The CAIB report concludes that while NASA's present Space Shuttle is not inherently unsafe, a number of mechanical fixes are required to make the Shuttle safer in the short term. The report also concludes that NASA's management system is unsafe to manage the shuttle system beyond the short term and that the agency does not have a strong safety culture.

The Board determined that physical and organizational causes played an equal role in the Columbia accident - that the NASA organizational culture had as much to do with the accident as the foam that struck the Orbiter on ascent. The report also notes other significant factors and observations that may help prevent the next accident.

The Board crafted the report to serve as a framework for a national debate about the future of human space flight, but suggests that it is in the nation's interest to replace the Shuttle as soon as possible as the primary means for transporting humans to and from Earth orbit.

The Board makes 29 recommendations in the 248-page final report, including 15 return-to-flight recommendations that should be implemented before the Shuttle Program returns to flight.

The report, which consists of 11 chapters grouped into three main sections, was the result of a seven-month-long investigation by the CAIB's 13 board members, more than 120 investigators, 400 NASA and contractor employees, and more than 25,000 searchers who recovered Columbia's debris.

Over the next several weeks, the Board expects to publish several additional volumes containing technical documents cited in the report or referenced as part of the investigation, as well as transcripts of the board's public hearings.

CAIB Report Executive Summary
The Columbia Accident Investigation Board's independent investigation into the February 1, 2003, loss of the Space Shuttle Columbia and its seven-member crew lasted nearly seven months. A staff of more than 120, along with some 400 NASA engineers, supported the Board's 13 members. Investigators examined more than 30,000 documents, conducted more than 200 formal interviews, heard testimony from dozens of expert witnesses, and reviewed more than 3,000 inputs from the general public.

In addition, more than 25,000 searchers combed vast stretches of the Western United States to retrieve the spacecraft's debris. In the process, Columbia's tragedy was compounded when two debris searchers with the U.S. Forest Service perished in a helicopter accident.

The Board recognized early on that the accident was probably not an anomalous, random event, but rather likely rooted to some degree in NASA's history and the human space flight program's culture. Accordingly, the Board broadened its mandate at the outset to include an investigation of a wide range of historical and organizational issues, including political and budgetary considerations, compromises, and changing priorities over the life of the Space Shuttle Program.

The Board's conviction regarding the importance of these factors strengthened as the investigation progressed, with the result that this report, in its findings, conclusions, and recommendations, places as much weight on these causal factors as on the more easily understood and corrected physical cause of the accident.

The physical cause of the loss of Columbia and its crew was a breach in the Thermal Protection System on the leading edge of the left wing, caused by a piece of insulating foam which separated from the left bipod ramp section of the External Tank at 81.7 seconds after launch, and struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel number 8.

During re-entry this breach in the Thermal Protection System allowed superheated air to penetrate through the leading edge insulation and progressively melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused loss of control, failure of the wing, and break-up of the Orbiter. This breakup occurred in a flight regime in which, given the current design of the Orbiter, there was no possibility for the crew to survive.

The organizational causes of this accident are rooted in the Space Shuttle Program's history and culture, including the original compromises that were required to gain approval for the Shuttle, subsequent years of resource constraints, fluctuating priorities, schedule pressures, mischaracterization of the Shuttle as operational rather than developmental, and lack of an agreed national vision for human space flight.

Cultural traits and organizational practices detrimental to safety were allowed to develop, including:

• reliance on past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing in accordance with requirements);
• organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion;
• lack of integrated management across program elements;
• and the evolution of an informal chain of command and decision-making processes that operated outside the organization's rules.

This report discusses the attributes of an organization that could more safely and reliably operate the inherently risky Space Shuttle, but does not provide a detailed organizational prescription.

Among those attributes are:

• a robust and independent program technical authority that has complete control over specifications and requirements, and waivers to them;
• an independent safety assurance organization with line authority over all levels of safety oversight;
• and an organizational culture that reflects the best characteristics of a learning organization.

This report concludes with recommendations, some of which are specifically identified and prefaced as "before return to flight." These recommendations are largely related to the physical cause of the accident, and include preventing the loss of foam, improved imaging of the Space Shuttle stack from liftoff through separation of the External Tank, and on-orbit inspection and repair of the Thermal Protection System.

The remaining recommendations, for the most part, stem from the Board's findings on organizational cause factors. While they are not "before return to flight" recommendations, they can be viewed as "continuing to fly" recommendations, as they capture the Board's thinking on what changes are necessary to operate the Shuttle and future spacecraft safely in the mid- to long-term.

These recommendations reflect both the Board's strong support for return to flight at the earliest date consistent with the overriding objective of safety, and the Board's conviction that operation of the Space Shuttle, and all human spaceflight, is a developmental activity with high inherent risks.

A view from inside the Launch Control Center as Columbia rolls out to Launch Complex 39-A on December 9, 2002.

Download The CAIB Report - 10MB PDF via Space.TV

Related Links
CAIB Site
SpaceDaily
Search SpaceDaily
Subscribe To SpaceDaily Express

Thanks for being here; We need your help. The SpaceDaily news network continues to grow but revenues have never been harder to maintain. With the rise of Ad Blockers, and Facebook - our traditional revenue sources via quality network advertising continues to decline. And unlike so many other news sites, we don't have a paywall - with those annoying usernames and passwords. Our news coverage takes time and effort to publish 365 days a year. If you find our news sites informative and useful then please consider becoming a regular supporter or for now make a one off contribution.
SpaceDaily Contributor $5 Billed Once credit card or paypal		SpaceDaily Monthly Supporter $5 Billed Monthly paypal only