Columbia Accident Investigation Board Report Excerpts

(Editor's note: This story was originally published on August 26, 2003.)

WASHINGTON -- Here are selected excerpts -- presented by topics -- from the Columbia Accident Investigation Board final report. The complete report is available to download from the Columbia Board's Web site at http://www.caib.us.

BOARD STATEMENTS IN INTRODUCTION

Our aim has been to improve shuttle safety by multiple means, not just by correcting the specific faults that cost the nation this orbiter and this crew. With that intent, the Board conducted not only an investigation of what happened to Columbia, but also to determine the conditions that allowed the accident to occur a safety evaluation of the entire space shuttle program.

Complex systems almost always fail in complex ways, and we believe it would be wrong to reduce the complexities and weaknesses associated with these systems to some simple explanation. Too often, accident investigations blame a failure only on the last step in a complex process, when a more comprehensive understanding of that process could reveal that earlier steps might be equally or even more culpable. In this Boards opinion, unless the technical, organizational, and cultural recommendations made in this report are implemented, little will have been accomplished to lessen the chance that another from its inception.

NASA is a federal agency like no other. Its mission is unique, and its stunning technological accomplishments, a source of pride and inspiration without equal, represent the best in American skill and courage. At times NASAs efforts have riveted the nation, and it is never far from public view and close scrutiny from many quarters. The loss of Columbia and her crew  represents a turning point, calling for a renewed public policy debate and commitment regarding human space exploration.

The Board recognized early on that the accident was probably not an anomalous, random event, but rather likely rooted to some degree in NASAs history and the human space flight programs culture.

THE CAUSE

The physical cause of the loss of Columbia  and its crew was a breach in the Thermal protection system on the leading edge of the left wing, caused by a piece of insulating foam which separated from the left bipod ramp section of the external tank at 81.7 seconds after launch, and struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel number 8. During re-entry this breach in the thermal protection system allowed superheated air to penetrate through the leading edge insulation and progressively melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused loss of control, failure of the wing, and breakup of the Orbiter. This breakup occurred in a flight regime in which, given the current design of the Orbiter, there was no possibility for the crew to survive.

How could a lightweight piece of foam travel so fast and hit the wing at 545 miles per hour?

Just prior to separating from the external tank, the foam was traveling with the shuttle stack at about 1,568 mph (2,300 feet per second). Visual evidence shows that the foam debris impacted the wing approximately 0.161 seconds after separating from the External tank. In that time, the velocity of the foam debris slowed from 1,568 mph to about 1,022 mph (1,500 feet per second). Therefore, the Orbiter hit the foam with a relative velocity of about 545 mph (800 feet per second). In essence, the foam debris slowed down and the Orbiter did not, so the Orbiter ran into the foam. The foam slowed down rapidly because such low-density objects have low ballistic coefficients, which means their speed rapidly decreases when they lose their means of propulsion.

MANAGEMENT PROBLEMS

The organizational causes of this accident are rooted in the space shuttle programs history and culture, including the original compromises that were required to gain approval for the shuttle, subsequent years of resource constraints, fluctuating priorities, schedule pressures, mischaracterization of the shuttle as operational rather than developmental, and lack of an agreed national vision for human space flight. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing in accordance with requirements); organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion; lack of integrated management across program elements; and the evolution of an informal chain of command and decision-making processes that operated outside the organizations rules.

NASA CULTURE

The pressure of maintaining the flight schedule created a management atmosphere that increasingly accepted less-than-specification performance of various components and systems, on the grounds that such deviations had not interfered with the success of previous flights.

The Orbiter that carried the STS-107 crew to orbit 22 years after its first flight reflects the history of the space shuttle program. When Columbia lifted off from Launch Complex 39-A at Kennedy Space Center  on January 16, 2003, it superficially resembled the Orbiter that had first flown in 1981, and indeed many elements of its airframe dated back to its first flight. More than 44 percent of its tiles, and 41 of the 44 wing leading edge Reinforced Carbon-Carbon (RCC) panels were original equipment. But there were also many new systems in Columbia, from a modern glass cockpit to second-generation main engines.

Although an engineering marvel that enables a wide-variety of on-orbit operations, including the assembly of the International space Station, the shuttle has few of the mission capabilities that NASA originally promised. It cannot be launched on demand, does not recoup its costs, no longer carries national security payloads, and is not cost-effective enough, nor allowed by law, to carry commercial satellites. Despite efforts to improve its safety, the shuttle remains a complex and risky system that remains central to U.S. ambitions in space. Columbia's failure to return home is a harsh reminder that the space shuttle is a developmental vehicle that operates not in routine flight but in the realm of dangerous exploration.

In our view, the NASA organizational culture had as much to do with this accident as the foam. Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of an institution. At the most basic level, organizational culture defines the assumptions that employees make as they carry out their work. It is a powerful force that can persist through reorganizations and the change of key personnel. It can be a positive or a negative force.

Though NASA underwent many management reforms in the wake of the Challenger accident and appointed new directors at the Johnson, Marshall, and Kennedy centers, the Agencys powerful human space flight culture remained intact, as did many institutional practices, even if in a modified form. As a close observer of NASAs organizational culture has observed, Cultural norms tend to be fairly resilient The norms bounce back into shape after being stretched or bent. Beliefs held in common throughout the organization resist alteration.12 This culture, as will become clear across the chapters of Part Two of this report, acted over time to resist externally imposed change. By the eve of the Columbia accident, institutional practices that were in effect at the time of the Challenger accident such as inadequate concern over deviations from expected performance, a silent safety program, and schedule pressure had returned to NASA.

CAMERA PROBLEMS AT LAUNCH

The image analysis [of the debris strike] was hampered by the lack of high resolution and high speed ground-based cameras. The existing camera locations are a legacy of earlier NASA programs, and are not optimum for the high-inclination space shuttle missions to the international space station and oftentimes cameras are not operating or, as in the case of STS-107, out of focus. Launch commit criteria should include that sufficient cameras are operating to track the shuttle from liftoff to solid rocket booster separation.

Similarly, a developmental vehicle like the shuttle should be equipped with high resolution cameras that monitor potential hazard areas. The wing leading edge system, the area around the landing gear doors, and other critical thermal protection system elements need to be imaged to check for damage. Debris sources, such as the external tank, also need to be monitored. Such critical images need to be downlinked so that potential problems are identified as soon as possible.

IMAGERY REQUESTS

Management decisions made during Columbias final flight reflect missed opportunities, blocked or ineffective communications channels, flawed analysis, and ineffective leadership. Perhaps most striking is the fact that management including shuttle program, Mission Management Team, Mission Evaluation Room, and Flight Director and Mission Control displayed no interest in understanding a problem and its implications. Because managers failed to avail themselves of the wide range of expertise and opinion necessary to achieve the best answer to the debris strike question Was this a safety-of-flight concern? some space shuttle program managers failed to fulfill the implicit contract to do whatever is possible to ensure the safety of the crew. In fact, their management techniques unknowingly imposed barriers that kept at bay both engineering concerns and dissenting views, and ultimately helped create blind spots that prevented them from seeing the danger the foam strike posed.

BUDGET PROBLEMS

A strong indicator of the priority the national political leadership assigns to a federally funded activity is its budget. By that criterion, NASAs space activities have not been high on the list of national priorities over the past three decades (see Figure 5.3-1). After a peak during the Apollo program, when NASAs budget was almost four percent of the federal budget, NASAs budget since the early 1970s has hovered at one percent of federal spending or less.

Particularly in recent years, as the national leadership has confronted the challenging task of allocating scarce public resources across many competing demands, NASA has had difficulty obtaining a budget allocation adequate to its continuing ambitions.

During the past decade, neither the White House nor Congress has been interested in a reinvigorated space program. Instead, the goal has been a program that would continue to produce valuable scientific and symbolic payoffs for the nation without a need for increased budgets. Recent budget allocations reflect this continuing policy reality. Between 1993 and 2002, the governments discretionary spending grew in purchasing power by more than 25 percent, defense spending by 15 percent, and non-defense spending by 40 percent. NASAs budget, in comparison, showed little change, going from $14.31 billion in Fiscal Year 1993 to a low of $13.6 billion in Fiscal Year 2000, and increasing to $14.87 billion in Fiscal Year 2002. This represented a loss of 13 percent in purchasing power over the decade.

Faced with this budget situation, NASA had the choice of either eliminating major programs or achieving greater efficiencies while maintaining its existing agenda. agency leaders chose to attempt the latter. They continued to develop the space station, continued robotic planetary and scientific missions, and continued shuttle-based missions for both scientific and symbolic purposes. In 1994 they took on the responsibility for developing an advanced technology launch vehicle in partnership with the private sector. They tried to do this by becoming more efficient. Faster, better, cheaper became the NASA slogan of the 1990s.

The flat budget at NASA particularly affected the human space flight enterprise. During the decade before the Columbiaaccident, NASA rebalanced the share of its budget allocated to human space flight from 48 percent of agency funding in Fiscal Year 1991 to 38 percent in Fiscal Year 1999, with the remainder going mainly to other science and technology efforts. On NASAs fixed budget, that meant the space shuttle and the international space station were competing for decreasing resources. In addition, at least $650 million of NASAs human space flight budget was used to purchase Russian hardware and services related to U.S.-Russian space cooperation. This initiative was largely driven by the Clinton administrations foreign policy and national security objectives of supporting the administration of Boris Yeltsin and halting the proliferation of nuclear weapons and the means to deliver them.

CONGRESSIONAL ROLE IN BUDGET PROBLEMS

Pressure on NASA's budget has come not only from the White House, but also from the Congress. In recent years there has been an increasing tendency for the Congress to add earmarks congressional additions to the NASA budget request that reflect targeted members interests. These earmarks come out of already-appropriated funds, reducing the amounts available for the original tasks. For example, as Congress considered NASA's Fiscal Year 2002 appropriation, the NASA administrator told the House Appropriations subcommittee with jurisdiction over the NASA budget that the agency was extremely concerned regarding the magnitude and number of congressional earmarks in the House and Senate versions of the NASA appropriations bill. He noted the total number of House and Senate earmarks is approximately 140 separate items, an increase of nearly 50 percent over FY 2001. These earmarks reflected an increasing fraction of items that circumvent the peer review process, or involve construction or other objectives that have no relation to NASA mission objectives. The potential Fiscal Year 2002 earmarks represented a net total of $540 million in reductions to ongoing NASA programs to extremely large number of earmarks.

SPACE STATION IMPACT ON SHUTTLE BUDGET

For the past 30 years, the space shuttle program has been NASAs single most expensive activity, and of all NASAs efforts, that program has been hardest hit by the budget constraints of the past decade. Given the high priority assigned after 1993 to completing the costly international space station, NASA managers have had little choice but to attempt to reduce the costs of operating the space shuttle. This left little funding for shuttle improvements. The squeeze on the shuttle budget was even more severe after the Office of Management and Budget in 1994 insisted that any cost overruns in the International space Station budget be made up from within the budget allocation for human space flight, rather than from the agencys budget as a whole. The shuttle was the only other large program within that budget category.

DAN GOLDIN

In 1992 the White House replaced NASA Administrator Richard Truly with aerospace executive Daniel S. Goldin, a self-proclaimed agent of change who held office from April 1, 1992, to Nov. 17, 2001 (in the process becoming the longest-serving NASA administrator). Seeing space exploration (manned and unmanned) as NASAs principal purpose with Mars as a destiny, as one management scholar observed, and favoring administrative transformation of NASA, Goldin engineered not one or two policy changes, but a torrent of changes. This was not evolutionary change, but radical or discontinuous change. His tenure at NASA was one of continuous turmoil, to which the space shuttle program was not immune.

Goldin made many positive changes in his decade at NASA. By bringing Russia into the space Station partnership in 1993, Goldin developed a new post-Cold War rationale for the agency while managing to save a program that was politically faltering. The international space station became NASAs premier program, with the shuttle serving in a supporting role. Goldin was also instrumental in gaining acceptance of the faster, better, cheaper approach to the planning of robotic missions and downsizing an agency that was considered bloated and bureaucratic when he took it over. Goldin described himself as sharp-edged and could often be blunt. He rejected the criticism that he was sacrificing safety in the name of efficiency. In 1994 he told an audience at the Jet Propulsion Laboratory, When I ask for the budget to be cut, Im told its going to impact safety on the space shuttle I think thats a bunch of crap.

One of Goldins high-priority objectives was to decrease involvement of the NASA engineering workforce with the space shuttle program and thereby free up those skills for finishing the space station and beginning work on his preferred objectivehuman exploration of Mars. Such a shift would return NASA to its exploratory mission. He was often at odds with those who continued to focus on the centrality of the shuttle to NASAs future.

SEAN OKEEFE

Daniel Goldin left NASA in November 2001 after more than nine years as Administrator. The White House chose Sean OKeefe, the Deputy Director of the White House Office of Management and Budget, as his replacement. OKeefe stated as he took office that he was not a rocket scientist, but rather that his expertise was in the management of large government programs. His appointment was an explicit acknowledgement by the new Bush administration that NASAs primary problems were managerial and financial.

By the time OKeefe arrived, NASA managers had come to recognize that 1990s funding reductions for the space shuttle program had resulted in an excessively fragile program, and also realized that a space shuttle replacement was not on the horizon. In 2002, with these issues in mind, OKeefe made a number of changes to the space shuttle program.

He transferred management of both the space shuttle program and the International space Station from Johnson space Center to NASA Headquarters. OKeefe also began considering whether to expand the space Flight Operations Contract to cover additional space shuttle elements, or to pursue competitive sourcing, a Bush administration initiative that encouraged government agencies to compete with the private sector for management responsibilities of publicly funded activities.

PRESSURES FROM SPACE STATION

To meet the new flight schedule, in 2002 NASA revised its shuttle manifest, calling for a docking adaptor to be installed in Columbia after the STS-107 mission so that it could make an October 2003 flight to the International space Station. Columbia was not optimal for Station flights the Orbiter could not carry enough payload but it was assigned to this flight because Discovery was scheduled for 18 months of major maintenance. To ensure adequate shuttle availability for the February 2004 Node 2 launch date, Columbia would fly an International space Station resupply mission.

The White House and Congress had put the International space Station program, the space shuttle program, and indeed NASA on probation. NASA had to prove it could meet schedules within cost, or risk halting space Station construction at core complete a configuration far short of what NASA anticipated. The new NASA management viewed the achievement of an on-schedule Node 2 launch  as an endorsement of its successful approach to shuttle and Station programs. Any suggestions that it would be difficult to meet that launch date were brushed aside.

This insistence on a fixed launch schedule was worrisome. The International space Station Management and Cost Evaluation Task Force, in particular, was concerned with the emphasis on a specific launch date. It noted in its 2002 review of progress toward meeting its recommendations that significant progress has been made in nearly all aspects of the ISS program, but that there was significant risk with the Node 2 (February .04) schedule.

By November 2002, NASA had flown 16 space shuttle missions dedicated to Station assembly and crew rotation. Five crews had lived onboard the Station, the last four of them delivered via space shuttles. As the Station had grown, so had the complexity of the missions required to complete it. With the International space Station assembly more than half complete, the Station and shuttle programs had become irreversibly linked. Any problems with or perturbations to the planned schedule of one program reverberated through both programs. For the shuttle program, this meant that the conduct of all missions, even non-Station missions like STS-107, would have an impact on the Node 2 launch date.

REPAIR OF SHUTTLE OR RESCUE OF CREW

The repair option, while logistically viable using existing materials onboard Columbia, relied on so many uncertainties that NASA rated this option high risk.

If program managers were able to unequivocally determine before Flight Day Seven that there was potentially catastrophic damage to the left wing, accelerated processing of Atlantis might have provided a window in which Atlantis could rendezvous with Columbia before Columbias limited consumables ran out.

Recommendation: For missions to the International space Station, develop a practicable capability to inspect and effect emergency repairs to the widest possible range of damage to the Thermal protection system, including both tile and Reinforced Carbon-Carbon, taking advantage of the additional capabilities available when near to or docked at the International space Station.

For non-Station missions, develop a comprehensive autonomous (independent of Station) inspection and repair capability to cover the widest possible range of damage scenarios.

Accomplish an on-orbit Thermal protection system inspection, using appropriate assets and capabilities, early in all missions.

The ultimate objective should be a fully autonomous capability for all missions to address the possibility that an International space Station mission fails to achieve the correct orbit, fails to dock successfully, or is damaged during or after undocking.

RETURN TO FLIGHT

The Board supports return to flight for the space shuttle at the earliest date consistent with an overriding consideration: safety. The recognition of human spaceflight as a developmental activity requires a shift in focus from operations and meeting schedules to a concern for the risks involved. Necessary measures include:

Identifying risks by looking relentlessly for the next eroding O-ring, the next falling foam; obtaining better data, analyzing and spotting trends.

Mitigating risks by stopping the failure at its source; when a failure does occur, improving the ability to tolerate it; repairing the damage on a timely basis.

Decoupling unforeseen events from the loss of crew and vehicle.

Exploring all options for survival, such as provisions for crew escape systems and safe havens.

Barring unwarranted departures from design standards, and adjusting standards only under the most rigorous, safety-driven process.

CONTINUING TO FLY

It is the view of the Board that the present shuttle is not inherently unsafe. However, the observations and recommendations in this report are needed to make the vehicle safe enough to operate in the coming years. In order to continue operating the shuttle for another decade or even more, which the Human space Flight program may find necessary, these significant measures must be taken:

Implement all the recommendations listed in Part One of this report that were not already accomplished as part of the return-to-flight reforms.

Institute all the organizational and cultural changes called for in Part Two of this report.

Undertake complete recertification of the shuttle, as detailed in the discussion and  recommendation below.

The urgency of these recommendations derives, at least in part, from the likely pattern of what is to come. In the near term, the recent memory of the Columbia accident will motivate the entire NASA organization to scrupulous attention to detail and vigorous efforts to resolve elusive technical problems. That energy will inevitably dissipate over time. This decline in vigilance is a characteristic of many large organizations, and it has been demonstrated in NASAs own history. As reported in Part Two of this report, the Human space Flight program has at times compromised safety because of its organizational problems and cultural traits. That is the reason, in order to prevent the return of bad habits over time, that the Board makes the recommendations in Part Two calling for changes in the organization and culture of the Human space Flight program. These changes will take more time and effort than would be reasonable to expect prior to return to flight.

U.S. FUTURE IN SPACE

The Board in its investigation has focused on the physical and organizational causes of the Columbia accident and the recommended actions required for future safe shuttle operation.

In the course of that investigation, however, two realities affecting those recommendations have become evident to the Board. One is the lack, over the past three decades, of any national mandate providing NASA a compelling mission requiring human presence in space. President John Kennedys 1961 charge to send Americans to the moon and return them safely to Earth before this decade is out linked NASAs efforts to core Cold War national interests. Since the 1970s, NASA has not been charged with carrying out a similar high priority mission that would justify the expenditure of resources on a scale equivalent to those allocated for Project Apollo. The result is the agency has found it necessary to gain the support of diverse constituencies. NASA has had to participate in the give and take of the normal political process in order to obtain the resources needed to carry out its programs. NASA has usually failed to receive budgetary support consistent with its ambitions. The result, as noted throughout Part Two of the report, is an organization straining to do too much with too little.

A second reality, following from the lack of a clearly defined long-term space mission, is the lack of sustained government commitment over the past decade to improving Us. access to space by developing a second-generation space transportation system. Without a compelling reason to do so, successive Administrations and Congresses have not been willing to commit the billions of dollars required to develop such a vehicle. In addition, the space community has proposed to the government the development of vehicles such as the National Aerospace Plane and X-33, which required leapfrog advances in technology; those advances have proven to be unachievable. As Apollo 11 Astronaut Buzz Aldrin, one of the members of the recent Commission on the Future of the United States Aerospace Industry, commented in the Commission s November 2002 report, Attempts at developing breakthrough space transportation systems have proved illusory.

The Board believes that the country should plan for future space transportation capabilities without making them dependent on technological breakthroughs.

SPACE SHUTTLE REPLACEMENT

Because of the risks inherent in the original design of the space shuttle, because that design was based in many aspects on now-obsolete technologies, and because the shuttle is now an aging system but still developmental in character, it is in the nations interest to replace the as soon as possible as the primary means for Transporting humans to and from Earth orbit.

At least in the mid-term, that replacement will be some form of what NASA now characterizes as an Orbital space Plane. The design of the system should give overriding priority to crew safety, rather than trade safety against other performance criteria, such as low cost and reusability, or against advanced space operation This conclusion implies that whatever design NASA chooses should become the primary means for taking people to and from the International space Station, not just a complement to the space shuttle. And it follows from the same conclusion that there is urgency in choosing that design, after serious review of a concept of operations for human space flight, and bringing it into operation as soon as possible. This is likely to require a significant commitment of resources over the next several years. The nation must not shy from making that commitment. The International space Station is likely to be the major destination for human space travel for the next decade or longer. The space shuttle would continue to be used when its  unique capabilities are required, both with respect to space station missions such as experiment delivery and retrieval or other logistical missions, and with respect to the few planned missions not traveling to the space station. When cargo can be carried to the space station or other destinations by an expendable launch vehicle, it should be.

The Boards perspective assumes, of course, that the United States wants to retain a continuing capability to send people into space, whether to Earth orbit or beyond. The Boards work over the past seven months has been motivated by the desire to honor the STS-107 crew by understanding the cause of the accident in which they died, and to help the United States and indeed all spacefaring countries to minimize the risks of future loss of lives in the exploration of space. The United States should continue with a Human space Flight program consistent with the resolve voiced by President George W. Bush on February 1, 2003: Mankind is led into the darkness beyond our world by the inspiration of discovery and the longing to understand. Our journey into space will go on.

Findings and Recommendations

It is the Board's opinion that good leadership can direct a culture to adapt to new realities. NASA's culture must change, and the Board intends the following recommendations to be steps toward effecting this change. Recommendations have been put forth in many of the chapters.In this chapter, the recommendations are grouped by subject area with the Return-to-Flight [RTF] tasks listed first within the subject area. Each Recommendation retains its number so the reader can refer to the related section for additional details. These recommendations are not listed in priority order.

PART ONE THE ACCIDENT

Thermal Protection System

R3.2-1 Initiate an aggressive program to eliminate all External Tank Thermal Protection System debris-shedding at the source with particular emphasis on the region where the bipod struts attach to the External Tank. [RTF]

R3.3-2 Initiate a program designed to increase the Orbiter's ability to sustain minor debris damage by measures such as improved impact-resistant Reinforced Carbon-Carbon and acreage tiles. This program should determine the actual impact resistance of current materials and the effect of likely debris strikes. [RTF]

R3.3-1 Develop and implement a comprehensive inspectionplan to determine the structural integrity of all Reinforced Carbon-Carbon system components.This inspection plan should take advantage of advanced non-destructive inspection technology.[RTF]

R6.4-1 For missions to the International Space Station, develop a practicable capability to inspect and effect emergency repairs to the widest possible range of damage to the Thermal Protection System,including both tile and Reinforced Carbon-Carbon, taking advantage of the additional capabilitiesavailable when near to or docked at the International Space Station. For non-Station missions, develop a comprehensiveautonomous (independent of Station) inspectionand repair capability to cover the widest possible range of damage scenarios. Accomplish an on-orbit Thermal Protection System inspection, using appropriate assets and capabilities, early in all missions. The ultimate objective should be a fully autonomouscapability for all missions to address the possibility that an International Space Station mission fails to achieve the correct orbit, fails to dock successfully, or is damaged during or after undocking. [RTF]

R3.3-3 To the extent possible, increase the Orbiter's ability to successfully re-enter Earth's atmosphere with minor leading edge structural sub-system damage.

R3.3-4 In order to understand the true material characteristicsof Reinforced Carbon-Carbon components, develop a comprehensive database of flown ReinforcedCarbon-Carbon material characteristics by destructive testing and evaluation.

R3.3-5 Improve the maintenance of launch pad structuresto minimize the leaching of zinc primer onto Reinforced Carbon-Carbon components.

R3.8-1 Obtain sufficient spare Reinforced Carbon-Carbonpanel assemblies and associated support components to ensure that decisions on ReinforcedCarbon-Carbon maintenance are made on the basis of component specifications, free of external pressures relating to schedules, costs, or other considerations.

R3.8-2 Develop, validate, and maintain physics-based computer models to evaluate Thermal ProtectionSystem damage from debris impacts. These tools should provide realistic and timely estimatesof any impact damage from possible debrisfrom any source that may ultimately impact the Orbiter. Establish impact damage thresholds that trigger responsive corrective action, such as on-orbit inspection and repair, when indicated.

Imaging

R3.4-1 Upgrade the imaging system to be capable of providing a minimum of three useful views of the Space Shuttle from liftoff to at least Solid Rocket Booster separation, along any expected ascent azimuth. The operational status of these assets should be included in the Launch CommitCriteria for future launches. Consider using ships or aircraft to provide additional views of the Shuttle during ascent. [RTF]

R3.4-2 Provide a capability to obtain and downlink high-resolution images of the External Tank after it separates. [RTF]

R3.4-3 Provide a capability to obtain and downlink high-resolution images of the underside of the Orbiter wing leading edge and forward section of both wings' Thermal Protection System. [RTF]

R6.3-2 Modify the Memorandum of Agreement with the National Imagery and Mapping Agency to make the imaging of each Shuttle flight while on orbit a standard requirement. [RTF]

Orbiter Sensor Data

R3.6-1 The Modular Auxiliary Data System instrumentation and sensor suite on each Orbiter should be maintained and updated to include current sensor and data acquisition technologies.

R3.6-2 The Modular Auxiliary Data System should be redesigned to include engineering performance and vehicle health information, and have the ability to be reconfigured during flight in order to allow certain data to be recorded, telemetered, or both as needs change.

Wiring

R4.2-2 As part of the Shuttle Service Life Extension Program and potential 40-year service life, develop a state-of-the-art means to inspect all Orbiter wiring, including that which is inaccessible.

Bolt Catchers

R4.2-1 Test and qualify the flight hardware bolt catchers. [RTF]

Closeouts

R4.2-3 Require that at least two employees attend all final closeouts and intertank area hand-spraying procedures. [RTF]

Micrometeoroid and Orbital Debris

R4.2-4 Require the Space Shuttle to be operated with the same degree of safety for micrometeoroid and orbital debris as the degree of safety calculated for the International Space Station. Change the micrometeoroid and orbital debris safety criteria from guidelines to requirements.

Foreign Object Debris

R4.2-5 Kennedy Space Center Quality Assurance and United Space Alliance must return to the straightforward, industry-standard definition of "Foreign Object Debris" and eliminate any alternate or statistically deceptive definitions like "processing debris."[RTF]

PART TWO -- WHY THE ACCIDENT OCCURRED

Scheduling


R6.2-1 Adopt and maintain a Shuttle flight schedule that is consistent with available resources. Although schedule deadlines are an important management tool, those deadlines must be regularly evaluated to ensure that any additional risk incurred to meet the schedule is recognized, understood, and acceptable. [RTF]

Training

R6.3-1 Implement an expanded training program in which the Mission Management Team faces potential crew and vehicle safety contingencies beyond launch and ascent. These contingencies should involve potential loss of Shuttle or crew, contain numerous uncertainties and unknowns, and require the Mission Management Team to assemble and interact with support organizations across NASA/Contractor lines and in various locations. [RTF]

Organization

R7.5-1 Establish an independent Technical Engineering Authority that is responsible for technical requirements and all waivers to them, and will build a disciplined, systematic approach to identifying, analyzing, and controlling hazards throughout the life cycle of the Shuttle System. The independent technical authority does the following as a minimum:

  • Develop and maintain technical standards for all Space Shuttle Program projects and elements
  • Be the sole waiver-granting authority for all technical standards
  • Conduct trend and risk analysis at the sub-system, system, and enterprise levels
  • Own the failure mode, effects analysis and hazard reporting systems
  • Conduct integrated hazard analysis
  • Decide what is and is not an anomalous event
  • Independently verify launch readiness
  • Approve the provisions of the recertification program called for in Recommendation R9.1-1.

The Technical Engineering Authority should be funded directly from NASA Headquarters, and should have no connection to or responsibility for schedule or program cost. 

R7.5-2 NASA Headquarters Office of Safety and Mission Assurance should have direct line authority over the entire Space Shuttle Program safety organization and should be independently resourced.

R7.5-3 Reorganize the Space Shuttle Integration Office to make it capable of integrating all elements of the Space Shuttle Program, including the Orbiter.

PART THREE A LOOK AHEAD

Organization


R9.1-1 Prepare a detailed plan for defining, establishing, transitioning, and implementing an independent Technical Engineering Authority, independent safety program, and a reorganized Space Shuttle Integration Office as described in R7.5-1, R7.5-2, and R7.5-3. In addition, NASA should submit annual reports to Congress, as part of the budget review process, on its implementation activities. [RTF]
Recertification
R9.2-1 Prior to operating the Shuttle beyond 2010, develop and conduct a vehicle recertification at the material, component, subsystem, and system levels. Recertification requirements should be included in the Service Life Extension Program.

Closeout Photos/Drawing System

R10.3-1 Develop an interim program of closeout photographs for all critical sub-systems that differ from engineering drawings. Digitize the closeout photograph system so that images are immediately available for on-orbit troubleshooting. [RTF]

R10.3-2 Provide adequate resources for a long-term program to upgrade the Shuttle engineering drawing
system including:

  • Reviewing drawings for accuracy
  • Converting all drawings to a computer-aided drafting system
  • Incorporating engineering changes

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