Initial Foam Strike Identification

As soon as Columbia reached orbit on the morning of January 16, 2003, NASA's Intercenter Photo Working Group began reviewing liftoff imagery by video and film cameras on the launch pad and at other sites at and nearby the Kennedy Space Center. The debris strike was not seen during the first review of video imagery by tracking cameras, but it was noticed at 9:30 a.m. EST the next day, Flight Day Two, by Intercenter Photo Working Group engineers at Marshall Space Flight Center. Within an hour, Intercenter Photo Working Group personnel at Kennedy also identified the strike on higher-resolution film images that had just been developed.

The images revealed that a large piece of debris from the left bipod area of the External Tank had struck the Orbiter's left wing. Because the resulting shower of post-impact fragments could not be seen passing over the top of the wing, analysts concluded that the debris had apparently impacted the left wing below the leading edge. Intercenter Photo Working Group members were concerned about the size of the object and the apparent momentum of the strike. In searching for better views, Intercenter Photo Working Group members realized that none of the other cameras provided a higher-quality view of the impact and the potential damage to the Orbiter.

Of the dozen ground-based camera sites used to obtain images of the ascent for engineering analyses, each of which has film and video cameras, five are designed to track the Shuttle from liftoff until it is out of view. Due to expected angle of view and atmospheric limitations, two sites did not capture the debris event. Of the remaining three sites positioned to "see" at least a portion of the event, none provided a clear view of the actual debris impact to the wing. The first site lost track of Columbia on ascent, the second site was out of focus - because of an improperly maintained lens - and the third site captured only a view of the upper side of Columbia's left wing. The Board notes that camera problems also hindered the Challenger investigation. Over the years, it appears that due to budget and camera-team staff cuts, NASA's ability to track ascending Shuttles has atrophied - a development that reflects NASA's disregard of the developmental nature of the Shuttle's technology.

Because they had no sufficiently resolved pictures with which to determine potential damage, and having never seen such a large piece of debris strike the Orbiter so late in ascent, Intercenter Photo Working Group members decided to ask for ground-based imagery of Columbia.

IMAGERY REQUEST 1

To accomplish this, the Intercenter Photo Working Group's Chair, Bob Page, contacted Wayne Hale, the Shuttle Program Manager for Launch Integration at Kennedy Space Center, to request imagery of Columbia's left wing on-orbit. Hale, who agreed to explore the possibility, holds a Top Secret clearance and was familiar with the process for requesting military imaging from his experience as a Mission Control Flight Director.

This would be the first of three discrete requests for imagery by a NASA engineer or manager. In addition to these three requests, there were, by the Board's count, at least eight "missed opportunities" where actions may have resulted in the discovery of debris damage.

Shortly after confirming the debris hit, Intercenter Photo Working Group members distributed a "L+1" (Launch plus one day) report and digitized clips of the strike via e-mail throughout the NASA and contractor communities. This report provided an initial view of the foam strike and served as the basis for subsequent decisions and actions.

Mission Management's Response to the Foam Strike

As soon as the Intercenter Working Group report was distributed, engineers and technical managers from NASA, United Space Alliance, and Boeing began responding. Engineers and managers from Kennedy Space Center called engineers and Program managers at Johnson Space Center. United Space Alliance and Boeing employees exchanged e-mails with details of the initial film analysis and the work in progress to determine the result of the impact. Details of the strike, actions taken in response to the impact, and records of telephone conversations were documented in the Mission Control operational log. The following section recounts in chronological order many of these exchanges and provides insight into why, in spite of the debris strike's severity, NASA managers ultimately declined to request images of Columbia's left wing on-orbit.

Flight Day Two, Friday, January 17, 2003

In the Mission Evaluation Room, a support function of the Shuttle Program office that supplies engineering expertise for missions in progress, a set of consoles are staffed by engineers and technical managers from NASA and contractor organizations. For record keeping, each Mission Evaluation Room member types mission-related comments into a running log. A log entry by a Mission Evaluation Room manager at 10:58 a.m. Central Standard Time noted that the vehicle may have sustained damage from a debris strike.

"John Disler [a photo lab engineer at Johnson Space Center] called to report a debris hit on the vehicle. The debris appears to originate from the ET Forward Bipod area...travels down the left side and hits the left wing leading edge near the fuselage...The launch video review team at KSC think that the vehicle may have been damaged by the impact. Bill Reeves and Mike Stoner (USA SAM) were notified." [ET=External Tank, KSC=Kennedy Space Center, USA SAM=United Space Alliance Sub-system Area Manager]

Already, by Friday afternoon, Shuttle Program managers and working engineers had different levels of concern about what the foam strike might have meant. After reviewing available film, Intercenter Photo Working Group engineers believed the Orbiter may have been damaged by the strike. They wanted on-orbit images of Columbia's left wing to confirm their suspicions and initiated action to obtain them. Boeing and United Space Alliance engineers decided to work through the holiday weekend to analyze the strike. At the same time, high-level managers Ralph Roe, head of the Shuttle Program Office of Vehicle Engineering, and Bill Reeves, from United Space Alliance, voiced a lower level of concern. It was at this point, before any analysis had started, that Shuttle Program managers officially shared their belief that the strike posed no safety issues, and that there was no need for a review to be conducted over the weekend. The following is a 4:28 p.m. Mission Evaluation Room manager log entry:

"Bill Reeves called, after a meeting with Ralph Roe, it is confirmed that USA/Boeing will not work the debris issue over the weekend, but will wait till Monday when the films are released. The LCC constraints on ice, the energy/speed of impact at +81 seconds, and the toughness of the RCC are two main factors for the low concern. Also, analysis supports single mission safe re-entry for an impact that penetrates the system..." [USA=United Space Alliance, LCC=Launch Commit Criteria]

The following is a 4:37 p.m. Mission Evaluation Room manager log entry.

"Bob Page told MER that KSC/TPS engineers were sent by the USA SAM/Woody Woodworth to review the video and films. Indicated that Page had said that Woody had said this was an action from the MER to work this issue and a possible early landing on Tuesday. MER Manager told Bob that no official action was given by USA or Boeing and they had no concern about landing early. Woody indicated that the TPS engineers at KSC have been 'turned away' from reviewing the films. It was stated that the film reviews wouldn't be finished till Monday." [MER=Mission Evaluation Room, KSC=Kennedy Space Center, TPS=Thermal Protection System, USA SAM=United Space Alliance Sub-system Area Manager]

The Mission Evaluation Room manager also wrote:

"I also confirmed that there was no rush on this issue and that it was okay to wait till the film reviews are finished on Monday to do a TPS review."

In addition to individual log entries by Mission Evaluation Room members, managers prepared "handover" notes for delivery from one working shift to the next. Handovers from Shift 1 to 2 on January 17 included the following entry under a "problem" category.

"Disler Report - Debris impact on port wing edge-appears to have originated at the ET fwd bipod - foam?- if so, it shouldn't be a problem - video clip will be available on the web soon - will look at high-speed film today." [ET=External Tank, fwd=forward]

Shortly after these entries were made, the deputy manager of Johnson Space Center Shuttle Engineering notified Rodney Rocha, NASA's designated chief engineer for the Thermal Protection System, of the strike and the approximate debris size. It was Rocha's responsibility to coordinate NASA engineering resources and work with contract engineers at United Space Alliance, who together would form a Debris Assessment Team that would be Co-Chaired by United Space Alliance engineering manager Pam Madera. The United Space Alliance deputy manager of Shuttle Engineering signaled that the debris strike was initially classified as "out-of-family" and therefore of greater concern than previous debris strikes. At about the same time, the Intercenter Photo Working Group's L+1 report, containing both video clips and still images of the debris strike, was e-mailed to engineers and technical managers both inside and outside of NASA.

Flight Days Three and Four, Saturday and Sunday, January 18 and 19, 2003

Though senior United Space Alliance Manager Bill Reeves had told Mission Evaluation Room personnel that the debris problem would not be worked over the holiday weekend, engineers from Boeing did in fact work through the weekend. Boeing analysts conducted a preliminary damage assessment on Saturday. Using video and photo images, they generated two estimates of possible debris size - 20 inches by 20 inches by 2 inches, and 20 inches by 16 inches by 6 inches - and determined that the debris was traveling at a approximately 750 feet per second, or 511 miles per hour, when it struck the Orbiter at an estimated impact angle of less than 20 degrees. These estimates later proved remarkably accurate.

To calculate the damage that might result from such a strike, the analysts turned to a Boeing mathematical modeling tool called Crater that uses a specially developed algorithm to predict the depth of a Thermal Protection System tile to which debris will penetrate. This algorithm, suitable for estimating small (on the order of three cubic inches) debris impacts, had been calibrated by the results of foam, ice, and metal debris impact testing. A similar Crater-like algorithm was also developed and validated with test results to assess the damage caused by ice projectiles impacting the RCC leading edge panels. These tests showed that within certain limits, the Crater algorithm predicted more severe damage than was observed. This led engineers to classify Crater as a "conservative" tool - one that predicts more damage than will actually occur.

Until STS-107, Crater was normally used only to predict whether small debris, usually ice on the External Tank, would pose a threat to the Orbiter during launch. The use of Crater to assess the damage caused by foam during the launch of STS-107 was the first use of the model while a mission was on orbit. Also of note is that engineers used Crater during STS-107 to analyze a piece of debris that was at maximum 640 times larger in volume than the pieces of debris used to calibrate and validate the Crater model (the Board's best estimate is that it actually was 400 times larger). Therefore, the use of Crater in this new and very different situation compromised NASA's ability to accurately predict debris damage in ways that Debris Assessment Team engineers did not fully comprehend (see Figure 6.3-1).

Figure 6.3-1. The small cylinder at top illustrates the size of debris Crater was intended to analyze. The larger cylinder was used for the STS-107 analysis; the block at right is the estimated size of the foam. Credit: CAIB

Over the weekend, an engineer certified by Boeing to use Crater entered the two estimated debris dimensions, the estimated debris velocity, and the estimated angle of impact. The engineer had received formal training on Crater from senior Houston-based Boeing engineering staff, but he had only used the program twice before, and had reservations about using it to model the piece of foam debris that struck Columbia. The engineer did not consult with more experienced engineers from Boeing's Huntington Beach, California, facility, who up until the time of STS-107 had performed or overseen Crater analysis. (Boeing completed the transfer of responsibilities for Crater analysis from its Huntington Beach engineers to its Houston office in January 2003. STS-107 was the first mission that the Huntington Beach engineers were not directly involved with.)

For the Thermal Protection System tile, Crater predicted damage deeper than the actual tile thickness. This seemingly alarming result suggested that the debris that struck Columbia would have exposed the Orbiter's underlying aluminum airframe to extreme temperatures, resulting in a possible burn-through during re-entry. Debris Assessment Team engineers discounted the possibility of burn through for two reasons. First, the results of calibration tests with small projectiles showed that Crater predicted a deeper penetration than would actually occur. Second, the Crater equation does not take into account the increased density of a tile's lower "densified" layer, which is much stronger than tile's fragile outer layer. Therefore, engineers judged that the actual damage from the large piece of foam lost on STS-107 would not be as severe as Crater predicted, and assumed that the debris did not penetrate the Orbiter's skin. This uncertainty, however, meant that determining the precise location of the impact was paramount for an accurate damage estimate. Some areas on the Orbiter's lower surface, such as the seals around the landing gear doors, are more vulnerable than others. Only by knowing precisely where the debris struck could the analysts more accurately determine if the Orbiter had been damaged.

To determine potential RCC damage, analysts used a Crater-like algorithm that was calibrated in 1984 by impact data from ice projectiles. At the time the algorithm was empirically tested, ice was considered the only realistic threat to RCC integrity. (See Appendix E.4, RCC Impact Analysis.) The Debris Assessment Team analysis indicated that impact angles greater than 15 degrees would result in RCC penetration. A separate "transport" analysis, which attempts to determine the path the debris took, identified 15 strike regions and angles of impact. Twelve transport scenarios predicted an impact in regions of Shuttle tile. Only one scenario predicted an impact on the RCC leading edge, at a 21-degree angle. Because the foam that struck Columbia was less dense than ice, Debris Assessment Team analysts used a qualitative extrapolation of the test data and engineering judgment to conclude that a foam impact angle up to 21 degrees would not penetrate the RCC. Although some engineers were uncomfortable with this extrapolation, no other analyses were performed to assess RCC damage. The Debris Assessment Team focused on analyzing the impact at locations other than the RCC leading edge. This may have been due, at least in part, to the transport analysis presentation and the long-standing belief that foam was not a threat to RCC panels. The assumptions and uncertainty embedded in this analysis were never fully presented to the Mission Evaluation Room or the Mission Management Team.

MISSED OPPORTUNITY 1

On Sunday, Rodney Rocha e-mailed a Johnson Space Center Engineering Directorate manager to ask if a Mission Action Request was in progress for Columbia's crew to visually inspect the left wing for damage. Rocha never received an answer.

Flight Day Five, Monday, January 20, 2003

On Monday morning, the Martin Luther King Jr. holiday, the Debris Assessment Team held an informal meeting before its first formal meeting, which was scheduled for Tuesday afternoon. The team expanded to include NASA and Boeing transport analysts expert in the movement of debris in airflows, tile and RCC experts from Boeing and NASA, aerothermal and thermal engineers from NASA, United Space Alliance, and Boeing, and a safety representative from the NASA contractor Science Applications International Corporation.

Engineers emerged from that informal meeting with a goal of obtaining images from ground-based assets. Uncertainty as to precisely where the debris had struck Columbia generated concerns about the possibility of a breach in the left main landing gear door seal. They conducted further analysis using angle and thickness variables and thermal data obtained by personnel at Boeing's Huntington Beach facility for STS-87 and STS-50, the two missions that had incurred Thermal Protection System damage.

Debris Assessment Team Co-Chair Pam Madera distributed an e-mail summarizing the day's events and outlined the agenda for Tuesday's first formal Debris Assessment Team meeting. Included on the agenda was the desire to obtain on-orbit images of Columbia's left wing.

According to an 11:39 a.m. entry in the Mission Evaluation Room Manager's log:

"...the debris 'blob' is estimated at 20" +/-10" in some direction, using the Orbiter hatch as a basis. It appears to be similar size as that seen in STS-112. There will be more comparison work done, and more info and details in tomorrow's report."

This entry illustrates, in NASA language, an initial attempt by managers to classify this bipod ramp foam strike as close to being within the experience base and therefore, being almost an "in-family" event, not necessarily a safety concern. While the size and source of STS-107 debris was somewhat similar to what STS-112 had experienced, the impact sites (the wing versus the Solid Rocket Booster) differed - a distinction not examined by mission managers.

Flight Day Six, Tuesday, January 21, 2003

At 7:00 a.m., the Debris Assessment Team briefed Don McCormack, the chief Mission Evaluation Room manager, that the foam's source and size was similar to what struck STS-112, and that an analysis of measured versus predicted tile damage from STS-87 was being scrutinized by Boeing. An hour later, McCormack related this information to the Mission Management Team at its first post-holiday meeting. Although Space Shuttle Program requirements state that the Mission Management Team will convene daily during a mission, the STS-107 Mission Management Team met only on January 17, 21, 24, 27, and 31. The transcript below is the first record of an official discussion of the debris impact at a Mission Management Team meeting. Before even referring to the debris strike, the Mission Management Team focused on end-of-mission "downweight" (the Orbiter was 150 pounds over the limit), a leaking water separator, a jammed Hasselblad camera, payload and experiment status, and a communications downlink problem. McCormack then stated that engineers planned to determine what could be done if Columbia had sustained damage. STS-107 Mission Management Team Chair Linda Ham suggested the team learn what rationale had been used to fly after External Tank foam losses on STS-87 and STS-112.

Transcript Excerpts from the January 21, Mission Management Team Meeting

Ham: "Alright, I know you guys are looking at the debris."

McCormack: "Yeah, as everybody knows, we took a hit on the, somewhere on the left wing leading edge and the photo TV guys have completed I think, pretty much their work although I'm sure they are reviewing their stuff and they've given us an approximate size for the debris and approximate area for where it came from and approximately where it hit, so we are talking about doing some sort of parametric type of analysis and also we're talking about what you can do in the event we have some damage there."

Ham: "That comment, I was thinking that the flight rationale at the FRR from tank and orbiter from STS-112 was.... I'm not sure that the area is exactly the same where the foam came from but the carrier properties and density of the foam wouldn't do any damage. So we ought to pull that along with the 87 data where we had some damage, pull this data from 112 or whatever flight it was and make sure that...you know I hope that we had good flight rationale then."

McCormack: "Yeah, and we'll look at that, you mentioned 87, you know we saw some fairly significant damage in the area between RCC panels 8 and 9 and the main landing gear door on the bottom on STS-87 we did some analysis prior to STS-89 so uh..."

Ham: "And I'm really I don't think there is much we can do so it's not really a factor during the flight because there is not much we can do about it. But what I'm really interested in is making sure our flight rationale to go was good, and maybe this is foam from a different area and I'm not sure and it may not be co-related, but you can try to see what we have."

McCormack: "Okay."

After the meeting, the rationale for continuing to fly after the STS-112 foam loss was sent to Ham for review. She then exchanged e-mails with her boss, Space Shuttle Program Manager Ron Dittemore:

-----Original Message-----
From: DITTEMORE, RONALD D. (JSC-MA) (NASA)
Sent: Wednesday, January 22, 2003 9:14 AM
To: HAM, LINDA J. (JSC-MA2) (NASA)
Subject: RE: ET Briefing - STS-112 Foam Loss

You remember the briefing! Jerry did it and had to go out and say that the hazard report had not changed and that the risk had not changed...But it is worth looking at again.

-----Original Message-----
From: HAM, LINDA J. (JSC-MA2) (NASA)
Sent: Tuesday, January 21, 2003 11:14 AM
To: DITTEMORE, RONALD D. (JSC-MA) (NASA)
Subject: FW: ET Briefing - STS-112 Foam Loss

You probably can't open the attachment. But, the ET rationale for flight for the STS-112 loss of foam was lousy. Rationale states we haven't changed anything, we haven't experienced any 'safety of flight' damage in 112 flights, risk of loss of bi-pod ramp TPS is same as previous flghts...So ET is safe to fly with no added risk

Rationale was lousy then and still is....

-----Original Message-----
From: MCCORMACK, DONALD L. (DON) (JSC-MV6) (NASA)
Sent: Tuesday, January 21, 2003 9:45 AM
To: HAM, LINDA J. (JSC-MA2) (NASA)
Subject: FW: ET Briefing - STS-112 Foam Loss
Importance: High

FYI - it kinda says that it will probably be all right

Ham's focus on examining the rationale for continuing to fly after the foam problems with STS-87 and STS-112 indicates that her attention had already shifted from the threat the foam posed to STS-107 to the downstream implications of the foam strike. Ham was due to serve, along with Wayne Hale, as the launch integration manager for the next mission, STS-114. If the Shuttle Program's rationale to fly with foam loss was found to be flawed, STS-114, due to be launched in about a month, would have to be delayed per NASA rules that require serious problems to be resolved before the next flight. An STS-114 delay could in turn delay completion of the International Space Station's Node 2, which was a high-priority goal for NASA managers.

During this same Mission Management Team meeting, the Space Shuttle Integration Office's Lambert Austin reported that engineers were reviewing long-range tracking film and that the foam debris that appeared to hit the left wing leading edge may have come from the bipod area of the External Tank. Austin said that the Engineering Directorate would continue to run analyses and compare this foam loss to that of STS-112. Austin also said that after STS-107 landed, engineers were anxious to see the crew-filmed footage of External Tank separation that might show the bipod ramp and therefore could be checked for missing foam.

MISSED OPPORTUNITY 2

Reviews of flight-deck footage confirm that on Flight Day One, Mission Specialist David Brown filmed parts of the External Tank separation with a Sony PD-100 Camcorder, and Payload Commander Mike Anderson photographed it with a Nikon F-5 camera with a 400-millimeter lens. Brown later downlinked 35 seconds of this video to the ground as part of his Flight Day One mission summary, but the bipod ramp area had rotated out of view, so no evidence of missing foam was seen when this footage was reviewed during the mission. However, after the Intercenter Photo Working Group caught the debris strike on January 17, ground personnel failed to ask Brown if he had additional footage of External Tank separation. Based on how crews are trained to film External Tank separation, the Board concludes Brown did in fact have more film than the 35 seconds he downlinked. Such footage may have confirmed that foam was missing from the bipod ramp area or could have identified other areas of missing foam. Austin's mention of the crew's filming of External Tank separation should have prompted someone at the meeting to ask Brown if he had more External Tank separation film, and if so, to downlink it immediately.

Flight Director Steve Stich discussed the debris strike with Phil Engelauf, a member of the Mission Operations Directorate, after Engelauf returned from the Mission Management Team meeting. As written in a timeline Stich composed after the accident, the conversation included the following.

"Phil said the Space Shuttle Program community is not concerned and that Orbiter Project is analyzing ascent debris...relayed that there had been no direction for MOD to ask DOD for any photography of possible damaged tiles" [MOD=Mission Operations Directorate, or Mission Control, DOD=Department of Defense]

"No direction for DOD photography" seems to refer to either a previous discussion of photography with Mission managers or an expectation of future activity. Since the interagency agreement on imaging support stated that the Flight Dynamics Officer is responsible for initiating such a request, Engelauf's comments demonstrates that an informal chain of command, in which the Mission Operations Directorate figures prominently, was at work.

About an hour later, Calvin Schomburg, a Johnson Space Center engineer with close connections to Shuttle management, sent the following e-mail to other Johnson engineering managers.

-----Original Message-----
From: SCHOMBURG, CALVIN (JSC-EA) (NASA)
Sent: Tuesday, January 21, 2003 9:26 AM
To: SHACK, PAUL E. (JSC-EA42) (NASA); SERIALE-GRUSH, JOYCE M. (JSC-EA) (NASA); HAMILTON, DAVID A. (DAVE) (JSC-EA) (NASA)
Subject: FW: STS-107 Post-Launch Film Review - Day 1

FYI-TPS took a hit-should not be a problem-status by end of week.

Seven minutes later, Paul Shack, Manager of the Shuttle Engineering Office, Johnson Engineering Directorate, e-mailed to Rocha and other Johnson engineering managers information on how previous bipod ramp foam losses were handled.

-----Original Message-----
From: SHACK, PAUL E. (JSC-EA42) (NASA)
Sent: Tuesday, January 21, 2003 9:33 AM
To: ROCHA, ALAN R. (RODNEY) (JSC-ES2) (NASA); SERIALE-GRUSH, JOYCE M. (JSC-EA) (NASA)
Cc: KRAMER, JULIE A. (JSC-EA4) (NASA); MILLER, GLENN J. (JSC-EA) (NASA); RICKMAN, STEVEN L. (JSC-ES3) (NASA); MADDEN, CHRISTOPHER B. (CHRIS) (JSC-ES3) (NASA)
Subject: RE: STS-107 Debris Analysis Team Plans

This reminded me that at the STS-113 FRR the ET Project reported on foam loss from the Bipod Ramp during STS-112. The foam (estimated 4X5X12 inches) impacted the ET Attach Ring and dented an SRB electronics box cover.

Their charts stated "ET TPS foam loss over the life of the Shuttle program has never been a 'Safety of Flight' issue". They were severely wire brushed over this and Brian O'Conner (Associate Administrator for Safety) asked for a hazard assessment for loss of foam.

The suspected cause for foam loss is trapped air pockets which expand due to altitude and aerothermal heating.

Shack's message informed Rocha that during the STS-113 Flight Readiness Review, foam loss was not considered to be a safety-of-flight issue. The "wirebrushing" that the External Tank Project received for stating that foam loss has "never been a 'Safety of Flight' issue" refers to the wording used to justify continuing to fly. Officials at the Flight Readiness Review insisted on classifying the foam loss as an "accepted risk" rather than "not a safety-of-flight problem" to indicate that although the Shuttle would continue to fly, the threat posed by foam is not zero but rather a known and acceptable risk.

It is here that the decision to fly before resolving the foam problem at the STS-113 Flight Readiness Review influences decisions made during STS-107. Having at hand a previously accepted rationale - reached just one mission ago - that foam strikes are not a safety-of-flight issue provides a strong incentive for Mission managers and working engineers to use that same judgment for STS-107. If managers and engineers were to argue that foam strikes are a safety-of-flight issue, they would contradict an established consensus that was a product of the Shuttle Program's most rigorous review - a review in which many of them were active participants.

An entry in a Mission Evaluation Room console log included a 10:30 a.m. report that compared the STS-107 foam loss to previous foam losses and subsequent tile damage, which reinforced management acceptance about foam strikes by indicating that the foam strike appeared to be more of an "in-family" event.

"...STS-107 debris measured at 22" long +/- 10". On STS-112 the debris spray pattern was a lot smaller than that of STS-107. On STS-50 debris that was determined to be the Bipod ramp which measured 26" x 10" caused damage to the left wing...to 1 tile and 20% of the adjacent tile. Same event occurred on STS-7 (no data available)."

MISSED OPPORTUNITY 3

The foam strike to STS-107 was mentioned by a speaker at an unrelated meeting of NASA Headquarters and National Imagery and Mapping Agency personnel, who then discussed a possible NASA request for Department of Defense imagery support. However, no action was taken.

IMAGERY REQUEST 2

Responding to concerns from his employees who were participating in the Debris Assessment Team, United Space Alliance manager Bob White called Lambert Austin on Flight Day Six to ask what it would take to get imagery of Columbia on orbit. They discussed the analytical debris damage work plan, as well as the belief of some integration team members that such imaging might be beneficial.

Austin subsequently telephoned the Department of Defense Manned Space Flight Support Office representative to ask about actions necessary to get imagery of Columbia on orbit. Austin emphasized that this was merely information gathering, not a request for action. This call indicates that Austin was unfamiliar with NASA/National Imagery and Mapping Agency imagery request procedures.

An e-mail that Lieutenant Colonel Timothy Lee sent to Don McCormack the following day shows that the Defense Department had begun to implement Austin's request.

-----Original Message-----
From: LEE, TIMOTHY F., LTCOL. (JSC-MT) (USAF)
Sent: Wednesday, January 22, 2003 9:01 AM
To: MCCORMACK, DONALD L. (DON) (JSC-MV6) (NASA)
Subject: NASA request for DOD

Don,

FYI: Lambert Austin called me yesterday requesting DOD photo support for STS-107. Specifically, he is asking us if we have a ground or satellite asset that can take a high resolution photo of the shuttle while on-orbit to see if there is any FOD damage on the wing. We are working his request.

Tim

First Debris Assessment Team Meeting

On Flight Day Six, the Debris Assessment Team held its first formal meeting to finalize Orbiter damage estimates and their potential consequences. Some participants joined the proceedings via conference call.

IMAGERY REQUEST 3

After two hours of discussing the Crater results and the need to learn precisely where the debris had hit Columbia, the Debris Assessment Team assigned its NASA Co-Chair, Rodney Rocha, to pursue a request for imagery of the vehicle on-orbit. Each team member supported the idea to seek imagery from an outside source. Rather than working the request up the usual mission chain of command through the Mission Evaluation Room to the Mission Management Team to the Flight Dynamics Officer, the Debris Assessment Team agreed, largely due to a lack of participation by Mission Management Team and Mission Evaluation Room managers, that Rocha would pursue the request through his division, the Engineering Directorate at Johnson Space Center. Rocha sent the following e-mail to Paul Shack shortly after the meeting adjourned.

-----Original Message-----
From: ROCHA, ALAN R. (RODNEY) (JSC-ES2) (NASA)
Sent: Tuesday, January 21, 2003 4:41 PM
To: SHACK, PAUL E. (JSC-EA42) (NASA); HAMILTON, DAVID A. (DAVE) (JSC-EA) (NASA); MILLER, GLENN J. (JSC-EA) (NASA)
Cc: SERIALE-GRUSH, JOYCE M. (JSC-EA) (NASA); ROGERS, JOSEPH E. (JOE) (JSC-ES2) (NASA); GALBREATH, GREGORY F. (GREG) (JSC-ES2) (NASA)
Subject: STS-107 Wing Debris Impact, Request for Outside Photo-Imaging Help

Paul and Dave,

The meeting participants (Boeing, USA, NASA ES2 and ES3, KSC) all agreed we will always have big uncertainties in any transport/trajectory analyses and applicability/extrapolation of the old Arc-Jet test data until we get definitive, better, clearer photos of the wing and body underside. Without better images it will be very difficult to even bound the problem and initialize thermal, trajectory, and structural analyses. Their answers may have a wide spread ranging from acceptable to not-acceptable to horrible, and no way to reduce uncertainty. Thus, giving MOD options for entry will be very difficult.

Can we petition (beg) for outside agency assistance? We are asking for Frank Benz with Ralph Roe or Ron Dittemore to ask for such. Some of the old timers here remember we got such help in the early 1980's when we had missing tile concerns.

Despite some nay-sayers, there are some options for the team to talk about: On-orbit thermal conditioning for the major structure (but is in contradiction with tire pressure temp. cold limits), limiting high cross-range de-orbit entries, constraining right or left had turns during the Heading Alignment Circle (only if there is struc. damage to the RCC panels to the extent it affects flight control.

Rodney Rocha
Structural Engineering Division (ES-SED)

• ES Div. Chief Engineer (Space Shuttle DCE)
• Chair, Space Shuttle Loads & Dynamics Panel

Mail Code ES2

Flight Day Seven, Wednesday, January 22, 2003

Conversations and log entries on Flight Day Seven document how three requests for images (Bob Page to Wayne Hale, Bob White to Lambert Austin, and Rodney Rocha to Paul Shack) were ultimately dismissed by the Mission Management Team, and how the order to halt those requests was then interpreted by the Debris Assessment Team as a direct and final denial of their request for imagery.

MISSED OPPORTUNITY 4

On the morning of Flight Day Seven, Wayne Hale responded to the earlier Flight Day Two request from Bob Page and a call from Lambert Austin on Flight Day Five, during which Austin mentioned that "some analysts" from the Debris Assessment Team were interested in getting imagery. Hale called a Department of Defense representative at Kennedy Space Center (who was not the designated Department of Defense official for coordinating imagery requests) and asked that the military start the planning process for imaging Columbia on orbit.

Within an hour, the Defense Department representative at NASA contacted U.S. Strategic Command (USSTRATCOM) at Colorado's Cheyenne Mountain Air Force Station and asked what it would take to get imagery of Columbia on orbit. (This call was similar to Austin's call to the Department of Defense Manned Space Flight Support Office in that the caller characterized it as "information gathering" rather than a request for action.) A representative from the USSTRATCOM Plans Office initiated actions to identify ground-based and other imaging assets that could execute the request.

Hale's earlier call to the Defense Department representative at Kennedy Space Center was placed without authorization from Mission Management Team Chair Linda Ham. Also, the call was made to a Department of Defense Representative who was not the designated liaison for handling such requests. In order to initiate the imagery request through official channels, Hale also called Phil Engelauf at the Mission Operations Directorate, told him he had started Defense Department action, and asked if Engelauf could have the Flight Dynamics Officer at Johnson Space Center make an official request to the Cheyenne Mountain Operations Center. Engelauf started to comply with Hale's request.

After the Department of Defense representatives were called, Lambert Austin telephoned Linda Ham to inform her about the imagery requests that he and Hale had initiated. Austin also told Wayne Hale that he had asked Lieutenant Colonel Lee at the Department of Defense Manned Space Flight Support Office about what actions were necessary to get on-orbit imagery.

MISSED OPPORTUNITIES 5 AND 6

Mike Card, a NASA Headquarters manager from the Safety and Mission Assurance Office, called Mark Erminger at the Johnson Space Center Safety and Mission Assurance for Shuttle Safety Program and Bryan O'Connor, Associate Administrator for Safety and Mission Assurance, to discuss a potential Department of Defense imaging request. Erminger said that he was told this was an "in-family" event. O'Connor stated he would defer to Shuttle management in handling such a request. Despite two safety officials being contacted, one of whom was NASA's highest-ranking safety official, safety personnel took no actions to obtain imagery.

The following is an 8:09 a.m. entry in the Mission Evaluation Room Console log.

"We received a visit from Mission Manager/Vanessa Ellerbe and FD Office/Phil Engelauf regarding two items: (1) the MMT's action item to the MER to determine the impacts to the vehicle's 150 lbs of additional weight...and (2) Mr. Engelauf wants to know who is requesting the Air Force to look at the vehicle." [FD=Flight Director, MMT=Mission Management Team, MER=Mission Evaluation Room]

CANCELLATION OF THE REQUEST FOR IMAGERY

At 8:30 a.m., the NASA Department of Defense liaison officer called USSTRATCOM and cancelled the request for imagery. The reason given for the cancellation was that NASA had identified its own in-house resources and no longer needed the military's help. The NASA request to the Department of Defense to prepare to image Columbia on-orbit was both made and rescinded within 90 minutes.

The Board has determined that the following sequence of events likely occurred within that 90-minute period. Linda Ham asked Lambert Austin if he knew who was requesting the imagery. After admitting his participation in helping to make the imagery request outside the official chain of command and without first gaining Ham's permission, Austin referred to his conversation with United Space Alliance Shuttle Integration manager Bob White on Flight Day Six, in which White had asked Austin, in response to White's Debris Assessment Team employee concerns, what it would take to get Orbiter imagery.

Even though Austin had already informed Ham of the request for imagery, Ham later called Mission Management Team members Ralph Roe, Manager of the Space Shuttle Vehicle Engineering Office, Loren Shriver, United Space Alliance Deputy Program Manager for Shuttle, and David Moyer, the on-duty Mission Evaluation Room manager, to determine the origin of the request and to confirm that there was a "requirement" for a request. Ham also asked Flight Director Phil Engelauf if he had a "requirement" for imagery of Columbia's left wing. These individuals all stated that they had not requested imagery, were not aware of any "official" requests for imagery, and could not identify a "requirement" for imagery. Linda Ham later told several individuals that nobody had a requirement for imagery.

What started as a request by the Intercenter Photo Working Group to seek outside help in obtaining images on Flight Day Two in anticipation of analysts' needs had become by Flight Day Six an actual engineering request by members of the Debris Assessment Team, made informally through Bob White to Lambert Austin, and formally in Rodney Rocha's e-mail to Paul Shack. These requests had then caused Lambert Austin and Wayne Hale to contact Department of Defense representatives. When Ham officially terminated the actions that the Department of Defense had begun, she effectively terminated both the Intercenter Photo Working Group request and the Debris Assessment Team request. While Ham has publicly stated she did not know of the Debris Assessment Team members' desire for imagery, she never asked them directly if the request was theirs, even though they were the team analyzing the foam strike.

Also on Flight Day Seven, Ham raised concerns that the extra time spent maneuvering Columbia to make the left wing visible for imaging would unduly impact the mission schedule; for example, science experiments would have to stop while the imagery was taken. According to personal notes obtained by the Board:

"Linda Ham said it was no longer being pursued since even if we saw something, we couldn't do anything about it. The Program didn't want to spend the resources."

The following is an entry in the Flight Director Handover Log.

"NASA Resident Office, Peterson AFB called and SOI at USSPACECOM was officially turned off. This went all the way up to 4 star General. Post flight we will write a memo to USSPACECOM telling them whom they should take SOI requests from."50 [AFB=Air Force Base, SOI=Spacecraft Object Identification, USSPACECOM=U.S. Space Command]

-----Original Message---
From: HAM, LINDA J. (JSC-MA2) (NASA)
Sent: Wednesday, January 22, 2003 9:33 AM
To: AUSTIN, LAMBERT D. (JSC-MS) (NASA); ROE, RALPH R. (JSC-MV) (NASA)
Subject: ET Foam Loss

Can we say that for any ET foam lost, no 'safety of flight' damage can occur to the Orbiter because of the density?

-----Original Message-----
From: ROE, RALPH R. (JSC-MV) (NASA)
Sent: Wednesday, January 22, 2003 9:38 AM
To: SCHOMBURG, CALVIN (JSC-EA) (NASA)
Subject: FW: ET Foam Loss

Calvin,

I wouldn't think we could make such a generic statement but can we bound it some how by size or acreage?

-----Original Message-----
From: DITTEMORE, RONALD D. (JSC-MA) (NASA)
Sent: Wednesday, January 22, 2003 10:15 AM
To: HAM, LINDA J. (JSC-MA2) (NASA)
Subject: RE: ET Briefing - STS-112 Foam Loss

Another thought, we need to make sure that the density of the ET foam cannot damage the tile to where it is an impact to the orbiter...Lambert and Ralph need to get some folks working with ET.

-----Original Message-----
From: SCHOMBURG, CALVIN (JSC-EA) (NASA)
Sent: Wednesday, January 22, 2003 10:53 AM
To: ROE, RALPH R. (JSC-MV) (NASA)
Subject: RE: ET Foam Loss

No-the amount of damage ET foam can cause to the TPS material-tiles is based on the amount of impact energy-the size of the piece and its velocity( from just after pad clear until about 120 seconds-after that it will not hit or it will not enough energy to cause any damage) - it is a pure kinetic problem - there is a size that can cause enough damage to a tile that enough of the material is lost that we could burn a hole through the skin and have a bad day - (loss of vehicle and crew -about 200-400 tile locations( out of the 23,000 on the lower surface) - the foam usually fails in small popcorn pieces - that is why it is vented - to make small hits - the two or three times we have been hit with a piece as large as the one this flight-we got a gouge about 8-10 inches long about 2 inches wide and 3/4 to an 1 inch deep across two or three tiles. That is what I expect this time-nothing worst. If that is all we get we have have no problem-will have to replace a couple of tiles but nothing else.

-----Original Message-----
From: AUSTIN, LAMBERT D. (JSC-MS) (NASA)
Sent: Wednesday, January 22, 2003 3:22 PM
To: HAM, LINDA J. (JSC-MA2) (NASA)
Cc: WALLACE, RODNEY O. (ROD) (JSC-MS2) (NASA); NOAH, DONALD S. (DON) (JSC-MS) (NASA)
Subject: RE: ET Foam Loss

NO. I will cover some of the pertinent rationale....there could be more if I spent more time thinking about it. Recall this issue has been discussed from time to time since the inception of the basic "no debris" requirement in Vol. X and at each review the SSP has concluded that it is not possible to PRECLUDE a potential catastrophic event as a result of debris impact damage to the flight elements. As regards the Orbiter, both windows and tiles are areas of concern.

You can talk to Cal Schomberg and he will verify the many times we have covered this in SSP reviews. While there is much tolerance to window and tile damage, ET foam loss can result in impact damage that under subsequent entry environments can lead to loss of structural integrity of the Orbiter area impacted or a penetration in a critical function area that results in loss of that function. My recollection of the most critical Orbiter bottom acreage areas are the wing spar, main landing gear door seal and RCC panels...of course Cal can give you a much better rundown.

We can and have generated parametric impact zone characterizations for many areas of the Orbiter for a few of our more typical ET foam loss areas. Of course, the impact/damage significance is always a function of debris size and density, impact velocity, and impact angle -- these latter 2 being a function of the flight time at which the ET foam becomes debris. For STS-107 specifically, we have generated this info and provided it to Orbiter. Of course, even this is based on the ASSUMPTION that the location and size of the debris is the same as occurred on STS-112------this cannot be verified until we receive the on-board ET separation photo evidence post Orbiter landing. We are requesting that this be expedited. I have the STS-107 Orbiter impact map based on the assumptions noted herein being sent down to you. Rod is in a review with Orbiter on this info right now.

A Mission Evaluation Room log entry at 10:37 a.m. records the decision not to seek imaging of Columbia's left wing.

"USA Program Manager/Loren Shriver, NASA Manager, Program Integration/Linda Ham, & NASA SSVEO/Ralph Roe have stated that there is no need for the Air Force to take a look at the vehicle." [USA=United Space Alliance, SSVEO=Space Shuttle Vehicle Engineering Office]

At 11:22 a.m., Debris Assessment Team Co-Chair Pam Madera sent an e-mail to team members setting the agenda for the team's second formal meeting that afternoon that included:

"... Discussion on Need/Rationale for Mandatory Viewing of damage site (All)..."

Earlier e-mail agenda wording did not include "Need/Rationale for Mandatory" wording as listed here, which indicates that Madera knew of management's decision to not seek images of Columbia's left wing and anticipated having to articulate a "mandatory" rationale to reverse that decision. In fact, a United Space Alliance manager had informed Madera that imagery would be sought only if the request was a "mandatory need." Twenty-three minutes later, an e-mail from Paul Shack to Rodney Rocha, who the day before had carried forward the Debris Assessment Team's request for imaging, stated the following.

"... FYI, According to the MER, Ralph Roe has told program that Orbiter is not requesting any outside imaging help ..." [MER=Mission Evaluation Room]

Earlier that morning, Ralph Roe's deputy manager, Trish Petite, had separate conversations with Paul Shack and tile expert Calvin Schomburg. In those conversations, Petite noted that an analysis of potential damage was in progress, and they should wait to see what the analysis showed before asking for imagery. Schomburg, though aware of the Debris Assessment Team's request for imaging, told Shack and Petite that he believed on-orbit imaging of potentially damaged areas was not necessary.

As the morning wore on, Debris Assessment Team engineers, Shuttle Program management, and other NASA personnel exchanged e-mail. Most messages centered on technical matters to be discussed at the Debris Assessment Team's afternoon meeting, including debris density, computer-aided design models, and the highest angle of incidence to use for a particular material property. One e-mail from Rocha to his managers and other Johnson engineers at 11:19 a.m., included the following.

"... there are good scenarios (acceptable and minimal damage) to horrible ones, depending on the extent of the damage incurred by the wing and location. The most critical locations seem to be the 1191 wing spar region, the main landing gear door seal, and the RCC panels. We do not know yet the exact extent or nature of the damage without being provided better images, and without such all the high powered analyses and assessments in work will retain significant uncertainties ..."

Second Debris Assessment Team Meeting

Some but not all of the engineers attending the Debris Assessment Team's second meeting had learned that the Shuttle Program was not pursuing imaging of potentially damaged areas. What team members did not realize was the Shuttle Program's decision not to seek on-orbit imagery was not necessarily a direct and final response to their request. Rather, the "no" was partly in response to the Kennedy Space Center action initiated by United Space Alliance engineers and managers and finally by Wayne Hale.

Not knowing that this was the case, Debris Assessment Team members speculated as to why their request was rejected and whether their analysis was worth pursuing without new imagery. Discussion then moved on to whether the Debris Assessment Team had a "mandatory need" for Department of Defense imaging. Most team members, when asked by the Board what "mandatory need" meant, replied with a shrug of their shoulders. They believed the need for imagery was obvious: without better pictures, engineers would be unable to make reliable predictions of the depth and area of damage caused by a foam strike that was outside of the experience base. However, team members concluded that although their need was important, they could not cite a "mandatory" requirement for the request. Analysts on the Debris Assessment Team were in the unenviable position of wanting images to more accurately assess damage while simultaneously needing to prove to Program managers, as a result of their assessment, that there was a need for images in the first place.

After the meeting adjourned, Rocha read the 11:45 a.m. e-mail from Paul Shack, which said that the Orbiter Project was not requesting any outside imaging help. Rocha called Shack to ask if Shack's boss, Johnson Space Center engineering director Frank Benz, knew about the request. Rocha then sent several e-mails consisting of questions about the ongoing analyses and details on the Shuttle Program's cancellation of the imaging request. An e-mail that he did not send but instead printed out and shared with a colleague follows.

"In my humble technical opinion, this is the wrong (and bordering on irresponsible) answer from the SSP and Orbiter not to request additional imaging help from any outside source. I must emphasize (again) that severe enough damage (3 or 4 multiple tiles knocked out down to the densification layer) combined with the heating and resulting damage to the underlying structure at the most critical location (viz., MLG door/wheels/tires/hydraulics or the X1191 spar cap) could present potentially grave hazards. The engineering team will admit it might not achieve definitive high confidence answers without additional images, but, without action to request help to clarify the damage visually, we will guarantee it will not. Can we talk to Frank Benz before Friday's MMT? Remember the NASA safety posters everywhere around stating, 'If it's not safe, say so'? Yes, it's that serious." [SSP=Space Shuttle Program, MLG=Main Landing Gear, MMT=Mission Management Team]

When asked why he did not send this e-mail, Rocha replied that he did not want to jump the chain of command. Having already raised the need to have the Orbiter imaged with Shack, he would defer to management's judgment on obtaining imagery.

Even after the imagery request had been cancelled by Program management, engineers in the Debris Assessment Team and Mission Control continued to analyze the foam strike. A structural engineer in the Mechanical, Maintenance, Arm and Crew Systems sent an e-mail to a flight dynamics engineer that stated:

"There is lots of speculation as to extent of the damage, and we could get a burn through into the wheel well upon entry."

Less than an hour later, at 6:09 p.m., a Mission Evaluation Room Console log entry stated the following.

"MMACS is trying to view a Quicktime movie on the debris impact but doesn't have Quicktime software on his console. He needs either an avi, mpeg file or a vhs tape. He is asking us for help." [MMACS=Mechanical, Maintenance, Arm and Crew Systems]

Flight Day Eight, Thursday, January 23, 2003

The morning after Shuttle Program Management decided not to pursue on-orbit imagery, Rodney Rocha received a return call from Mission Operations Directorate representative Barbara Conte to discuss what kinds of imaging capabilities were available for STS-107.

MISSED OPPORTUNITY 7

Conte explained to Rocha that the Mission Operations Directorate at Johnson did have U.S. Air Force standard services for imaging the Shuttle during Solid Rocket Booster separation and External Tank separation. Conte explained that the Orbiter would probably have to fly over Hawaii to be imaged. The Board notes that this statement illustrates an unfamiliarity with National imaging assets. Hawaii is only one of many sites where relevant assets are based. Conte asked Rocha if he wanted her to pursue such a request through Missions Operations Directorate channels. Rocha said no, because he believed Program managers would still have to support such a request. Since they had already decided that imaging of potentially damaged areas was not necessary, Rocha thought it unlikely that the Debris Assessment Team could convince them otherwise without definitive data.

Later that day, Conte and another Mission Operations Directorate representative were attending an unrelated meeting with Leroy Cain, the STS-107 ascent/entry Flight Director. At that meeting, they conveyed Rocha's concern to Cain and offered to help with obtaining imaging. After checking with Phil Engelauf, Cain distributed the following e-mail.

-----Original Message-----
From: CAIN, LEROY E. (JSC-DA8) (NASA)
Sent: Thursday, January 23, 2003 12:07 PM
To: JONES, RICHARD S. (JSC-DM) (NASA); OLIVER, GREGORY T. (GREG) (JSC-DM4) (NASA); CONTE, BARBARA A. (JSC-DM) (NASA)
Cc: ENGELAUF, PHILIP L. (JSC-DA8) (NASA); AUSTIN, BRYAN P. (JSC-DA8) (NASA); BECK, KELLY B. (JSC-DA8) (NASA); HANLEY, JEFFREY M. (JEFF) (JSC-DA8) (NASA); STICH, J. S. (STEVE) (JSC-DA8) (NASA)
Subject: Help with debris hit

The SSP was asked directly if they had any interest/desire in requesting resources outside of NASA to view the Orbiter (ref. the wing leading edge debris concern).

They said, No.

After talking to Phil, I consider it to be a dead issue.[SSP=Space Shuttle Program]

Mission Control personnel thought they should tell Commander Rick Husband and Pilot William McCool about the debris strike, not because they thought that it was worthy of the crew's attention but because the crew might be asked about it in an upcoming media interview. Flight Director Steve Stitch sent the following e-mail to Husband and McCool and copied other Flight Directors.

-----Original Message-----
From: STICH, J. S. (STEVE) (JSC-DA8) (NASA)
Sent: Thursday, January 23, 2003 11:13 PM
To: CDR; PLT
Cc: BECK, KELLY B. (JSC-DA8) (NASA); ENGELAUF, PHILIP L. (JSC-DA8) (NASA); CAIN, LEROY E. (JSC-DA8) (NASA); HANLEY, JEFFREY M. (JEFF) (JSC-DA8) (NASA); AUSTIN, BRYAN P. (JSC-DA8) (NASA)
Subject: INFO: Possible PAO Event Question

Rick and Willie,

You guys are doing a fantastic job staying on the timeline and accomplishing great science. Keep up the good work and let us know if there is anything that we can do better from an MCC/POCC stand-point.

There is one item that I would like to make you aware of for the upcoming PAO event on Blue FD 10 and for future PAO events later in the mission. This item is not even worth mentioning other than wanting to make sure that you are not surprised by it in a question from a reporter.

During ascent at approximately 80 seconds, photo analysis shows that some debris from the area of the -Y ET Bipod Attach Point came loose and subsequently impacted the orbiter left wing, in the area of transition from Chine to Main Wing, creating a shower of smaller particles. The impact appears to be totally on the lower surface and no particles are seen to traverse over the upper surface of the wing. Experts have reviewed the high speed photography and there is no concern for RCC or tile damage. We have seen this same phenomenon on several other flights and there is absolutely no concern for entry.

That is all for now. It's a pleasure working with you every day.

Later, a NASA liaison to USSTRATCOM sent an e-mail thanking personnel for the prompt response to the imagery request. The e-mail asked that they help NASA observe "official channels" for this type of support in the future. Excerpts from this message follow.

"Let me assure you that, as of yesterday afternoon, the Shuttle was in excellent shape, mission objectives were being performed, and that there were no major debris system problems identified. The request that you received was based on a piece of debris, most likely ice or insulation from the ET, that came off shortly after launch and hit the underside of the vehicle. Even though this is not a common occurrence it is something that has happened before and is not considered to be a major problem. The one problem that this has identified is the need for some additional coordination within NASA to assure that when a request is made it is done through the official channels. The NASA/ USSTRAT (USSPACE) MOA identifies the need for this type of support and that it will be provided by USSTRAT. Procedures have been long established that identifies the Flight Dynamics Officer (for the Shuttle) and the Trajectory Operations Officer (for the International Space Station) as the POCs to work these issues with the personnel in Cheyenne Mountain. One of the primary purposes for this chain is to make sure that requests like this one does not slip through the system and spin the community up about potential problems that have not been fully vetted through the proper channels. Two things that you can help us with is to make sure that future requests of this sort are confirmed through the proper channels. For the Shuttle it is via CMOC to the Flight Dynamics Officer. For the International Space Station it is via CMOC to the Trajectory Operations Officer. The second request is that no resources are spent unless the request has been confirmed. These requests are not meant to diminish the responsibilities of the DDMS office or to change any previous agreements but to eliminate the confusion that can be caused by a lack of proper coordination." [ET=External Tank, MOA=Memorandum of Agreement, POC=Point of Contact, CMOC=Cheyenne Mountain Operations Center, DDMS=Department of Defense Manned Space Flight Support Office]

Third Debris Assessment Team Meeting

The Debris Assessment Team met for the third time Thursday afternoon to review updated impact analyses. Engineers noted that there were no alternate re-entry trajectories that the Orbiter could fly to substantially reduce heating in the general area of the foam strike. Engineers also presented final debris trajectory data that included three debris size estimates to cover the continuing uncertainty about the size of the debris. Team members were told that imaging would not be forthcoming. In the face of this denial, the team discussed whether to include a presentation slide supporting their desire for images of the potentially damaged area. Many still felt it was a valid request and wanted their concerns aired at the upcoming Mission Evaluation Room brief and then at the Mission Management Team level. Eventually, the idea of including a presentation slide about the imaging request was dropped.

Just prior to attending the third assessment meeting, tile expert Calvin Schomburg and Rodney Rocha met to discuss foam impacts from other missions. Schomburg implied that the STS-107 foam impact was in the Orbiter's experience base and represented only a maintenance issue. Rocha disagreed and argued about the potential for burn-through on re-entry. Calvin Schomburg stated a belief that if there was severe damage to the tiles, "nothing could be done." (See Section 6.4.) Both then joined the meeting already in progress.

According to Boeing analysts who were members of the Debris Assessment Team, Schomburg called to ask about their rationale for pursuing imagery. The Boeing analysts told him that something the size of a large cooler had hit the Orbiter at 500 miles per hour. Pressed for additional reasons and not fully understanding why their original justification was insufficient, the analysts said that at least they would know what happened if something were to go terribly wrong. The Boeing analysts next asked why they were working so hard analyzing potential damage areas if Shuttle Program management believed the damage was minor and that no safety-of-flight issues existed. Schomburg replied that the analysts were new and would learn from this exercise.

Flight Day Nine, Friday, January 24, 2003

At 7:00 a.m., Boeing and United Space Alliance contract personnel presented the Debris Assessment Team's findings to Don McCormack, the Mission Evaluation Room manager. In yet another signal that working engineers and mission personnel shared a high level of concern for Columbia's condition, so many engineers crowded the briefing room that it was standing room only, with people lining the hallway.

The presentation included viewgraphs that discussed the team's analytical methodology and five scenarios for debris damage, each based on different estimates of debris size and impact point. A sixth scenario had not yet been completed, but early indications suggested that it would not differ significantly from the other five. Each case was presented with a general overview of transport mechanics, results from the Crater modeling, aerothermal considerations, and predicted thermal and structural effects for Columbia's re-entry. The briefing focused primarily on potential damage to the tiles, not the RCC panels.

While the team members were confident that they had conducted the analysis properly - with-in the limitations of the information they had - they stressed that many uncertainties remained. First, there was great uncertainty about where the debris had struck. Second, Crater, the analytical tool they used to predict the penetration depth of debris impact, was being used on a piece of debris that was 400 times larger than the standard in Boeing's database. (At the time, the team believed that the debris was 640 times larger.) Engineers ultimately concluded that their analysis, limited as it was, did not show that a safety-of-flight issue existed. Engineers who attended this briefing indicated a belief that management focused on the answer - that analysis proved there was no safety-of-flight issue - rather than concerns about the large uncertainties that may have undermined the analysis that provided that answer.

At the Mission Management Team's 8:00 a.m. meeting, Mission Evaluation Room manager Don McCormack verbally summarized the Debris Assessment Team's 7:00 a.m. brief. It was the third topic discussed. Unlike the earlier briefing, McCormack's presentation did not include the Debris Assessment Team's presentation charts. The Board notes that no supporting analysis or examination of minority engineering views was asked for or offered, that neither Mission Evaluation Room nor Mission Management Team members requested a technical paper of the Debris Assessment Team analysis, and that no technical questions were asked.

January 24, 2003, Mission Management Team Meeting Transcript

The following is a transcript of McCormack's verbal briefing to the Mission Management Team, which Linda Ham Chaired. Early in the meeting, Phil Engelauf, Chief of the Flight Director's office, reported that he had made clear in an e-mail to Columbia's crew that there were "no concerns" that the debris strike had caused serious damage. The Board notes that this conclusion about whether the debris strike posed a safety-of-flight issue was presented to Mission Management Team members before they discussed the debris strike damage assessment.

Engelauf: "I will say that crew did send down a note last night asking if anybody is talking about extension days or going to go with that and we sent up to the crew about a 15 second video clip of the strike just so they are armed if they get any questions at the press conferences or that sort of thing, but we made it very clear to them no, no concerns."

Linda Ham: "When is the press conference? Is it today?"

Engelauf: "It's later today."

Ham: "They may get asked because the press is aware of it."

Engelauf: "The press is aware of it I know folks have asked me because the press corps at the cape have been asking...wanted to make sure they were properly..."

Ham: "Okay, back on the temperature..." The meeting went on for another 25 minutes. Other mission-related subjects were discussed before team members returned to the debris strike.

Ham: "Go ahead, Don."

Don McCormack: "Okay. And also we've received the data from the systems integration guys of the potential ranges of sizes and impact angles and where it might have hit. And the guys have gone off and done an analysis, they use a tool they refer to as Crater which is their official evaluation tool to determine the potential size of the damage. So they went off and done all that work and they've done thermal analysis to the areas where there may be damaged tiles. The analysis is not complete. There is one case yet that they wish to run, but kind of just jumping to the conclusion of all that, they do show that, obviously, a potential for significant tile damage here, but thermal analysis does not indicate that there is potential for a burn-through. I mean there could be localized heating damage. There is... obviously there is a lot of uncertainty in all this in terms of the size of the debris and where it hit and the angle of incidence."

Ham: "No burn through, means no catastrophic damage and the localized heating damage would mean a tile replacement?"

McCormack: "Right, it would mean possible impacts to turnaround repairs and that sort of thing, but we do not see any kind of safety of flight issue here yet in anything that we've looked at."

Ham: "And no safety of flight, no issue for this mission, nothing that we're going to do different, there may be a turnaround."

McCormack: "Right, it could potentially hit the RCC and we don't indicate any other possible coating damage or something, we don't see any issue if it hit the RCC. Although we could have some significant tile damage if we don't see a safety-of-flight issue."

Ham: "What do you mean by that?"

McCormack: "Well it could be down through the ... we could lose an entire tile and then the ramp into and out of that, I mean it could be a significant area of tile damage down to the SIP perhaps, so it could be a significant piece missing, but..." [SIP refers to the denser lower layers of tile to which the debris may have penetrated.]

Ham: "It would be a turnaround issue only?"

McCormack: "Right."

(Unintelligible speaker)

At this point, tile expert Calvin Schomburg states his belief that no safety-of-flight issue exists. However, some participants listening via teleconference to the meeting are unable to hear his comments.

Ham: "Okay. Same thing you told me about the other day in my office. We've seen pieces of this size before haven't we?"

Unknown speaker. "Hey Linda, we're missing part of that conversation."

Ham: "Right."

Unknown speaker: "Linda, we can't hear the speaker."

Ham: "He was just reiterating with Calvin that he doesn't believe that there is any burn-through so no safety of flight kind of issue, it's more of a turnaround issue similar to what we've had on other flights. That's it? Alright, any questions on that?"

The Board notes that when the official minutes of the January 24 Mission Management Team were produced and distributed, there was no mention of the debris strike. These minutes were approved and signed by Frank Moreno, STS-107 Lead Payload Integration Manager, and Linda Ham. For anyone not present at the January 24 Mission Management Team who was relying on the minutes to update them on key issues, they would have read nothing about the debris-strike discussions between Don McCormack and Linda Ham.

A subsequent 8:59 a.m. Mission Evaluation Room console log entry follows.

"MMT Summary...McCormack also summarized the debris assessment. Bottom line is that there appears to be no safety of flight issue, but good chance of turnaround impact to repair tile damage." [MMT=Mission Management Team]

Flight Day 10 through 16, Saturday through Friday, January 25 through 31, 2003

Although "no safety-of-flight issue" had officially been noted in the Mission Evaluation Room log, the Debris Assessment Team was still working on parts of its analysis of potential damage to the wing and main landing gear door. On Sunday, January 26, Rodney Rocha spoke with a Boeing thermal analyst and a Boeing stress analyst by telephone to express his concern about the Debris Assessment Team's overall analysis, as well as the remaining work on the main landing gear door analysis. After the Boeing engineers stated their confidence with their analyses, Rocha became more comfortable with the damage assessment and sent the following e-mail to his management.

-----Original Message-----
From: ROCHA, ALAN R. (RODNEY) (JSC-ES2) (NASA)
Sent: Sunday, January 26, 2003 7:45 PM
To: SHACK, PAUL E. (JSC-EA42) (NASA); MCCORMACK, DONALD L. (DON) (JSC-MV6) (NASA); OUELLETTE, FRED A. (JSC-MV6) (NASA)
Cc: ROGERS, JOSEPH E. (JOE) (JSC-ES2) (NASA); GALBREATH, GREGORY F. (GREG) (JSC-ES2) (NASA); JACOBS, JEREMY B. (JSC-ES4) (NASA); SERIALE-GRUSH, JOYCE M. (JSC-EA) (NASA); KRAMER, JULIE A. (JSC-EA4) (NASA); CURRY, DONALD M. (JSC-ES3) (NASA); KOWAL, T. J. (JOHN) (JSC-ES3) (NASA); RICKMAN, STEVEN L. (JSC-ES3) (NASA); SCHOMBURG, CALVIN (JSC-EA) (NASA); CAMPBELL, CARLISLE C., JR (JSC-ES2) (NASA)
Subject: STS-107 Wing Debris Impact on Ascent: Final analysis case completed

As you recall from Friday's briefing to the MER, there remained open work to assess analytically predicted impact damage to the wing underside in the region of the main landing gear door. This area was considered a low probability hit area by the image analysis teams, but they admitted a debris strike here could not be ruled out.

As with the other analyses performed and reported on Friday, this assessment by the Boeing multi-technical discipline engineering teams also employed the system integration's dispersed trajectories followed by serial results from the Crater damage prediction tool, thermal analysis, and stress analysis. It was reviewed and accepted by the ES-DCE (R. Rocha) by Sunday morning, Jan. 26. The case is defined by a large area gouge about 7 inch wide and about 30 inch long with sloped sides like a crater, and reaching down to the densified layer of the TPS.

SUMMARY: Though this case predicted some higher temperatures at the outer layer of the honeycomb aluminum face sheet and subsequent debonding of the sheet, there is no predicted burn-through of the door, no breeching of the thermal and gas seals, nor is there door structural deformation or thermal warpage to open the seal to hot plasma intrusion. Though degradation of the TPS and door structure is likely (if the impact occurred here), there is no safety of flight (entry, descent, landing) issue.

Note to Don M. and Fred O.: On Friday I believe the MER was thoroughly briefed and it was clear that open work remained (viz., the case summarized above), the message of open work was not clearly given, in my opinion, to Linda Ham at the MMT. I believe we left her the impression that engineering assessments and cases were all finished and we could state with finality no safety of flight issues or questions remaining. This very serious case could not be ruled out and it was a very good thing we carried it through to a finish.
Rodney Rocha (ES2)

• Division Shuttle Chief Engineer (DCE), ES-Structural Engineering Division
• Chair, Space Shuttle Loads & Dynamics Panel

On Monday morning, January 27, Doug Drewry, a structural engineering manager from Johnson Space Center, summoned several Johnson engineers and Rocha to his office and asked them if they all agreed with the completed analyses and with the conclusion that no safety-of-flight issues existed. Although all participants agreed with that conclusion, they also knew that the Debris Assessment Team members and most structural engineers at Johnson still wanted images of Columbia's left wing but had given up trying to make that desire fit the "mandatory" requirement that Shuttle management had set.

Langley Research Center

Although the Debris Analysis Team had completed its analysis and rendered a "no safety-of-flight" verdict, concern persisted among engineers elsewhere at NASA as they learned about the debris strike and potential damage. On Monday, January 27, Carlisle Campbell, the design engineer responsible for landing gear/tires/brakes at Johnson Space Center forwarded Rodney Rocha's January 26, e-mail to Bob Daugherty, an engineer at Langley Research Center who specialized in landing gear design. Engineers at Langley and Ames Research Center and Johnson Space Center did not entertain the possibility of Columbia breaking up during re-entry, but rather focused on the idea that landing might not be safe, and that the crew might need to "ditch" the vehicle (crash land in water) or be prepared to land with damaged landing gear.

Campbell initially contacted Daugherty to ask his opinion of the arguments used to declare the debris strike "not a safety-of-flight issue." Campbell commented that someone had brought up worst-case scenarios in which a breach in the main landing gear door causes two tires to go flat. To help Daugherty understand the problem, Campbell forwarded him e-mails, briefing slides, and film clips from the debris damage analysis.

Both engineers felt that the potential ramifications of landing with two flat tires had not been sufficiently explored. They discussed using Shuttle simulator facilities at Ames Research Center to simulate a landing with two flat tires, but initially ruled it out because there was no formal request from the Mission Management Team to work the problem. Because astronauts were training in the Ames simulation facility, the two engineers looked into conducting the simulations after hours. Daugherty contacted his management on Tuesday, January 28, to update them on the plan for after-hours simulations. He reviewed previous data runs, current simulation results, and prepared scenarios that could result from main landing gear problems.

The simulated landings with two flat tires that Daugherty eventually conducted indicated that it was a survivable but very serious malfunction. Of the various scenarios he prepared, Daugherty shared the most unfavorable only with his management and selected Johnson Space Center engineers. In contrast, his favorable simulation results were forwarded to a wider Johnson audience for review, including Rodney Rocha and other Debris Assessment Team members. The Board is disappointed that Daugherty's favorable scenarios received a wider distribution than his discovery of a potentially serious malfunction, and also does not approve of the reticence that he and his managers displayed in not notifying the Mission Management Team of their concerns or his assumption that they could not displace astronauts who were training in the Ames simulator.

At 4:36 p.m. on Monday, January 27, Daugherty sent the following to Campbell.

-----Original Message-----
From: Robert H. Daugherty
Sent: Monday, January 27, 2003 3:35 PM
To: CAMPBELL, CARLISLE C., JR (JSC-ES2) (NASA)
Subject: Video you sent

WOW!!!

I bet there are a few pucker strings pulled tight around there!

Thinking about a belly landing versus bailout...... (I would say that if there is a question about main gear well burn thru that its crazy to even hit the deploy gear button...the reason being that you might have failed the wheels since they are aluminum..they will fail before the tire heating/pressure makes them fail..and you will send debris all over the wheel well making it a possibility that the gear would not even deploy due to ancillary damage...300 feet is the wrong altitude to find out you have one gear down and the other not down...you're dead in that case)

Think about the pitch-down moment for a belly landing when hitting not the main gear but the trailing edge of the wing or body flap when landing gear up...even if you come in fast and at slightly less pitch attitude...the nose slapdown with that pitching moment arm seems to me to be pretty scary...so much so that I would bail out before I would let a loved one land like that.

My two cents.

See ya,
Bob

The following reply from Campbell to Daugherty was sent at 4:49 p.m.

-----Original Message-----
From: "CAMPBELL, CARLISLE C., JR (JSC-ES2) (NASA)"
To: "'Bob Daugherty'"
Subject: FW: Video you sent
Date: Mon, 27 Jan 2003 15:59:53 -0600
X-Mailer: ßInternet Mail Service (5.5.2653.19)

Thanks. That's why they need to get all the facts in early on -- such as look at impact damage from the spy telescope. Even then, we may not know the real effect of the damage.

The LaRC ditching model tests 20 some years ago showed that the Orbiter was the best ditching shape that they had ever tested, of many. But, our structures people have said that if we ditch we would blow such big holes in the lower panels that the orbiter might break up. Anyway, they refuse to even consider water ditching any more -- I still have the test results[ Bailout seems best.

-----Original Message-----
From: Robert H. Daugherty
Sent: Tuesday, January 28, 2003 12:39 PM
To: CAMPBELL, CARLISLE C., JR (JSC-ES2) (NASA)
Subject: Tile Damage

Any more activity today on the tile damage or are people just relegated to crossing their fingers and hoping for the best?

See ya,
Bob

-----Original Message-----
From: "CAMPBELL, CARLISLE C., JR (JSC-ES2) (NASA)"
To: "'Robert H. Daugherty'"
Subject: RE: Tile Damage
Date: Tue, 28 Jan 2003 13:29:58 -0600
X-Mailer: Internet Mail Service (5.5.2653.19)

I have not heard anything new. I'll let you know if I do.

CCC

"In order to alleviate concerns regarding the worst case scenario which could potentially be caused by the debris impact under the Orbiter's left wing during launch, EG conducted some landing simulations on the Ames Vertical Motion Simulator which tested the ability of the crew and vehicle to survive a condition where two main gear tires are deflated before landing. The results, although limited, showed that this condition is controllable, including the nose slap down rates. These results may give MOD a different decision path should this scenario become a reality. Previous opinions were that bailout was the only answer." [EG=Aeroscience and Flight Mechanics Division, MOD=Mission Operations Directorate]

"[MCC SAIC] called asking if any SR&QA people were involved in the decision to say that the ascent debris hit (left wing) is safe. [SAIC engineer] has indeed been involved in the analysis and stated that he concurs with the analysis. Details about the debris hit are found in the Flight Day 12 MER Manager and our Daily Report." [MCC=Mission Control Center, SAIC=Science Applications International Corporation, SR&QA=Safety, Reliability, and Quality Assurance, MER=Mission Evaluation Room]

MISSED OPPORTUNITY 8

According to a Memorandum for the Record written by William Readdy, Associate Administrator for Space Flight, Readdy and Michael Card, from NASA's Safety and Mission Assurance Office, discussed an offer of Department of Defense imagery support for Columbia. This January 29, conversation ended with Readdy telling Card that NASA would accept the offer but because the Mission Management Team had concluded that this was not a safety-of-flight issue, the imagery should be gathered only on a low priority "not-to-interfere" basis. Ultimately, no imagery was taken.

The Board notes that at the January 31, Mission Management Team meeting, there was only a minor mention of the debris strike. Other issues discussed included onboard crew consumables, the status of the leaking water separator, an intercom anomaly, SPACEHAB water flow rates, an update of the status of onboard experiments, end-of-mission weight concerns, landing day weather forecasts, and landing opportunities. The only mention of the debris strike was a brief comment by Bob Page, representing Kennedy Space Center's Launch Integration Office, who stated that the crew's hand-held cameras and External Tank films would be expedited to Marshall Space Flight Center via the Shuttle Training Aircraft for post-flight foam/debris imagery analysis, per Linda Ham's request.

Summary: Mission Management Decision Making

Discovery and Initial Analysis of Debris Strike

In the course of examining film and video images of Columbia's ascent, the Intercenter Photo Working Group identified, on the day after launch, a large debris strike to the leading edge of Columbia's left wing. Alarmed at seeing so severe a hit so late in ascent, and at not having a clear view of damage the strike might have caused, Intercenter Photo Working Group members alerted senior Program managers by phone and sent a digitized clip of the strike to hundreds of NASA personnel via e-mail. These actions initiated a contingency plan that brought together an interdisciplinary group of experts from NASA, Boeing, and the United Space Alliance to analyze the strike. So concerned were Intercenter Photo Working Group personnel that on the day they discovered the debris strike, they tapped their Chair, Bob Page, to see through a request to image the left wing with Department of Defense assets in anticipation of analysts needing these images to better determine potential damage. By the Board's count, this would be the first of three requests to secure imagery of Columbia on-orbit during the 16-day mission.

Upon learning of the debris strike on Flight Day Two, the responsible system area manager from United Space Alliance and her NASA counterpart formed a team to analyze the debris strike in accordance with mission rules requiring the careful examination of any "out-of-family" event. Using film from the Intercenter Photo Working Group, Boeing systems integration analysts prepared a preliminary analysis that afternoon. (Initial estimates of debris size and speed, origin of debris, and point of impact would later prove remarkably accurate.)

As Flight Day Three and Four unfolded over the Martin Luther King Jr. holiday weekend, engineers began their analysis. One Boeing analyst used Crater, a mathematical prediction tool, to assess possible damage to the Thermal Protection System. Analysis predicted tile damage deeper than the actual tile depth, and penetration of the RCC coating at impact angles above 15 degrees. This suggested the potential for a burn-through during re-entry. Debris Assessment Team members judged that the actual damage would not be as severe as predicted because of the inherent conservatism in the Crater model and because, in the case of tile, Crater does not take into account the tile's stronger and more impact-resistant "densified" layer, and in the case of RCC, the lower density of foam would preclude penetration at impact angles under 21 degrees.

On Flight Day Five, impact assessment results for tile and RCC were presented at an informal meeting of the Debris Assessment Team, which was operating without direct Shuttle Program or Mission Management leadership. Mission Control's engineering support, the Mission Evaluation Room, provided no direction for team activities other than to request the team's results by January 24. As the problem was being worked, Shuttle managers did not formally direct the actions of or consult with Debris Assessment Team leaders about the team's assumptions, uncertainties, progress, or interim results, an unusual circumstance given that NASA managers are normally engaged in analyzing what they view as problems. At this meeting, participants agreed that an image of the area of the wing in question was essential to refine their analysis and reduce the uncertainties in their damage assessment.

Each member supported the idea to seek imagery from an outside source. Due in part to a lack of guidance from the Mission Management Team or Mission Evaluation Room managers, the Debris Assessment Team chose an unconventional route for its request. Rather than working the request up the normal chain of command - through the Mission Evaluation Room to the Mission Management Team for action to Mission Control - team members nominated Rodney Rocha, the team's Co-Chair, to pursue the request through the Engineering Directorate at Johnson Space Center. As a result, even after the accident the Debris Assessment Team's request was viewed by Shuttle Program managers as a non-critical engineering desire rather than a critical operational need.

When the team learned that the Mission Management Team was not pursuing on-orbit imaging, members were concerned. What Debris Assessment Team members did not realize was the negative response from the Program was not necessarily a direct and final response to their official request. Rather, the "no" was in part a response to requests for imagery initiated by the Intercenter Photo Working Group at Kennedy on Flight Day 2 in anticipation of analysts' needs that had become by Flight Day 6 an actual engineering request by the Debris Assessment Team, made informally through Bob White to Lambert Austin, and formally through Rodney Rocha's e-mail to Paul Shack. Even after learning that the Shuttle Program was not going to provide the team with imagery, some members sought information on how to obtain it anyway.

Debris Assessment Team members believed that imaging of potentially damaged areas was necessary even after the January 24, Mission Management Team meeting, where they had reported their results. Why they did not directly approach Shuttle Program managers and share their concern and uncertainty, and why Shuttle Program managers claimed to be isolated from engineers, are points that the Board labored to understand. Several reasons for this communications failure relate to NASA's internal culture and the climate established by Shuttle Program management, which are discussed in more detail in Chapters 7 and 8.

A Flawed Analysis

An inexperienced team, using a mathematical tool that was not designed to assess an impact of this estimated size, performed the analysis of the potential effect of the debris impact. Crater was designed for "in-family" impact events and was intended for day-of-launch analysis of debris impacts. It was not intended for large projectiles like those observed on STS-107. Crater initially predicted possible damage, but the Debris Assessment Team assumed, without theoretical or experimental validation, that because Crater is a conservative tool - that is, it predicts more damage than will actually occur - the debris would stop at the tile's densified layer, even though their experience did not involve debris strikes as large as STS-107's. Crater-like equations were also used as part of the analysis to assess potential impact damage to the wing leading edge RCC. Again, the tool was used for something other than that for which it was designed; again, it predicted possible penetration; and again, the Debris Assessment Team used engineering arguments and their experience to discount the results.

As a result of a transition of responsibility for Crater analysis from the Boeing Huntington Beach facility to the Houston-based Boeing office, the team that conducted the Crater analyses had been formed fairly recently, and therefore could be considered less experienced when compared with the more senior Huntington Beach analysts. In fact, STS-107 was the first mission for which they were solely responsible for providing analysis with the Crater tool. Though post-accident interviews suggested that the training for the Houston Boeing analysts was of high quality and adequate in substance and duration, communications and theoretical understandings of the Crater model among the Houston-based team members had not yet developed to the standard of a more senior team. Due in part to contractual arrangements related to the transition, the Houston-based team did not take full advantage of the Huntington Beach engineers' experience.

At the January 24, Mission Management Team meeting at which the "no safety-of-flight" conclusion was presented, there was little engineering discussion about the assumptions made, and how the results would differ if other assumptions were used.

Engineering solutions presented to management should have included a quantifiable range of uncertainty and risk analysis. Those types of tools were readily available, routinely used, and would have helped management understand the risk involved in the decision. Management, in turn, should have demanded such information. The very absence of a clear and open discussion of uncertainties and assumptions in the analysis presented should have caused management to probe further.

Shuttle Program Management's Low Level of Concern

While the debris strike was well outside the activities covered by normal mission flight rules, Mission Management Team members and Shuttle Program managers did not treat the debris strike as an issue that required operational action by Mission Control. Program managers, from Ron Dittemore to individual Mission Management Team members, had, over the course of the Space Shuttle Program, gradually become inured to External Tank foam losses and on a fundamental level did not believe foam striking the vehicle posed a critical threat to the Orbiter. In particular, Shuttle managers exhibited a belief that RCC panels are impervious to foam impacts. Even after seeing the video of Columbia's debris impact, learning estimates of the size and location of the strike, and noting that a foam strike with sufficient kinetic energy could cause Thermal Protection System damage, management's level of concern did not change.

The opinions of Shuttle Program managers and debris and photo analysts on the potential severity of the debris strike diverged early in the mission and continued to diverge as the mission progressed, making it increasingly difficult for the Debris Assessment Team to have their concerns heard by those in a decision-making capacity. In the face of Mission managers' low level of concern and desire to get on with the mission, Debris Assessment Team members had to prove unequivocally that a safety-of-flight issue existed before Shuttle Program management would move to obtain images of the left wing. The engineers found themselves in the unusual position of having to prove that the situation was unsafe - a reversal of the usual requirement to prove that a situation is safe.

Other factors contributed to Mission management's ability to resist the Debris Assessment Team's concerns. A tile expert told managers during frequent consultations that strike damage was only a maintenance-level concern and that on-orbit imaging of potential wing damage was not necessary. Mission management welcomed this opinion and sought no others. This constant reinforcement of managers' pre-existing beliefs added another block to the wall between decision makers and concerned engineers.

Another factor that enabled Mission management's detachment from the concerns of their own engineers is rooted in the culture of NASA itself. The Board observed an unofficial hierarchy among NASA programs and directorates that hindered the flow of communications. The effects of this unofficial hierarchy are seen in the attitude that members of the Debris Assessment Team held. Part of the reason they chose the institutional route for their imagery request was that without direction from the Mission Evaluation Room and Mission Management Team, they felt more comfortable with their own chain of command, which was outside the Shuttle Program. Further, when asked by investigators why they were not more vocal about their concerns, Debris Assessment Team members opined that by raising contrary points of view about Shuttle mission safety, they would be singled out for possible ridicule by their peers and managers.

A Lack of Clear Communication

Communication did not flow effectively up to or down from Program managers. As it became clear during the mission that managers were not as concerned as others about the danger of the foam strike, the ability of engineers to challenge those beliefs greatly diminished. Managers' tendency to accept opinions that agree with their own dams the flow of effective communications.

After the accident, Program managers stated privately and publicly that if engineers had a safety concern, they were obligated to communicate their concerns to management. Managers did not seem to understand that as leaders they had a corresponding and perhaps greater obligation to create viable routes for the engineering community to express their views and receive information. This barrier to communications not only blocked the flow of information to managers, but it also prevented the downstream flow of information from managers to engineers, leaving Debris Assessment Team members no basis for understanding the reasoning behind Mission Management Team decisions.

The January 27 to January 31, phone and e-mail exchanges, primarily between NASA engineers at Langley and Johnson, illustrate another symptom of the "cultural fence" that impairs open communications between mission managers and working engineers. These exchanges and the reaction to them indicated that during the evaluation of a mission contingency, the Mission Management Team failed to disseminate information to all system and technology experts who could be consulted. Issues raised by two Langley and Johnson engineers led to the development of "what-if" landing scenarios of the potential outcome if the main landing gear door sustained damaged. This led to behind-the-scenes networking by these engineers to use NASA facilities to make simulation runs of a compromised landing configuration. These engineers - who understood their systems and related technology - saw the potential for a problem on landing and ran it down in case the unthinkable occurred. But their concerns never reached the managers on the Mission Management Team that had operational control over Columbia.

A Lack of Effective Leadership

The Shuttle Program, the Mission Management Team, and through it the Mission Evaluation Room, were not actively directing the efforts of the Debris Assessment Team. These management teams were not engaged in scenario selection or discussions of assumptions and did not actively seek status, inputs, or even preliminary results from the individuals charged with analyzing the debris strike. They did not investigate the value of imagery, did not intervene to consult the more experienced Crater analysts at Boeing's Huntington Beach facility, did not probe the assumptions of the Debris Assessment Team's analysis, and did not consider actions to mitigate the effects of the damage on re-entry. Managers' claims that they didn't hear the engineers' concerns were due in part to their not asking or listening.

The Failure of Safety's Role

As will be discussed in Chapter 7, safety personnel were present but passive and did not serve as a channel for the voicing of concerns or dissenting views. Safety representatives attended meetings of the Debris Assessment Team, Mission Evaluation Room, and Mission Management Team, but were merely party to the analysis process and conclusions instead of an independent source of questions and challenges. Safety contractors in the Mission Evaluation Room were only marginally aware of the debris strike analysis. One contractor did question the Debris Assessment Team safety representative about the analysis and was told that it was adequate. No additional inquiries were made. The highest-ranking safety representative at NASA headquarters deferred to Program managers when asked for an opinion on imaging of Columbia. The safety manager he spoke to also failed to follow up.

Summary

Management decisions made during Columbia's 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.

Because this chapter has focused on key personnel who participated in STS-107 bipod foam debris strike decisions, it is tempting to conclude that replacing them will solve all NASA's problems. However, solving NASA's problems is not quite so easily achieved. Peoples' actions are influenced by the organizations in which they work, shaping their choices in directions that even they may not realize.