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Aircraft accident investigations are discussed with emphasis on those accidents that involved weather as a contributing factor. The organization of the accident investigation board for air carrier accidents is described along with the hearings, and formal report preparation. Statistical summaries of the investigations of general aviation accidents are provided.
On February 1, 2003, the Space Shuttle Columbia broke apart during reentry, resulting in loss of the vehicle and its seven crewmembers. For the next several months, an extensive investigation of the accident ensued involving a nationwide team of experts from NASA, industry, and academia, spanning dozens of technical disciplines. The Columbia Accident Investigation Board (CAIB), a group of experts assembled to conduct an investigation independent of NASA, concluded in August, 2003 that the most likely cause of the loss of Columbia and its crew was a breach in the left wing leading edge Reinforced Carbon-Carbon (RCC) thermal protection system initiated by the impact of thermal insulating foam that had separated from the orbiters external fuel tank 81 seconds into the mission's launch. During reentry, this breach allowed superheated air to penetrate behind the leading edge and erode the aluminum structure of left wing, which ultimately led to the breakup of the orbiter. The findings of the CAIB were supported by ballistic impact tests, which simulated the physics of External Tank Foam impact on the RCC wing leading edge material. These tests ranged from fundamental material characterization tests to full-scale Orbiter Wing Leading Edge tests. Following the accident investigation, NASA spent the next 18 months focused on returning the shuttle safely to flight. In order to fully evaluate all potential impact threats from the many debris sources on the Space Shuttle during ascent, NASA instituted a significant impact testing program. The results from these tests led to the validation of high-fidelity computer models, capable of predicting actual or potential Shuttle impact events, were used in the certification of STS-114, NASA s Return to Flight Mission, as safe to fly. This presentation will provide a look into the inner workings of the Space Shuttle and a behind the scenes perspective on the impact analysis and testing done for the Columbia Accident Investigation and NASA's Return to Flight programs. In addition, highlights from recent Shuttle missions are presented.
On February 1, 2003, the Space Shuttle Columbia broke apart during reentry resulting in loss of 7 crewmembers and craft. For the next several months an extensive investigation of the accident ensued involving a nationwide team of experts from NASA, industry, and academia, spanning dozens of technical disciplines. The Columbia Accident Investigation Board (CAIB), a group of experts assembled to conduct an investigation independent of NASA concluded in August, 2003 that the cause of the loss of Columbia and its crew was a breach in the left wing leading edge Reinforced Carbon-Carbon (RCC) thermal protection system initiated by the impact of thermal insulating foam that had separated from the orbiters external fuel tank 81 seconds into the missions launch. During reentry, this breach allowed superheated air to penetrate behind the leading edge and erode the aluminum structure of left wing which ultimately led to the breakup of the orbiter. In order to gain a better understanding the foam impact on the orbiters RCC wing leading edge, a multi-center team of NASA and Boeing impact experts was formed to characterize the foam and RCC materials for impact analysis using LS Dyna. Dyna predictions were validated with sub-component and full scale tests. LS Dyna proved to be a valuable asset in supporting both the Columbia Accident Investigation and NASA s return to flight efforts. This paper summarizes Columbia Accident and the nearly seven month long investigation that followed. The use of LS-DYNA in this effort is highlighted. Contributions to the investigation and return to flight efforts of the multicenter team consisting of members from NASA Glenn, NASA Langley, and Boeing Philadelphia are introduced and covered in detail in papers to follow in these proceedings.
The Space Shuttle Columbia accident investigation was a fusion of many disciplines into a single effort. From the recovery and reconstruction of the debris, Figure 1, to the analysis, both destructive and nondestructive, of chemical and metallurgical samples, Figure 2, a multitude of analytical techniques and tools were employed. Destructive and non-destructive testing were utilized in tandem to determine if a breach in the left wing of the Orbiter had occurred, and if so, the path of the resultant high temperature plasma flow. Nondestructive analysis included topometric scanning, laser mapping, and real-time radiography. These techniques were useful in constructing a three dimensional virtual representation of the reconstruction project, specifically the left wing leading edge reinforced carbon/carbon heat protectant panels. Similarly, they were beneficial in determining where sampling should be performed on the debris. Analytic testing included such techniques as Energy Dispersive Electron Microprobe Analysis (EMPA), Electron Spectroscopy Chemical Analysis (ESCA), and X-Ray dot mapping; these techniques related the characteristics of intermetallics deposited on the leading edge of the left wing adjacent to the location of a suspected plasma breach during reentry. The methods and results of the various analyses, along with their implications into the accident, are discussed, along with the findings and recommendations of the Columbia Accident Investigation Board. Likewise, NASA's Return To Flight efforts are highlighted.
The Columbia Accident Investigation Board's 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 investigation's 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 NASA's 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 NASA's 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 Board's views on what is needed to improve 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.
During the Space Shuttle Columbia Accident Investigation, it was determined that a large chunk of polyurethane insulating foam (= 1.67 lbs) on the External Tank (ET) came loose during Columbia's ascent on 2-1-03. The foam piece struck some of the protective Reinforced Carbon-Carbon (RCC) panels on the leading edge of Columbia's left wing in the mid-wing area. This impact damaged Columbia to the extent that upon re-entry to Earth, superheGed air approaching 3,000 F caused the vehicle to break up, killing all seven astronauts on board. A paper after the Columbia Accident Investigation highlighted thermal analysis testing performed on External Tank TPS materials (1). These materials included BX-250 (now BX-265) rigid polyurethane foam and SLA-561 Super Lightweight Ablator (highly-filled silicone rubber). The large chunk of foam from Columbia originated fiom the left bipod ramp of the ET. The foam in this ramp area was hand-sprayed over the SLA material and various fittings, allowed to dry, and manually shaved into a ramp shape. In Return-to-Flight (RTF) efforts following Columbia, the decision was made to remove the foam in the bipod ramp areas. During RTF efforts, further thermal analysis testing was performed on BX-265 foam by DSC and DMA. Flat panels of foam about 2-in. thick were sprayed on ET tank material (aluminum alloys). The DSC testing showed that foam material very close to the metal substrate cured more slowly than bulk foam material. All of the foam used on the ET is considered fully cured about 21 days after it is sprayed. The RTF culminated in the successful launch of Space Shuttle Discovery on 7-26-05. Although the flight was a success, there was another serious incident of foam loss fiom the ET during Shuttle ascent. This time, a rather large chunk of BX-265 foam (= 0.9 lbs) came loose from the liquid hydrogen (LH2) PAL ramp, although the foam did not strike the Shuttle Orbiter containing the crew. DMA testing was performed on foam samples taken fiom a simulated PAL ramp panel. It was found that the smooth rind on the foam facing the cable tray did significantly affect the properties of foam at the PAL ramp surface. The smooth rind increased the storage modulus E' of the foam as much as 20- 40% over a temperature range of -145 to 95 C. Because of foam loss fiom the PAL ramp, future Shuttle flights were grounded indefinitely to allow further testing to better understand foam properties. The decision was also made to remove foam from the LH2 PAL, ramp. Other RTF efforts prior to the launch of Discovery included
Human factors has become an integral part of the accident investigation protocol. However, much of the investigative process remains focussed on the flight deck, airframe, and power plant systems. As a consequence, little data has been collected regarding the human factors issues within and involving the cabin during an accident. Therefore, the possibility exists that contributing factors that lie within that domain may be overlooked. The FAA Office of Accident Investigation is sponsoring a two-day workshop on cabin safety accident investigation. This course, within the workshop, will be of two hours duration and will explore relevant areas of human factors research. Specifically, the three areas of discussion are: Information transfer and resource management, fatigue and other physical stressors, and the human/machine interface. Integration of these areas will be accomplished by providing a suggested checklist of specific cabin-related human factors questions for investigators to probe following an accident.
The Columbia Accident Investigation Board's (CAIB) independent investigation into the February 1, 2003 destruction of the Space Shuttle Columbia produced a six volume report. This is Volume III of the report. Volume III contains other technical documents produced by NASA and other organizations, which were provided to the CAIB in support of its inquiry into the tragedy. Technical documents included in the report are: Appendix E.1 CoFR Endorsements; Appendix E.2 STS-107 Image Analysis Team Final Report; Appendix E.3 An Assessment of Potential Material Candidates for the 'Flight Day 2', Radar Object Observed during the NASA Mission STS-107; Appendix E.4 Columbia Early Sighting Assessment Team Final Report.
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 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. These recommendations reflect both the Board's strong support for return to flight at the earliest date consistent with the overriding objective of safety, and the Board's conviction that operation of the Space Shuttle, and all human space-flight, is a developmental activity with high inherent risks.
In support of the Columbia Accident Investigation, inviscid computations of the aerodynamic characteristics for various Shuttle Orbiter damage scenarios were performed using the FELISA unstructured CFD solver. Computed delta aerodynamics were compared with the reconstructed delta aerodynamics in order to postulate a progression of damage through the flight trajectory. By performing computations at hypervelocity flight and CF4 tunnel conditions, a bridge was provided between wind tunnel testing in Langley's 20-Inch CF4 facility and the flight environment experienced by Columbia during re-entry. The rapid modeling capability of the unstructured methodology allowed the computational effort to keep pace with the wind tunnel and, at times, guide the wind tunnel efforts. These computations provided a detailed view of the flowfield characteristics and the contribution of orbiter components (such as the vertical tail and wing) to aerodynamic forces and moments that were unavailable from wind tunnel testing. The damage scenarios are grouped into three categories. Initially, single and multiple missing full RCC panels were analyzed to determine the effect of damage location and magnitude on the aerodynamics. Next is a series of cases with progressive damage, increasing in severity, in the region of RCC panel 9. The final group is a set of wing leading edge and windward surface deformations that model possible structural deformation of the wing skin due to internal heating of the wing structure. By matching the aerodynamics from selected damage scenarios to the reconstructed flight aerodynamics, a progression of damage that is consistent with the flight data, debris forensics, and wind tunnel data is postulated.
This is Volume Four of a set of six reports produced by NASA and other organizations which were provided to the Columbia Accident Investigation Board (CAIB) in support of its inquiry into the February 1, 2003 destruction of the Space Shuttle Columbia. The Technical Documents included in this volume are: Appendix F.1 Water Absorption by Foam; Appendix F.2 Follow the TPS; Appendix F.3 MADS Sensor Data; Appendix F.4 ET Cryoinsulation; Appendix F.5 Space Shuttle STS-107 Columbia Accident Investigation, and External Tank Working Group Final Report - Volume 1.
The Space Shuttle fleet has been grounded since the Columbia accident. As a result, 'Return to Flight' has become not just a phrase but a program and the global of virtually everyone associated with NASA. Even those who are not affiliated with the Shuttle Program are looking forward to the safe and successful completion of the next Shuttle mission. In this recovery process, NASA will be guided by the Report of the Columbia Accident Investigation Board (CAIB). The CAIB was an investigating body, convened by NASA Administrator O'Keefe the day of the Columbia accident, according to procedures established after the loss of Space Challenger.
Volume II of the Report contains appendices that were cited in Volume I. The Columbia Accident Investigation Board produced many of these appendices as working papers during the investigation into the February 1, 2003 destruction of the Space Shuttle Columbia. Other appendices were produced by other organizations (mainly NASA) in support of the Board investigation. In the case of documents that have been published by others, they are included here in the interest of establishing a complete record, but often at less than full page size. Contents include: CAIB Technical Documents Cited in the Report: Reader's Guide to Volume II; Appendix D. a Supplement to the Report; Appendix D.b Corrections to Volume I of the Report; Appendix D.1 STS-107 Training Investigation; Appendix D.2 Payload Operations Checklist 3; Appendix D.3 Fault Tree Closure Summary; Appendix D.4 Fault Tree Elements - Not Closed; Appendix D.5 Space Weather Conditions; Appendix D.6 Payload and Payload Integration; Appendix D.7 Working Scenario; Appendix D.8 Debris Transport Analysis; Appendix D.9 Data Review and Timeline Reconstruction Report; Appendix D.10 Debris Recovery; Appendix D.11 STS-107 Columbia Reconstruction Report; Appendix D.12 Impact Modeling; Appendix D.13 STS-107 In-Flight Options Assessment; Appendix D.14 Orbiter Major Modification (OMM) Review; Appendix D.15 Maintenance, Material, and Management Inputs; Appendix D.16 Public Safety Analysis; Appendix D.17 MER Manager's Tiger Team Checklist; Appendix D.18 Past Reports Review; Appendix D.19 Qualification and Interpretation of Sensor Data from STS-107; Appendix D.20 Bolt Catcher Debris Analysis.
In the course of its inquiry into the February 1, 2003 destruction of the Space Shuttle Columbia, the Columbia Accident Investigation Board conducted a series of public hearings at Houston, Texas; Cape Canaveral, Florida; and Washington, DC. Testimony from these hearings was recorded and then transcribed. This appendix, Volume VI of the Report, is a compilation of those transcripts. Contents: Transcripts of Board Public Hearings; Appendix H.1 March 6, 2003 Houston, Texas; Appendix H.2 March 17, 2003 Houston, Texas; Appendix H.3 March 18, 2003 Houston, Texas; Appendix H. 4 March 25, 2003 Cape Canaveral, Florida; Appendix H.5 March 26, 2003 Cape Canaveral, Florida; Appendix H.6 April 7, 2003 Houston, Texas; Appendix H.7 April 8, 2003 Houston, Texas; Appendix H.8 April 23, 2003 Houston, Texas; Appendix H.9 May 6, 2003 Houston, Texas; Appendix H.10 June 12, 2003 Washington, DC.
NASA's space shuttle Columbia broke apart on February 1, 2003 as it returned to Earth from a 16-day science mission. All seven astronauts aboard were killed. NASA created the Columbia Accident Investigation Board (CAIB), chaired by Adm. (Ret.) Harold Gehman, to investigate the accident. The Board released its report (available at [http://www.caib.us]) on August 26, 2003, concluding that the tragedy was caused by technical and organizational failures. The CAIB report included 29 recommendations, 15 of which the Board specified must be completed before the shuttle returns to flight status. This report provides a brief synopsis of the Board's conclusions, recommendations, and observations. Further information on Columbia and issues for Congress are available in CRS Report RS21408. This report will not be updated.
During the launch of the Space Shuttle Columbia on January 16, 2003, foam originating from the external tank impacted the shuttle's left wing 81 seconds after lift-off. Then on February 1st, Space Shuttle Columbia broke-up during re-entry. In the weeks that followed, the Columbia Accident Investigation Board had formed various teams to investigate every aspect of the tragedy. One of these teams was the Impact Analysis Team, which was asked to investigate the foam impact on the wing leading edge. This paper will describe the approach and methodology used by the team to support the accident investigation, and more specifically the use of LS-DYNA for analyzing the foam impact event. Due to the success of the analytical predictions, the impact analysis team has also been asked to support Return to Flight activities. These activities will analyze a far broader range of impact events, but not with just foam and not only on the wing leading edge. The debris list has expanded and so have the possible impact locations. This paper will discuss the Return to Flight activities and the use of LS-DYNA to support them.
Volume V of the Report contains appendices that were not cited in VolumeI. These consist of documents produced by NASA and other organizations, which were provided to the Columbia Accident Investigation Board in support of its inquiry into the February 1, 2003 destruction of the Space Shuttle Columbia The contents include:. Appendix G.1 Requirements and Procedures for Certification of Flight Readiness; Appendix G.2 Appendix R, Space Shuttle Program Contingency Action Plan; Appendix G.3 CAIB Charter, with Revisions; Appendix G.4 Group 1 Matrix Brief on Maintenance, Material, and Management; Appendix G.5 Vehicle Data Mapping(VDM) Team Final Report, Jun 13, 2003; Appendix G.6 SRB Working Group Presentation to CAIB; Appendix G. 7 Starfire Team Final Report, Jun 3, 2003; Appendix G.8 Using the Data and Observations from Flight STS-107, Executive Summary; Appendix G.9 Contracts, Incentives, and Safety/Technical Excellence; Appendix G.10 Detailed Summaries: Rogers Commission Report, ASAP Report, SIAT Report; Appendix G.11 Foam Application and Production Chart; Appendix G.12 Crew Survivability Report; and Appendix G.12 Aero/Aerothermal/ Thermal/Structures Team FinalReport, August 6, 2003.
Accident reports play a key role in the safety of complex systems. These reports present the recommendations that are intended to help avoid any recurrence of past failures. However, the value of these findings depends upon the causal analysis that helps to identify the reasons why an accident occurred. Various techniques have been developed to help investigators distinguish root causes from contributory factors and contextual information. This paper presents the results from a study into the individual differences that can arise when a group of investigators independently apply the same technique to identify the causes of an accident. This work is important if we are to increase the consistency and coherence of investigations following major accidents.