Columbia Accident Investigation Board
Report Volume 1 - August 2003
Harold W. Gehman, Jr. Admiral U.S. Navy (retired) - Chairman
This is the Columbia Accident Investigation Board Report on the Space Shuttle Columbia Accident on February 1, 2003. The Crew of the Space Shuttle died in the break-up of the vehicle during reentry: Rick D. Husband - Commander William C. McCool - Pilot Michael P Anderson - Payload Commander David M. Brown - Mission Specialist Kalpana Chawla - Mission Specialist Laurel Blair Salton Clark - Mission Specialist Ilan Ramon - Payload Specialist This is the complete Accident Report (Volume 1). Other Volumes contained Technical and other significant documents (Volumes II to V) and a transcript of Board Public Hearings. The accident investigation was headed by Chairman Harold W Gehman, Jr, a retired Admiral of the U.S. Navy The aim of the investigation was "to arrive at findings and recomendations aimed at significantly reducing the chances of further accident." The board also conducted a safety evaluation of the entire Space Shuttle Program. Table of Contents VOLUME l In Memoriam . Board Statement. Executive Summary Report Synopsis PART ONE THE ACCIDENT Chapter 1 The Evolution of the Space Shuttle Program l. l Genesis of the Space Transportation System 1.2 Merging Conflicting Interests 1.3 Shuttle Development, Testing, and Qualification 1 .4 The Shuttle Becomes "Operational" 1.5 The Challenger Accident 1.6 Concluding Thoughts Chapter 2 Columbia's Final Flight 2.1 Mission Objectives and Their Rationales 2.2 Flight Preparation 2.3 Launch Sequence 2.4 On-Orbit Events 2.5 Debris Strike Analysis and Requests for Imagery 2.6 De-Orbit Burn and Re-Entry Events 2.7 Events Immediately Following the Accident Chapter 3 Accident Analysis 3.1 The Physical Cause 3.2 The External Tank and Foam 3.3 Wing Leading Edge Structural Subsystem 3.4 Image and Transport Analyses 3.5 On-Orbit Debris Separation - The "Flight Day 2" Object 3.6 De-Orbit/Re-Entry 3.7 Debris Analysis 3.8 Impact Analysis and Testing Chapter 4 Other Factors Considered 4.1 Fault Tree 4.2 Remaining Factors PART TWO WHY THE ACCIDENT OCCURRED Chapter 5 From Challenger to Columbia 5.1 The Challenger Accident and its Aftermath. 5.2 The NASA Human Space Flight Culture. 5.3 An Agency Trying to Do Too Much With Too Little . 5.4 Turbulence in NASA Hits the Space Shuttle Program 5.5 When to Replace the Space Shuttle? 5.6 A Change in NASA Leadership 5.7 The Return of Schedule Pressure 5.8 Conclusion Chapter 6 Decision Making at NASA 6.1 A History of Foam Anomalies 6.2 Schedule Pressure 6.3 Decision-Making During the Flight of STS-107 6.4 Possibility of Rescue or Repair Chapter 7 The Accident's Organizational Causes 7.1 Organizational Causes: Insights from History 7.2 Organizational Causes: Insights from Theory 7.3 Organizational Causes: Evaluating Best Safety Practices 7.4 Organizational Causes: A Broken Safety Culture 7.5 Organizational Causes: Impact of a Flawed Safety Culture on STS-107 7.6 Findings and Recommendations Chapter 8 History as Cause: Columbia and Challenger 8.1 Echoes of Challenger 8.2 Failures of Foresight: Two Decision Histories and the Normalization of Deviance 8.3 System Effects: The Impact of History and Politics on Risky Work 8.4 Organization, Culture, and Unintended Consequences 8.5 History as Cause: Two Accidents 8.6 Changing NASA's Organizational System PART THREE A LOOK AHEAD Chapter 9 Implications for the Future of Human Space Flight 9.1 Near-Term: Return to Flight 9.2 Mid-Term: Continuing to Fly 9.3 Long-Term: Future Directions for the U.S. in Space Chapter 10 Other Significant Observations 10.1 Public Safety 10.2 Crew Escape and Survival 10.3 Shuttle Engineering Drawings and Closeout Photographs 10.4 Industrial Safety and Quality Assurance 10.5 Maintenance Documentation 10.6 Orbiter Maintenance Down Period/Orbiter Major Modification 10.7 Orbiter Corrosion 10.8 Brittle Fracture of A-286 Bolts 10.9 Hold-Down Post Cable Anomaly 10.10 Solid Rocket Booster External Tank Attachment Ring 10.11 Test Equipment Upgrades 10.12 Leadership/Managerial Training Chapter 11 Recommendations PART FOUR APPENDICES Appendix A The Investigation Appendix B Board Member Biographies Appendix C Board Staff
Softcover, large format
248 Seiten / pages
many illustrations and photographs
very good condition, with a name label of the previous owner
Washington D.C. - 2003 - NASA - National Aeronautics and Space Administration
Art.Nr. 25289
