What Went Wrong

TECHNICAL

• External Tank Insulation: The tanks shed foam, which has hit shuttles during takeoff on numerous occasions. Board members questioned the quality, application and inspection of the insulation and NASA's efforts to reduce debris strikes.
• Bolt-catchers: Baskets designed to catch bolts that explode to release spent solid rocket boosters from the shuttle can break and hit the shuttle.
• Carbon-reinforced composites: Panels that protect the leading edges of the wings from extreme temperatures during liftoff and return, are susceptible to aging and manufacturing defects.
• Stoody balls: Cracks found in the metal spheres roughly the size of golf balls that float inside the shuttle's liquid oxygen propellant lines did not constitute a safety hazard.
• Auxiliary power units: The turbines that generate hydraulic power for the shuttle's flight control surfaces and landing gear have overheated numerous times.
• Hold-down posts: Eight bolt-like posts hold the shuttle on its launch pad. Nuts on the posts explode to release the vehicle at liftoff. The system has not always worked as designed.

MANAGEMENT

• Shuttle: Budget, schedule, safety shortfalls; design trade-offs; mishandling of performance and safety upgrades; unclear lines of authority; staffing shortages; and miscommunication.
• Finances: NASA has tended to fit projects to available funds; and cost accounting has been poor to nonexistent.
• Shuttle Contract: Privatization and performance incentives may have affected safety and independence of component testing.
• Weighing Risks: Attention has focused on waivers of requirements, launch readiness, handling of in-flight problems and debris hits, the system for reporting and correcting problems, the aging of shuttles and whether safety margins are adequate.
• Safety: The panel reviewed whether NASA makes improvements and up-front investments to ensure safety.
• NASA Culture: The board studied the role of NASA's competing "tribes" of expertise and the "normalization of deviance" in both the Challenger and Columbia accidents.

Sourses: Minutes of Columbia Accident Investigation Board Open Meetings, The Washington Post