The Columbia Accident Investigation Boards independent investigation into the tragic February 1, 2003, loss of the Space Shuttle Columbia and its seven-member crew lasted nearly seven months and involved 13 Board members, approximately 120 Board investigators, and thousands of NASA and support personnel. Because the events that initiated the accident were not apparent for some time, the investigations depth and breadth were unprecedented in NASA history. Further, the Board determined early in the investigation that it intended to put this accident into context. We considered it unlikely that the accident was a random event; rather, it was likely related in some degree to NASAs budgets, history, and program culture, as well as to the politics, compromises, and changing priorities of the democratic process. We are convinced that the management practices overseeing the Space Shuttle Program were as much a cause of the accident as the foam that struck the left wing. The Board was also influenced by discussions with members of Congress, who suggested that this nation needed a broad examination of NASAs Human Space Flight Program, rather than just an investigation into what physical fault caused Columbia to break up during re-entry.

Findings and recommendations are in the relevant chapters and all recommendations are compiled in Chapter 11.

Volume I is organized into four parts: The Accident; Why the Accident Occurred; A Look Ahead; and various appendices. To put this accident in context, Parts One and Two begin with histories, after which the accident is described and then analyzed, leading to findings and recommendations. Part Three contains the Boards views on what is needed to im-prove the safety of our voyage into space. Part Four is reference material. In addition to this first volume, there will be subsequent volumes that contain technical reports generated by the Columbia Accident Investigation Board and NASA, as well as volumes containing reference documentation and other related material.

PART ONE: THE ACCIDENT

Chapter 1 relates the history of the Space Shuttle Program before the Challenger accident. With the end looming for the Apollo moon exploration program, NASA unsuccessfully attempted to get approval for an equally ambitious (and expensive) space exploration program. Most of the proposed programs started with space stations in low-Earth orbit and included a reliable, economical, medium-lift vehicle to travel safely to and from low-Earth orbit. After many failed attempts, and finally agreeing to what would be untenable compromises, NASA gained approval from the Nixon Administration to develop, on a fixed budget, only the transport vehicle. Because the Administration did not approve a low-Earth-orbit station, NASA had to create a mission for the vehicle. To satisfy the Administrations require-ment that the system be economically justifiable, the vehicle had to capture essentially all space launch business, and to do that, it had to meet 　wideranging requirements. These sometimes-competing requirements resulted in a compromise vehicle that was less than optimal for manned flights. NASA designed and developed a remarkably capable and resilient vehicle, consisting of an Orbiter with three Main Engines, two Solid Rocket Boosters, and an External Tank, but one that has never met any of its original requirements for reliability, cost, ease of turnaround, maintainability, or, regrettably, safety.

Chapter 2 documents the final flight of Columbia. As a straightforward record of the event, it contains no findings or recommendations. Designated STS-107, this was the Space Shuttle Programs 113th flight and Columbias 28th. The flight was close to trouble-free. Unfortunately, there were no indications to either the crew onboard Columbia or to engi-neers in Mission Control that the mission was in trouble as a result of a foam strike during ascent. Mission management failed to detect weak signals that the Orbiter was in trouble and take corrective action.

Columbia was the first space-rated Orbiter. It made the Space Shuttle Programs first four orbital test flights. Because it was the first of its kind, Columbia differed slightly from Orbiters Challenger, Discovery, Atlantis, and Endeavour. Built to an earlier engineering standard, Columbia was slightly heavier, and, although it could reach the high-inclination orbit of the International Space Station, its payload was insufficient to make Columbia cost-effective for Space Station missions. Therefore, Columbia was not equipped with a Space Station docking system, which freed up space in the payload bay for longer cargos, such as the science modules Spacelab and SPACEHAB. Consequently, Columbia generally flew sci-ence missions and serviced the Hubble Space Telescope.

STS-107 was an intense science mission that required the seven-member crew to form two teams, enabling round-the-clock shifts. Because the extensive science cargo and its extra power sources required additional checkout time, the launch sequence and countdown were about 24 hours longer than normal. Nevertheless, the countdown proceeded as planned, and Columbia was launched from Launch Com-plex 39-A on January 16, 2003, at 10:39 a.m. Eastern Stan-dard Time (EST).

At 81.7 seconds after launch, when the Shuttle was at about 65,600 feet and traveling at Mach 2.46 (1,650 mph), a large piece of hand-crafted insulating foam came off an area where the Orbiter attaches to the External Tank. At 81.9 seconds, it struck the leading edge of Columbias left wing. This event was not detected by the crew on board or seen by ground support teams until the next day, during detailed reviews of all launch camera photography and videos. This foam strike had no apparent effect on the daily conduct of the 16-day mission, which met all its objectives.

The de-orbit burn to slow Columbia down for re-entry into Earths atmosphere was normal, and the flight profile throughout re-entry was standard. Time during re-entry is measured in seconds from "Entry Interface," an arbitrarily determined altitude of 400,000 feet where the Orbiter be-gins to experience the effects of Earths atmosphere. Entry Interface for STS-107 occurred at 8:44:09 a.m. on February 1. Unknown to the crew or ground personnel, because the data is recorded and stored in the Orbiter instead of being transmitted to Mission Control at Johnson Space Center, the first abnormal indication occurred 270 seconds after Entry Interface. Chapter 2 reconstructs in detail the events lead-ing to the loss of Columbia and her crew, and refers to more details in the appendices.

In Chapter 3, the Board analyzes all the information available to conclude that the direct, physical action that initiated the chain of events leading to the loss of Columbia and her crew was the foam strike during ascent. This chapter re-views five analytical paths ｭ aerodynamic, thermodynamic, sensor data timeline, debris reconstruction, and imaging evidence ｭ to show that all five independently arrive at the same conclusion. The subsequent impact testing conducted by the Board is also discussed.

That conclusion is that Columbia re-entered Earths atmosphere with a preexisting breach in the leading edge of its left wing in the vicinity of Reinforced Carbon-Carbon (RCC) panel 8. This breach, caused by the foam strike on ascent, was of sufficient size to allow superheated air (probably ex-ceeding 5,000 degrees Fahrenheit) to penetrate the cavity behind the RCC panel. The breach widened, destroying the insulation protecting the wings leading edge support structure, and the superheated air eventually melted the thin aluminum wing spar. Once in the interior, the superheated air began to destroy the left wing. This destructive process was carefully reconstructed from the recordings of hundreds of sensors in-side the wing, and from analyses of the reactions of the flight control systems to the changes in aerodynamic forces.

By the time Columbia passed over the coast of California in the pre-dawn hours of February 1, at Entry Interface plus 555 seconds, amateur videos show that pieces of the Orbiter were shedding. The Orbiter was captured on videotape dur-ing most of its quick transit over the Western United States. The Board correlated the events seen in these videos to sensor readings recorded during re-entry. Analysis indicates that the Orbiter continued to fly its pre-planned flight profile, although, still unknown to anyone on the ground or aboard Columbia, her control systems were working furiously to maintain that flight profile. Finally, over Texas, just southwest of Dallas-Fort Worth, the increasing aerodynamic forces the Orbiter experienced in the denser levels of the atmosphere overcame the catastrophically damaged left wing, causing the Orbiter to fall out of control at speeds in excess of 10,000 mph.

The chapter details the recovery of about 38 percent of the Orbiter (some 84,000 pieces) and the reconstruction and analysis of this debris. It presents findings and recommenda-tions to make future Space Shuttle operations safer.

Chapter 4 describes the investigation into other possible physical factors that may have contributed to the accident. The chapter opens with the methodology of the fault tree analysis, which is an engineering tool for identifying every conceivable fault, then determining whether that fault could have caused the system in question to fail. In all, more than 3,000 individual elements in the Columbia accident fault tree were examined.

In addition, the Board analyzed the more plausible fault sce-narios, including the impact of space weather, collisions with micrometeoroids or "space junk," willful damage, flight crew performance, and failure of some critical Shuttle hardware. The Board concludes in Chapter 4 that despite certain fault tree exceptions left "open" because they cannot be conclusively disproved, none of these factors caused or contributed to the accident. This chapter also contains findings and rec-ommendations to make Space Shuttle operations safer.

PART TWO: WHY THE ACCIDENT OCCURRED

Part Two, "Why the Accident Occurred," examines NASAs 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 Or-biters 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 re-lates 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 NASAs 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 NASAs organizational curlture will enable it to succeed.

This chapter measures the Shuttle Programs practices against this organizational context and finds them wanting. The Board concludes that NASAs 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 con-tributed to this accident. The chapter opens with "echoes of Challenger" that compares the two accidents. This chapter captures the Boards views of the need to adjust manage-ment to enhance safety margins in Shuttle operations, and reaffirms the Boards 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 ｭ and will be internally resisted.

PART THREE: A LOOK AHEAD

Part Three summarizes the Boards 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 sum-mary of the Boards recommendations.

In Chapter 9, the Board first reviews its short-term recom-mendations. 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 dis-cusses what needs to be done to operate the Shuttle in the mid-term, 3 to 15 years. Based on NASAs history of ignor-ing 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 sched-uling 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 na-tion has, in the Boards view, of developing either a comple-ment 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 recom-mendations 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 Inves-tigation Board contains material relevant to this volume organized in appendices. Additional, stand-alone volumes will contain more reference, background, and analysis ma-terials.