Columbia Accident Investigation Board Report, Volume I

Contents

• IN MEMORIAM p. 2 Read →
• BOARD STATEMENT p. 9 Read →
• EXECUTIVE SUMMARY p. 10 Read →
• PART ONE: THE ACCIDENT p. 12 Read →
• PART TWO: WHY THE ACCIDENT OCCURRED p. 13 Read →
• PART THREE: A LOOK AHEAD p. 14 Read →
• THE ORBITER p. 15 Read →
• THE LOCATIONS p. 17 Read →
• (SFOC COTR) p. 19 Read →
• 1.2 MERGING CONFLICTING INTERESTS p. 23 Read →
• AND QUALIFICATION Read →
• 1.4 THE SHUTTLE BECOMES "OPERATIONAL" p. 24 Read →
• 1.5 THE CHALLENGER ACCIDENT p. 25 Read →
• 1.6 CONCLUDING THOUGHTS p. 1 Read →
• 2.1 MISSION OBJECTIVES AND THEIR RATIONALES p. 28 Read →
• COLUMBIA p. 29 Read →
• T HE CREW p. 30 Read →
• FREESTAR p. 32 Read →
• 2.3 LAUNCH SEQUENCE p. 33 Read →
• 2.4 ON-ORBIT EVENTS p. 36 Read →
• 2.5 DEBRIS STRIKE ANALYSIS AND REQUESTS FOR IMAGERY p. 38 Read →
• 2.6 DE-ORBIT BURN AND RE-ENTRY EVENTS p. 39 Read →
• MISSION CONTROL CENTER COMMUNICATIONS p. 43 Read →
• 3.1 THE PHYSICAL CAUSE p. 50 Read →
• FOAM FRACTURE UNDER HYDROSTATIC PRESSURE p. 55 Read →
• REINFORCED CARBON-CARBON (RCC) p. 56 Read →
• 3.4 IMAGE AND TRANSPORT ANALYSES p. 60 Read →
• THE ORBITER "RAN INTO" THE FOAM p. 61 Read →
• ON-ORBIT COLLISION AVOIDANCE p. 64 Read →
• 3.6 DE-ORBIT/RE-ENTRY p. 65 Read →
• TEMPERATURE (F) p. 67 Read →
• THE KIRTLAND IMAGE p. 72 Read →
• 3.7 DEBRIS ANALYSIS p. 74 Read →
• BOARD TESTING Read →
• 3.8 IMPACT ANALYSIS AND TESTING p. 79 Read →
• 4.1 FAULT TREE p. 86 Read →
• 4.2 REMAINING FACTORS p. 87 Read →
• ORB,FWD" p. 97 Read →
• 5.1 THE CHALLENGER ACCIDENT AND ITS AFTERMATH p. 100 Read →
• SELECTED ROGERS COMMISSION RECOMMENDATIONS p. 101 Read →
• ORGANIZATIONAL CULTURE p. 102 Read →
• WHAT THE EXPERTS HAVE SAID p. 104 Read →
• EARMARKS p. 105 Read →
• CONGRESSIONAL BUDGET REDUCTIONS p. 106 Read →
• SPACE FLIGHT OPERATIONS CONTRACT p. 110 Read →
• 5.5 WHEN TO REPLACE THE SPACE SHUTTLE? p. 111 Read →
• PAST REPORTS REVIEWED p. 113 Read →
• 5.6 A CHANGE IN NASA LEADERSHIP p. 116 Read →
• 5. 7 THE RETURN OF SCHEDULE PRESSURE p. 117 Read →
• 5.8 CONCLUSION p. 118 Read →
• Roger Guillemette, "Vandenberg: Space Shuttle Launch and Landing p. 121 Read →
• 6.1 A HISTORY OF FOAM ANOMALIES p. 122 Read →
• DEFINITIONS p. 123 Read →
• UMBILICAL CAMERAS AND THE STATISTICS OF BIPOD RAMP LOSS p. 125 Read →
• SPACE SHUTTLE PROGRAM Read →
• SPACE SHUTTLE PROGRAM p. 126 Read →
• MISSION DATE COMMENTS p. 129 Read →
• 6.2 SCHEDULE PRESSURE p. 132 Read →
• IMAGERY REQUEST p. 141 Read →
• ENGINEERING COORDINATION AT NASA AND UNITED SPACE ALLIANCE p. 143 Read →
• THE CRATER MODEL p. 145 Read →
• MISSED OPPORTUNITY p. 146 Read →
• MISSED OPPORTUNITY Read →
• (NASA); MADDEN, CHRISTOPHER B. (CHRIS) (JSC-ES3) (NASA) p. 150 Read →
• CANCELLATION OF THE REQUEST FOR IMAGERY p. 154 Read →
• ACCIDENT INVESTIGATION BOARD p. 157 Read →
• MISSED OPPORTUNITY p. 159 Read →
• MISSED OPPORTUNITY p. 167 Read →
• MISSED OPPORTUNITIES p. 168 Read →
• 6.4 POSSIBILITY OF RESCUE OR REPAIR p. 174 Read →
• Elisabeth Paté-Cornell and Paul S. Fischbeck, "Risk Management p. 177 Read →
• UNDERSTANDING CAUSES p. 178 Read →
• 7.1 ORGANIZATIONAL CAUSES: INSIGHTS FROM HISTORY p. 179 Read →
• 7.2 ORGANIZATIONAL CAUSES: INSIGHTS FROM THEORY p. 181 Read →
• 7.3 ORGANIZATIONAL CAUSES: EVALUATING BEST SAFETY PRACTICES p. 183 Read →
• SUBSAFE p. 184 Read →
• ISS/SSP p. 186 Read →
• SPACE SHUTTLE SAFETY UPGRADE PROGRAM p. 189 Read →
• 7.5 ORGANIZATIONAL CAUSES: IMPACT OF p. 190 Read →
• ENGINEERING BY VIEWGRAPHS p. 192 Read →
• 7.6 FINDINGS AND RECOMMENDATIONS p. 193 Read →
• 8.1 ECHOES OF CHALLENGER p. 196 Read →
• 8.2 FAILURES OF FORESIGHT : TWO DECISION HISTORIES AND THE NORMALIZATION OF DEVIANCE p. 197 Read →
• 8.3 SYSTEM EFFECTS: THE IMPACT OF HISTORY AND POLITICS ON RISKY WORK p. 198 Read →
• UNINTENDED CONSEQUENCES Read →
• 8.5 HISTORY AS CAUSE: TWO ACCIDENTS p. 200 Read →
• 8.6 CHANGING NASAʼS ORGANIZATIONAL SYSTEM p. 203 Read →
• 9.2 MID-TERM: CONTINUING TO FLY p. 209 Read →
• 9.3 LONG-TERM: FUTURE DIRECTIONS FOR THE U.S. IN SPACE p. 210 Read →
• 10.1 PUBLIC SAFETY p. 214 Read →
• 10.2 CREW ESCAPE AND SURVIVAL p. 215 Read →
• HAS THE RIGHT p. 219 Read →
• 10.5 MAINTENANCE DOCUMENTATION Read →
• 10.6 ORBITER MAINTENANCE DOWN PERIOD/ ORBITER MAJOR MODIFICATION p. 221 Read →
• 10.7 ORBITER CORROSION p. 222 Read →
• 10.12 LEADERSHIP/MANAGERIAL TRAINING p. 225 Read →
• PART ONE – THE ACCIDENT p. 226 Read →
• APPENDIX A A.1 ACTIVATION OF THE COLUMBIA ACCIDENT INVESTIGATION BOARD p. 232 Read →
• A.2 BOARD CHARTER AND ORGANIZATION Read →
• A.3 INVESTIGATION PROCESS AND SCOPE p. 233 Read →
• A.4 BOARD POLICIES AND PROCEDURES p. 234 Read →
• A.5 INVESTIGATION INTERFACE WITH NASA p. 235 Read →
• A.6 BOARD DOCUMENTATION SYSTEM p. 236 Read →
• A.7 LIST OF PUBLIC HEARINGS p. 239 Read →
• SCOTT HUBBARD p. 241 Read →
• APPENDIX C ADVISORS TO THE CHAIR p. 244 Read →

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