Columbia Accident Investigation Board Report: Volume One

The Columbia Accident Investigation Board's 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 Board's 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 spacecraft's debris. In the process, Columbia's tragedy was compounded when two debris searchers with the U.S. Forest Service perished in a helicopter accident. 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 independent 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 organizational 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 preventing 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 Protection System. The remaining recommendations, for the most part, stem from the Board's 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 Board's thinking on what changes are necessary to operate the Shuttle and future spacecraft safely in the mid- to long-term.