PART TWO: WHY THE ACCIDENT OCCURRED

¶Part Two, "Why the Accident Occurred," examines NASAʼs organizational, historical, and cultural factors, as well as how these factors contributed to the accident.

¶As in Part One, Part Two begins with history. Chapter 5 examines the post-Challenger history of NASA and its Human Space Flight Program. A summary of the relevant portions of the Challenger investigation recommendations is presented, followed by a review of NASA budgets to indicate how committed the nation is to supporting human space flight, and within the NASA budget we look at how the Space Shuttle Program has fared. Next, organizational and management history, such as shifting management systems and locations, are reviewed.

¶Chapter 6 documents management performance related to Columbia to establish events analyzed in later chapters. The chapter begins with a review of the history of foam strikes on the Orbiter to determine how Space Shuttle Program managers rationalized the danger from repeated strikes on the Orbiterʼs Thermal Protection System. Next is an explanation of the intense pressure the program was under to stay on schedule, driven largely by the self-imposed requirement to complete the International Space Station. Chapter 6 then relates in detail the effort by some NASA engineers to obtain additional imagery of Columbia to determine if the foam strike had damaged the Orbiter, and how management dealt with that effort.

¶In Chapter 7, the Board presents its view that NASAʼs organizational culture had as much to do with this accident as foam did. By examining safety history, organizational theory, best business practices, and current safety failures, the report notes that only significant structural changes to NASAʼs organizational curlture will enable it to succeed.

¶This chapter measures the Shuttle Programʼs practices against this organizational context and finds them wanting. The Board concludes that NASAʼs current organization does not provide effective checks and balances, does not have an independant safety program, and has not demonstrated the characteristics of a learning organization. Chapter 7 provides recommendations for adjustments in organizational culture.

¶Chapter 8, the final chapter in Part Two, draws from the previous chapters on history, budgets, culture, organization, and safety practices, and analyzes how all these factors contributed to this accident. The chapter opens with "echoes of Challenger" that compares the two accidents. This chapter captures the Boardʼs views of the need to adjust management to enhance safety margins in Shuttle operations, and reaffirms the Boardʼs position that without these changes, we have no confidence that other "corrective actions" will improve the safety of Shuttle operations. The changes we recommend will be difficult to accomplish – and will be internally resisted.

PART THREE: A LOOK AHEAD

¶Part Three summarizes the Boardʼs conclusions on what needs to be done to resume our journey into space, lists significant observations the Board made that are unrelated to the accident but should be recorded, and provides a summary of the Boardʼs recommendations.

¶In Chapter 9, the Board first reviews its short-term recommendations. These return-to-flight recommendations are the minimum that must be done to essentially fix the problems that were identified by this accident. Next, the report discusses what needs to be done to operate the Shuttle in the mid-term,³³ See John M. Logsdon, "The Space Shuttle Program: A Policy Failure?" Report, 1985. Science, May 30, 1986 (Vol. 232), pp. 1099-1105 for an account of this 14 The quote is from page 2 of the We Deliver brochure, reproduced in decision process. Most of the information and quotes in this section are Exploring the Unknown Volume IV, p. 423. taken from this article. 15 NASA Johnson Space Center, "Technology Influences on the SpaceShow full note to 15 years. Based on NASAʼs history of ignoring external recommendations, or making improvements that atrophy with time, the Board has no confidence that the Space Shuttle can be safely operated for more than a few years based solely on renewed post-accident vigilance.

¶Chapter 9 then outlines the management system changes the Board feels are necessary to safely operate the Shuttle in the mid-term. These changes separate the management of scheduling and budgets from technical specification authority, build a capability of systems integration, and establish and provide the resources for an independent safety and mission assurance organization that has supervisory authority. The third part of the chapter discusses the poor record this nation has, in the Boardʼs view, of developing either a complement to or a replacement for the Space Shuttle. The report is critical of several bodies in the U.S. government that share responsibility for this situation, and expresses an opinion on how to proceed from here, but does not suggest what the next vehicle should look like.

¶Chapter 10 contains findings, observations, and recommendations that the Board developed over the course of this extensive investigation that are not directly related to the accident but should prove helpful to NASA.

¶Chapter 11 is a compilation of all the recommendations in the previous chapters.

PART FOUR: APPENDICES

¶Part Four of the report by the Columbia Accident Investigation Board contains material relevant to this volume organized in appendices. Additional, stand-alone volumes will contain more reference, background, and analysis ma- This Earth view of the Sinai Peninsula, Red Sea, Egypt, Nile River, terials. and the Mediterranean was taken from Columbia during STS-107.

AN INTRODUCTION TO THE SPACE SHUTTLE

¶The Space Shuttle is one of the most complex machines ever devised. Its main elements – the Orbiter, Space Shuttle Main Engines, External Tank, and Solid Rocket Boosters – are assembled from more than 2.5 million parts, 230 miles of wire, 1,060 valves, and 1,440 circuit breakers. Weighing approximately 4.5 million- pounds at launch, the Space Shuttle accelerates to an orbital velocity of 17,500 miles per hour – 25 times faster than the speed of sound – in just over eight minutes. Once on orbit, the Orbiter must protect its crew from the vacuum of space while enabling astronauts to conduct scientific research, deploy and service satellites, and assemble the International Space Station. At the end of its mission, the Shuttle uses the Earthʼs atmosphere as a brake to decelerate from orbital velocity to a safe landing at 220 miles per hour, dissipating in the process all the energy it gained on its way into orbit.