The Columbia Accident Investigation Boards independent investigation into the February 1, 2003, loss of the Space Shuttle Columbia and its seven-member crew lasted nearly seven months. A staff of more than 120, along with some 400 NASA engineers, supported the Boards 13 members. Investigators examined more than 30,000 documents, conducted more than 200 formal interviews, heard testimony from dozens of expert witnesses, and reviewed more than 3,000 inputs from the general public. In addition, more than 25,000 searchers combed vast stretches of the Western United States to retrieve the spacecrafts debris. In the process, Columbias tragedy was compounded when two debris searchers with the U.S. Forest Service perished in a helicopter accident.

The Board recognized early on that the accident was prob-ably not an anomalous, random event, but rather likely root-ed to some degree in NASAs history and the human space flight programs culture. Accordingly, the Board broadened its mandate at the outset to include an investigation of a wide range of historical and organizational issues, including polit-ical and budgetary considerations, compromises, and chang-ing priorities over the life of the Space Shuttle Program. The Boards conviction regarding the importance of these factors strengthened as the investigation progressed, with the result that this report, in its findings, conclusions, and recommen-dations, places as much weight on these causal factors as on the more easily understood and corrected physical cause of the accident.

The physical cause of the loss of Columbia and its crew was a breach in the Thermal Protection System on the leading edge of the left wing, caused by a piece of insulating foam which separated from the left bipod ramp section of the External Tank at 81.7 seconds after launch, and struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel number 8. During re-entry this breach in the Thermal Protection System allowed superheated air to pen-etrate through the leading edge insulation and progressively melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused loss of control, failure of the wing, and break-up of the Orbiter. This breakup occurred in a flight regime in which, given the current design of the Orbiter, there was no possibility for the crew to survive.

The organizational causes of this accident are rooted in the Space Shuttle Programs history and culture, including the original compromises that were required to gain approval for the Shuttle, subsequent years of resource constraints, fluc-tuating priorities, schedule pressures, mischaracterization of the Shuttle as operational rather than developmental, and lack of an agreed national vision for human space flight. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing in accordance with requirements); organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion; lack of integrated management across program elements; and the evolution of an informal chain of command and decision-making pro-cesses that operated outside the organizations rules.

This report discusses the attributes of an organization that could more safely and reliably operate the inherently risky Space Shuttle, but does not provide a detailed organizational prescription. Among those attributes are: a robust and in-dependent program technical authority that has complete control over specifications and requirements, and waivers to them; an independent safety assurance organization with line authority over all levels of safety oversight; and an or-ganizational culture that reflects the best characteristics of a learning organization.

This report concludes with recommendations, some of which are specifically identified and prefaced as "before return to flight." These recommendations are largely related to the physical cause of the accident, and include prevent-ing the loss of foam, improved imaging of the Space Shuttle stack from liftoff through separation of the External Tank, and on-orbit inspection and repair of the Thermal Protec-tion System. The remaining recommendations, for the most part, stem from the Boards findings on organizational cause factors. While they are not "before return to flight" recommendations, they can be viewed as "continuing to fly" recommendations, as they capture the Boards thinking on what changes are necessary to operate the Shuttle and future spacecraft safely in the mid- to long-term.

These recommendations reflect both the Boards strong support for return to flight at the earliest date consistent with the overriding objective of safety, and the Boards conviction that operation of the Space Shuttle, and all human space-flight, is a developmental activity with high inherent risks.