ACCIDENT INVESTIGATION BOARD

We can and have generated parametric impact zone characterizations for many areas of the Orbiter for a few of our more typical ET foam loss areas. Of course, the impact/damage significance is always a function of debris size and density, impact velocity, and impact angle--these latter 2 being a function

¶[continued from

of the previous flight page] time at which the ET foam becomes debris. For STS-107 specifically, we have generated

this info and provided it to Orbiter. Of course, even this is based on the ASSUMPTION that the location and size of the debris is the same as occurred on STS-112------this cannot be verified until we receive the on-board ET separation photo evidence post Orbiter landing. We are requesting that this be expedited. I have the STS-107 Orbiter impact map based on the assumptions noted herein being sent down to you. Rod is in a review with Orbiter on this info right now.

¶[SSP=Space Shuttle Program, ET=External Tank]

¶The Board notes that these e-mail exchanges indicate that senior Mission Management Team managers, including the Shuttle Program Manager, Mission Management Team Chair, head of Space Shuttle Systems Integration, and a Shuttle tile expert, correctly identified the technical bounds of the foam strike problem and its potential seriousness. Mission managers understood that the relevant question was not whether foam posed a safety-of-flight issue – it did – but rather whether the observed foam strike contained sufficient kinetic energy to cause damage that could lead to a burn-through. Here, all the key managers were asking the right question and admitting the danger. They even identified RCC as a critical impact zone. Yet little follow- through occurred with either the request for imagery or the Debris Assessment Team analysis. (See Section 3.4 and 3.6 for details on the kinetics of foam strikes.)

¶A Mission Evaluation Room log entry at 10:37 a.m. records the decision not to seek imaging of Columbiaʼs left wing.

¶"USA Program Manager/Loren Shriver, NASA Manager, Program Integration/Linda Ham,

¶& NASA SSVEO/Ralph Roe have stated that there is no need for the Air Force to take a look at the vehicle." [USA=United Space Alliance, SSVEO=Space Shuttle Vehicle Engineering Office]

¶At 11:22 a.m., Debris Assessment Team Co-Chair Pam Madera sent an e-mail to team members setting the agenda for the teamʼs second formal meeting that afternoon that included:

¶"… Discussion on Need/Rationale for Mandatory Viewing of damage site (All)…"

¶Earlier e-mail agenda wording did not include "Need/Rationale for Mandatory" wording as listed here, which indicates that Madera knew of managementʼs decision to not seek images of Columbiaʼs left wing and anticipated having to articulate a "mandatory" rationale to reverse that decision. In fact, a United Space Alliance manager had informed Madera that imagery would be sought only if the request was a "mandatory need." Twenty-three minutes later, an e-mail from Paul Shack to Rodney Rocha, who the day before had carried forward the Debris Assessment Teamʼs request for imaging, stated the following.

¶"… FYI, According to the MER, Ralph Roe has told program that Orbiter is not requesting any outside imaging help …" [MER=Mission Evaluation Room]

¶Earlier that morning, Ralph Roeʼs deputy manager, Trish Petite, had separate conversations with Paul Shack and tile expert Calvin Schomburg. In those conversations, Petite noted that an analysis of potential damage was in progress, and they should wait to see what the analysis showed before asking for imagery. Schomburg, though aware of the Debris Assessment Teamʼs request for imaging, told Shack and Petite that he believed on-orbit imaging of potentially damaged areas was not necessary.

¶As the morning wore on, Debris Assessment Team engineers, Shuttle Program management, and other NASA personnel exchanged e-mail. Most messages centered on technical matters to be discussed at the Debris Assessment Teamʼs afternoon meeting, including debris density, computer-aided design models, and the highest angle of incidence to use for a particular material property. One e-mail from Rocha to his managers and other Johnson engineers at 11:19 a.m., included the following.

¶"… there are good scenarios (acceptable and minimal damage) to horrible ones, depending on the extent of the damage incurred by the wing and location. The most critical locations seem to be the 1191 wing spar region, the main landing gear door seal, and the RCC panels. We do not know yet the exact extent or nature of the damage without being provided better images, and without such all the high powered analyses and assessments in work will retain significant uncertainties …"

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¶Second Debris Assessment Team Meeting

¶Some but not all of the engineers attending the Debris Assessment Teamʼs second meeting had learned that the Shuttle Program was not pursuing imaging of potentially damaged areas. What team members did not realize was the Shuttle Programʼs decision not to seek on-orbit imagery was not necessarily a direct and final response to their request. Rather, the "no" was partly in response to the Kennedy Space Center action initiated by United Space Alliance engineers and managers and finally by Wayne Hale.

¶Not knowing that this was the case, Debris Assessment Team members speculated as to why their request was rejected and whether their analysis was worth pursuing without new imagery. Discussion then moved on to whether the Debris Assessment Team had a "mandatory need" for Department of Defense imaging. Most team members, when asked by the Board what "mandatory need" meant, replied with a shrug of their shoulders. They believed the need for imagery was obvious: without better pictures, engineers would be unable to make reliable predictions of the depth and area of damage caused by a foam strike that was outside of the experience base. However, team members concluded that although their need was important, they could not cite a "mandatory" requirement for the request. Analysts on the Debris Assessment Team were in the unenviable position of wanting images to more accurately assess damage while simultaneously needing to prove to Program managers, as a result of their assessment, that there was a need for images in the first place.

¶After the meeting adjourned, Rocha read the 11:45 a.m. e-mail from Paul Shack, which said that the Orbiter Project was not requesting any outside imaging help. Rocha called Shack to ask if Shackʼs boss, Johnson Space Center engineering director Frank Benz, knew about the request. Rocha then sent several e-mails consisting of questions about the ongoing analyses and details on the Shuttle Programʼs cancellation of the imaging request. An e-mail that he did not send but instead printed out and shared with a colleague follows.

¶"In my humble technical opinion, this is the wrong (and bordering on irresponsible) answer from the SSP and Orbiter not to request additional imaging help from any outside source. I must emphasize (again) that severe enough damage (3 or 4 multiple tiles knocked out down to the densification layer) combined with the heating and resulting damage to the underlying structure at the most critical location (viz., MLG door/wheels/tires/hydraulics or the X1191 spar cap) could present potentially grave hazards. The engineering team will admit it might not achieve definitive high confidence answers without additional images, but, without action to request help to clarify the damage visually, we will guarantee it will not. Can we talk to Frank Benz before Fridayʼs MMT? Remember the NASA safety posters everywhere around stating, ʻIf itʼs not safe, say soʼ? Yes, itʼs that serious." [SSP=Space

¶Shuttle Program, MLG=Main Landing Gear, MMT=Mission Management Team]

¶When asked why he did not send this e-mail, Rocha replied that he did not want to jump the chain of command. Having already raised the need to have the Orbiter imaged with Shack, he would defer to managementʼs judgment on obtaining imagery.

¶Even after the imagery request had been cancelled by Program management, engineers in the Debris Assessment Team and Mission Control continued to analyze the foam strike. A structural engineer in the Mechanical, Maintenance, Arm and Crew Systems sent an e-mail to a flight dynamics engineer that stated:

¶"There is lots of speculation as to extent of the damage, and we could get a burn through into the wheel well upon entry."

¶Less than an hour later, at 6:09 p.m., a Mission Evaluation Room Console log entry stated the following.

¶"MMACS is trying to view a Quicktime movie on the debris impact but doesnʼt have Quicktime software on his console. He needs either an avi, mpeg file or a vhs tape. He is asking us for help." [MMACS=Mechanical, Maintenance, Arm and Crew Systems]

158

¶The controller at the Mechanical, Maintenance, Arm and Crew Systems console would be among the first in Mission Control to see indications of burn-through during Columbiaʼs re-entry on the morning of February 1. This log entry also indicates that Mission Control personnel were aware of the strike.

¶Flight Day Eight, Thursday, January 23, 2003

¶The morning after Shuttle Program Management decided not to pursue on-orbit imagery, Rodney Rocha received a return call from Mission Operations Directorate representative Barbara Conte to discuss what kinds of imaging capabilities were available for STS-107.