Columbia Accident Investigation Board Report, Volume I

MISSED OPPORTUNITY

MISSED OPPORTUNITY

Conte explained to Rocha that the Mission Operations Directorate at Johnson did have U.S. Air Force standard services for imaging the Shuttle during Solid Rocket Booster separation and External Tank separation. Conte explained that the Orbiter would probably have to fly over Hawaii to be imaged. The Board notes that this statement illustrates an unfamiliarity with National imaging assets. Hawaii is only one of many sites where relevant assets are based. Conte asked Rocha if he wanted her to pursue such a request through Missions Operations Directorate channels. Rocha said no, because he believed Program managers would still have to support such a request. Since they had already decided that imaging of potentially damaged areas was not necessary, Rocha thought it unlikely that the Debris Assessment Team could convince them otherwise without definitive data.

Later that day, Conte and another Mission Operations Directorate representative were attending an unrelated meeting with Leroy Cain, the STS-107 ascent/entry Flight Director. At that meeting, they conveyed Rochaʼs concern to Cain and offered to help with obtaining imaging. After checking with Phil Engelauf, Cain distributed the following e-mail.

-----Original Message----- From: CAIN, LEROY E. (JSC-DA8) (NASA) Sent: Thursday, January 23, 2003 12:07 PM To: JONES, RICHARD S. (JSC-DM) (NASA); OLIVER, GREGORY T. (GREG) (JSC-DM4) (NASA); CONTE, BARBARA A. (JSC-DM) (NASA) Cc: ENGELAUF, PHILIP L. (JSC-DA8) (NASA); AUSTIN, BRYAN P. (JSC-DA8) (NASA); BECK, KELLY B. (JSC-DA8) (NASA); HANLEY, JEFFREY M. (JEFF) (JSC-DA8) (NASA); STICH, J. S. (STEVE) (JSC-DA8) (NASA) Subject: Help with debris hit

The SSP was asked directly if they had any interest/desire in requesting resources outside of NASA to view the Orbiter (ref. the wing leading edge debris concern).

They said, No. After talking to Phil, I consider it to be a dead issue.

[SSP=Space Shuttle Program]

Also on Flight Day Eight, Debris Assessment Team engineers presented their final debris trajectory estimates to their NASA, United Space Alliance, and Boeing managers. These estimates formed the basis for predicting the Orbiterʼs damaged areas as well as the extent of damage, which in turn determined the ultimate threat to the Orbiter during re-entry.

Mission Control personnel thought they should tell Commander Rick Husband and Pilot William McCool about the debris strike, not because they thought that it was worthy of the crewʼs attention but because the crew might be asked about it in an upcoming media interview. Flight Director Steve Stitch sent the following e-mail to Husband and McCool and copied other Flight Directors.

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From: STICH, J. S. (STEVE) (JSC-DA8) (NASA) Sent: Thursday, January 23, 2003 11:13 PM To: CDR; PLT Cc: BECK, KELLY B. (JSC-DA8) (NASA); ENGELAUF, PHILIP L. (JSC-DA8) (NASA); CAIN, LEROY E. (JSC-DA8)

(NASA); HANLEY, JEFFREY M. (JEFF) (JSC-DA8) (NASA); AUSTIN, BRYAN P. (JSC-DA8) (NASA) Subject: INFO: Possible PAO Event Question

Rick and Willie,

You guys are doing a fantastic job staying on the timeline and accomplishing great science. Keep up the good work and let us know if there is anything that we can do better from an MCC/POCC stand- point.

There is one item that I would like to make you aware of for the upcoming PAO event on Blue FD 10 and for future PAO events later in the mission. This item is not even worth mentioning other than wanting to make sure that you are not surprised by it in a question from a reporter.

During ascent at approximately 80 seconds, photo analysis shows that some debris from the area of the -Y ET Bipod Attach Point came loose and subsequently impacted the orbiter left wing, in the area of transition from Chine to Main Wing, creating a shower of smaller particles. The impact appears to be totally on the lower surface and no particles are seen to traverse over the upper surface of the wing. Experts have reviewed the high speed photography and there is no concern for RCC or tile damage. We have seen this same phenomenon on several other flights and there is absolutely no concern for entry.

That is all for now. It's a pleasure working with you every day.

[MCC/POCC=Mission Control Center/Payload Operations Control Center, PAO=Public Affairs Officer, FD 10=Flight Day Ten, -Y=left, ET=External Tank]

This e-mail was followed by another to the crew with an attachment of the video showing the debris impact. Husband acknowledged receipt of these messages.

Later, a NASA liaison to USSTRATCOM sent an e-mail thanking personnel for the prompt response to the imagery request. The e-mail asked that they help NASA observe "official channels" for this type of support in the future. Excerpts from this message follow.

"Let me assure you that, as of yesterday afternoon, the Shuttle was in excellent shape, mission objectives were being performed, and that there were no major debris system problems identified. The request that you received was based on a piece of debris, most likely ice or insulation from the ET, that came off shortly after launch and hit the underside of the vehicle. Even though this is not a common occurrence it is something that has happened before and is not considered to be a major problem. The one problem that this has identified is the need for some additional coordination within NASA to assure that when a request is made it is done through the official channels. The NASA/ USSTRAT (USSPACE) MOA identifies the need for this type of support and that it will be provided by USSTRAT. Procedures have been long established that identifies the Flight Dynamics Officer (for the Shuttle) and the Trajectory Operations Officer (for the International Space Station) as the POCs to work these issues with the personnel in Cheyenne Mountain. One of the primary purposes for this chain is to make sure that requests like this one does not slip through the system and spin the community up about potential problems that have not been fully vet- ted through the proper channels. Two things that you can help us with is to make sure that future requests of this sort are confirmed through the proper channels. For the Shuttle it is via CMOC to the Flight Dynamics Officer. For the International Space Station it is via CMOC to the Trajectory Operations Officer. The second request is that no resources are spent unless the request has been confirmed. These requests are not meant to diminish the responsibilities of the DDMS office or to change any previous agreements but to eliminate the confusion that can be caused by a lack of proper coordination." [ET=External Tank,

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MOA=Memorandum of Agreement, POC=Point of Contact, CMOC=Cheyenne Mountain Operations Center, DDMS=Department of Defense Manned Space Flight Support Office]

Third Debris Assessment Team Meeting

The Debris Assessment Team met for the third time Thursday afternoon to review updated impact analyses. Engineers noted that there were no alternate re-entry trajectories that the Orbiter could fly to substantially reduce heating in the general area of the foam strike. Engineers also presented final debris trajectory data that included three debris size estimates to cover the continuing uncertainty about the size of the debris. Team members were told that imaging would not be forthcoming. In the face of this denial, the team discussed whether to include a presentation slide supporting their desire for images of the potentially damaged area. Many still felt it was a valid request and wanted their concerns aired at the upcoming Mission Evaluation Room brief and then at the Mission Management Team level. Eventually, the idea of including a presentation slide about the imaging request was dropped.

Just prior to attending the third assessment meeting, tile expert Calvin Schomburg and Rodney Rocha met to discuss foam impacts from other missions. Schomburg implied that the STS-107 foam impact was in the Orbiterʼs experience base and represented only a maintenance issue. Rocha disagreed and argued about the potential for burn-through on re-entry. Calvin Schomburg stated a belief that if there was severe damage to the tiles, "nothing could be done." (See Section 6.4.) Both then joined the meeting already in progress.

According to Boeing analysts who were members of the Debris Assessment Team, Schomburg called to ask about their rationale for pursuing imagery. The Boeing analysts told him that something the size of a large cooler had hit the Orbiter at 500 miles per hour. Pressed for additional reasons and not fully understanding why their original justification was insufficient, the analysts said that at least they would know what happened if something were to go terribly wrong. The Boeing analysts next asked why they were working so hard analyzing potential damage areas if Shuttle Program management believed the damage was minor and that no safety-of-flight issues existed. Schomburg replied that the analysts were new and would learn from this exercise.

Flight Day Nine, Friday, January 24, 2003

At 7:00 a.m., Boeing and United Space Alliance contract personnel presented the Debris Assessment Teamʼs findings to Don McCormack, the Mission Evaluation Room manager. In yet another signal that working engineers and mission personnel shared a high level of concern for Columbiaʼs condition, so many engineers crowded the briefing room that it was standing room only, with people lining the hallway.

The presentation included viewgraphs that discussed the teamʼs analytical methodology and five scenarios for debris damage, each based on different estimates of debris size and impact point. A sixth scenario had not yet been completed, but early indications suggested that it would not differ significantly from the other five. Each case was presented with a general overview of transport mechanics, results from the Crater modeling, aerothermal considerations, and predicted thermal and structural effects for Columbiaʼs re-entry. The briefing focused primarily on potential damage to the tiles, not the RCC panels. (An analysis of how the poor construction of these viewgraphs effectively minimized key assumptions and uncertainties is presented in Chapter 7.)

While the team members were confident that they had conducted the analysis properly – within the limitations of the information they had – they stressed that many uncertainties remained. First, there was great uncertainty about where the debris had struck. Second, Crater, the analytical tool they used to predict the penetration depth of debris impact, was being used on a piece of debris that was 400 times larger than the standard in Boeingʼs database. (At the time, the team believed that the debris was 640 times larger.) Engineers ultimately concluded that their analysis, limited as it was, did not show that a safety-of-flight issue existed. Engineers who attended this briefing indicated a belief that management focused on the answer – that analysis proved there was no safety-of-flight issue – rather than concerns about the large uncertainties that may have undermined the analysis that provided that answer.

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At the Mission Management Teamʼs 8:00 a.m. meeting, Mission Evaluation Room manager Don McCormack verbally summarized the Debris Assessment Teamʼs 7:00 a.m. brief. It was the third topic discussed. Unlike the earlier briefing, McCormackʼs presentation did not include the Debris Assessment Teamʼs presentation charts. The Board notes that no supporting analysis or examination of minority engineering views was asked for or offered, that neither Mission Evaluation Room nor Mission Management Team members requested a technical paper of the Debris Assessment Team analysis, and that no technical questions were asked.

January 24, 2003, Mission Management Team Meeting Transcript

The following is a transcript of McCormackʼs verbal briefing to the Mission Management Team, which Linda Ham Chaired. Early in the meeting, Phil Engelauf, Chief of the Flight Directorʼs office, reported that he had made clear in an e-mail to Columbiaʼs crew that there were "no concerns" that the debris strike had caused serious damage. The Board notes that this conclusion about whether the debris strike posed a safety-of-flight issue was presented to Mission Management Team members before they discussed the debris strike damage assessment.

Engelauf: "I will say that crew did send down a note last night asking if anybody is talking about extension days or going to go with that and we sent up to the crew about a 15 second video clip of the strike just so they are armed if they get any questions at the press conferences or that sort of thing, but we made it very clear to them no, no concerns."

Linda Ham: "When is the press conference? Is it today?"

Engelauf: "Itʼs later today."

Ham: "They may get asked because the press is aware of it."

Engelauf: "The press is aware of it I know folks have asked me because the press corps at the cape have been asking…wanted to make sure they were properly…"

Ham: "Okay, back on the temperature…"

The meeting went on for another 25 minutes. Other mission-related subjects were discussed before team members returned to the debris strike.

Ham: "Go ahead, Don."

Don McCormack: "Okay. And also weʼve received the data from the systems integration guys of the potential ranges of sizes and impact angles and where it might have hit. And the guys have gone off and done an analysis, they use a tool they refer to as Crater which is their official evaluation tool to determine the potential size of the damage. So they went off and done all that work and theyʼve done thermal analysis to the areas where there may be damaged tiles. The analysis is not complete. There is one case yet that they wish to run, but kind of just jumping to the conclusion of all that, they do show that, obviously, a potential for significant tile damage here, but thermal analysis does not indicate that there is potential for a burn-through. I mean there could be localized heating damage. There is… obviously there is a lot of uncertainty in all this in terms of the size of the debris and where it hit and the angle of incidence."

Ham: "No burn through, means no catastrophic damage and the localized heating damage would mean a tile replacement?"

McCormack: "Right, it would mean possible impacts to turnaround repairs and that sort of thing, but we do not see any kind of safety of flight issue here yet in anything that weʼve looked at."

Ham: "And no safety of flight, no issue for this mission, nothing that weʼre going to do different, there may be a turnaround."

McCormack: "Right, it could potentially hit the RCC and we donʼt indicate any other possible coating damage or something, we donʼt see any issue if it hit the RCC. Although we could have some significant tile damage if we donʼt see a safety-of-flight issue."

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Ham: "What do you mean by that?"

McCormack: "Well it could be down through the … we could lose an entire tile and then the ramp into and out of that, I mean it could be a significant area of tile damage down to the SIP perhaps, so it could be a significant piece missing, but…" [SIP refers to the denser lower layers of tile to which the debris may have penetrated.]

Ham.: "It would be a turnaround issue only?"

McCormack: "Right."

(Unintelligible speaker)

At this point, tile expert Calvin Schomburg states his belief that no safety-of-flight issue exists. However, some participants listening via teleconference to the meeting are unable to hear his comments.

Ham: "Okay. Same thing you told me about the other day in my office. Weʼve seen pieces of this size before havenʼt we?"

Unknown speaker. "Hey Linda, weʼre missing part of that conversation."

Ham: "Right."

Unknown speaker: "Linda, we canʼt hear the speaker."

Ham: "He was just reiterating with Calvin that he doesnʼt believe that there is any burn-through so no safety of flight kind of issue, itʼs more of a turnaround issue similar to what weʼve had on other flights. Thatʼs it? Alright, any questions on that?"

The Board notes that when the official minutes of the January 24 Mission Management Team were produced and distributed, there was no mention of the debris strike. These minutes were approved and signed by Frank Moreno, STS-107 Lead Payload Integration Manager, and Linda Ham. For anyone not present at the January 24 Mission Management Team who was relying on the minutes to update them on key issues, they would have read nothing about the debris-strike discussions between Don McCormack and Linda Ham.

A subsequent 8:59 a.m. Mission Evaluation Room console log entry follows.

"MMT Summary…McCormack also summarized the debris assessment. Bottom line is that there appears to be no safety of flight issue, but good chance of turnaround impact to repair tile damage." [MMT=Mission Management Team]

Flight Day 10 through 16, Saturday through Friday, January 25 through 31, 2003

Although "no safety-of-flight issue" had officially been noted in the Mission Evaluation Room log, the Debris Assessment Team was still working on parts of its analysis of potential damage to the wing and main landing gear door. On Sunday, January 26, Rodney Rocha spoke with a Boeing thermal analyst and a Boeing stress analyst by telephone to express his concern about the Debris Assessment Teamʼs overall analysis, as well as the remaining work on the main landing gear door analysis. After the Boeing engineers stated their confidence with their analyses, Rocha became more comfortable with the damage assessment and sent the following e-mail to his management.

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From: ROCHA, ALAN R. (RODNEY) (JSC-ES2) (NASA) Sent: Sunday, January 26, 2003 7:45 PM To: SHACK, PAUL E. (JSC-EA42) (NASA); MCCORMACK, DONALD L. (DON) (JSC-MV6) (NASA); OUELLETTE, FRED A. (JSC-MV6) (NASA) Cc: ROGERS, JOSEPH E. (JOE) (JSC-ES2) (NASA); GALBREATH, GREGORY F. (GREG) (JSC-ES2) (NASA); JACOBS,

JEREMY B. (JSC-ES4) (NASA); SERIALE-GRUSH, JOYCE M. (JSC-EA) (NASA); KRAMER, JULIE A. (JSC-EA4) (NASA); CURRY, DONALD M. (JSC-ES3) (NASA); KOWAL, T. J. (JOHN) (JSC-ES3) (NASA); RICKMAN, STEVEN L. (JSC-ES3) (NASA); SCHOMBURG, CALVIN (JSC-EA) (NASA); CAMPBELL, CARLISLE C., JR (JSC-ES2) (NASA)

Subject: STS-107 Wing Debris Impact on Ascent: Final analysis case completed

As you recall from Friday's briefing to the MER, there remained open work to assess analytically predicted impact damage to the wing underside in the region of the main landing gear door. This area was considered a low probability hit area by the image analysis teams, but they admitted a debris strike here could not be ruled out.

As with the other analyses performed and reported on Friday, this assessment by the Boeing multi- technical discipline engineering teams also employed the system integration's dispersed trajectories followed by serial results from the Crater damage prediction tool, thermal analysis, and stress analysis. It was reviewed and accepted by the ES-DCE (R. Rocha) by Sunday morning, Jan. 26. The case is defined by a large area gouge about 7 inch wide and about 30 inch long with sloped sides like a crater, and reaching down to the densified layer of the TPS.

SUMMARY: Though this case predicted some higher temperatures at the outer layer of the honeycomb aluminum face sheet and subsequent debonding of the sheet, there is no predicted burn-through of the door, no breeching of the thermal and gas seals, nor is there door structural deformation or thermal warpage to open the seal to hot plasma intrusion. Though degradation of the TPS and door structure is likely (if the impact occurred here), there is no safety of flight (entry, descent, landing) issue.

Note to Don M. and Fred O.: On Friday I believe the MER was thoroughly briefed and it was clear that open work remained (viz., the case summarized above), the message of open work was not clearly given, in my opinion, to Linda Ham at the MMT. I believe we left her the impression that engineering assessments and cases were all finished and we could state with finality no safety of flight issues or questions remaining. This very serious case could not be ruled out and it was a very good thing we carried it through to a finish.

Rodney Rocha (ES2)

• Division Shuttle Chief Engineer (DCE), ES-Structural Engineering Division

• Chair, Space Shuttle Loads & Dynamics Panel

[MER=Mission Evaluation Room, ES-DCE=Structural Engineering-Division Shuttle Chief Engineer, TPS=Thermal Protection System]

In response to this e-mail, Don McCormack told Rocha that he would make sure to correct Linda Hamʼs possible misconception that the Debris Assessment Teamʼs analysis was finished as of the briefing to the Mission Management Team. McCormack informed Ham at the next Mission Management Team meeting on January 27, that the damage assessment had in fact been ongoing and that their final conclusion was that no safety-of-flight issue existed. The debris strike, in the official estimation of the Debris Assessment Team, amounted to only a post-landing turn-around maintenance issue.

On Monday morning, January 27, Doug Drewry, a structural engineering manager from Johnson Space Center, summoned several Johnson engineers and Rocha to his office and asked them if they all agreed with the completed analyses and with the conclusion that no safety-of-flight issues existed. Although all participants agreed with that conclusion, they also knew that the Debris Assessment Team members and most structural engineers at Johnson still wanted images of Columbiaʼs left wing but had given up trying to make that desire fit the "mandatory" requirement that Shuttle management had set.

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Langley Research Center

Although the Debris Analysis Team had completed its analysis and rendered a "no safety-of-flight" verdict, concern persisted among engineers elsewhere at NASA as they learned about the debris strike and potential damage. On Monday, January 27, Carlisle Campbell, the design engineer responsible for landing gear/tires/brakes at Johnson Space Center forwarded Rodney Rochaʼs January 26, e-mail to Bob Daugherty, an engineer at Langley Research Center who specialized in landing gear design. Engineers at Langley and Ames Research Center and Johnson Space Center did not entertain the possibility of Columbia breaking up during re-entry, but rather focused on the idea that landing might not be safe, and that the crew might need to "ditch" the vehicle (crash land in water) or be prepared to land with damaged landing gear.

Campbell initially contacted Daugherty to ask his opinion of the arguments used to declare the debris strike "not a safety-of-flight issue." Campbell commented that someone had brought up worst-case scenarios in which a breach in the main landing gear door causes two tires to go flat. To help Daugherty understand the problem, Campbell forwarded him e-mails, briefing slides, and film clips from the debris damage analysis.

Both engineers felt that the potential ramifications of landing with two flat tires had not been sufficiently explored. They discussed using Shuttle simulator facilities at Ames Research Center to simulate a landing with two flat tires, but initially ruled it out because there was no formal request from the Mission Management Team to work the problem. Because astronauts were training in the Ames simulation facility, the two engineers looked into conducting the simulations after hours. Daugherty contacted his management on Tuesday, January 28, to update them on the plan for after-hours simulations. He reviewed previous data runs, current simulation results, and prepared scenarios that could result from main landing gear problems.

The simulated landings with two flat tires that Daugherty eventually conducted indicated that it was a survivable but very serious malfunction. Of the various scenarios he prepared, Daugherty shared the most unfavorable only with his management and selected Johnson Space Center engineers. In contrast, his favorable simulation results were forwarded to a wider Johnson audience for review, including Rodney Rocha and other Debris Assessment Team members. The Board is disappointed that Daughertyʼs favorable scenarios received a wider distribution than his discovery of a potentially serious malfunction, and also does not approve of the reticence that he and his managers displayed in not notifying the Mission Management Team of their concerns or his assumption that they could not displace astronauts who were training in the Ames simulator.

At 4:36 p.m. on Monday, January 27, Daugherty sent the following to Campbell.

-----Original Message----- From: Robert H. Daugherty Sent: Monday, January 27, 2003 3:35 PM To: CAMPBELL, CARLISLE C., JR (JSC-ES2) (NASA) Subject: Video you sent

WOW!!! I bet there are a few pucker strings pulled tight around there! Thinking about a belly landing versus bailout...... (I would say that if there is a question about main gear well burn thru that its crazy to even hit the deploy gear button...the reason being that you might have failed the wheels since they are aluminum..they will fail before the tire heating/pressure makes them fail..and you will send debris all over the wheel well making it a possibility that the gear would not even deploy due to ancillary damage...300 feet is the wrong altitude to find out you have one gear down and the other not down...you're dead in that case) Think about the pitch-down moment for a belly landing when hitting not the main gear but the trailing edge of the wing or body flap when landing gear up...even if you come in fast and at slightly less pitch attitude...the nose slapdown with that pitching moment arm seems to me to be pretty scary...so much so that I would bail out before I would let a loved one land like that. My two cents. See ya, Bob

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The following reply from Campbell to Daugherty was sent at 4:49 p.m.

-----Original Message----- From: "CAMPBELL, CARLISLE C., JR (JSC-ES2) (NASA)" To: "'Bob Daugherty'" Subject: FW: Video you sent Date: Mon, 27 Jan 2003 15:59:53 -0600 X-Mailer: ßInternet Mail Service (5.5.2653.19)

Thanks. That's why they need to get all the facts in early on--such as look at impact damage from the spy telescope. Even then, we may not know the real effect of the damage.

The LaRC ditching model tests 20 some years ago showed that the Orbiter was the best ditching shape that they had ever tested, of many. But, our structures people have said that if we ditch we would blow such big holes in the lower panels that the orbiter might break up. Anyway, they refuse to even consider water ditching any more--I still have the test results[ Bailout seems best.

[LaRC=Langley Research Center]

On the next day, Tuesday, Daugherty sent the following to Campbell.

-----Original Message----- From: Robert H. Daugherty Sent: Tuesday, January 28, 2003 12:39 PM To: CAMPBELL, CARLISLE C., JR (JSC-ES2) (NASA) Subject: Tile Damage

Any more activity today on the tile damage or are people just relegated to crossing their fingers and hoping for the best? See ya, Bob

Campbellʼs reply:

-----Original Message----- From: "CAMPBELL, CARLISLE C., JR (JSC-ES2) (NASA)" To: "'Robert H. Daugherty'" Subject: RE: Tile Damage Date: Tue, 28 Jan 2003 13:29:58 -0600 X-Mailer: Internet Mail Service (5.5.2653.19)

I have not heard anything new. I'll let you know if I do.

CCC

Carlisle Campbell sent the following e-mail to Johnson Space Center engineering managers on January 31.

"In order to alleviate concerns regarding the worst case scenario which could potentially be caused by the debris impact under the Orbiterʼs left wing during launch, EG conducted some landing simulations on the Ames Vertical Motion Simulator which tested the ability of the crew and vehicle to survive a condition where two main gear tires are deflated before landing. The results, although limited, showed that this condition is controllable, including the nose slap down rates. These results may give MOD a different decision path should this scenario become a reality. Previous opinions were that bailout was the only answer." [EG=Aeroscience and Flight Mechanics Division, MOD=Mission Operations Directorate]

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In the Mission Evaluation Room, a safety representative from Science Applications International Corporation, NASAʼs contract safety company, made a log entry at the Safety and Quality Assurance console on January 28, at 12:15 p.m. It was only the second mention of the debris strike in the safety console log during the mission (the first was also minor).

"[MCC SAIC] called asking if any SR&QA people were involved in the decision to say that the ascent debris hit (left wing) is safe. [SAIC engineer] has indeed been involved in the analysis and stated that he concurs with the analysis. Details about the debris hit are found in the Flight Day 12 MER Manager and our Daily Report." [MCC=Mission Control Center,

SAIC=Science Applications International Corporation, SR&QA=Safety, Reliability, and Quality Assurance, MER=Mission Evaluation Room]