CAIB report highlights and comments

One of the perks of being a graduate student is that I can take a
morning off to read gigantic PDF files. :-) Still I'm only about a
third of the way through. On the whole, the first section, about the
actual loss of the orbiter, is about what I expected. I haven't gotten
to the institutional culture sections yet...

So here are a few things that jumped out at me as being noteworthy
thus far: (Page numbers refer to the complete PDF file.)

page 11: "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."
[Nothing we didn't know already, but I believe this is the first
time it's been put so frankly in a government document.]

page 13: "Based on NASA's history of ignoring 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."
[ Yep, it's ugly all right. But that's what's needed, I think.]

page 21: "This chapter charts how the Shuttle emerged from a series of
political compromises that produced unreasonable expectations even
myths about its performance,how the Challenger accident shattered
those myths several years after NASA began acting upon them as
fact,and how,in retrospect,the Shuttle's technically ambitious
design resulted in an inherently vulnerable vehicle,the safe operation
of which exceeded NASA's organizational capabilities as they existed
at the time of the Columbia accident."
[ Ouch again.]

page 52:
"Although there is no evidence that substandard methods were used to
qualify the bipod ramp design,tests made near- ly three decades ago
were rudimentary by today's standards and capabilities. Also,testing
did not follow the often-used engineering and design philosophy of
'Fly what you test and test what you fly.'"

page 53: "Foam loss has occurred on more than 80 percent of the 79
missions for which imagery is available,and foam was lost from the
left bipod ramp on nearly 10 percent of missions where the left bipod
ramp was visible following External Tank separation."

page 54: Prof. Osheroff's foam experiment, in his own words.

page 69: Figure 3.6-11 is probably the best graphic of the airflow
within the wing I have seen yet. Poor Columbia...

Page 72: Figure 3.7-1. "Wow", said out loud, was my reaction to this
photo of the recovered debris from the two wings. The left wing's
just -gone-... Given that it now seems that a very large fraction of
the left wing peeled off as the early debris trails, it's amazing
that the nominal flight plan was maintained so long. Kudos again
to the flight control software team.

Marshall Perrin wrote:

One of the perks of being a graduate student is that I can take a
morning off to read gigantic PDF files. :-) Still I'm only about a
third of the way through. On the whole, the first section, about the
actual loss of the orbiter, is about what I expected. I haven't gotten
to the institutional culture sections yet...

The institutional culture sections were the FIRST thing I jumped to.
See below. I know they can fix this particular technical problem, but
where we go from here after that's fixed is the real issue.


page 21: "This chapter charts how the Shuttle emerged from a series of
political compromises that produced unreasonable expectations even
myths about its performance,how the Challenger accident shattered
those myths several years after NASA began acting upon them as
fact,and how,in retrospect,the Shuttle's technically ambitious
design resulted in an inherently vulnerable vehicle,the safe operation
of which exceeded NASA's organizational capabilities as they existed
at the time of the Columbia accident."
[ Ouch again.]


Here's more sound bites, all from Chapter 7:

177-178: "NASA?s initial briefings to the Board on its safety programs
espoused a risk-averse philosophy
that empowered any employee to stop an operation at the mere glimmer of
a problem. Unfortunately, NASA?s views of its safety culture in those
briefings did not reflect reality. Shuttle Program safety personnel
failed to adequately assess anomalies and frequently accepted critical
risks without qualitative or quantitative support, even when the tools
to provide more comprehensive assessments were available. Similarly, the
Board expected to find NASA?s Safety and Mission Assurance organization
deeply engaged at every level of Shuttle management: the Flight
Readiness Review, the Mission Management Team, the Debris Assessment
Team, the Mission Evaluation Room, and so forth. This was not the case.
In briefing after briefing, interview after interview, NASA remained in
denial: in the agency?s eyes, “there were no safety-of-flight issues,”
and no safety compromises
in the long history of debris strikes on the Thermal
Protection System. The silence of Program-level safety processes
undermined oversight; when they did not speak up, safety personnel could
not fulfill their stated mission to provide “checks and balances.” A
pattern of acceptance prevailed throughout the organization that
tolerated foam problems without sufficient engineering justification for
doing so."

179: "NASA culture
has become reactive, complacent, and dominated by unjustified optimism.
Over time, slowly and unintentionally,
independent checks and balances intended to increase safety have been
eroded in favor of detailed processes that produce massive amounts of
data and unwarranted consensus, but little effective communication.
Organizations that successfully deal with high-risk technologies create
and sustain a disciplined safety system
capable of identifying, analyzing, and controlling hazards throughout a
technology?s life cycle."

181: "Importance of Communication: At every juncture
of STS-107, the Shuttle Program?s structure and processes,
and therefore the managers in charge, resisted new information. Early in
the mission, it became clear that the Program was not going to authorize
imaging of the Orbiter because, in the Program?s opinion, images were
not needed. Overwhelming evidence indicates that Program leaders decided
the foam strike was merely a maintenance problem long before any
analysis had begun.
Every manager knew the party line: “we?ll wait for the analysis – no
safety-of-flight issue expected.” Program
leaders spent at least as much time making sure hierarchical rules and
processes were followed as they did trying to establish why anyone would
want a picture of the Orbiter. These attitudes are incompatible with an
organization that deals with high-risk technology."

181: "Conditioned by Success: Even after it was clear from the launch
videos that foam had struck the Orbiter in a manner never before seen,
Space Shuttle Program managers
were not unduly alarmed. They could not imagine why anyone would want a
photo of something that could be fixed after landing. More importantly,
learned attitudes about foam strikes diminished management?s wariness of
their danger. The Shuttle Program turned “the experience of failure into
the memory of success.”
18 Managers also failed to develop simple contingency
plans for a re-entry emergency. They were convinced, without study, that
nothing could be done about such an emergency. The intellectual
curiosity and skepticism that a solid safety culture requires was almost
entirely absent. Shuttle managers did not embrace safety-conscious
attitudes. Instead, their attitudes were shaped and reinforced by an
organization that, in this instance,
was incapable of stepping back and gauging its biases. Bureaucracy and
process trumped thoroughness and reason."

181: "Significance of Redundancy: The Human Space Flight Program has
compromised the many redundant processes,
checks, and balances that should identify and correct small errors.
Redundant systems essential to every high-risk enterprise have fallen
victim to bureaucratic efficiency. Years of workforce reductions and
outsourcing have culled from NASA?s workforce the layers of experience
and hands-on systems knowledge that once provided a capacity for safety
oversight. Safety and Mission Assurance personnel have been eliminated,
careers in safety have lost organizational prestige, and the Program now
decides on its own how much safety and engineering oversight it needs.
Aiming to align its inspection
regime with the International Organization for Standardization 9000/9001
protocol, commonly used in industrial environments – environments very
different than the Shuttle Program – the Human Space Flight Program
shifted from a comprehensive “oversight” inspection process to a more
limited “insight” process, cutting mandatory inspection points by more
than half and leaving even fewer workers to make “second” or “third”
Shuttle systems checks (see Chapter 10)."

186: "The Board believes that although the Space Shuttle Program has
effective safety practices at the “shop floor” level, its operational
and systems safety program is flawed by its dependence on the Shuttle
Program. Hindered by a cumbersome
organizational structure, chronic understaffing, and poor management
principles, the safety apparatus is not currently capable of fulfilling
its mission. An independent safety structure would provide the Shuttle
Program a more effective operational safety process. Crucial components
of this structure include a comprehensive integration of safety across
all the Shuttle programs and elements, and a more independent system of
checks and balances."

190: "During the STS-113 Flight Readiness Review, the bipod foam strike
to STS-112 was rationalized by simply restating
earlier assessments of foam loss. The question of why bipod foam would
detach and strike a Solid Rocket Booster spawned no further analysis or
heightened curiosity; nor did anyone challenge the weakness of External
Tank Project
Manager?s argument that backed launching the next mission. After
STS-113?s successful flight, once again the STS-112 foam event was not
discussed at the STS-107 Flight Readiness Review. The failure to mention
an outstanding technical anomaly, even if not technically a violation of
NASA?s own procedures, desensitized the Shuttle Program to the dangers
of foam striking the Thermal Protection System,
and demonstrated just how easily the flight preparation process can be
compromised. In short, the dangers of bipod foam got “rolled-up,” which
resulted in a missed opportunity
to make Shuttle managers aware that the Shuttle required, and did not
yet have a fix for the problem.
Once the Columbia foam strike was discovered, the Mission Management
Team Chairperson asked for the rationale the STS-113 Flight Readiness
Review used to launch in spite of the STS-112 foam strike. In her
e-mail, she admitted that the analysis used to continue flying was, in a
word, “lousy” (Chapter 6). This admission – that the rationale to fly
was rubber-stamped – is, to say the least, unsettling."


There's lots more but as you can see, NASA has a whole lot of reform to
do. And that's going to require a big infusion of lots of new blood.


--
Steven D. Litvintchouk
Email:

Remove the NOSPAM before replying to me.

"Bruce Palmer" wrote in message
...
Marshall Perrin spewed out:

snip

page 69: Figure 3.6-11 is probably the best graphic of the airflow
within the wing I have seen yet. Poor Columbia...

One of my pet peeves through all this has been how all the media continues
to
refer to the "hot gases" or "superheated air" that breached the wing. It
was
neither; it was _plasma_.

Now on this page I see "... close enough to the breach for the gas plume
to hit
them ..." and "... showed that superheated air flowing into a breached
...."

---clip---

We had an extended discussion of this way, way, back there somewhere on this
newsgroup. As I recall, the aerodynamicists (I don't remember if Widnall
was on board at the CAIB yet) concluded that with shock and boundary
effects, the gases which entered the breach would not have a large
percentage of ionized molecules, and thus could not really be considered a
"plasma". After a few early press releases from Adm. Gehman about "plasma
blowtorches" and the like, everybody started referring to "superheated air"
instead. I'll dig for the papers and notes if nobody else has the
information at hand.

JJ Robinson II
Houston, TX

Heartbreak spewed out:
We had an extended discussion of this way, way, back there somewhere on this
newsgroup. As I recall, the aerodynamicists (I don't remember if Widnall
was on board at the CAIB yet) concluded that with shock and boundary
effects, the gases which entered the breach would not have a large
percentage of ionized molecules, and thus could not really be considered a
"plasma". After a few early press releases from Adm. Gehman about "plasma
blowtorches" and the like, everybody started referring to "superheated air"
instead. I'll dig for the papers and notes if nobody else has the
information at hand.

JJ Robinson II
Houston, TX

I must have missed that. If true then I'll feel somewhat better.

It seems to me that any air or gas plume would have to consist of what otherwise
would be the molecules that make up the aerodynamic pressure on the vehicle
surfaces. Ah, well, I could be wrong. I'm also leaving tomorrow on a trip that
won't bring me home until Sunday night. I doubt I'll have time to do much
Google research between now and then. I'll resist the urge to spew at this point.

--
bp
Proud Member of the Human O-Ring Society Since 2003

In article ,
"Heartbreak" wrote:

"Bruce Palmer" wrote in message
...
Marshall Perrin spewed out:

snip

page 69: Figure 3.6-11 is probably the best graphic of the airflow
within the wing I have seen yet. Poor Columbia...

One of my pet peeves through all this has been how all the media continues
to
refer to the "hot gases" or "superheated air" that breached the wing. It
was
neither; it was _plasma_.

Now on this page I see "... close enough to the breach for the gas plume
to hit
them ..." and "... showed that superheated air flowing into a breached
..."

---clip---

We had an extended discussion of this way, way, back there somewhere on this
newsgroup. As I recall, the aerodynamicists (I don't remember if Widnall
was on board at the CAIB yet) concluded that with shock and boundary
effects, the gases which entered the breach would not have a large
percentage of ionized molecules, and thus could not really be considered a
"plasma". After a few early press releases from Adm. Gehman about "plasma
blowtorches" and the like, everybody started referring to "superheated air"
instead. I'll dig for the papers and notes if nobody else has the
information at hand.

JJ Robinson II
Houston, TX



Well, not only that, but any plasma entering the breach probably reacted
with the materials in the wing in a whole slew of cascading secondary
chemical (i.e., oxidation) and physical reactions (i.e., phase changes:
solid - liquid - gaseous - condensing back to liquid and then solid
over time). All this would render the phase of the matter entering the
wing as mixed plasma and gas anyway, all of which would contain
increasing amounts of wing materials mixed and in suspension, entrained
with the flow, further confusing the situation.

All in all, I think sticking with terms like "superheated air", "gas"
and so forth for Volume I of the public report is a good idea. Let us
space geeks argue the semantics; I can wait to debate the actual
composition of the flow inside the wing structure (if such is ever
necessary) until after I have the subsequent technical volumes.

--
Herb Schaltegger, B.S., J.D.
Reformed Aerospace Engineer
"Heisenberg might have been here."
~ Anonymous

Herb Schaltegger wrote:

Well, not only that, but any plasma entering the breach probably reacted
with the materials in the wing in a whole slew of cascading secondary
chemical (i.e., oxidation) and physical reactions (i.e., phase changes:
solid - liquid - gaseous - condensing back to liquid and then solid
over time). All this would render the phase of the matter entering the
wing as mixed plasma and gas anyway, all of which would contain
increasing amounts of wing materials mixed and in suspension, entrained
with the flow, further confusing the situation.

Herb, even the gas at the hottest point the shock is still only
weakly ionized. The reentry 'plasma' is still overwhelmingly composed
of neutral atoms and molecules.

The gas inside the wing *would* have been contaminated with aluminum
vapor, though, and that would contribute substantially to the electron
density at a temperature at which ordinary air would have very low ionization.

Paul

jeff findley wrote in message ...
"Steven D. Litvintchouk" writes:

There's lots more but as you can see, NASA has a whole lot of reform to
do. And that's going to require a big infusion of lots of new blood.

New, experienced blood. NASA has, in the past, attracted college
graduates who've spent their entire career at NASA and have become
fully assimilated into the NASA culture. They are, in fact, a great
contributor to NASA culture. They're part of the source of arrogance.
They see themselves as the best and brightest. Unfortunately, the
best and brightest out of college does not necessarily make them the
best and brightest for the remainder of their careers.

Jeff

Where will this new experienced blood come from? We make more lawyers
than engineers these days. In my goings around in the aerospace field
many ( dare I say most ) are ready for retirement.

Perhaps we could look at other high-risk engineering fields. Gee we
haven't built a new atomic power plant since 1978. We'll have to use
ex-Navy types there.

The biomedical engineering field is another where attention to detail
is extremely important, but how does NASA and the aerospace community
in general woo these people? They are quite used to important things
like job security being more than a project's cancellation away.

Automotive safety engineers might make good candidates. They are used
to job insecurity! But then Detroit's track record of compromising
safety for economics is infamous.

Maybe the best place to look for experienced types is in the armed
forces themselves. Both the USAF and the USN have greatly improved
flying safety over the past 40 years without diminishing operational
capability. During this time the military even added risky things like
Red-Flag and Top-Gun. Yet the accident rate went down. We last had a
major loss of nuclear vessel in 1968, so I would say the submarine
forces are doing something right.

The sub forces themselves were shaped by Hyman Rickover. He had
immense control over the entire operation for a very long time and
today's sub forces are the living legacy of Rickover. Perhaps the
legacy of bull-nosed guys like Chris Kraft and Gene Kranz has worn
off. They were NASA'S Rickovers.

Gene

(Gene DiGennaro) wrote in
om:

The sub forces themselves were shaped by Hyman Rickover. He had
immense control over the entire operation for a very long time and
today's sub forces are the living legacy of Rickover. Perhaps the
legacy of bull-nosed guys like Chris Kraft and Gene Kranz has worn
off. They were NASA'S Rickovers.

I wouldn't be too sure about that. After Kranz left the flight director
office, he served at the FOD/MOD console (and as such was a member of the
MMT), then as chief of MOD itself, through 1994. As such, he was privy to
the post-launch video/film analysis reports, post-landing tile damage
reports, and Flight Readiness Review presentations. He knew about the ET
foam shedding problem - there can be absolutely *no* doubt about that.
Arguably, he is part of the generation of management who "got comfortable"
with the problem.

Kraft retired in 1982, so that gets him off the hook for the foam shedding
problem. But he also chaired a committee whose influential 1995 report
convinced NASA to treat the shuttle as "operational" - which the CAIB is
now convinced was a mistake.
--
JRF

Reply-to address spam-proofed - to reply by E-mail,
check "Organization" (I am not assimilated) and
think one step ahead of IBM.

"Derek Lyons" wrote in message
...
(Gene DiGennaro) wrote:

Perhaps the legacy of bull-nosed guys like Chris Kraft and Gene Kranz
has worn off. They were NASA'S Rickovers.

Let's hope not. Rickover did as much harm as good.

Please expand.

Derek Lyons wrote:
"Richard Henry" wrote:

"Derek Lyons" wrote in message
...

(Gene DiGennaro) wrote:


Perhaps the legacy of bull-nosed guys like Chris Kraft and Gene Kranz
has worn off. They were NASA'S Rickovers.

Let's hope not. Rickover did as much harm as good.

Please expand.



He repeatedly attempted to gain control over submarine specification
and design, something he was not qualified to do. He repeatedly
promised advances reactors, which he did not supply, while stifling
research with the other hand. He repeatedly tried to gain control
over submarine operations, which was decidely outside both his purview
and experience. He repeatedly attempted to change propulsion designs
from the proven scheme (reduction geared turbines) to more advanced
schemes (none of which ever performed well in service). The need to
politically pacify him warped the designs of both the 688 and 726
classes.

D.

True, Rickover kept a stranglehold on nuclear submarine development, so
much so that ripples still run through the community. Only now is the
operational side starting to get more attention and funding than the
engineering group. Still, the legacy of Rickover continues...a
commanding officer needs an outstanding reactor examination if he
expects to make O6.

At NASA, however, the Kraft/Kranz legacy was lost in the 80's (or
earlier). So, I don't think you can draw a comparison with Rickover.