
 

biological payloads, 51, 60, 64, 131
 

crew-related debris, 38, 45, 80, 140
 

and crew survival future 

recommendations, 137–140
 

EPA’s role in, 19
 

overview, 14
 

procedures for commingled crew 

remains and debris, 30
 

reconstruction of Shuttle, 14, 58–61,
 

63–64, 138–140
 

deceleration injury, 106, 110, 148
 

decision-making guidelines for search and 

recovery, 23, 24–25

deconditioning of crewmembers from 

microgravity, 130
 

dental records, 37
 

deorbit burn, 11, 89
 

deorbit preparation, lack of time for, 89
 

depressurization, 88–91, 97, 101–103, 112,
 

dignity, honor, and reverence imperative, 

18, 22–23, 24–25, 28, 31, 35, 37–38,
 

39, 46
 

Disaster Field Offices, 14, 34, 35, 43
 

DNA analysis of crew remains, 26, 29, 37,
 

45
 

DOD Manned Space Flight Program 

Support Office (DDMS), 32, 42, 46, 50
 

dog teams in recovery operations, 27–28

Dolgov, Pyotr, 126
 

double sonic boom, 10
 

Dover AFB, Delaware, 28, 29, 31, 33,
 

35–39, 42–48, 51
 

Dover Mortuary Affairs Office, 37
 

dynamic rotating environment, effect on 

crew, 91–92

E 

ear barotrauma, 102
 

ebullism, 102, 103, 112, 124, 127, 133, 147
 

Effenhauser, Rainer, 51, 79
 

8, 8, 8 Rule, 25
 

ejection seats, 127–128, 129
 

Emergency Assistance Act, 115
 

emergency planning. See contingency 

planning 

EMS (emergency medical services) at KSC, 

32, 55
 

energy-management maneuvers on reentry, 

10–12

engineering analysis, CSWG, 81
 

Engineering Directorate, JSC, 80
 

entry interface point, 10
 

environmental analysis, crew survival 

investigation, 145. See also acceleration 

forces 

EPA (Environmental Protection Agency), 

14, 19
 

equipment analysis, crew, 147–148. See 

also life-support equipment 

ERTs (Evidence Response Teams), FBI, 

18–19, 24, 30
 

escape suits, 32, 129. See also pressure 

suits
 

ET (external tank), 54
 

European Research in Space and Terrestrial 

Osteoporosis experiment, 7
 

Export Administration Regulations, 115
 

Export Control Act, 115
 

F 

FACA (Federal Advisory Committee Act), 

115–116
 

fail-safe parachute, 131
 

families 

approval of CSWG report, 83
 

CACOs’ role in providing for, 72
 

consultation on disposition of remains, 

46
 

dissemination of identification
 

information, 29
 

flight surgeons’support role for, 33,

50–51, 70–71
 

informing of by MIT, 37
 

KSC’s focus on, 56–57
 

privacy rights, 40, 119–122
 

providing accurate and timely 

information for, 51, 71–72
 

and reluctance to publicize crew’s
 

mishap experience, 81, 83
 

FBI (Federal Bureau of Investigation), 14,
 

18–19, 24, 80
 

Federal Advisory Committee Act (FACA), 

115–116
 

Federal Tort Claims Act, 118
 

FEMA (Federal Emergency Management 

Agency), 14, 19, 115, 117
 

field conditions, recovery challenges, 18,
 

27, 57
 

financial impacts on crew protection, 3, 129
 

fire in CMCE, lack of evidence for, 109,
 

113
 

Fischer, Craig, 37–38, 51
 

five-point harness system, 105
 

flail injuries, 103–104, 106, 111, 147, 148
 

Flight Crew Operations Directorate, NASA, 

18, 21
 

flight deck, 3, 97, 98, 111, 139
 

flight dynamics, 8–10, 87, 91–92, 99, 143
 

flight suits for Challenger crew, 128
 

flight surgeons. See also MIT; 

psychological and medical support 

operations 

CFS’s investigative role, 76, 78, 79,
 

80–81
 

as consultants for STS-107 mission, 4
 

contingency planning with AFIP–
 

OAFME, 39, 42
 

emergency procedures coordination at 

KSC, 55
 

family support role of, 33, 50, 70–71
 

mission support for crews, 33, 63,
 

65–68
 

in team cohesion, 69–70
 

training and support role for astronauts, 

32–33
 

Flynn, Chris, 30
 

Foale, Michael, 130
 

foam debris damage to Columbia, 10–11,
 

56
 

forebody-midbody separation. See CE 

(Catastrophic Event) 

foreign material in crew survival analysis, 

140
 

forensic pathology analysis. See also AFIP 

crew awareness, 97
 

crew configuration during reentry, 98
 

CSWG report, 81
 

data protection importance, 135
 

depressurization injuries, 102–103, 146
 

DNA analysis of crew remains, 26, 29,
 

37, 45
 

146
170 SECTION 6 – APPENDIX

	 	 	 	 	 	

	 	

				

	 	 	 	 	 	

				 	 	

	 	 	 	 	

	 	 	 	

				 	

	 	 	

	 	 	 	

	 	 	 	 	

	 	 	

	 	 	 	

				

	 	 	

	 	 	 	 	 	

	 	

	 	 	 	 	

				

				 	

				 	

				

	 	

	 	 	

				 	

				

				

	 	 	

	 	 	

	 	

	 	

	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	

				

				 	

	 	 	

	 	 	 	

	 	 	 	

				 	 	

	 	 	 	

	 	 	 	

	 	

	 	

	 	 	

	 	 	

	 	 	

	 	 	 	

				 	 	

	 	 	

				 	

	 	 	 	

	 	 	 	 	 	 	

				 	

				 	 	

	 	 	

	 	

	 	

	 	 	

	 	 	 	 	

	 	 	 	 	

				

	 	 	 	

	 	

				 	

				

	 	 	

	 	

	 	

	 	 	 	 	

	 	 	

				 	

	 	

	 	 	 	

	 	 	 	 	 	 	

				 	

				 	

	 	 	

	 	 	 	 	 	 	

				 	 	 	 	

	 	 	

	 	 	 	

	 	 	 	

				 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	

	 	 	

				 	

	 	 	 	

	 	 	

	 	 	

	 	 	 	

	 	 	 	 	

	 	 	 	

				

	 	

	 	 	

	 	

	 	 	

	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

 	 	 	

	 	 	 	

	 	

	 	

	 	 	

				 	 	

	 	

	 	 	

	 	 	

	 	

	 	 	

	 	 	

	 	 	

	 	

				 	

	 	 	

	 	

	 	 	 	

	 	 	 	

	 	 	

	 	 	 	

ebullism, 102, 103, 112, 124, 127, 147
 

findings and recommendations, 112–113
 

future considerations for crew survival, 

148
 

identification of crew remains, 28, 29,
 

35, 36–37, 44–45
 

importance of swift recovery for, 24–25
 

introduction, 96
 

mechanical injuries, 100–101, 103–106,
 

110–111, 112
 

OAFME’s role, 41, 45
 

orbiter motion entry simulation, 99
 

Ortega’s role in support of, 38
 

overview, 29
 

summary, 111
 

thermal injuries, 106, 108–110
 

timeline of crew-related events, 113
 

and timing of human remains transfer, 

28–29
 

Fort Polk, Louisiana, 26
 

Fort Worth Naval Air Station, Texas, 14
 

Forward Coordinator, recovery, 21
 

forward-deployed execution posts, 19, 20,
 

21
 

Freedom of Information Act (FOIA) 

(1966), 115
 

free-fall descent of crewmember remains, 

110, 111
 

future considerations for crew survival 

crew cabin environment assessments, 

145–147

crew condition, 148–149

crew equipment assessment, 147–148

crew survival investigation assessment, 

141, 142
 

data and information management, 

135–136

debris recovery and reconstruction, 

137–140
 

imagery, 136–137
 

introduction, 134
 

mechanisms of survival, 150–151
 

medical forensics assessment, 148
 

spacecraft assessments, 141, 143–145
 

space flight considerations, 135
 

team member selection, 135
 

timelines, 140–141
 

G 

Gehman, Adm. Harold W., 13, 50, 83, 114
 

G loads on crew, 97, 110–111, 127
 

GPS (Global Positioning System), 27, 131,
 

132
 

grieving process for families and friends, 

supporting, 70–71
 

Grissom, Virgil “Gus,” 125
 

ground impact, 94, 110, 111
 

ground observations of STS-107 reentry
 

and breakup, 12–13

Ground Operations Officer, recovery, 21
 

ground system historical incidents, 124
 

ground-truth data, 25
 

Grunsfeld, John, 21
 

H 

Ham, Capt. Kenneth, 38
 

Hansen, Laurie, 51, 79
 

Hart, Stephen, 33, 51
 

hazardous materials handling during
 

recovery, 41, 50
 

head flail injuries, 103–104
 

helicopter spotters in recovery operations, 

28, 57–58

helmets 

Challenger’s launch and entry, 128
 

impact of rotational motion on, 91, 103,
 

104, 111
 

need for automatic visor activation, 

89–90, 103, 112
 

Hemphill, Texas, 14, 73
 

high-altitude mishaps, 125–127
 

Hite, Greg, 51
 

Horowitz, Col Scott, 21
 

horse teams in recovery operations, 28
 

Howell, Gen Jefferson, 50, 51, 80
 

human factors in environmental analysis, 

145
 

human forensic analysis, CSWG, 81
 

human performance limits, 142
 

Human Remains for Columbia Recovery 

Guidelines, 116
 

Human Space Flight Independent 

Investigation Commission, 121–122

Husband, Rick D. 

in middeck sleep compartments, 67
 

during mission, 7
 

official photo, ix
 

profile and role in mission, 4–5
 

reentry activities prior to mishap, 11
 

and team cohesion, 69
 

at Terminal Countdown Demonstration 

Test, 66
 

hypervelocity. See acceleration forces 

hypoxia, 102, 146
 

I
 

ICM (Isothermal Containment Module), 7
 

identification of crew remains, 28, 29, 35,
 

36–37, 44–45
 

imagery, management recommendations 

for, 136–137

impact injuries. See mechanical injuries 

incapacitation of crew, 101–103
 

inertial reel mechanism failure to lock, 91,
 

92, 100, 105, 112, 131
 

information control. See data collection and 

information control 

injury analysis. See also acceleration 

forces; mechanical injuries; thermal 

 injuries and effects 

barotraumas, 97, 102, 146–147
 

deceleration injury, 106, 110, 148
 

depressurization, 88–91, 97, 101–103,
 

112, 146
 

ebullism, 102, 103, 112, 124, 127, 147
 

helmets as cause of injury, 91, 103, 104,

 111
 

life-support equipment, 38, 46, 148
 

MIT’s observations of patterns, 36–37
 

OAFME’s reasons for not providing 

conclusions, 45–46
 

investigation phase legal issues, 119–121
 

Irwin, James B., 126
 

Isothermal Containment Module (ICM), 7
 

Israeli Space Agency, 4. See also Ramon, 

Ilan 

ISS (International Space Station), ix, x, 3
 

ITAR (International Traffic in Arms
 

Regulations), 115
 

Ivins, Marsha, 21
 

J 

James, John T., 50
 

Jarvis, Gregory, 128
 

Jennings, James L., 15
 

Jett, Capt Brent, 21
 

Johnston, Smith, 33, 43, 51
 

JSC (Johnson Space Center), 13, 38, 46, 80.
 

See also flight surgeons; psychological

and medical support operations; SLSD 

jurisdiction for crew remains, 44
 

K 

King, David, 20–21
 

Kittinger, Joe, 125–126
 

Knittel, Capt Douglas, 34
 

KSC (Kennedy Space Center) 

Aerospace Medicine and Occupational 

Health Branch, 42
 

conclusions and recommendations, 64
 

debris handling protocol, 58
 

debris recovery role, 14
 

emergency planning, 55–56
 

EMS at, 32, 55
 

families focus of, 56–57
 

landing day support, 56–57
 

lessons learned, 62–64
 

long-term disposition of recovered 

debris, 61
 

medical support system, 54–55
 

memorials, 15, 62
 

protection of hangar personnel, 60–61
 

reconstruction of Columbia debris, 58
 

recovery operations support, 57–58
 

screening for human remains, 58–60
 
SECTION 6 – APPENDIX 171

	 	 	 	

				 	

	 	 	

				 	

	 	 	 	 	

				

	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	

	 	 	 	 	 	

				 	 	 	

	 	 	 	

	 	 	 	 	

	 	 	

	 	

				

	 	 	

	 	 	 	

				 	 	 	

	 	 	 	

	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	

	 	 	 	

				 	

	 	 	 	

				 	 	

	 	

	 	 	 	 	

	 	 	

	 	

	 	

	 	 	

	 	 	 	 	

	 	 	

				 	

	 	 	

	 	

	 	 	 	

	 	 	 	

	 	 	 	

	 	 	 	 	 	

				

	 	 	

				

	 	

	 	 	 	

				 	

	 	 	 	 	

 

	 	 	 	 		

				 	 	 	 	 	

				 	 	

	 	

	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	

				

	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	

				

	 	 	 	

				 	

	 	 	

				 	

	 	 	 	

	 	 	

	 	

	 	 	 	 	

				

				

	 	

	 	 	 	 	

				 	

	 	

	 	 	

	 	 	

	 	 	 	 	

				 	

				

	 	 	 	

	 	 	 	

	 	 	 	 	 	 	

				

	 	 	 	

				 	 	 	

	 	 	 	 	 	

				 	

				 	 	 	 	 	

				 	 	 	

	 	 	 	 	 	 	 

				 	 	 	 	 	

				 	 	 	 	 	

				 	 	 	

	 	 	 	 	 	

	 	 	 	 	

				 	

	 	

	 	

	 	 	

				 	

				 	

	 	 	 	

	 	 	 	

	 	 	

	 	 	 	

				

	 	

	 	 	 	

	 	 	 	

	 	 	

	 	 	 	 	

	 	

				 	

				 	

	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

				 	

	 	

	 	 	 	 	

	 	 	

	 	 	

	 	 	

L 

Laminar Soot Processes experiment, 7
 

landing-based emergency planning at KSC, 

55, 56–57
 

landing historical incidents, 126
 

landowners in recovery area, agreements 

with, 117
 

launch and reentry dynamics, normal, 8–10
 

launch-based emergency planning at KSC, 

54–55
 

launch damage to orbiter, 10–11, 56
 

Launch Entry Suit, 129. See also ACES
 

left wing, orbiter’s loss of, 81, 97, 99
 

legal analysis and issues, 44, 46, 114–122
 

life-critical actions, 150
 

life science experiments on STS-107, 51,
 

60, 64, 67, 131
 

life-support equipment. See also pressure 

suits; restraint systems 

acceleration forces effects on, 36
 

crewmembers’ failure to properly use, 82
 

CSWG’s analysis of, 80
 

disposition of, 38
 

as focus in debris recovery and 

reconstruction, 137
 

injuries caused by, 148
 

injury analysis, 38, 46, 148
 

nominal operations compatibility issue, 

90, 112, 124, 133
 

parachutes, 94, 125, 127, 129–130
 

recovery and analysis by OAFME, 46
 

loads in crew survival analysis, 140
 

Loss of Signal (LOS), 12, 33, 42, 81, 97
 

Lufkin, Texas, 14, 20, 34, 43, 50
 

Lufkin Civic Center, 19–20
 

M 

Mallak, CDR Craig, 35, 119
 

Manned Balloon Flights (MBFs), Red Bull 

Stratos, 127
 

Marshall Space Flight Center, 22
 

materials analysis, crew survival 

investigation, 140, 144–145
 

McAuliffe, Christa, 128
 

MCC (Mission Control Center), 33, 117
 

McCluskey, Richard, 33, 34
 

McCool, William C. 

during mission, 7
 

official photo, ix
 

preparations for landing, 10
 

profile and role in mission, 4–5
 

reentry activities prior to mishap, 11
 

and team cohesion, 69
 

at Terminal Countdown Demonstration 

Test, 66
 

McGuirk, Col. Charles, 34
 

McNair, Ronald, 128
 

mechanical injuries 

bracing injuries during CE, 100–101
 

between CE and CMCE, 103–106
 

during CMCE, 108, 110, 111
 

flail injuries, 103–104, 106, 111, 147,
 

148
 

forensic findings and recommendations,
 

112
 

guidelines for investigating, 145–146
 

timing of initiation of, 97
 

mechanisms of crew injury, ascertaining, 

150. See also injury analysis
 

Medical Code Zero Plan, KSC, 56
 

medical examiner and pathology report. 

See OAFME 

medical operations. See MIT 

Medical Operations Branch, JSC, 32–33,
 

50, 65, 76. See also flight surgeons
 

MEIDEX (Mediterranean-Israeli Dust 

Experiment), 4, 6
 

Melroy, Pam, 51
 

memorials, 15, 49, 62, 65, 72, 73
 

Merritt Island Launch Annex (MILA), 13
 

microgravity environment, 2, 3, 130, 145,
 

149
 

midbody-forebody separation. See CE 

(Catastrophic Event) 

middeck, 3, 89, 97, 98, 100, 110
 

Mission Control Center (MCC), 33, 117
 

mission crew flight surgeons, 33, 43, 51,
 

66–68
 

Mission Management Team (MMT), 13,
 

14, 33
 

MIT (Mishap Investigation Team) 

activation of, 33–35, 50
 

background on medical operations at 

NASA, 32–33
 

conclusions, 39–40
 

crew remains recovery process, 35
 

formation of, 14, 114
 

informing families, 37
 

initial organization at recovery location,
 

76
 

and JSC Space Life Sciences 

investigation, 51
 

lessons learned, 39–40
 

public misconceptions, 36
 

recovery and identification of human
 

remains, 36–37
 

summary of investigation, 38–39
 

termination of operations, 38
 

transfer of remains, 37–38
 

MMT (Mission Management Team), 13,
 

14, 33
 

Modular Auxiliary Data System recorder, 

14
 

monatomic oxygen (O2

), xi, 92, 110, 131
 

mortuary, Barksdale, 22, 28, 35
 

Mortuary Affairs, 30, 34, 42, 45, 59, 63
 

motion analysis, crew survival 

investigation, 143–144

MPCV (Multi-Purpose Crew Vehicle), 88,
 

91, 92, 94, 132
 

N 

National Aeronautics and Space Act (1958),
 

114, 121
 

National Space Transportation System 

Crew Egress and Escape Study, 129
 

National Transportation Safety Board 

(NTSB), 14, 35, 40
 

near vacuum, exposure to, xi, 93–94, 124.
 

See also depressurization
 

nominal operations, life-support equipment 

compatibility issue, 90, 112, 124, 133
 

non-conformal helmets, impact of 

rotational motion, 91, 103, 104, 112
 

NTSB (National Transportation Safety 

Board), 14, 35, 40
 

O 

OAFME (Office of the Armed Forces

 Medical Examiner) 

analysis and identification of crew

remains, 44–46
 

capabilities of, 41–42
 

findings, 47
 

future recommendations, 47–48
 

lessons learned, 46–47
 

life-support equipment analysis, 46
 

limitations in support available to 

NASA, 47
 

Medical Operations Branch coordination 

with, 33
 

memorial at Dover AFB, 48
 

overview of forensic analysis, 29
 

Port Mortuary facility, 43
 

recovery investigation role, 30, 42–44,
 

46
 

SLSD coordination with, 50
 

termination of recovery efforts, 46
 

and transfer of remains, 38
 

Ogden, Maj John, 34
 

O’Keefe, Sean, ix, 15, 50, 114
 

Onizuka, Ellison, 128
 

operational leadership team, recovery 

operations, 20–22

operational management team, recovery 

operations, 23–24
 

Operational Search Director, 21
 

orbital maneuvering system, loss of, 97
 

orbiter motion after loss of control, 97, 99,
 

103. See also CE (Catastrophic Event)
 

Orion MPCV, 132
 

Ortega, Maj Hernando (Joe), 38, 46
 

overpressure condition (explosion), 146
 

Owens, Col Jerry, 34
 

Owens Valley Radio Observatory, 96
 
172 SECTION 6 – APPENDIX

	 	 	 	

	 	

	 	 	 	

				 	 	 	

	 	

				 	 	

	 	

	 	 	 	 	 	

	 	

	 	 	 	 	

				 	 	

				 	 	 	

				 	 	 	 	

	 	 	 	

				 	

	 	

	 	 	 	

	 	 	 	

				 	

	 	 	 	

	 	 	 	 	

	 	

	 	 	

	 	 	 	 	

	 	

	 	 	

				 	 	

	 	 	 	

	 	 	 	 	

	 	

	 	 	 	 	

				

	 	

	 	 	 	

				 	 	

				 	 	 	

	 	 	 	 	 	 	

				 	 	

	 	

				 	 	 	 	

				 	 	 	 	 	

	 	 	

	 	 	

				 	 	 	 	 	

	 	

	 	 	 	 	 	

	 	 	 	 	 	

				 	

	 	 	

				 	

	 	 	

	 	

	 	 	 	 	 	

				 	

 

	 	 	 	

	 	 	

	 	 	

	 	 	 	 	 	

	 	 	 	 	

				 	

	 	 	

	 	

				

	 	 	

	 	

	 	

				

	 	 	

	 	

	 	 	 	 	

				 	 	

	 	

	 	 	 	 	

				 	

	 	

	 	 	 	 	

				 	 	

	 	 	 	

	 	 	 	 	

				

	 	 	 	

	 	

	 	 	 	

				 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	

	 	 	

	 	 	 	

	 	 	

	 	 	

				

	 	

	 	 	

	 	 	 	

	 	 	

				 	 	 	 	 	

	 	 	

	 	 	

	 	

	 	 	

 

	 	

				 	 	 	 	

	 	

	 	 	

	 	

	 	 	

	 	 	

	 	 	

	 	 	 	 	

	 	 	 	 	 	

				 	

	 	

	 	 	 	 

	 	 	 	 	

				 	 	

	 	

	 	 	 	

	 	 	

				 	 	 	 	 	

				

				

 	 	 	 	

				 	 	 	

	 	 	

	 	 	 	

	 	 	 	

P 

parachutes, 94, 125, 127, 129–130
 

pathology. See AFIP; forensic pathology 

analysis; OAFME 

Patlach, Robert, 34
 

Patrick AFB, Florida, 32, 55
 

personal protective equipment (PPE) for 

hangar reconstruction personnel, 60
 

Pettys, Richard, 37
 

photographs, recommendations for 

managing, 136, 137
 

Piantinata, Nick, 126
 

political and financial issues, 3, 40, 129
 

Pool, Sam, 50
 

Port Mortuary, Dover AFB, 33, 43
 

postmishap event impacts on crew, 

analyzing, 148, 149
 

PPE (personal protective equipment) for 

hangar reconstruction personnel, 60
 

premishap event impacts on crew, 

analyzing, 140, 141, 143, 148
 

pressure injuries, analyzing, 89–90,
 

102–103, 146
 

pressure suits. See also helmets 

altitude survivability of, 93
 

development of ACES, 32, 129
 

improvement plans for, 132, 133
 

incompatibilities with Shuttle operations, 

89–91, 112
 

post-CMCE loss of, 92, 108
 

procedure for donning during reentry, 98
 

protection limits, 127
 

Privacy Act (1974), 115
 

privacy protection for families, 40, 119–122
 

Project Excelsior, 125–126
 

Project Strato Jump, 126
 

psychological and medical support 

operations 

for astronauts in recovery operations, 

22–23, 30–31, 84
 

importance in Columbia mishap, 63
 

introduction, 65–66
 

KSC planning for, 56, 57, 58
 

lessons learned, 71–73
 

medical operations for STS-107 mission,
 

66–68

mishap response, 70–71

and shielding from specific identification

of remains, 29
 

SLSD’s concern for families and 

collectors of remains, 51
 

stress of search for human remains, 28,
 

30, 58, 73
 

team cohesion, 69–70
 

psychological and physical condition of 

crew prior to mission, 148–149

public interest vs. security and privacy, 

managing, 36, 40, 64, 70–71, 119–122
 

public release, defined, 120
 

pulmonary barotrauma, 97, 102
 

R 

radio communications, establishing for 

recovery operation, 20, 76, 78, 84
 

Ramon, Ilan 

during mission, 7
 

profile and role in mission, 4–5, 6
 

respecting of religious traditions for, 37,
 

44, 46
 

and team cohesion, 69
 

at Terminal Countdown Demonstration 

Test, 66
 

in training module, 149
 

Readdy, Bill, 130
 

reconstruction of Shuttle debris, 14, 58–61,
 

63–64, 138–140

recovery operations. See also 

communications; crew recovery; 

debris recovery and analysis; 

psychological and medical support 

operations 

AFIP–OAFME role in, 30, 42–46
 

command center selection, 19–20
 

decision-making guidelines, 23, 24–25
 

field conditions, challenges of, 18, 27, 57
 

hazardous materials handling, 34, 38,
 

41, 50
 

helicopter spotters, 28, 57–58
 

horse teams, 28
 

initial organizational development,
 

18–19
 

KSC support function, 57–58
 

legal issues, 117–119
 

management positions, 21
 

need for worker support enhancement, 

63
 

operational leadership team, 20–22
 

overview, 13–14
 

planning for, 23–24
 

search area definition and fine-tuning,
 

24, 25–26, 78
 

search methods, 27–28
 

termination of recovery efforts, 29–30,
 

38, 46
 

transportation needs, 76
 

volunteer workers, 20, 27–28, 29–31, 36
 

Red Bull Stratos high-altitude skydiving 

project, 93, 126–127
 

Red Team, 4–5, 10, 67
 

reentry sequence and dynamics, 9–13, 98
 

regulations affecting Columbia 

investigation, 116
 

reimbursable and tort claims, 117–118
 

Resnik, Judith, 128
 

restraint systems 

effect on crew, 91–92, 147–148

inertial reel mechanism failure to lock, 

91, 92, 100, 105, 112, 131
 

MPCV, 94
 

need for improvement of, 112, 131, 132
 

return to flight, ix, x, 9, 47, 130
 

Return to Flight Task Group, 130
 

Right of Entry Agreements, 117
 

Robinson, Capt Rabbi Harold, 37
 

Rogers, William P., 121
 

Rominger, Capt. Kent, 15
 

root-cause vs. crew survival investigation, 

134
 

S 

Scarpa, Philip, 59
 

science mission 

Columbia’s design for, 3
 

complexity of training for, 66
 

crew activities during, 7
 

life science experiments in recovery 

operations, 51, 60, 64, 67, 131
 

NASA’a dedication to, 2
 

STS-107 mission profile, 3–4
 

Scobee, Francis, 128
 

Scott, David R., 126
 

SCSIIT (Spacecraft Crew Survival 

Integrated Investigation Team) 

cabin depressurization, 88–91
 

CE impacts, 92
 

dynamic rotating environment effects 

and lack of restraint, 91–92
 

ground impact, 94
 

high-altitude exposure effects, 93–94
 

introduction, 86–88
 

legal aspects, 121
 

SLSD role, 51, 53
 

summary of conclusions, 131
 

teams and consultants, 52
 

threat matrix and survival gap, 93
 

timeline, 90
 

search area definition and fine-tuning, 24,
 

25–26, 78
 

Search Director, 21
 

search methods, 14, 27–28. See also

 recovery operations 

seat-restraint system. See restraint systems 

security, communications, 22, 29, 34, 35,
 

76, 78, 84
 

Shepherd, William, 129–130
 

shock layer on reentry, 8
 

shock wave interactions, 108
 

shoulder harnesses, lack of automatic lock, 

91, 92, 100, 105, 112, 131
 

Shuttle Evolution II Crew Escape Study, 

129
 

site documentation in debris recovery plan, 

137–138

SLSD (Space Life Sciences Directorate), 

JSC. See also CMG; flight surgeons

and CFS’s crew survival investigation, 

iv, 51, 53, 79
 

and CMG, 32–33, 38
 

contingency action plan activation, 13
 

final analysis phase, 51, 53
 
SECTION 6 – APPENDIX 173

				

	 	 	

	 	 	 	 	

	 	

	 	 	 	

	 	

	 	 	 	

	 	 	 	

				

 

	 	 	 	 	

				 	 	 	

	 	 	 	

	 	 	 	 	 	

 

	 	 	 	

	 	 	 	

	 	 	 	

				 	

	 	 	 	 	

				 	 	 	

	 	 	

	 	

				 	 	

	 	

	 	

	 	

	 	

	 	 	

	 	 	

	 	 	 	

				 	 	 	 	

	 	 	 	 	

	 	 	

				 	 	

	 	

	 	 	

	 	 	

	 	 	 	

	 	 	 	 	

	 	

	 	

	 	

	 	

	 	 	 	

	 	 	 	 	 	 	

				 	

	 	 	 	 	

				 	

	 	 	

	 	 	 	

	 	

	 	 	 	

				 	 	 	 	

	 	 	 	

	 	

	 	

	 	

	 	 	 	 	 	

				 	

				 	 	 	 	

				 	

	 	 	 	 

	 	

	 	 	 	 	

	 	 	 	

	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	

	 	 	

				 	 	 	 	

	 	 	 	 	

	 	 	 	

	 	 	 	 	

				

	 	 	 	 	

				

	 	 	 	

	 	 	

	 	 	 	 	 	

				

	 	 	 	

	 	 	 	 	

	 	 	 	 	 	

				 	 	 	 	

	 	 	 	

				

				 	

	 	 	

				 	 	 	

	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

				

	 	

	 	 	 	 	

	 	 	

	 	 	

	 	

	 	 	

	 	 	 	 	 	

				 	 	

	 	 	 	 	 	 	

				

	 	 	

	 	 	 	 	

				 	

18

human remains recovery responsibility, 

initial analysis phase, 51
 

initial response to accident, 34, 50
 

memorials, 15
 

mission of, 49
 

MIT recovery phase role, 51
 

Smith, Michael, 128
 

solid rocket booster, 3, 54
 

Soyuz 1, parachute failure, 126
 

spacecraft analyses in crew survival 

investigation, 141–142

Spacecraft Crew Survival Integrated 

 Investigation Team (SCSIIT). 

See SCSIIT 

SPACEHAB Research Double Module, 3,

7, 66, 68, 131
 

space in environmental analysis, 145
 

Spacelab, 3
 

Space Medicine Division, JSC, 32, 42.
 

See also SLSD 

Space Shuttle. See also Columbia Space 

Shuttle 

historical crew escape systems, 128
 

KSC’s medical support system, 54–55
 

on-orbit inspection after STS-107
 

mishap, 9
 

pressure suit incompatibilities with, 89,
 

90, 112, 124, 133
 

Vehicle Assembly Building, 54
 

vehicle structure, 3
 

Space Technology And Research Students 

(STARS) payload, 7
 

SR-71 high-altitude breakup, 127
 

Stafford Act, 115
 

Stegemoeller, Charles, 50
 

Stencil, Craig, 51
 

Stepaniak, Philip 

appointment to MIT, 33
 

death certificate issuance, 119
 

identification of crew remains, 29
 

management of crew remains recovery, 

28, 29, 43, 50, 76
 

planning for recovery operations, 34, 35
 

Strategic Command Center, 19
 

structural analysis, crew survival 

investigation, 140, 144
 

STS-1, 2
 

STS-107 mission
 

accident overview, ix–xi
 

vs. Challenger disaster, 131
 

crew qualifications and roles, 4–7
 

crew survival lessons learned, 130–131
 

debris damage at launch, 10–11, 56
 

insignia for, 4
 

introduction, 2
 

mishap profile, 8–15
 

mishap timeline, 82
 

mission outline, 3–4
 

NASA environment, 3
 

orbiter maneuvering system, loss of, 97
 

orbiter motion after loss of control, 97,
 

99, 103
 

reconstruction of debris, 14, 58–61,
 

63–64, 138–140
 

Shuttle vehicle structure, 3
 

wing loss, 81, 97, 99
 

STS-114, 9, 47
 

survival gap, 93, 131
 

CSWG’s mission to determine, 80
 

survival of crew. See crew survival 

survivor privacy rights, 40, 119–122
 

Sutton, Mike, 19
 

Swann, Mark, 37
 

T 

T-38 flyby, x
 

Tactical Command Center at Lufkin, 14,
 

19, 35
 

TAEM (terminal area energy management) 

phase of reentry, 10, 13
 

technical expertise, need for accurate crew 

survival investigation, 84
 

temperature shift extremes, 144. See also

 thermal injuries and effects 

terrestrial environmental analysis, 145
 

Texas Army National Guard, 26, 27
 

Texas Death Investigation System, 119
 

theft of debris, controlling, 118–119
 

thermal injuries and effects 

after CE but prior to CMCE, 106, 108
 

during and after CMCE, 106, 108–110
 

cold temperatures after CMCE, 93
 

future recommendations for crew 

survival analysis, 140, 144, 146
 

and loss of pressure suits, 92
 

orbiter’s experience during reentry, 8–9
 

summary of forensic findings and
 

recommendations, 112–113
 

Thermal Protection System (TPS), 8–9, 133
 

timelines, value in crew survival 

investigation, 140–141
 

toxicological injuries analysis, 140, 146
 

transecting fractures, 111, 147–148
 

transfer of crew remains, 28–29, 37–38, 45
 

transportation needs for recovery operation, 

76
 

triage forces at KSC, 55
 

turbopumps as search area guide, 26
 

TWA 800 airliner accident, 28, 32–33, 42
 

U 

upper-body restraint, impact of lack of, 

91–92, 100, 105, 112, 131
 

V
 

VAB (Vehicle Assembly Building), 54
 

vacuum chamber test historical incidents, 

124
 

videos, future recommendations for 

managing, 136
 

virtual reconstruction, 138
 

Volga stratospheric balloon parachute, 126
 

volunteer workers in recovery operations, 

20, 27–28, 29–31, 36
 

W 

Walheim, Col Rex, 37
 

Wall of Fallen Heroes, 48
 

Wetherbee, Capt James, 21, 29, 34, 35, 43,
 

78
 

White, Ed, 125
 

White, Lt Col Donald, 51, 80
 

Whittle, David, 35, 36
 

Williams, Dafydd (Dave), 34
 

Williams, Richard, 50
 

Wilmore, Capt Barry, 38
 

windblast effects on crew post-CMCE, 93,
 

106, 108, 110
 

wing departure from orbiter (left), 81, 97,
 

99
 

Worden, Alfred M., 126
 

work conditions, recovery operations, 18,
 

27, 57
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REPORT DOCUMENTATION PAGE Form Approved 

OMB No. 0704-0188 

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1. AGENCY USE ONLY (Leave Blank) 2. REPORT DATE 

May 2014 

3. REPORT TYPE AND DATES COVERED 

Special Publication 

4. TITLE AND SUBTITLE 

Loss of Signal:Aeromedical Lessons Learned from the STS-107 Columbia Space Shuttle 

Mishap 

5. FUNDING NUMBERS 

6. AUTHOR(S) 

Philip C. Stepaniak; Helen W. Lane, Jeffrey R. Davis 

7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 

Lyndon B. Johnson Space Center 

Houston, Texas 77058 

8. PERFORMING ORGANIZATION 

REPORT NUMBERS 

S-1151 

9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 

National Aeronautics and Space Administration 

Washington, DC 20546-0001 

10. SPONSORING/MONITORING 

AGENCY REPORT NUMBER 

SP-2014-616 

11. SUPPLEMENTARY NOTES 

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Available from the NASA Center for AeroSpace Information (CASI) 

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13. ABSTRACT (Maximum 200 words) 

Loss of Signal, presents the aeromedical lessons learned from the Columbia accident that will result in enhanced crew safety and 

survival on human space flight missions. As we embark on the development of new spacefaring vehicles through both government and 

commercial efforts, the NASA Johnson Space Center Human Health and Performance Directorate is continuing to make this 

information available to a wider audience engaged in the design and development of future space vehicles. Loss of Signal summarizes 

and consolidates the aeromedical impacts of the Columbia mishap process—the response, recovery, identification, investigative 

studies, medical and legal forensic analysis, and future preparation that are needed to respond to spacecraft mishaps. The goal of this 

book is to provide an account of the aeromedical aspects of the Columbia accident and the investigation that followed, and to 

encourage aerospace medical specialists to continue to capture information, learn from it, and improve procedures and spacecraft 

designs for the safety of future crews. 

14. SUBJECT TERMS 

Columbia (orbiter), accident investigation, lessons learned, spacecraft breakup, reentry, 

forensic sciences, aerospace medicine, search and recovery, hypervelocity 

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190 

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174 SECTION 6 – APPENDIX
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