Contents

Cover Sheets

In Memoriam
Board Statement
Executive Summary
Report Synopsis
An Introduction to the Space Shuttle
An Introduction to NASA


PART ONE THE ACCIDENT

Chapter 1 The Evolution of the Space Shuttle Program

1.1 Genesis of the Space Transportation System
1.2 Merging Conflicting Interests
1.3 Shuttle Development, Testing, and Qualification
1.4 The Shuttle Becomes "Operational"
1.5 The Challenger Accident
1.6 Concluding Thoughts


Chapter 2 Columbias Final Flight

2.1 Mission Objectives and Their Rationales
Columbia
The Crew
2.2 Flight Preparation
NASA Times
2.3 Launch Sequence
2.4 On-Orbit Events
2.5 Debris Strike Analysis and Requests for Imagery
2.6 De-Orbit Burn and Re-Entry Events
Mission Control Center Communication
2.7 Events Immediately Following the Accident


Chapter 3 Accident Analysis

3.1 The Physical Cause
3.2 The External Tank and Foam
FOAM FRACTURE UNDER HYDROSTATIC PRESSURE
3.3 Wing Leading Edge Structural Subsystem
REINFORCED CARBON-CARBON (RCC)
LEFT WING AND WING LEADING EDGE
3.4 Image and Transport Analyses
THE ORBITER "RAN INTO" THE FOAM
3.5 On-Orbit Debris Separation - The "Flight Day 2" Object
ON-ORBIT COLLISION AVOIDANCE
3.6 De-Orbit/Re-Entry
THE KIRTLAND IMAGE
3.7 Debris Analysis
STS-107 CREW SURVIVABILITY
3.8 Impact Analysis and Testing
BOARD TESTING


Chapter 4 Other Factors Considered

4.1 Fault Tree
4.2 Remaining Factors


PART TWO WHY THE ACCIDENT OCCURRED

Chapter 5 From Challenger to Columbia

5.1 The Challenger Accident and its Aftermath
5.2 The NASA Human Space Flight Culture
5.3 An Agency Trying to Do Too Much With Too Little
5.4 Turbulence in NASA Hits the Space Shuttle Program
5.5 When to Replace the Space Shuttle?
5.6 A Change in NASA Leadership
5.7 The Return of Schedule Pressure
5.8 Conclusion


Chapter 6 Decision Making at NASA

6.1 A History of Foam Anomalies
6.2 Schedule Pressure
6.3 Decision-Making During the Flight of STS-107
6.4 Possibility of Rescue or Repair


Chapter 7 The Accidents Organizational Causes

7.1 Organizational Causes: Insights from History
7.2 Organizational Causes: Insights from Theory
7.3 Organizational Causes: Evaluating Best Safety Practices
7.4 Organizational Causes: A Broken Safety Culture
7.5 Organizational Causes: Impact of a Flawed Safety Culture on STS-107
7.6 Findings and Recommendations


Chapter 8 History as Cause: Columbia and Challenger

8.1 Echoes of Challenger
8.2 Failures of Foresight: Two Decision Histories and the Normalization of Deviance
8.3 System Effects: The Impact of History and Politics on Risky Work
8.4 Organization, Culture, and Unintended Consequences
8.5 History as Cause: Two Accidents
8.6 Changing NASAs Organizational System


PART THREE A LOOK AHEAD

Chapter 9 Implications for the Future of Human Space Flight

9.1 Near-Term: Return to Flight
9.2 Mid-Term: Continuing to Fly
9.3 Long-Term: Future Directions for the U.S. in Space


Chapter 10 Other Significant Observations

10.1 Public Safety
10.2 Crew Escape and Survival
10.3 Shuttle Engineering Drawings and Closeout Photographs
10.4 Industrial Safety and Quality Assurance
10.5 Maintenance Documentation
10.6 Orbiter Maintenance Down Period/Orbiter Major Modification
10.7 Orbiter Corrosion
10.8 Brittle Fracture of A-286 Bolts
10.9 Hold-Down Post Cable Anomaly
10.10 Solid Rocket Booster External Tank Attachment Ring
10.11 Test Equipment Upgrades
10.12 Leadership/Managerial Training


Chapter 11 Recommendations


PART FOUR APPENDICES

Appendix A The Investigation

Appendix B Board Member Biographies

Appendix C Board Staff


VOLUME II Appendix D CAIB Technical Documents Cited in the Report

VOLUME III Appendix E Other Technical Documents Cited in the Report

VOLUME IV Appendix F Other Technical Documents

VOLUME V Appendix G Other Significant Documents

VOLUME VI Appendix H Transcripts of Board Public Hearings