RS21606 -- NASA's Space Shuttle Columbia: Synopsis of the Report of the Columbia Accident InvestigationBoard September 2, 2003 The following synopsis focuses on what appear to be the major questions being asked about the CAIB's findings about the tragedy and recommendations on thefuture of the shuttle program. All quotations are from the CAIB report unless otherwise noted. What Caused the Columbia Accident? The Board "recognized early on that the accident was probably not ananomalous, random event, but rather likely rooted to some degree in NASA's history and the human space flightprogram's culture." (p. 9) Therefore, it alsolooked at "political and budgetary considerations, compromises, and changing priorities over the life" of the shuttleprogram, and "places as much weight onthese causal factors as on the ... physical cause...." (p. 9) The physical cause was damage to Columbia' s left wing by a 1.7 pound piece of insulating foam that detached from the left "bipod ramp" that connects theExternal Tank (1) to the orbiter, and struck the orbiter'sleft wing 81.9 seconds after launch. The foam strike created a hole in a Reinforced Carbon-Carbon(RCC) panel on the leading edge of the wing, allowing superheated air (perhaps exceeding 5,000 o F)to enter the wing during reentry. The extreme heat causedthe wing to fail structurally, creating aerodynamic forces that led to the disintegration of the orbiter. (Described indetail in Chapters 2 and 3.) Regarding organizational causes , the Board concluded the accident was -- ... rooted in the Space Shuttle Program's history and culture, including the original compromises that were requiredto gain approval for the Shuttle, subsequent years of resource constraints, fluctuating priorities, schedule pressures,mischaracterization of the Shuttle asoperational rather than developmental, and lack of an agreed national vision for human space flight. Cultural traitsand organizational practices detrimental tosafety were allowed to develop, including: reliance on past success as a substitute for sound engineering practices...,organizational barriers that preventedeffective communication of critical safety information and stifled professional differences of opinion; lack ofintegrated management across program elements;and the evolution of an informal chain of command and decision-making processes that operated outside theorganization's rules. (p.9) The Board found that there is a "broken safety culture " at NASA (pp. 184-189). Schedule pressure (pp. 131-139) related to construction of the InternationalSpace Station, budget constraints (pp. 102-105), and workforce reductions (pp. 106-110) also were factors. The Board concluded that the shuttle program"has operated in a challenging and often turbulent environment...." (p. 118) "It is to the credit of Space Shuttlemanagers and the Shuttle workforce that thevehicle was able to achieve its program objectives for as long as it did." (p. 119) Should the Shuttle Continue to Fly? The Board concluded that "the present Shuttle is not inherently unsafe"but the "observations and recommendations in this report are needed to make the vehicle safe enough to operate inthe coming years." (p. 208) CAIB "supportsreturn to flight for the Space Shuttle at the earliest date consistent with an overriding consideration: safety." (p. 208) NASA has a target of March/April 2004for return to flight, and Adm. Gehman stated in an interview on PBS' The NewsHour with Jim Lehrer on August26 that he saw no reason why NASA could notmeet that schedule. The CAIB report contains 29 recommendations (listed below) -- 23 technical and six organizational -- of which 15 must be implemented before the shuttlereturns to flight status. The others are "continuing to fly" recommendations assuming the shuttle will be used foryears to come. The Board recommended that,if the shuttle is to be used beyond 2010, that it be recertified (p. 209). But the Board said it reached an "inescapableconclusion" -- Because of the risks inherent in the original design of the Space Shuttle, because the design was based in manyaspects on now-obsolete technologies, and because the Shuttle is now an aging system but still developmental incharacter, it is in the nation's interest toreplace the Shuttle as soon as possible as the primary means for transporting humans to and from Earth orbit. (p. 210-211. Emphasis inoriginal.) Why Did NASA Decide Not to Obtain Imagery from DOD Satellites to Assess the Damage? A centralquestion during the investigation was why NASA did not ask the Department of Defense (DOD) to image the shuttlewith its high resolution ground- orspace-based systems to help assess whether the orbiter had been damaged by the foam. The Board found (pp.140-172) that three requests for imagery weremade by NASA engineers but through incorrect channels, plus there were several "missed opportunities"whenmanagers could have pursued the issue. Onerequest did reach the appropriate DOD personnel, but NASA canceled the request 90 minutes later. The Boardconcluded that the likely sequence of events wasthat the chair of STS-107's Mission Management Team (MMT), after informally learning that there had been a"request" for imagery, called three other MMTmembers and determined that none knew of a "requirement" for imagery. CAIB cited a flawed analysis of the extentto which the orbiter might have beendamaged by the foam that was too readily accepted by program managers, a low level of concern by programmanagers, a lack of clear communication, a lack ofeffective leadership, and a failure of the role of safety personnel as reasons why the imagery was not obtained. Whether such images would, in fact, have shownthe damage remains unclear, but the Board recommended that such images now be taken on all shuttle missions. Could the Crew Have Been Saved? The Board concluded that the crew died from "blunt trauma andhypoxia" (lack of oxygen) after the crew cabin separated from the rest of the disintegrating shuttle and, itself,disintegrated; there was no explosion. (p. 77) TheBoard asked NASA to evaluate two options for returning the crew safely if the degree of damage had beenunderstood early in the mission: repairing thedamage on-orbit, or rescuing the crew with another shuttle mission. The repair option "while logisticallyviable....relied on so many uncertainties that NASArated this option 'high risk.'" (p. 173) The rescue option "was considered challenging but feasible." (p. 174) What Are the "Echoes" of Challenger? Former shuttle astronaut Sally Ride served on the RogersCommission that investigated the January 1986 Challenger accident, which claimed the lives of sevenastronauts, and on CAIB. During the Columbia investigation, she said she heard "echoes" of Challenger as it became clear that the accidentresulted from NASA failing to recognize that a technical failure(bipod ramp foam shedding) that had occurred on previous shuttle flights could have safety-of-flight implicationseven if the earlier missions were completedsuccessfully. In the case of Challenger , it was erosion of seals (O-rings) between segments of the SolidRocket Booster, which had been noted on previousmissions. Some engineers warned NASA not to launch Challenger that day because unusually coldweather could have weakened the resiliency of the O-rings. They were overruled. CAIB concluded that "both accidents were 'failures of foresight'" and the parallels betweenthem demonstrate that: "the causes of theinstitutional failure responsible for Challenger have not been fixed"; "if these persistent, systemic flawsare not resolved, the scene is set for another accident";and that while individuals must be accountable for their actions, "NASA's problems cannot be solved simply byretirements, resignations, or transferringpersonnel." (p. 195) CAIB's 29 recommendations are compiled in Chapter 11 of its report. Adm. Gehman stated at the Board's August 26 press conference that there is no hierarchyin the recommendations -- all have equal weight. The Board also made 27 "observations" in Chapter 10. Followingare abbreviated versions of therecommendations -- separated into those that must be implemented prior to Return to Flight, and those that are"continuing to fly" recommendations -- andobservations. Some have been combined for brevity. Return to Flight (RTF) Recommendations.