STS-107 COLUMBIAby

Doug Dieker & Can Bayrak

MSA 608 – Aviation / Aerospace Accident Investigation & Safety SystemsFinal Discussion

April 2011

Overview• The Accident• Emergency Response • Investigation• Contributing Factors• Recommendations• Safety Issues• Report Deficiencies• Bibliography

2

The Accident• Before Launch Preparation

– Orbiter Prep– Flight Prep– Launch Readiness Prep– Flight Readiness Prep– Certificate of Flight Readiness

3

The Accident• Launch

– Abnormal Countdown– Wind Shear

• 57 sec. after launch during max-q

– I-Loads• 70% or less of design

– Nozzle Deflections• Booster thrust mismatch within limits

– Debris Strike• Foam separation

4

The Accident• Orbit Arrival

– Day 2• Object separation from module

– Day 5• Rotary separator 2 SPACEHAB

– Day 6• SPACEHAB reached 81 degrees• Contingency plan created

5

The Accident• Re-Entry

– Entry Interface [08:44:09 AM]– Left wing leading edge spar

• Leading edge showed abnormal strains

– 8 minutes in Re-Entry• Left wing reached 2800 0F degrees

– Crossing California• Signs of debris shed

– 11 minutes in Re-Entry• Left wing reached 3000 0F degrees

– Last transmission from commander [08:59:32 AM]

6

Emergency Response• Shuttle ETA [09:16 AM]• Shuttle contingency plan activated

– “GC Flight, GC Flight; Lock the Doors”– Established post “Challenger”– Search & Rescue initiated

• Suiting

– East Texas declared disaster area

7

Investigation• Debris Recovery

– Vital in the Accident– Widespread– Photo Presentations– Nationwide debris recovery efforts

• A helicopter crashed while searching for wreckage

8

Contributing Factors• Physical Cause• Design

– External Tank– Left Bipod Foam Loss– Combination of Factors

• Cyroingestion• Combination of Conditions

– Negligence– Foam Separation

• Findings• Orbiter Left Wing

– Foam Strike Force9

Contributing Factors• Design

– External Tank• Largest element of the Shuttle• Main Structural Component during assembly• Adhesion of foam

– Cleanly prepped surface

– Left Bipod Foam Loss– Combination of Factors

• Pre-existing defects• Different eras of parts• Foam uniformity of production• Subsurface defects

10

Contributing Factors• Cyroingestion

– Y-Joint• Liquification

– Bipod Foam Ramps• Liquid hydrogen-intertank flange

– Flash Evaporation

11

Contributing Factors• Combination of Conditions

– May be individually within limits• Wind shear, solid rocket response, liquid oxygen “sloshing”

– Each individually• Not consistent with causing accident

– Combination• Contribution to accident unknown

– Negligence– Acceptability of foam separation– Direct cause may never be understood

12

Contributing Factors• Findings

• NASA does not fully understand the mechanisms that cause foam loss on almost all flights

• No non-destructive evaluation techniques for the as-installed foam.• Foam loss from an External Tank is unrelated to the tankʼs age and to its

total pre-launch expo sure to the elements. • The Board found instances of left bipod ramp shedding on launch

previously unknown to dance.• Subsurface defects were found during the dissection of 3 other foam

bipod ramps• Foam loss occurred on over 80 percent of the 79 missions for which

imagery was available to confirm or rule out foam loss.• 30 percent of all missions lacked sufficient imagery to determine foam

loss.• Analysis of separate variables indicated that none could be identified as

the sole initiating factor of bipod foam loss. The Board concludecd that a combination of factors resulted in bipod foam loss.

13

Contributing Factors• Orbiter Left Wing

– Left Wing damage• Panels 6-10

– Past instances• 5 occasions carbide layer loss

– Findings– Foam strike force

14

Contributing Factors• Physical Cause

– Breach in Thermal Protection System• Leading edge of the orbiter’s left wing

– Foam separation• Left bipod ramp of external tank• Lower half of RCC panel 8

– Superheated air• Penetrated leading edge insulation• Weakened aluminum structure

– Aerodynamic forces• Failure of wing structure• Loss of control

15

Recommendations• Thermal Protection System

16

Recommendations• Thermal Protection System

– External Tank’s debris-shedding elimination techniques at the source

– Reinforced Carbon-Carbon (RCC) enforcement• Comprehensive testing• Investigation under debris strike• Increasing ability to sustain under re-entry dynamics• Establishing debris damage thresholds before

enforcement

– Providing spare RCC panels• ISS missions, developing space-walks to repair• Non-station missions, developing autonomous repair

capabilities

– Analysis software development for simulating such strikes

17

Recommendations• Suiting

– Depressurization resistance

– Full integration of suits to seats• Upper-body restraints enhancement

• Extreme rotational dynamics endurance

– Endurance to extreme external conditions• Very-low temperature

• Near-vacuum pressurization

• Thermal events (in-flight fire, explosions, etc.)

• Aero dynamical effects

– Ground impact resistance – Seating parachute system– Crew training

• Emphasizing on re-entry & launch

18

Recommendations• Imaging

– Upgrading imaging system– Additional imaging options

• Naval, air, etc.• At least 3 different angles

– Additional imaging options to monitor structures• External Tank (until separation)• Wings’ leading edges & RCCs

– Imaging the orbiter while in orbit– External sources can be utilized to some point

• Requires broadening public TV rights• Launch site security clearence for TV operators

– Highly dependent on technological advancements

19

Recommendations• Data Collection

– The Modular Auxiliary Data System • Should be maintained & updated frequently• Redesign to include-

– Engineering performance– Vehicle health information– Ability to be reconfigured during flight to in order to allow

certain data to be recorded

• Should transmit real-time data to mission control; not providing data for post-flight only.

– Orbiter Experiment Instrumentation• Should be renewed• Should be redesigned for a longer service life

– Increase in Orbiter’s wiring inspection frequency

20

Recommendations• Scheduling

– Flexibility for adhoc challenges– Sourcing the crew for unexpected schedule changes/delays– Flexibility in schedule in order to have enough time for a

rescue mission (‘Launch on Need missions)

• Training– Additional crew training on maintenance & repair

• Stationary missions space walks• Non-stationary missions space walks

– Mission Management Team training for unexpected challenges• Crew loss• Shuttle loss

– Enhancement in support among various departments across NASA & contractors

21

Recommendations• Organizational

– Establishment of a ‘Technical Engineering Authority’• Responsible for technical documentation, standardization, certification and all

waivers to them• a Safety Management System

– funded directly by NASA– No responsibilities towards costs or schedule

• Responsible for identifying, analyzing, controlling hazards• Responsible for mitigating operational risks• Developing technical standards• Establishment of a “non-punitive” hazard reporting system within the entire

organization• Responsible for verification of launch GO/ No-GO

– Establishment of an independent safety program/ authority to inspect & audit organizational procedures

– Reorganization of the ‘Space Shuttle Integration Office’– Submitting annual reports directly to the Congress, as part of the

budget review process22

Safety Issues• Safety Culture

– “We couldn’t have done anything about it anyway.”• Anonymous top ranked NASA manager

– “NASA had conflicting goals of cost, schedule, and safety; and unfortunately, safety lost out.”• Major General John Barry - U.S. Air Force

– “It didn’t get fixed the last time(’86, the Challenger disaster); there has to be another approach.”• Steven B. Wallace – Dir., FAA Office of Accident Investigation

– “You have to do what we did in the Apollo program. You have to plan for the worst and hope for the best; and I don’t think we are doing that.”• John Watts Young, former NASA astronaut & Columbia

commander

23

Safety Issues• Safety Culture

– “Landing unmanned probes safely on Mars and flying the next space shuttle safely do not require NASA to learn anything new -- just to stop forgetting the meticulous, courageous, no-holds-barred thinking that got us to the moon the first time.” (Oberg, 2004)

– NASA knew, immediately after the liftoff with the help of video footage and flight data that the piece of foam had come off the fuel tank, struck the left wing and damaged it (Yomiuri, 2003).

– “In the two weeks between launch and re-entry, NASA experienced a massive internal communication collapse for such astonishingly pedestrian reasons as emails that went unanswered, key personnel went on vacation, and junior staff dared not question decisions, or non-decisions, by their superiors and risk being fired.” (Fisher,2005)

24

Safety Issues• Safety Culture

– Overconfident, & self deceptive culture (CAIB, 2003).– Only 5 safety conferences were held in a 16-day mission.– U.S. Military’s surveillance telescope identification offer was rejected.– High budget related constraints

• Safety department is bound to a budget limit reserved for that Program only• Strict hierarchical budget assignments for different departments. The Safety &

Mission Assurance department does not have high priority within NASA.

– High confidentiality necessity• Lacking of an open & anonymous hazard reporting system • Dependence of departments to their selves limit exposure / communication among

other departments• Lack of an independent safety department

– Each department is for itself• There is no integration among departments’ databases• The Safety & Mission Assurance Pre-Launch Assessment Review process is not

recognized by the Space Shuttle Program (NSTS 22778).• Lacking of an integration among departments causes communication &

responsibility interruptions

25

Safety Issues• Lack of Testing

– “NASA must do better testing of all components, not just the largest systems.” - Major General John Barry; U.S. Air Force

– “NASA had not conducted a simple testing on foam that I was able to perform at my kitchen table.” – Douglas D. Osheroff; CAIB board member

– “You don't feel this can do anything. But you fire this at 500 miles an hour, and you saw it. That's when it came home to me what (½)mv2 means.” – G. Scott Hubbard, Dir. NASA Ames Research Center

26

Safety Issues• Lack of Testing

– The testing on the new bolt assemblies on the solid rocket boosters and fuel tanks, which were produced by United Space Alliance, LLC, was not done as well as it should have been (Glanz, 2003).

– The foam that hit Columbia was hundreds of times larger than anything the CRATER - a structural analysis program that Boeing has developed for its space program - had been intended to evaluate (Schwartz, 2003).

– The foam could not have done a major damage to the ceramic tiles on the underside of Columbia to threaten the mission; but NASA had very little data about how RCC, which is chosen not for strength but for its ability to withstand heat, would withstand the debris impact(Wald, 2003).

– NASA's budget for the shuttle program fell from $4.05B in ‘93 to $3.2B in ’02 (Glanz, 2003).

27

Safety Issues• Rescue or Repair Options

– Crew was not trained for a repair mission– STS-107 was not carrying related repairing sources – Tight schedule– Not enough resources to support life– Atlantis was not ready for an adhoc mission– Launch on Need (LON) Mission Program has been established

after the STS-107, Columbia disaster• STS-3xx coded missions

28

Report Deficiencies• Lack of Visual Evidence• Different investigation reports state

different causes– i.e. CAIB report do not focus on suiting issues– i.e. NASA’s own report do not focus on organizational flaws

• Widespread debris– Not all of the orbiter was recovered

• Political issues– “Shuttle program will continue” – George W. Bush

29

Bibliography• Anonymous. (2003, August 28). NASA's culture must change. The Daily Yomiuri (Tokyo), p.12. • Columbia Accident Investigation Board. (2003, August). Report Volume I. Author.• Fisher, J. (2005, July 13). NASA's cultural flaws. The Toronto Star, pp. A17. • Glanz, W. (2003, June 13). NASA discovers problem with bolts on space shuttles. The Washington Times, pp. A03. • McKenna, B. (2003, August 27). Shuttle probe blasts NASA's dysfunctional atmosphere; 'overconfident' culture sacrificed

safety to meet budgets and deadlines, report says. The Globe and Mail (Canada), pp. A9. • National Aeronautics and Space Administration (NASA). (n.d.) Columbia Crew Survival Investigation Report.

(NASA/SP-2008-565). Author.• NASA. (2006, August 23). NASA – Columbia – Home. Retrieved March/30, 2010, from

http://www.nasa.gov/columbia/home/index.html• NASA. (2009, April 13). NASA – Columbia – Media. Retrieved March/30, 2010, from

http://www.nasa.gov/columbia/media/index.html• Oberg, A. C. (2004, January 27). A year after columbia, Usa Today.• Schwartz, J. (2003, August 25). Computer program that analyzed shuttle damage was misused, engineer says. The New York

Times, pp. 9. • Schwartz, J. (2003, June 5). NASA's foam test offered A vivid lesson in kinetics. The New York Times, pp. 29. • Schwartz, J. (2003, June 14). Shuttle inquiry finds new risks. The New York Times, pp. 1.• Wald, M. L., & Schwartz, J. (2003, July 8). Test shows foam was likely cause of shuttle's loss. The New York Times, pp. 1. • Watson, T. (2005, March 21). NASA's culture still poses danger, ex-astronauts say. Usa Today.

30

Questions ??

31