A compilation of the findings of the Columbia Accident Investigation Board:
F3.2-1 NASA does not fully understand the mechanisms that cause foam loss on almost all flights from larger areas of foam coverage and from areas that are sculpted by hand.
F3.2-2 There are no qualified non-destructive evaluation techniques for the as-installed foam to determine the characteristics of the foam before flight.
F3.2-3 Foam loss from an External Tank is unrelated to the tank's age and to its total pre-launch exposure to the elements. Therefore, the foam loss on STS-107 is unrelated to either the age or exposure of External Tank 93 before launch.
F3.2-4 The Board found no indications of negligence in the application of the External Tank Thermal Protection System.
F3.2-5 The Board found instances of left bipod ramp shedding on launch that NASA was not aware of, bringing the total known left bipod ramp shedding events to 7 out of 72 missions for which imagery of the launch or External Tank separation is available.
F3.2-6 Subsurface defects were found during the dissection of three bipod foam ramps, suggesting that similar defects were likely present in the left bipod ramp of External Tank 93 used on STS-107.
F3.2-7 Foam loss occurred on more than 80 percent of the 79 missions for which imagery was available to confirm or rule out foam loss.
F3.2-8 Thirty percent of all missions lacked sufficient imagery to determine if foam had been lost.
F3.2-9 Analysis of numerous separate variables indicated that none could be identified as the sole initiating factor of bipod foam loss. The Board therefore concludes that a combination of several factors resulted in bipod foam loss.
F3.3-1 The original design specifications required the RCC components to have essentially no impact resistance.
F3.3-2 Current inspection techniques are not adequate to assess structural integrity of the RCC components.
F3.3-3 After manufacturer's acceptance non-destructive evaluation, only periodic visual and touch tests are conducted.
F3.3-4 RCC components are weakened by mass loss caused by oxidation within the substrate, which accumulates with age. The extent of oxidation is not directly measurable, and the resulting mission life reduction is developed analytically.
F3.3-5 To date, only two flown RCC panels, having achieved 15 and 19 missions, have been destructively tested to determine actual loss of strength due to oxidation.
F3.3-6 Contamination from zinc leaching from a primer under the paint topcoat on the launch pad structure increases the opportunities for localized oxidation.
F3.4-1 Photographic evidence during ascent indicates the projectile that struck the Orbiter was the left bipod ramp foam.
F3.4-2 The same photographic evidence, confirmed by independent analysis, indicates the projectile struck the underside of the leading edge of the left wing in the vicinity of RCC panels 6 through 9 or the tiles directly behind, with a velocity of approximately 775 feet per second.
F3.4-3 There is a requirement to obtain and downlink on-board engineering quality imaging from the Shuttle during launch and ascent.
F3.4-4 The current long-range camera assets on the Kennedy Space Center and Eastern Range do not provide best possible engineering data during Space Shuttle ascents.
F3.4-5 Evaluation of STS-107 debris impact was hampered by lack of high resolution, high speed cameras (temporal and spatial imagery data).
F3.4-6 Despite the lack of high quality visual evidence, the information available about the foam impact during the mission was adequate to determine its effect on both the thermal tiles and RCC.
F3.5-1 The object seen on orbit with Columbia on Flight Day 2 through 4 matches the radar cross-section and area-to-mass measurements of an RCC panel fragment.
F3.5-2 Though the Board could not positively identify the Flight Day 2 object, the U.S. Air Force exclusionary test and analysis processes reduced the potential Flight Day 2 candidates to an RCC panel fragment.
F3.6-1 The de-orbit burn and re-entry flight path were normal until just before Loss of Signal.
F3.6-2 Columbia re-entered the atmosphere with a pre- existing breach in the left wing.
F3.6-3 Data from the Modular Auxiliary Data System recorder indicates the location of the breach was in the RCC panels on the left wing leading edge.
F3.6-4 Abnormal heating events preceded abnormal aerodynamic events by several minutes.
F3.6-5 By the time data indicating problems was telemetered to Mission Control Center, the Orbiter had already suffered damage from which it could not recover.
F3.7-1 Multiple indications from the debris analysis establish the point of heat intrusion as RCC panel 8-left.
F3.7-2 The recovery of debris from the ground and its reconstruction was critical to understanding the accident scenario.
F3.8-1 The impact test program demonstrated that foam can cause a wide range of impact damage, from cracks to a 16- by 17-inch hole.
F3.8-2 The wing leading edge Reinforced Carbon-Carbon composite material and associated support hardware are remarkably tough and have impact capabilities that far exceed the minimal impact resistance specified in their original design requirements. Nevertheless, these tests demonstrate that this inherent toughness can be exceeded by impacts representative of those that occurred during Columbia's ascent.
F3.8-3 The response of the wing leading edge to impacts is complex and can vary greatly, depending on the location of the impact, projectile mass, orientation, composition, and the material properties of the panel assembly, making analytic predictions of damage to RCC assemblies a challenge.17
F3.8-4 Testing indicates the RCC panels and T-seals have much higher impact resistance than the design specifications call for.
F3.8-5 NASA has an inadequate number of spare Reinforced Carbon-Carbon panel assemblies.
F3.8-6 NASA's current tools, including the Crater model, are inadequate to evaluate Orbiter Thermal Protection System damage from debris impacts during pre-launch, on-orbit, and post-launch activity.
F3.8-7 The bipod ramp foam debris critically damaged the leading edge of Columbia's left wing.
F4.2-1 The certification of the bolt catchers flown on STS-107 was accomplished by extrapolating analysis done on similar but not identical bolt catchers in original testing. No testing of flight hardware was performed.
F4.2-2 Board-directed testing of a small sample size demonstrated that the "as-flown" bolt catchers do not have the required 1.4 margin of safety.
F4.2-3 Quality assurance processes for bolt catchers (a Criticality 1 subsystem) were not adequate to assure contract compliance or product adequacy.
F4.2-4 An unknown metal object was seen separating from the stack during Solid Rocket Booster separation during six Space Shuttle missions. These objects were not identified, but were characterized as of little to no concern.
F4.2-5 Based on the extensive wiring inspections, maintenance, and modifications prior to STS-107, analysis of sensor/wiring failure signatures, and the alignment of the signatures with thermal intrusion into the wing, the Board found no evidence that Kapton wiring problems caused or contributed to this accident.
F4.2-6 Crushed foam does not appear to have contributed to the loss of the bipod foam ramp off the External Tank during the ascent of STS-107.
F4.2-7 The hypergolic spill was not a factor in this accident.
F4.2-8 Space weather was not a factor in this accident. Recommendations:
F4.2-9 A "rough wing" was not a factor in this accident.
F4.2-10 The Board concludes that training and on-orbit considerations were not factors in this accident.
F4.2-11 The payloads Columbia carried were not a factor in this accident.
F4.2-12 The Board found no evidence that willful damage was a factor in this accident.
F4.2-13 Two close-out processes at the Michoud Assembly Facility are currently able to be performed by a single person.
F4.2-14 Photographs of every close out activity are not routinely taken.
F4.2-15 There is little evidence that Columbia encountered either micrometeoroids or orbital debris on this flight.
F4.2-16 The Board found markedly different criteria for margins of micrometeoroid and orbital debris safety between the International Space Station and the Shuttle.
F4.2-17 Based on a thorough investigation of maintenance records and interviews with maintenance personnel, the Board found no errors during Columbia's most recent Orbiter Major Modification that contributed to the accident.
F4.2-18 Since 2001, Kennedy Space Center has used a non-standard approach to define foreign object debris. The industry standard term "Foreign Object Damage" has been divided into two categories, one of which is much more permissive.
F6.1-1 NASA has not followed its own rules and requirements on foam-shedding. Although the agency continuously worked on the foam-shedding problem, the debris impact requirements have not been met on any mission.
F6.1-2 Foam-shedding, which had initially raised serious safety concerns, evolved into "in-family" or "no safety-of-flight" events or were deemed an "accepted risk."
F6.1-3 Five of the seven bipod ramp events occurred on missions flown by Columbia, a seemingly high number. This observation is likely due to Columbia having been equipped with umbilical cameras earlier than other Orbiters.
F6.1-4 There is lack of effective processes for feedback or integration among project elements in the resolution of In-Flight Anomalies.
F6.1-5 Foam bipod debris-shedding incidents on STS-52 and STS-62 were undetected at the time they occurred, and were not discovered until the Board directed NASA to examine External Tank separation images more closely.
F6.1-6 Foam bipod debris-shedding events were classified as In-Flight Anomalies up until STS-112, which was the first known bipod foam-shedding event not classified as an In-Flight Anomaly.
F6.1-7 The STS-112 assignment for the External Tank Project to "identify the cause and corrective action of the bipod ramp foam loss event" was not due until after the planned launch of STS-113, and then slipped to after the launch of STS-107.
F6.1-8 No External Tank configuration changes were made after the bipod foam loss on STS-112.
F6.1-9 Although it is sometimes possible to obtain imagery of night launches because of light provided by the Solid Rocket Motor plume, no imagery was obtained for STS-113.
F6.1-10 NASA failed to adequately perform trend analysis on foam losses. This greatly hampered the agency's ability to make informed decisions about foam losses.
F6.1-11 Despite the constant shedding of foam, the Shuttle Program did little to harden the Orbiter against foam impacts through upgrades to the Thermal Protection System. Without impact resistance and strength requirements that are calibrated to the energy of debris likely to impact the Orbiter, certification of new Thermal Protection System tile will not adequately address the threat posed by debris.
F6.2-1 NASA Headquarters' focus was on the Node 2 launch date, February 19, 2004.
F6.2-2 The intertwined nature of the Space Shuttle and Space Station programs signifi cantly increased the complexity of the schedule and made meeting the schedule far more challenging.
F6.2-3 The capabilities of the system were being stretched to the limit to support the schedule. Projections into 2003 showed stress on vehicle processing at the Kennedy Space Center, on flight controller training at Johnson Space Center, and on Space Station crew rotation schedules. Effects of this stress included neglecting flight controller recertification requirements, extending crew rotation schedules, and adding incremental risk by scheduling additional Orbiter movements at Kennedy.
F6.2-4 The four flights scheduled in the five months from October 2003, to February 2004, would have required a processing effort comparable to the effort immediately before the Challenger accident.
F6.2-5 There was no schedule margin to accommodate unforeseen problems. When fl ights come in rapid succession, there is no assurance that anomalies on one flight will be identified and appropriately addressed before the next flight.
F6.2-6 The environment of the countdown to Node 2 and the importance of maintaining the schedule may have begun to influence managers' decisions, including those made about the STS-112 foam strike.
F6.2-7 During STS-107, Shuttle Program managers were concerned with the foam strike's possible effect on the launch schedule.
F6.3-1 The foam strike was first seen by the Intercenter Photo Working Group on the morning of Flight Day Two during the standard review of launch video and high-speed photography. The strike was larger than any seen in the past, and the group was concerned about possible damage to the Orbiter. No conclusive images of the strike existed. One camera that may have provided an additional view was out of focus because of an improperly maintained lens.
F6.3-2 The Chair of the Intercenter Photo Working Group asked management to begin the process of getting outside imagery to help in damage assessment. This request, the first of three, began its journey through the management hierarchy on Flight Day Two.
F6.3-3 The Intercenter Photo Working Group distributed its first report, including a digitized video clip and initial assessment of the strike, on Flight Day Two. This information was widely disseminated to NASA and contractor engineers, Shuttle Program managers, and Mission Operations Directorate personnel.
F6.3-4 Initial estimates of debris size, speed, and origin were remarkably accurate. Initial information available to managers stated that the debris originated in the left bipod area of the External Tank, was quite large, had a high velocity, and struck the underside of the left wing near its leading edge. The report stated that the debris could have hit the RCC or tile.
F6.3-5 A Debris Assessment Team began forming on Flight Day two to analyze the impact. Once the debris strike was categorized as "out of family" by United Space Alliance, contractual obligations led to the Team being Co-Chaired by the cognizant contractor sub-system manager and her NASA counterpart. The team was not designated a Tiger Team by the Mission Evaluation Room or Mission Management Team.
F6.3-6 Though the Team was clearly reporting its plans (and final results) through the Mission Evaluation Room to the Mission Management Team, no Mission manager appeared to "own" the Team's actions. The Mission Management Team, through the Mission Evaluation Room, provided no direction for team activities, and Shuttle managers did not formally consult the Team's leaders about their progress or interim results.
F6.3-7 During an organizational meeting, the Team discussed the uncertainty of the data and the value of on-orbit imagery to "bound" their analysis. In its first official meeting the next day, the Team gave its NASA Co-Chair the action to request imagery of Columbia on-orbit.
F6.3-8 The Team routed its request for imagery through Johnson Space Center's Engineering Directorate rather than through the Mission Evaluation Room to the Mission Management Team to the Flight Dynamics Officer, the channel used during a mission. This routing diluted the urgency of their request. Managers viewed it as a non- critical engineering desire rather than a critical operational need.
F6.3-9 Team members never realized that management's decision against seeking imagery was not intended as a direct or final response to their request.
F6.3-10 The Team's assessment of possible tile damage was performed using an impact simulation that was well outside Crater's test database. The Boeing analyst was inexperienced in the use of Crater and the interpretation of its results. Engineers with extensive Thermal Protection System expertise at Huntington Beach were not actively involved in determining if the Crater results were properly interpreted.
F6.3-11 Crater initially predicted tile damage deeper than the actual tile depth, but engineers used their judgment to conclude that damage would not penetrate the densified layer of tile. Similarly, RCC damage conclusions were based primarily on judgment and experience rather than analysis.
F6.3-12 For a variety of reasons, including management failures, communication breakdowns, inadequate imagery, inappropriate use of assessment tools, and flawed engineering judgments, the damage assessments contained substantial uncertainties.
F6.3-13 The assumptions (and their uncertainties) used in the analysis were never presented or discussed in full to either the Mission Evaluation Room or the Mission Management Team.
F6.3-14 While engineers and managers knew the foam could have struck RCC panels; the briefings on the analysis to the Mission Evaluation Room and Mission Management Team did not address RCC damage, and neither Mission Evaluation Room nor Mission Management Team managers asked about it.
F6.3-15 There were lapses in leadership and communication that made it difficult for engineers to raise concerns or understand decisions. Management failed to actively engage in the analysis of potential damage caused by the foam strike.
F6.3-16 Mission Management Team meetings occurred infrequently (five times during a 16 day mission), not every day, as specified in Shuttle Program management rules.
F6.3-17 Shuttle Program Managers entered the mission with the belief, recently reinforced by the STS-113 Flight Readiness Review, that a foam strike is not a safety-of-flight issue.
F6.3-18 After Program managers learned about the foam strike, their belief that it would not be a problem was confirmed (early, and without analysis) by a trusted expert who was readily accessible and spoke from "experience." No one in management questioned this conclusion.
F6.3-19 Managers asked "Who's requesting the photos?" instead of assessing the merits of the request. Management seemed more concerned about the staff following proper channels (even while they were themselves taking informal advice) than they were about the analysis.
F6.3-20 No one in the operational chain of command for STS-107 held a security clearance that would enable them to understand the capabilities and limitations of National imagery resources.
F6.3-21 Managers associated with STS-107 began investigating the implications of the foam strike on the launch schedule, and took steps to expedite post-flight analysis.
F6.3-22 Program managers required engineers to prove that the debris strike created a safety- of-flight issue: that is, engineers had to produce evidence that the system was unsafe rather than prove that it was safe.
F6.3-23 In both the Mission Evaluation Room and Mission Management Team meetings over the Debris Assessment Team's results, the focus was on the bottom line - was there a safety-of-flight issue, or not? There was little discussion of analysis, assumptions, issues, or ramifications.
F6.3-24 Communication did not flow effectively up to or down from Program managers.
F6.3-25 Three independent requests for imagery were initiated.
F6.3-26 Much of Program managers' information came through informal channels, which prevented relevant opinion and analysis from reaching decision makers.
F6.3-27 Program Managers did not actively communicate with the Debris Assessment Team. Partly as a result of this, the Team went through institutional, not mission-related, channels with its request for imagery, and confusion surrounded the origin of imagery requests and their subsequent denial.
F6.3-28 Communication was stifled by the Shuttle Program attempts to find out who had a "mandatory requirement" for imagery.
F6.3-29 Safety representatives from the appropriate organizations attended meetings of the Debris Assessment Team, Mission Evaluation Room, and Mission Management Team, but were passive, and therefore were not a channel through which to voice concerns or dissenting views.
F6.4-1 The repair option, while logistically viable using existing materials onboard Columbia, relied on so many uncertainties that NASA rated this option "high risk."
F6.4-2 If Program managers were able to unequivocally determine before Flight Day Seven that there was potentially catastrophic damage to the left wing, accelerated processing of Atlantis might have provided a window in which Atlantis could rendezvous with Columbia before Columbia's limited consumables ran out.
F7.1-1 Throughout its history, NASA has consistently struggled to achieve viable safety programs and adjust them to the constraints and vagaries of changing budgets. Yet, according to multiple high level independent reviews, NASA's safety system has fallen short of the mark.
F7.4-1 The Associate Administrator for Safety and Mission Assurance is not responsible for safety and mission assurance execution, as intended by the Rogers Commission, but is responsible for Safety and Mission Assurance policy, advice, coordination, and budgets. This view is consistent with NASA's recent philosophy of management at a strategic level at NASA Headquarters but contrary to the Rogers' Commission recommendation.
F7.4-2 Safety and Mission Assurance organizations supporting the Shuttle Program are largely dependent upon the Program for funding, which hampers their status as independent advisors.
F7.4-3 Over the last two decades, little to no progress has been made toward attaining integrated, independent, and detailed analyses of risk to the Space Shuttle system.
F7.4-4 System safety engineering and management is separated from mainstream engineering, is not vigorous enough to have an impact on system design, and is hidden in the other safety disciplines at NASA Headquarters.
F7.4-5 Risk information and data from hazard analyses are not communicated effectively to the risk assessment and mission assurance processes. The Board could not find adequate application of a process, database, or metric analysis tool that took an integrated, systemic view of the entire Space Shuttle system.
F7.4-6 The Space Shuttle Systems Integration Office handles all Shuttle systems except the Orbiter. Therefore, it is not a true integration office.
F7.4-7 When the Integration Office convenes the Integration Control Board, the Orbiter Office usually does not send a representative, and its staff makes verbal inputs only when requested.
F7.4-8 The Integration office did not have continuous responsibility to integrate responses to bipod foam shedding from various offices. Sometimes the Orbiter Office had responsibility, sometimes the External Tank Office at Marshall Space Flight Center had responsibility, and sometime the bipod shedding did not result in any designation of an In-Flight Anomaly. Integration did not occur.
F7.4-9 NASA information databases such as The Problem Reporting and Corrective Action and the Web Program Compliance Assurance and Status System are marginally effective decision tools.
F7.4-10 Senior Safety, Reliability & Quality Assurance and element managers do not use the Lessons Learned Information System when making decisions. NASA subsequently does not have a constructive program to use past lessons to educate engineers, managers, astronauts, or safety personnel.
F7.4-11 The Space Shuttle Program has a wealth of data tucked away in multiple databases without a convenient way to integrate and use the data for management, engineering, or safety decisions.
F7.4-12 The dependence of Safety, Reliability & Quality Assurance personnel on Shuttle Program support limits their ability to oversee operations and communicate potential problems throughout the organization.
F7.4-13 There are conflicting roles, responsibilities, and guidance in the Space Shuttle safety programs. The Safety & Mission Assurance Pre-Launch Assessment Review process is not recognized by the Space Shuttle Program as a requirement that must be followed (NSTS 22778). Failure to consistently apply the Pre-Launch Assessment Review as a requirements document creates confusion about roles and responsibilities in the NASA safety organization.
F10.1-1 The Columbia accident demonstrated that Orbiter breakup during re-entry has the potential to cause casualties among the general public.
F10.1-2 Given the best information available to date, a formal risk analysis sponsored by the Board found that the lack of general-public casualties from Columbia*s break-up was the expected outcome.
F10.1-3 The history of U.S. space flight has a flawless public safety record. Since the 1950s, hundreds of space flights have occurred without a single public injury.
F10.1-4 The FAA and U.S. space launch ranges have safety standards designed to ensure that the general public is exposed to less than a one-in-a-million chance of serious injury from the operation of space launch vehicles and unmanned aircraft.
F10.1-5 NASA did not demonstrably follow public risk acceptability standards during past Orbiter re- entries. NASA efforts are underway to define a national policy for the protection of public safety during all operations involving space launch vehicles.