"After almost seven months of investigation, the team reached findings and recommendations designed to significantly reduce the risk of further accidents. Our goal was to improve the safety of the shuttles in many ways, not only by fixing the specific malfunctions that caused the loss of the spacecraft and its crew. With such a trend, the team carried out not only an investigation of what happened to Columbia, but also to upgrade the safety of the entire shuttle program. Most of the efforts of the members of the investigation committee were made with an open mind. Of necessity, the safety upgrade is done according to public demand. "
In their memory
Rick D. The husband, commander
William C. McCall - pilot
Michael P. Anderson - cargo commander
David M. Brown - Mission Specialist
Kalpana Chawla – Mission Specialist
Laurel Blair Salton Clark - Mission Specialist
Ilan Ramon - cargo expert
Jules F. Mayer - the pilot of the helicopter that crashed while searching for the fragments
Charles Crank - an expert in locating fragments from the air.
The reason for research and discovery is not a choice we chose, it is a desire written in the human heart. We found the best among us, sent them to the unmanned darkness, and prayed for their return. They came in peace for all men and all humanity is their debt.
President Bush, February 4, 2003-08-26
introduction:
For all those who are inspired by space flights, and for the nation where powered flight was first achieved, 2003 was the year many people expected to celebrate on December 17th - the centenary of the Wright brothers' first flight. However, 2003 began instead with a disaster of wonderful people being suddenly taken from us and a severe loss. On February 1, the space shuttle Columbia was destroyed in a disaster that claimed the lives of all seven crew members
While the February 1 disaster was an occasion for mourning, the efforts made should also be a source of national pride. NASA kept the nation updated non-stop on any information that became available. The Columbia disaster investigation team was established within two hours of losing contact with the spacecraft, according to a procedure established by NASA after the Challenger disaster 17 years earlier.
Since the disaster, everyone who was close to the investigative committee felt that we were honoring their legacy. Like them, our mission was also a journey of discovery. We came to find out the conditions that caused the tragic result in order to receive the lesson that one must ensure that the nation's space program comes out stronger and safer. If these lessons are indeed learned then the Columbia team will be making a contribution to the effort that each of them valued so much.
After nearly seven months of investigation, the team reached findings and recommendations designed to significantly reduce the risk of further accidents.
Our goal was to improve the safety of the shuttles in many ways, not only by fixing the specific malfunctions that caused the loss of the spacecraft and its crew. With such a trend, the team carried out not only an investigation of what happened to Columbia, but also to upgrade the safety of the entire shuttle program. Most of the efforts of the members of the investigation committee were made with an open mind. Of necessity, the safety upgrade is done according to public demand.
In order to understand the findings and recommendations in this report, it is important to appreciate the way in which the committee looked at this accident. Our view is that complex systems always fail in complex ways, and we believe it would be wrong to reduce the complexities and vulnerabilities that these systems always have through simple explanations. Too often, accident investigators blame the failure only on the last step in a complex process, when a more comprehensive understanding of the process can reveal that an earlier event was just as guilty of the disaster and may have contributed even more. In the opinion of the committee members, until the technical, organizational and cultural recommendations in this report are implemented, very little will be achieved to reduce the risk of a similar accident occurring again.
From our point of view, the members of the investigative committee declare themselves independent and accountable to the general public, the White House, Congress, the astronauts and their families, and NASA. With the support of these parties, the members of the investigation committee decided to expand the scope of the accident investigation to a much more far-reaching examination of NASA's performance in the operation of the shuttle fleet. We investigated the impact of NASA's corporate history with an emphasis on shuttle safety, as well as the role of public expectations and policy decision makers.
In this process, the team identified several relevant factors, which we divided into three categories:
1. Physical malfunctions that led directly to the destruction of Columbia
2. A weakness all along the line, looked for in NASA's history and organization that might have led the way to disaster.
3. Additional significant observations were made during the investigation, but may not have directly caused the disaster, but if they remain unchanged any of these factors may result in the loss of another ferry in the future.
To create the credibility of the findings and recommendations, the committee considered scientific and engineering principles. We consulted with the authorities not only in the mechanical fields but also experts in organizational theories and experts in the practice of organizations. These specialization areas of authority include risk management, safety engineering, and examination of practice studies carried out in large organizations dealing with risks, and which are known for their reliability. Among these organizations - nuclear power plants, petrochemical plants, nuclear weapons production systems, nuclear submarine operation and companies that manufacture missiles for one-time launch.
NASA is a federal agency unlike any other. Its mission is unique, and its technological achievements - a source of unparalleled pride and inspiration, represent the best of American ability and courage. In the days when NASA's efforts thrilled the nation, and even afterward, it never ceased to be under constant public scrutiny. The loss of Columbia and its crew represents a turning point, calling for renewed public debate and commitment to manned space exploration programs. One of our goals was to lay the foundations for the public debate.
Named after the first American ship to circumnavigate the globe over two hundred years ago, in 1981 Columbia became the first spaceship of its kind to take off into Earth orbit and successfully completed 27 missions over twenty years. During Mission 107, Columbia and its crew traveled over 10 million kilometers over 16 days. The crash of the spacecraft, just 16 minutes before the planned landing, showed the public that space flight is still far from routine. It involves a necessary element of risk, which should be acknowledged, but never accepted. The seven crew members believed the risk was worth the reward. The members of the investigative committee saluted their courage and dedicated this report to their memory.
The investigation lasted almost seven months. A team of over 120 people, along with 400 engineers from NASA supported the 13 committee members. The researchers examined over 30 users, conducted over two hundred formal interviews, heard testimony from dozens of expert witnesses, and examined over 3,000 pieces of information received from the general public. Over 25 thousand searchers plowed the western US to locate the wreckage of the Columbia. In the process, the Columbia disaster was compounded when two prospectors from the US Forest Service perished in a helicopter crash.
The members of the committee realized at a fairly early stage that the accident was not caused by an unusual and random event, but rather has deep roots in the history of NASA and the culture of the manned flight programs. As a result, the committee expanded its mandate to include an inquiry into a wide range of historical and organizational issues, including political and budgetary arrangements, and the changes in priorities during the shuttle program. The committee became convinced of the importance of these factors as the investigation progressed, and the result is found in the report and its findings, conclusions and recommendations, in which these circumstantial factors have a heavy weight as well as for a better understanding and correction of the physical factors of the accident.
The physical cause of the loss of the Columbia and its crew was a crack in the front left edge of the left wing, caused by a piece of insulating foam that separated from the external fuel tank, in the area where the shuttle connects to it via a two-legged ramp. This occurred 81.7 seconds after launch, striking the wing in the area of the lower half of forced carbon-carbon panel number 8. During reentry into the atmosphere, this crack in the thermal protection system allowed very hot air to penetrate through the front of the left wing and eventually melt the aluminum structure of the wing the dress The result is a weakness in the structure until aerodynamic forces cause loss of control, failure of the wing and disintegration of the aircraft. There was no way for the team to survive.
The organizational factors that caused the accident have their roots in the history and culture of the shuttle program, including original compromises regarding the demands of the shuttles, consecutive years of lack of resources, fluid priorities, schedule pressures, a poor understanding of the shuttle as an operational tool instead of a tool under development, and a lack of an agreed-upon vision among the public regarding for a manned space program.
Cultural characteristics and habits established at NASA regarding safety have evolved without interruption. Including: reliance on past successes as subtitles for the practices of sound engineers (such as an examination to understand why systems did not perform what was assigned to them according to the requirements), organizational barriers that prevented effective communication of critical safety information and silenced different opinions, a lack of integrated management throughout many elements of the program, and the development of a chain of command and an informal decision-making process that operated outside the organization's rules.
This report discusses the characteristics of the organization that could have been more safe and reliable in the operation of the space shuttle, which is a tool in which the risk is built in, but it does not provide detailed data on how to correct the necessary correction in the organization. Among the recommendations: the establishment of a stable and independent body that will be a technical authority and that will have complete control over the specifications and requirements, and commit to them; An external body to certify safety with authority over all safety error levels; and an organizational culture that will reflect the best characteristics of a learning organization.
The report ends with several recommendations, some of which have been defined because they must be carried out before returning to the flight. "Most of these recommendations refer to the physical causes of the accident, including prevention of foam loss, improvement of the shuttle's imaging system and its photography from the moment of launch until the separation of all external fuel, and an examination in space as well as the ability to repair the thermal protection system in orbit. The rest of the recommendations, for the most part, were derived from the committee's findings regarding the organizational factors that contributed to the disaster. While these recommendations do not have to be carried out before returning to the flight, they can be seen as a necessity before continuing the flights as a whole, because they captured the minds of the committee members about the changes necessary for the safe operation of the shuttles and future spaceships in the medium and long term.
These recommendations reflect the support of the committee members for a return to flight as early as possible considering the implementation of the safety recommendations and the conviction of the committee members that the operation of the space shuttles and all other manned flights will be considered a development activity with inherent high risks.
One response
Who has the strength to read all this?!