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Columbia Accident Investigation Board Report Volume I
Volume 1 of a six volume set. Investigates loss of the Space Shuttle Columbia, STS -107, and its seven-member crew on February 1, 2003. Four parts The Accident; Why the Accident Occurred; A Look Ahead; and Appendices A, B, C. Concludes with recommendations.
248 pages, Paperback
First published October 10, 2003
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Displaying 1 - 6 of 6 reviews
April 3, 2009
On the morning of Feb 1 2003, I was in Sunnyvale, California, staying with my friend and colleague Beth Ann. The Shuttle was due to land that day, and its approach path was going to take it right over us. We set our alarms to get up early enough to see it. But the sky was overcast, and after hanging around for ten minutes we went back to bed. We were woken up a couple of hours later by a phone call from Beth Ann's sister, who had just heard the horrible news that the Columbia had broken up over Texas, killing everyone on board. Beth Ann is a real tough cookie, but she started crying. She had met Kalpana Chawla a couple of times, and had really liked and admired her.
Later that day, there was a big open-air meeting at NASA Ames Research Center, which a couple of thousand people must have attended. It was like a funeral; I've never seen such a large crowd look so subdued. The Center Director gave a speech, and among other things he promised that there would be a full investigation. It was vital to know exactly what had happened. The investigation was, indeed, staggeringly thorough and efficient, and in October they issued their report. It's an absolute model for how to conduct an inquiry of this kind; even if you have no particular interest in space-flight, it's worth reading. They examined the problem from every angle, and I found the conclusions very interesting.
First, there was a painstaking piece of scientific detective work, which established beyond any reasonable doubt what the proximate cause of the accident had been. As most people now know, a piece of insulation foam had broken off the fuel tank during take-off, and had hit the wing, breaking one of the Reinforced Carbon-Carbon panels. This created a hole, which during re-entry allowed superheated gases to get into the wing cavity, melting everything inside it and destroying the Shuttle.
Next, the investigation board wanted to determine why no one had realized that falling pieces of foam could have this disastrous effect. They focused on the administrative procedures that had been used to sign off on safety, and found some disturbing patterns. Engineers would make recommendations about safety procedures based on their understanding of things that they thought could be potentially dangerous. But, if safety rules were broken, and nothing bad actually happened, there was a strong tendency to assume that the recommendations were not in fact important. In this particular case, people had been aware that falling pieces of foam might be dangerous during the take-off sequence. However, since the phenomenon had been seen to occur several times, and there had been no obvious consequences, it was in practice ignored.
Moving back another step in the chain of cause and effect, the investigators wanted to know why these unsatisfactory management procedures had been deemed acceptable. They concluded that NASA was being put under great pressure to keep to schedules which were inherently unrealistic, given available resources. If they couldn't make Shuttle launches when they were supposed to, construction of the International Space Station slowed down, and milestones were missed. This looked bad politically, and there was a strong temptation to cut corners by relaxing safety requirements. In the end, something was almost certain to go wrong. If it hadn't been the foam, it would have been something else.
Finally, the board asked the most basic question of all: why did NASA allow this whole situation to develop? Their ultimate conclusion was that the agency had lost its way, at least as regarded manned space-flight. No one really knew any more why they were doing it. There was wide-spread skepticism about the true value of building and running the International Space Station, and no long-term plan for space exploration that would build further on it. Nearly all the people I talked to at NASA agreed with this. It wasn't in the report, but I also heard from several sources that NASA had never really wanted to build the Station in the first place; it had been a political move from then-President Reagan, and he had gone against the expert recommendations.
I don't believe that the investigation board could have done a better job. However, they reported to George W. Bush, since NASA is under the Executive Branch of the US Government. In January 2004, Bush announced the Moon, Mars and Beyond initiative, which, as a first goal, involves returning to the Moon by 2020. The budget assigned to cover this task is, unfortunately, at the bottom end of the feasible range. The task will only be achievable if people creatively stretch resources to the limit, with the known implications for safety.
As Hegel famously said: the only thing we learn from history is that we don't.
Later that day, there was a big open-air meeting at NASA Ames Research Center, which a couple of thousand people must have attended. It was like a funeral; I've never seen such a large crowd look so subdued. The Center Director gave a speech, and among other things he promised that there would be a full investigation. It was vital to know exactly what had happened. The investigation was, indeed, staggeringly thorough and efficient, and in October they issued their report. It's an absolute model for how to conduct an inquiry of this kind; even if you have no particular interest in space-flight, it's worth reading. They examined the problem from every angle, and I found the conclusions very interesting.
First, there was a painstaking piece of scientific detective work, which established beyond any reasonable doubt what the proximate cause of the accident had been. As most people now know, a piece of insulation foam had broken off the fuel tank during take-off, and had hit the wing, breaking one of the Reinforced Carbon-Carbon panels. This created a hole, which during re-entry allowed superheated gases to get into the wing cavity, melting everything inside it and destroying the Shuttle.
Next, the investigation board wanted to determine why no one had realized that falling pieces of foam could have this disastrous effect. They focused on the administrative procedures that had been used to sign off on safety, and found some disturbing patterns. Engineers would make recommendations about safety procedures based on their understanding of things that they thought could be potentially dangerous. But, if safety rules were broken, and nothing bad actually happened, there was a strong tendency to assume that the recommendations were not in fact important. In this particular case, people had been aware that falling pieces of foam might be dangerous during the take-off sequence. However, since the phenomenon had been seen to occur several times, and there had been no obvious consequences, it was in practice ignored.
Moving back another step in the chain of cause and effect, the investigators wanted to know why these unsatisfactory management procedures had been deemed acceptable. They concluded that NASA was being put under great pressure to keep to schedules which were inherently unrealistic, given available resources. If they couldn't make Shuttle launches when they were supposed to, construction of the International Space Station slowed down, and milestones were missed. This looked bad politically, and there was a strong temptation to cut corners by relaxing safety requirements. In the end, something was almost certain to go wrong. If it hadn't been the foam, it would have been something else.
Finally, the board asked the most basic question of all: why did NASA allow this whole situation to develop? Their ultimate conclusion was that the agency had lost its way, at least as regarded manned space-flight. No one really knew any more why they were doing it. There was wide-spread skepticism about the true value of building and running the International Space Station, and no long-term plan for space exploration that would build further on it. Nearly all the people I talked to at NASA agreed with this. It wasn't in the report, but I also heard from several sources that NASA had never really wanted to build the Station in the first place; it had been a political move from then-President Reagan, and he had gone against the expert recommendations.
I don't believe that the investigation board could have done a better job. However, they reported to George W. Bush, since NASA is under the Executive Branch of the US Government. In January 2004, Bush announced the Moon, Mars and Beyond initiative, which, as a first goal, involves returning to the Moon by 2020. The budget assigned to cover this task is, unfortunately, at the bottom end of the feasible range. The task will only be achievable if people creatively stretch resources to the limit, with the known implications for safety.
As Hegel famously said: the only thing we learn from history is that we don't.
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January 22, 2025The fact that this is 200 pages of them shitting on NASA's management is the best part. The whole tragedy would've been avoided if management listened to engineers concerns and didn't assume so much.
Going to update later with some of my favorite quotes from the Board. Would recommend if you like to read about space and NASA.
I'm not rating this.
Going to update later with some of my favorite quotes from the Board. Would recommend if you like to read about space and NASA.
I'm not rating this.
August 4, 2019
A little dry but interesting just the same. Motivated to read it by the videos at the MoF.
July 13, 2024
Not overly difficult or technically unapproachable. An important primary-source read for anyone interested in the Columbia tragedy.
November 2, 2016
I read quite a few accident investigation reports, usually by NTSB as they are available online for free. I enjoy the forensic analysis of events that lead to a conclusion. I don't usually add them to my Goodreads list. I'm making an exception with this one though. Why? Because this report made me cry. After reading the background information, I'm surprised this kind of catastrophic incident took so long to occur. The thing that struck me the most though, was that they knew something terrible was liable to happen. An email between NASA officials actually states, "Any more activity today on the tile damage or are people just relegated to crossing their fingers and hoping for the best?"
The more I read of the report, the more I kept thinking, "Those poor people." There were so many missed opportunities to identify and do something about the damage, but all went unheeded or was dismissed. Yes, NASA was under budget constraints with reduced funding year after year. Yes, they were being asked to do more with less. Yes, there was competition from other agencies. Yes, management was a pile of spaghetti. Yes, they knew that foam strikes occurred in 80% of missions that were able to be visually studied. It was like the dirty little secret everyone knew about but hoped would never cause any real problem. You can't be complacent with people's lives. It's horrible to think about.
This report is a full in depth analysis of the history, lead up, occurrence and aftermath of the Columbia disaster. I refuse to call it an accident, because the cause was a known hazard. People always say we should learn from incidents like this. I suppose NASA eventually did, by shutting down the shuttle programme and is now returning to manned vehicles atop rocket boosters with a crew recovery system. The shuttle programme never reached its design potential anyway.
I would recommend this report if you are interested in getting your information from the source rather than relying on documentaries, blogs or Youtube videos by conspiracy nuts that are subject to bias or do not tell the whole story. This has everything from radio communication transcripts, emails, photo evidence, calculations, reconstructive analysis etc. Very interesting, very sad, and it will quite possibly make you very angry.
The more I read of the report, the more I kept thinking, "Those poor people." There were so many missed opportunities to identify and do something about the damage, but all went unheeded or was dismissed. Yes, NASA was under budget constraints with reduced funding year after year. Yes, they were being asked to do more with less. Yes, there was competition from other agencies. Yes, management was a pile of spaghetti. Yes, they knew that foam strikes occurred in 80% of missions that were able to be visually studied. It was like the dirty little secret everyone knew about but hoped would never cause any real problem. You can't be complacent with people's lives. It's horrible to think about.
This report is a full in depth analysis of the history, lead up, occurrence and aftermath of the Columbia disaster. I refuse to call it an accident, because the cause was a known hazard. People always say we should learn from incidents like this. I suppose NASA eventually did, by shutting down the shuttle programme and is now returning to manned vehicles atop rocket boosters with a crew recovery system. The shuttle programme never reached its design potential anyway.
I would recommend this report if you are interested in getting your information from the source rather than relying on documentaries, blogs or Youtube videos by conspiracy nuts that are subject to bias or do not tell the whole story. This has everything from radio communication transcripts, emails, photo evidence, calculations, reconstructive analysis etc. Very interesting, very sad, and it will quite possibly make you very angry.
November 11, 2008
Grim reading, but valuable insight into how organizations can go wrong, and how important it is for engineers to speak up when they are unhappy with a management decision...
Displaying 1 - 6 of 6 reviews