ENDNOTES FOR CHAPTER 4

¶The citations that contain a reference to "CAIB document" with CAB or

¶CTF followed by seven to eleven digits, such as CAB001-0010, refer to a document in the Columbia Accident Investigation Board database maintained by the Department of Justice and archived at the National Archives.

¶SRB Forward Separation Bolt Test Plan, Document Number 90ENG00XX, April 2, 2003. CAIB document CTF044-62496260.²² Guidelines per NASA Policy Guideline 8621.

¶Cynthia Furse and Randy Haupt, "Down to the Wire," in the online version of the IEEE Spectrum magazine, accessed at http:// www.spectrum.ieee.org/WEBONLY/publicfeature/feb01/wire.html on 2

¶August 2002.

¶Boeing Inspection Report, OV-102 J3, V30/V31 (Wire) Inspection Report,

¶September 1999-February 2001. CAIB document CTF070-34793501.

¶Boeing briefing, "Arc Tracking Separation of Critical Wiring Redundancy

¶Violations", present to NASA by Joe Daileda and Bill Crawford, April 18,

CAIB document CAB033-43774435.

¶E-mail message from Jim Feeley, Lockheed Martin, Michoud Assembly

¶Facility, April 24, 2003. This External Tank (ET-93) was originally mated to the Solid Rocket Boosters and bipod struts in anticipation of an earlier launch date for mission STS-107. Since Space Station missions require the use of a Super Light Weight Tank, ET-93 (which is a Light Weight

¶Tank) had to be de-mated from the Solid Rocket Boosters so that they could be mated to such a Super Light Weight Tank. The mating of the bipod struts to ET-93 was performed in anticipation of an Orbiter mate.

¶Once STS-107 was delayed and ET-93 had to be de-mated from the Solid

¶Rocket Boosters, the bipod struts were also de-mated, since they are not designed to be attached to the External Tank during subsequent Solid

¶Rocket Booster de-mate/mate operations.⁶⁶ Quoted in Jenkins, Space Shuttle, p. 171. Press, 1996). 7 18 Memorandum from J. Fletcher to J. Rose, Special Assistant to the See John M. Logsdon, "Return to Flight: Richard H. Truly and the President, November 22, 1971; Logsdon, John, "The Space Shuttle Recovery from the Challenger Accident," in Pamela E. Mack, editor, Program: A Policy Failure?" Science, May 30, 1986, Volume 232, pp. From Engineering to Big Science: The NACA and NASA Collier Trophy 1099-1105. Research Project Winners, NASA SP-4219 (Washington: GovernmentShow full note

¶"Production Info – Splinter Meeting," presented at Michoud Assembly

¶Facility, March 13, 2002. TSPB ET-93-ST-003, "Bipod Strut Removal,"

¶August 1, 2002. 7

¶PR ET-93-TS-00073, "There Is An Area Of Crushed Foam From The

¶Installation Of The –Y Bipod," August 8, 2002.

¶"Crushed Foam Testing." CAIB document CTF059-10561058.⁹⁹ R. J. Gomex et al, "STS-107 Foam Transport Final Report," NSNS- 60506, August 2003. 84 Report Volume I August 2003

¶PR ET-93-TS-00073, "There Is An Area Of Crushed Foam From The

¶Installation Of The –Y Bipod," August 8, 2002; Meeting with John Blue,

¶USA Engineer, Kennedy Space Center, March 10, 2003.¹⁰¹⁰ The civil aviation study indicates that the risk to groundlings is significantly 25 Julie Kramer, et al., "Minutes from CAIB / Engineering Meeting to higher in the vicinity of an airport. The average annual risk of fatality Discuss CAIB Action / Request for Information B1-000193," April 24, within 0.2 miles of a busy (top 100) airport is about 1 in a million. 2003. CAIB document CTF042-00930095.

¶Lockheed Martin drawing 80911019109-509, "BIPOD INSTL,ET/

ORB,FWD"

¶"Crushed Foam Testing." CAIB document CTF059-10561058.¹²¹² Howard E. McCurdy, Inside NASA: High Technology and Organizational 27 Demingʼs management philosophy was not the only new notion that Change in the U.S. Space Program (Baltimore: The Johns Hopkins Goldin attempted to apply to NASA. He was also an advocate of the University Press, 1993), p. 24. "Total Quality Management" approach and other modern management 13 schemes. Trying to adapt to these various management theories was a Garry D. Brewer, "Perfect Places: NASA as an Idealized Institution," in Radford Byerly, Jr., ed., Space Policy Reconsidered (Boulder, CO: source of some stress. Westview Press, 1989), p. 158. Brewer, when he wrote these words, 28 For a discussion of Goldinʼs approach, see Howard McCurdy, Faster, was a professor of organizational behavior at Yale University with no Better, Cheaper: Low-Cost Innovation in the U.S. Space Program prior exposure to NASA. For first-hand discussions of NASAʼs Apollo-era (Baltimore: The Johns Hopkins University Press, 2001). It is worth noting organizational culture, see Christopher Kraft, Flight: My Life in Mission that while the "faster, better, cheaper" approach led to many more Control (New York: E.P. Dutton, 2001); Gene Kranz, Failure is Not an NASA robotic missions being launched after 1992, not all of those Option: Mission Control from Mercury to Apollo 13 (New York: Simon & missions were successful. In particular, there were two embarrassing Schuster, 2000); and Thomas J. Kelly, Moon Lander: How We Developed failures of Mars missions in 1999. the Apollo Lunar Module (Washington: Smithsonian Institution Press, 29 2001). Lambright, Transforming Government, provides an early but 14 comprehensive evaluation of the Goldin record. The quote is from p. Brewer, "Perfect Places," pp. 159-165. 28.Show full note

¶Minutes of Orbiter Structures Telecon meeting, June 19, 2001, held with

¶NASA, KSC, USA, JSC, BNA-Downey, Huntington Beach and Palmdale.

¶CAIB document CAB033-38743888. 13

¶NASA Report NSTS-37398. 14

¶Standard Operating Procedure, Foreign Object Debris (FOD) Reporting,

¶Revision A, Document Number SOP-O-0801-035, October 1, 2002,

¶United Space Alliance, Kennedy Space Center, pg. 3.¹⁵¹⁵ As NASA human space flight personnel began to become closely 30 Goldin is quoted in Bill Harwood, "Pace of Cuts Fuels Concerns About involved with their counterparts in the Russian space program after Shuttle," Space News, December 19-25, 1994, p. 1. 1992, there was grudging acceptance that Russian human space flight 31 personnel were also skilled in their work, although they carried it out McCurdy, Faster, Better, Cheaper. rather differently than did NASA. Report Volume I August 2003 119Show full note

¶Ibid, pg. 2. 16

¶"An effective FOD prevention program identifies potential problems, corrects negative factors, provides awareness, effective employee training, and uses industry "lessons learned" for continued improvement.

¶There is no mention of Processing Debris, but the guidance does address potential Foreign Object Damage and Foreign Object Debris. While

¶NASA has done a good job of complying with almost every area of this guideline, the document addresses Foreign Object investigations in a singular sense: "All incidents of actual or potential FOD should be reported and investigated. These reports should be directed to the FOD

¶Focal Point who should perform tracking and trending analysis. The focal point should also assure all affected personnel are aware of all potential

¶(near mishap) and actual FOD reports to facilitate feedback (ʻlessons learnedʼ)." 17

¶Space Flight Operations Contract, Performance Measurement System

¶Reports for January 2003, February 2003, USA004840, issue 014, contract NAS9-2000.