Part Two Why the Accident Occurred
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Space Reporter's Handbook Mission Supplement
CBS News Space Reporter's Handbook - Mission Supplement Page 1 The CBS News Space Reporter's Handbook Mission Supplement Shuttle Mission STS-125: Hubble Space Telescope Servicing Mission 4 Written and Produced By William G. Harwood CBS News Space Analyst [email protected] CBS News 5/10/09 Page 2 CBS News Space Reporter's Handbook - Mission Supplement Revision History Editor's Note Mission-specific sections of the Space Reporter's Handbook are posted as flight data becomes available. Readers should check the CBS News "Space Place" web site in the weeks before a launch to download the latest edition: http://www.cbsnews.com/network/news/space/current.html DATE RELEASE NOTES 08/03/08 Initial STS-125 release 04/11/09 Updating to reflect may 12 launch; revised flight plan 04/15/09 Adding EVA breakdown; walkthrough 04/23/09 Updating for 5/11 launch target date 04/30/09 Adding STS-400 details from FRR briefing 05/04/09 Adding trajectory data; abort boundaries; STS-400 launch windows Introduction This document is an outgrowth of my original UPI Space Reporter's Handbook, prepared prior to STS-26 for United Press International and updated for several flights thereafter due to popular demand. The current version is prepared for CBS News. As with the original, the goal here is to provide useful information on U.S. and Russian space flights so reporters and producers will not be forced to rely on government or industry public affairs officers at times when it might be difficult to get timely responses. All of these data are available elsewhere, of course, but not necessarily in one place. -
Space Shuttle Discovery Launched on the First Post-Columbia Mission on July 26, 2005, 905 Days After the Accident
AFTERWORD Space shuttle Discovery launched on the first post-Columbia mission on July 26, 2005, 905 days after the accident. Coincidentally, the launch took place at 10:39 A.M. EDT, the same time as Columbia’s launch on its final flight. STS-114 was the culmination of a $1.4 billion effort to improve the shuttle, most notably the External Tank. The bipod foam was replaced with an electrical heater to prevent ice from forming. Marshall Space- flight Center External Tank manager Sandy Coleman promised that no foam larger than a marshmallow would fall off of the improved tank. In the 147-page press kit’s description of all of the improvements to the shuttle, KSC’s acceptance of the industry standard definition for FOD (Foreign Object Debris) is presented as a positive. In a spin doctor- ing attempt it’s described how new FOD procedures improve safety, and ignores that FOD rules existed until two years before the Columbia acci- dent when the rules were reduced in a conscious move to make more bonus money for the contractor. Over 100 tracking cameras viewed Discovery’s launch. The E208 camera in Cocoa Beach, the one that had been “soft focused” on STS- 107, was replaced with a state-of-the-art setup. Cameras were also mounted on Discovery’s External Tank and Solid Rocket Boosters, and The bipod fitting on STS-114, on the right, shows the most significant external change— there is no longer any foam on the bipod fitting. 428 AFTERWORD 429 two aircraft with high-definition cameras offered the unique perspective of a shuttle flying toward the viewer. -
The Accident S Organizational Causes
COLUMBIA ACCIDENT INVESTIGATION BOARD CHAPTER 7 The Accidentʼs Organizational Causes Many accident investigations make the same mistake in UNDERSTANDING C AUSES defining causes. They identify the widget that broke or mal- functioned, then locate the person most closely connected In the Boardʼs view, NASAʼs organizational culture and with the technical failure: the engineer who miscalculated structure had as much to do with this accident as the Exter- an analysis, the operator who missed signals or pulled the nal Tank foam. Organizational culture refers to the values, wrong switches, the supervisor who failed to listen, or the norms, beliefs, and practices that govern how an institution manager who made bad decisions. When causal chains are functions. At the most basic level, organizational culture limited to technical flaws and individual failures, the ensu- defines the assumptions that employees make as they carry ing responses aimed at preventing a similar event in the out their work. It is a powerful force that can persist through future are equally limited: they aim to fix the technical prob- reorganizations and the reassignment of key personnel. lem and replace or retrain the individual responsible. Such corrections lead to a misguided and potentially disastrous Given that todayʼs risks in human space flight are as high belief that the underlying problem has been solved. The and the safety margins as razor thin as they have ever been, Board did not want to make these errors. A central piece of there is little room for overconfidence. Yet the attitudes our expanded cause model involves NASA as an organiza- and decision-making of Shuttle Program managers and tional whole. -
Space Shuttle CHALLENGER Accident
National Aeronautics and Space Administration Report to the President I Actions to Implement the Recommendations of The Prazdential Commission on the Space Shuttle ChulhgmAcczdent July 14,1986 3 Washington, D.C. L DEDICATION Those of us at NASA, who have worked incessantly since that day in January when the CHALLENGER and her crew, our friends, were lost, dedicate this report to those who willfly again into space in the future. THE WHITE HOUSE WASHINGTON June 13, 1986 Dear Jim: I have completed my review of the report from the Commission on the Space Shuttle CHALLENGER Accident. I believe that a program must be undertaken to implement its recommenda- tions as soon as possible. The procedural and organizational changes suggested in the report will be essential to resuming effective and efficient Space Transportation System operations , and will be crucial in restoring U.S. space launch activities to full operational status. Specifically, I would like NASA to report back to me in 30 days on how and when the Commission's recommendations will be implemented. This report should include milestones by which progress in the implementation process can be measured. Let me emphasize, as I have so many times, that the men and women of NASA and the tasks they so ably perform are essential to the nation if we are to retain our leadership in the pursuit of technological and scientific progress. Despite misfortunes and setbacks, we are determined to press on in our space programs. Again, Jim, we turn to you for leadership. You and the NASA team have our support and our blessings to do what has to be done to make our space program eafe, reliable, and a source of pride to our nation and of benefit to all mankind. -
Appendix F: Personal Observations on the Reliability of the Shuttle
Appendix F: Personal Observations on the Reliability of the Shu琀tle Richard P. Feynman June 9, 1986 1. Introduction t appears that there are enormous differences of opinion as to the prob- I ability of a failure with loss of vehicle and of human life. 吀he estimates range from roughly 1 in 100 to 1 in 100,000. 吀he higher figures come from the working engineers, and the very low figures from management. What are the causes and consequences of this lack of agreement? Since 1 part in 100,000 would imply that one could put a Shu琀tle up each day for 300 years expecting to lose only one, we could properly ask “What is the cause of management’s fantastic faith in the machinery?” We have also found that certification criteria used in Flight Readiness Reviews o昀ten develop a gradually decreasing strictness. 吀he argument thatthe same risk was flown before without failure is o昀ten accepted as an argument for the safety of accepting it again. Because of this, obvious weaknesses are accepted again and again, sometimes without a sufficiently serious a琀tempt to remedy them, or to delay a flight because of their continued presence. 吀here are several sources of information. 吀here are published criteria for certification, including a history of modifications in the form of waivers and deviations. In addition, the records of the Flight Readiness Reviews for each flight document the arguments used to accept the risks of the flight. Information was obtained from the direct testimony and the reports of the range safety officer, Louis J. Ullian, with respect to the history of success of solid fuel rockets. -
Download the PDF Case Study
National Aeronautics and Space Administration Academy of Program/Project & Engineering Leadership Columbia's Last Mission Columbia’s Last Mission The Space Shuttle Columbia thundered skyward at 10:39 AM on January 16, 2003 from Kennedy Space Center. Little more than a minute later, a chunk of insulating foam tore away from the external fuel tank and splintered against Columbia’s left wing. The incident did not disrupt Columbia’s planned path to orbit; indeed, nobody on the ground or in the orbiter even noticed it. It would be another day before routine reviews of launch photos revealed the foam strike and triggered discussions within NASA about what, if anything should be done about it.1 Background Established in January 1972, the Shuttle Program was charged with developing and deploying a fleet of reusable, cost-efficient vehicles that would make routine human space flight possible. The first Shuttle mission, STS-1, was flown by Columbia on April 12, 1981. A vast team of workers – some 17,500 NASA employees and contractors spread across the country – were supporting Columbia’s latest mission, STS-107, the Shuttle Program’s 113th mission. The Shuttle Program workforce operated facilities hosted by various NASA Centers. The Space Shuttle Program Office at the Johnson Space Center was responsible for all aspects of developing, supporting, and flying the Space Shuttle. The prime contractor for space flight operations was United Space Alliance (USA), a corporate partnership formed in 1995 between Lockheed Martin and Rockwell (later Boeing) exclusively to serve the Shuttle program. USA employees comprised the bulk of the contractor workforce at Johnson Space Center. -
Toward a History of the Space Shuttle an Annotated Bibliography
Toward a History of the Space Shuttle An Annotated Bibliography Part 2, 1992–2011 Monographs in Aerospace History, Number 49 TOWARD A HISTORY OF THE SPACE SHUTTLE AN ANNOTATED BIBLIOGRAPHY, PART 2 (1992–2011) Compiled by Malinda K. Goodrich Alice R. Buchalter Patrick M. Miller of the Federal Research Division, Library of Congress NASA History Program Office Office of Communications NASA Headquarters Washington, DC Monographs in Aerospace History Number 49 August 2012 NASA SP-2012-4549 Library of Congress – Federal Research Division Space Shuttle Annotated Bibliography PREFACE This annotated bibliography is a continuation of Toward a History of the Space Shuttle: An Annotated Bibliography, compiled by Roger D. Launius and Aaron K. Gillette, and published by NASA as Monographs in Aerospace History, Number 1 in December 1992 (available online at http://history.nasa.gov/Shuttlebib/contents.html). The Launius/Gillette volume contains those works published between the early days of the United States’ manned spaceflight program in the 1970s through 1991. The articles included in the first volume were judged to be most essential for researchers writing on the Space Shuttle’s history. The current (second) volume is intended as a follow-on to the first volume. It includes key articles, books, hearings, and U.S. government publications published on the Shuttle between 1992 and the end of the Shuttle program in 2011. The material is arranged according to theme, including: general works, precursors to the Shuttle, the decision to build the Space Shuttle, its design and development, operations, and management of the Space Shuttle program. Other topics covered include: the Challenger and Columbia accidents, as well as the use of the Space Shuttle in building and servicing the Hubble Space Telescope and the International Space Station; science on the Space Shuttle; commercial and military uses of the Space Shuttle; and the Space Shuttle’s role in international relations, including its use in connection with the Soviet Mir space station. -
Columbia's Last Flight | Langewiesche Page 1 of 31
The Atlantic | November 2003 | Columbia's Last Flight | Langewiesche Page 1 of 31 Print this Page Close Window The Atlantic Monthly | November 2003 Columbia's Last Flight The inside story of the investigation—and the catastrophe it laid bare BY WILLIAM LANGEWIESCHE ..... pace flight is known to be a risky business, but during the minutes before dawn last February 1, as the doomed shuttle Columbia began to descend into the upper atmosphere over the Pacific Ocean, only a handful of people—a few engineers deep inside of NASA—worried that the vehicle and its seven souls might actually come to grief. It was the responsibility of NASA's managers to hear those suspicions, and from top to bottom they failed. After the fact, that's easy to see. But in fairness to those whose reputations have now been sacrificed, seventeen years and eighty- nine shuttle flights had passed since the Challenger explosion, and within the agency a new generation had risen that was smart, perhaps, but also unwise—confined by NASA's walls and routines, and vulnerable to the self-satisfaction that inevitably had set in. Moreover, this mission was a yawn—a low-priority "science" flight forced onto NASA by Congress and postponed for two years because of a more pressing schedule of construction deliveries to the International Space Station. The truth is, it had finally been launched as much to clear the books as to add to human knowledge, and it had gone nowhere except into low Earth orbit, around the globe every ninety minutes for sixteen days, carrying the first Israeli -
Space Reporter's Handbook Mission Supplement
CBS News Space Reporter's Handbook - Mission Supplement Page 1 The CBS News Space Reporter's Handbook Mission Supplement Shuttle Mission STS-127/ISS-2JA: Station Assembly Enters the Home Stretch Written and Produced By William G. Harwood CBS News Space Analyst [email protected] CBS News 6/15/09 Page 2 CBS News Space Reporter's Handbook - Mission Supplement Revision History Editor's Note Mission-specific sections of the Space Reporter's Handbook are posted as flight data becomes available. Readers should check the CBS News "Space Place" web site in the weeks before a launch to download the latest edition: http://www.cbsnews.com/network/news/space/current.html DATE RELEASE NOTES 06/10/09 Initial STS-127 release 06/15/09 Updating to reflect launch delay to 6/17/09 Introduction This document is an outgrowth of my original UPI Space Reporter's Handbook, prepared prior to STS-26 for United Press International and updated for several flights thereafter due to popular demand. The current version is prepared for CBS News. As with the original, the goal here is to provide useful information on U.S. and Russian space flights so reporters and producers will not be forced to rely on government or industry public affairs officers at times when it might be difficult to get timely responses. All of these data are available elsewhere, of course, but not necessarily in one place. The STS-127 version of the CBS News Space Reporter's Handbook was compiled from NASA news releases, JSC flight plans, the Shuttle Flight Data and In-Flight Anomaly List, NASA Public Affairs and the Flight Dynamics office (abort boundaries) at the Johnson Space Center in Houston. -
COLUMBIA ACCIDENT INVESTIGATION BOARD Part Two
COLUMBIA ACCIDENT INVESTIGATION BOARD Part Two Why The Accident Occurred Many accident investigations do not go far enough. They vehicle called the Space Shuttle. When the agency did this, identify the technical cause of the accident, and then connect it accepted the bargain to operate and maintain the vehicle it to a variant of “operator error” – the line worker who forgot in the safest possible way. The Board is not convinced that to insert the bolt, the engineer who miscalculated the stress, NASA has completely lived up to the bargain, or that Con- or the manager who made the wrong decision. But this is sel- gress and the Administration has provided the funding and dom the entire issue. When the determinations of the causal support necessary for NASA to do so. This situation needs to chain are limited to the technical flaw and individual failure, be addressed – if the nation intends to keep conducting hu- typically the actions taken to prevent a similar event in the fu- man space flight, it needs to live up to its part of the bargain. ture are also limited: fix the technical problem and replace or retrain the individual responsible. Putting these corrections in Part Two of this report examines NASAʼs organizational, place leads to another mistake – the belief that the problem is historical, and cultural factors, as well as how these factors solved. The Board did not want to make these errors. contributed to the accident. As in Part One, this part begins with history. Chapter 5 examines the post-Challenger his- Attempting to manage high-risk technologies while mini- tory of NASA and its Human Space Flight Program. -
Apollo Mission Control the Making of a National Historic Landmark
Apollo Mission Control The Making of a National Historic Landmark More information about this series at http://www.springer.com/series/4097 Other Springer-Praxis books by Manfred “Dutch” von Ehrenfried Stratonauts: Pioneers Venturing into the Stratosphere, 2014 ISBN:978-3-319-02900-9 The Birth of NASA: The Work of the Space Task Group, America’s First True Space Pioneers, 2016 ISBN:978-3-319-28426-2 Exploring the Martian Moons: A Human Mission to Deimos and Phobos, 2017 ISBN:978-3-319-52699-7 Manfred “Dutch” von Ehrenfried Apollo Mission Control The Making of a National Historic Landmark Manfred “Dutch” von Ehrenfried Leander, Texas, USA SPRINGER-PRAXIS BOOKS IN SPACE EXPLORATION Springer Praxis Books ISBN 978-3-319-76683-6 ISBN 978-3-319-76684-3 (eBook) https://doi.org/10.1007/978-3-319-76684-3 Library of Congress Control Number: 2018939417 © Springer International Publishing AG, part of Springer Nature 2018 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. -
Risk Analysis of the Space Shuttle: Pre-Challenger Prediction of Failure
Risk Analysis of the Space Shuflte: Pre-Challenger Prediction of Failure SIDDHARTHA R. DALAL, EDWARD B. FOWLKES, and BRUCE HOADLEY* The Rogers Commission report on the space shuttle Challenger accident concluded that the accident was caused by a combustion gas leak through a joint in one of the booster rockets, which was sealed by a device called an 0-ring. The commission further concluded that 0-rings do not seal properly at low temperatures. In this article, data from the 23 preaccident launches of the space shuttle is used to predict 0-ring performance under the Challenger launch conditions and relate it to the catastrophic failure of the shuttle. Analyses via binomial and binary logistic regression show that there is strong statistical evidence of a temperature effect on incidents of 0-ring thermal distress. In addition, a probabilistic risk assessment at 310F, the temperature at which Challenger was launched, yields at least a 13% probability of catastrophic field-joint 0-ring failure. Postponement to 60?F would have reduced the probability to at least 2%. To assess uncertainty in estimates and for any future prediction under the Challenger scenario, a postanalysis prior distribution of the probability of a catastrophic failure is derived. The mean and median for this distribution for 31?F are at least .16 and .13, and for 60?F they are at least .004 and .02, respectively. The analysis of this article demonstrates that statistical science can play an important role in the space-shuttle risk-management process. KEY WORDS: Catastrophic failure; Data analysis; 0-rings; Probability risk assessment; Statistical science.