introduction (Раздаточные материалы)

COLUMBIAACCIDENT INVESTIGATION BOARDReport Volume IAugust 2003COLUMBIAACCIDENT INVESTIGATION BOARDOn the Front CoverThis was the crew patch for STS-107. The central elementof the patch was the microgravity symbol, µg, flowing intothe rays of the Astronaut symbol. The orbital inclination wasportrayed by the 39-degree angle of the Earthʼs horizon tothe Astronaut symbol. The sunrise was representative of thenumerous science experiments that were the dawn of a newera for continued microgravity research on the InternationalSpace Station and beyond.

The breadth of science conducted on this mission had widespread benefits to life on Earthand the continued exploration of space, illustrated by theEarth and stars. The constellation Columba (the dove) waschosen to symbolize peace on Earth and the Space ShuttleColumbia. In addition, the seven stars represent the STS-107crew members, as well as honoring the original Mercury 7astronauts who paved the way to make research in spacepossible.

The Israeli flag represented the first person fromthat country to fly on the Space Shuttle.On the Back CoverThis emblem memorializes the three U.S. human space flightaccidents – Apollo 1, Challenger, and Columbia. The wordsacross the top translate to: “To The Stars, Despite Adversity– Always Explore“Limited First Printing, August 2003, by theColumbia Accident Investigation BoardSubsequent Printing and Distribution by theNational Aeronautics and Space Administrationand theGovernment Printing OfficeWashington, D.C.2Report Volume IAugust 2003IN MEMORIAMRick D. HusbandCommanderWilliam C.

McCoolPilotMichael P. AndersonPayload CommanderDavid M. BrownMission SpecialistKalpana ChawlaMission SpecialistLaurel Blair Salton ClarkMission SpecialistIlan RamonPayload SpecialistJules F. Mier, Jr.Debris Search PilotCharles KrenekDebris Search Aviation SpecialistThis cause of exploration and discovery is not an option we choose; it is a desire written in the human heart …We find the best among us, send them forth into unmapped darkness, and pray they will return.They go in peace for all mankind, and all mankind is in their debt.– President George W. Bush, February 4, 2003The quarter moon, photographed from Columbia on January 26, 2003, during the STS-107 mission.COLUMBIAACCIDENT INVESTIGATION BOARDVOLUME IIn Memoriam .................................................................................................................................................

3Board Statement ............................................................................................................................................. 6Executive Summary ....................................................................................................................................... 9Report Synopsis ........................................................................................................................................... 11PART ONETHE ACCIDENTChapter 11.11.21.31.41.51.6The Evolution of the Space Shuttle ProgramGenesis of the Space Transportation System ...............................................................................................Merging Conflicting Interests ......................................................................................................................Shuttle Development, Testing, and Qualification .........................................................................................The Shuttle Becomes “Operational”.............................................................................................................The Challenger Accident .............................................................................................................................Concluding Thoughts ...................................................................................................................................212223232425Chapter 22.12.22.32.42.52.62.7Columbiaʼs Final FlightMission Objectives and Their Rationales ....................................................................................................Flight Preparation ........................................................................................................................................Launch Sequence .........................................................................................................................................On-Orbit Events ...........................................................................................................................................Debris Strike Analysis and Requests for Imagery .......................................................................................De-Orbit Burn and Re-Entry Events ............................................................................................................Events Immediately Following the Accident ...............................................................................................27313235373839Chapter 33.13.23.33.43.53.63.73.8Accident AnalysisThe Physical Cause ......................................................................................................................................The External Tank and Foam .......................................................................................................................Wing Leading Edge Structural Subsystem ..................................................................................................Image and Transport Analyses .....................................................................................................................On-Orbit Debris Separation – The “Flight Day 2” Object ..........................................................................De-Orbit/Re-Entry .......................................................................................................................................Debris Analysis ............................................................................................................................................Impact Analysis and Testing ........................................................................................................................4950555962647378Chapter 44.14.2Other Factors ConsideredFault Tree .....................................................................................................................................................

85Remaining Factors ....................................................................................................................................... 86PART TWOWHY THE ACCIDENT OCCURREDChapter 55.15.25.35.45.55.65.75.8From Challenger to ColumbiaThe Challenger Accident and its Aftermath ................................................................................................ 99The NASA Human Space Flight Culture ................................................................................................... 101An Agency Trying to Do Too Much With Too Little .................................................................................

102Turbulence in NASA Hits the Space Shuttle Program .............................................................................. 105When to Replace the Space Shuttle? ......................................................................................................... 110A Change in NASA Leadership .................................................................................................................

115The Return of Schedule Pressure ............................................................................................................... 116Conclusion .................................................................................................................................................

117Chapter 66.16.26.36.4Decision Making at NASAA History of Foam Anomalies ....................................................................................................................121Schedule Pressure ...................................................................................................................................... 131Decision-Making During the Flight of STS-107 ....................................................................................... 140Possibility of Rescue or Repair ..................................................................................................................

173Chapter 77.17.27.3The Accidentʼs Organizational CausesOrganizational Causes: Insights from History ........................................................................................... 178Organizational Causes: Insights from Theory ........................................................................................... 180Organizational Causes: Evaluating Best Safety Practices ......................................................................... 1824Report Volume IAugust 2003COLUMBIAACCIDENT INVESTIGATION BOARD7.47.57.6Organizational Causes: A Broken Safety Culture ......................................................................................

184Organizational Causes: Impact of a Flawed Safety Culture on STS-107 .................................................. 189Findings and Recommendations ................................................................................................................ 192Chapter 88.18.28.38.48.58.6History as Cause: Columbia and ChallengerEchoes of Challenger ................................................................................................................................Failures of Foresight: Two Decision Histories and the Normalization of Deviance .................................System Effects: The Impact of History and Politics on Risky Work .........................................................Organization, Culture, and Unintended Consequences .............................................................................History as Cause: Two Accidents ..............................................................................................................Changing NASAʼs Organizational System ................................................................................................PART THREEA LOOK AHEADChapter 99.19.29.3Implications for the Future of Human Space FlightNear-Term: Return to Flight ......................................................................................................................