1. STS-107 COLUMBIA by Doug Dieker & Can Bayrak MSA 608 – Aviation / Aerospace Accident Investigation & Safety Systems Final Discussion April 2011

2. Overview The Accident Emergency Response Investigation Contributing Factors Recommendations Safety Issues Report Deficiencies Bibliography 2

3. The Accident Before Launch Preparation Orbiter Prep Flight Prep Launch Readiness Prep Flight Readiness Prep Certificate of Flight Readiness 3

4. The Accident Launch Abnormal Countdown Wind Shear 57 sec. after launch during max-q I-Loads 70% or less of design Nozzle Deflections Booster thrust mismatch within limits Debris Strike Foam separation 4

5. The Accident Orbit Arrival Day 2 Object separation from module Day 5 Rotary separator 2 SPACEHAB Day 6 SPACEHAB reached 81 degrees Contingency plan created 5

6. The Accident Re-Entry Entry Interface [08:44:09 AM] Left wing leading edge spar Leading edge showed abnormal strains 8 minutes in Re-Entry Left wing reached 2800 0F degrees Crossing California Signs of debris shed 11 minutes in Re-Entry Left wing reached 3000 0F degrees Last transmission from commander [08:59:32 AM] 6

7. Emergency Response Shuttle ETA [09:16 AM] Shuttle contingency plan activated “GC Flight, GC Flight; Lock the Doors” Established post “Challenger” Search & Rescue initiated Suiting East Texas declared disaster area 7

8. Investigation Debris Recovery Vital in the Accident Widespread Photo Presentations Nationwide debris recovery efforts A helicopter crashed while searching for wreckage 8

10. Contributing Factors Design External Tank Largest element of the Shuttle Main Structural Component during assembly Adhesion of foam Cleanly prepped surface Left Bipod Foam Loss Combination of Factors Pre-existing defects Different eras of parts Foam uniformity of production Subsurface defects 10

11. Contributing Factors Cyroingestion Y-Joint Liquification Bipod Foam Ramps Liquid hydrogen-intertank flange Flash Evaporation 11

12. Contributing Factors Combination of Conditions May be individually within limits Wind shear, solid rocket response, liquid oxygen “sloshing” Each individually Not consistent with causing accident Combination Contribution to accident unknown Negligence Acceptability of foam separation Direct cause may never be understood 12

13. Contributing Factors Findings NASA does not fully understand the mechanisms that cause foam loss on almost all flights No non-destructive evaluation techniques for the as-installed foam. Foam loss from an External Tank is unrelated to the tankʼs age and to its total pre-launch expo­sure to the elements. The Board found instances of left bipod ramp shedding on launch previously unknown to dance. Subsurface defects were found during the dissection of 3 other foam bipod ramps Foam loss occurred on over 80 percent of the 79 missions for which imagery was available to confirm or rule out foam loss. 30 percent of all missions lacked sufficient imagery to determine foam loss. Analysis of separate variables indicated that none could be identified as the sole initiating factor of bipod foam loss. The Board concludecd that a combination of factors resulted in bipod foam loss. 13

14. Contributing Factors Orbiter Left Wing Left Wing damage Panels 6-10 Past instances 5 occasions carbide layer loss Findings Foam strike force 14

15. Contributing Factors Physical Cause Breach in Thermal Protection System Leading edge of the orbiter’s left wing Foam separation Left bipod ramp of external tank Lower half of RCC panel 8 Superheated air Penetrated leading edge insulation Weakened aluminum structure Aerodynamic forces Failure of wing structure Loss of control 15

16. Recommendations Thermal Protection System 16

17. Recommendations Thermal Protection System External Tank’s debris-shedding elimination techniques at the source Reinforced Carbon-Carbon (RCC) enforcement Comprehensive testing Investigation under debris strike Increasing ability to sustain under re-entry dynamics Establishing debris damage thresholds before enforcement Providing spare RCC panels ISS missions, developing space-walks to repair Non-station missions, developing autonomous repair capabilities Analysis software development for simulating such strikes 17

18. Recommendations Suiting Depressurization resistance Full integration of suits to seats Upper-body restraints enhancement Extreme rotational dynamics endurance Endurance to extreme external conditions Very-low temperature Near-vacuum pressurization Thermal events (in-flight fire, explosions, etc.) Aero dynamical effects Ground impact resistance Seating parachute system Crew training Emphasizing on re-entry & launch 18

19. Recommendations Imaging Upgrading imaging system Additional imaging options Naval, air, etc. At least 3 different angles Additional imaging options to monitor structures External Tank (until separation) Wings’ leading edges & RCCs Imaging the orbiter while in orbit External sources can be utilized to some point Requires broadening public TV rights Launch site security clearence for TV operators Highly dependent on technological advancements 19

20. Recommendations Data Collection The Modular Auxiliary Data System Should be maintained & updated frequently Redesign to include- Engineering performance Vehicle health information Ability to be reconfigured during flight to in order to allow certain data to be recorded Should transmit real-time data to mission control; not providing data for post-flight only. Orbiter Experiment Instrumentation Should be renewed Should be redesigned for a longer service life Increase in Orbiter’s wiring inspection frequency 20

21. Recommendations Scheduling Flexibility for adhoc challenges Sourcing the crew for unexpected schedule changes/delays Flexibility in schedule in order to have enough time for a rescue mission (‘Launch on Need missions) Training Additional crew training on maintenance & repair Stationary missions space walks Non-stationary missions space walks Mission Management Team training for unexpected challenges Crew loss Shuttle loss Enhancement in support among various departments across NASA & contractors 21

22. Recommendations Organizational Establishment of a ‘Technical Engineering Authority’ Responsible for technical documentation, standardization, certification and all waivers to them a Safety Management System funded directly by NASA No responsibilities towards costs or schedule Responsible for identifying, analyzing, controlling hazards Responsible for mitigating operational risks Developing technical standards Establishment of a “non-punitive” hazard reporting system within the entire organization Responsible for verification of launch GO/ No-GO Establishment of an independent safety program/ authority to inspect & audit organizational procedures Reorganization of the ‘Space Shuttle Integration Office’ Submitting annual reports directly to the Congress, as part of the budget review process 22

23. Safety Issues Safety Culture “We couldn’t have done anything about it anyway.” Anonymous top ranked NASA manager “NASA had conflicting goals of cost, schedule, and safety; and unfortunately, safety lost out.” Major General John Barry - U.S. Air Force “It didn’t get fixed the last time(’86, the Challenger disaster); there has to be another approach.” Steven B. Wallace – Dir., FAA Office of Accident Investigation “You have to do what we did in the Apollo program. You have to plan for the worst and hope for the best; and I don’t think we are doing that.” John Watts Young, former NASA astronaut & Columbia commander 23

24. Safety Issues Safety Culture “Landing unmanned probes safely on Mars and flying the next space shuttle safely do not require NASA to learn anything new -- just to stop forgetting the meticulous, courageous, no-holds-barred thinking that got us to the moon the first time.” (Oberg, 2004) NASA knew, immediately after the liftoff with the help of video footage and flight data that the piece of foam had come off the fuel tank, struck the left wing and damaged it (Yomiuri, 2003). “In the two weeks between launch and re-entry, NASA experienced a massive internal communication collapse for such astonishingly pedestrian reasons as emails that went unanswered, key personnel went on vacation, and junior staff dared not question decisions, or non-decisions, by their superiors and risk being fired.” (Fisher,2005) 24

25. Safety Issues Safety Culture Overconfident, & self deceptive culture (CAIB, 2003). Only 5 safety conferences were held in a 16-day mission. U.S. Military’s surveillance telescope identification offer was rejected. High budget related constraints Safety department is bound to a budget limit reserved for that Program only Strict hierarchical budget assignments for different departments. The Safety & Mission Assurance department does not have high priority within NASA. High confidentiality necessity Lacking of an open & anonymous hazard reporting system Dependence of departments to their selves limit exposure / communication among other departments Lack of an independent safety department Each department is for itself There is no integration among departments’ databases The Safety & Mission Assurance Pre-Launch Assessment Review process is not recognized by the Space Shuttle Program (NSTS 22778). Lacking of an integration among departments causes communication & responsibility interruptions 25

26. Safety Issues Lack of Testing “NASA must do better testing of all components, not just the largest systems.” - Major General John Barry; U.S. Air Force “NASA had not conducted a simple testing on foam that I was able to perform at my kitchen table.” – Douglas D. Osheroff; CAIB board member “You don't feel this can do anything. But you fire this at 500 miles an hour, and you saw it. That's when it came home to me what (½)mv2means.”– G. Scott Hubbard, Dir. NASA Ames Research Center 26

27. Safety Issues Lack of Testing The testing on the new bolt assemblies on the solid rocket boosters and fuel tanks, which were produced by United Space Alliance, LLC, was not done as well as it should have been (Glanz, 2003). The foam that hit Columbia was hundreds of times larger than anything the CRATER - a structural analysis program that Boeing has developed for its space program - had been intended to evaluate (Schwartz, 2003). The foam could not have done a major damage to the ceramic tiles on the underside of Columbia to threaten the mission; but NASA had very little data about how RCC, which is chosen not for strength but for its ability to withstand heat, would withstand the debris impact(Wald, 2003). NASA's budget for the shuttle program fell from $4.05B in ‘93 to $3.2B in ’02 (Glanz, 2003). 27

28. Safety Issues Rescue or Repair Options Crew was not trained for a repair mission STS-107 was not carrying related repairing sources Tight schedule Not enough resources to support life Atlantis was not ready for an adhoc mission Launch on Need (LON) Mission Program has been established after the STS-107, Columbia disaster STS-3xx coded missions 28

29. Report Deficiencies Lack of Visual Evidence Different investigation reports state different causes i.e. CAIB report do not focus on suiting issues i.e. NASA’s own report do not focus on organizational flaws Widespread debris Not all of the orbiter was recovered Political issues “Shuttle program will continue” – George W. Bush 29

30. Bibliography Anonymous. (2003, August 28). NASA's culture must change. The Daily Yomiuri (Tokyo), p.12. Columbia Accident Investigation Board. (2003, August). Report Volume I. Author. Fisher, J. (2005, July 13). NASA's cultural flaws. The Toronto Star, pp. A17. Glanz, W. (2003, June 13). NASA discovers problem with bolts on space shuttles. The Washington Times, pp. A03. McKenna, B. (2003, August 27). Shuttle probe blasts NASA's dysfunctional atmosphere; 'overconfident' culture sacrificed safety to meet budgets and deadlines, report says. The Globe and Mail (Canada), pp. A9. National Aeronautics and Space Administration (NASA). (n.d.) Columbia Crew Survival Investigation Report. (NASA/SP-2008-565). Author. NASA. (2006, August 23). NASA – Columbia – Home. Retrieved March/30, 2010, from http://www.nasa.gov/columbia/home/index.html NASA. (2009, April 13). NASA – Columbia – Media. Retrieved March/30, 2010, from http://www.nasa.gov/columbia/media/index.html Oberg, A. C. (2004, January 27). A year after columbia, Usa Today. Schwartz, J. (2003, August 25). Computer program that analyzed shuttle damage was misused, engineer says. The New York Times, pp. 9. Schwartz, J. (2003, June 5). NASA's foam test offered A vivid lesson in kinetics. The New York Times, pp. 29. Schwartz, J. (2003, June 14). Shuttle inquiry finds new risks. The New York Times, pp. 1. Wald, M. L., & Schwartz, J. (2003, July 8). Test shows foam was likely cause of shuttle's loss. The New York Times, pp. 1. Watson, T. (2005, March 21). NASA's culture still poses danger, ex-astronauts say. Usa Today. 30

31. Questions ?? 31