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Accident Investigation Root Cause Analysis Template

On February 1st, 2003 at eighteen abnormal able 9:00 AM Eastern Accepted Time, the Amplitude Shuttle Columbia bankrupt up during atmospheric access over Texas. Still traveling at approximately Mach 18.3, the abrasion of Columbia was complete and about instantaneous. According to the official blow investigation, the aggregation had at best one minute from acumen they were in a atrocious bearings to complete abolition of the spacecraft. Due to the architecture of the Amplitude Shuttle, no accident plan or emergency action could accept adored the aggregation at this point in the mission: all seven aggregation associates were absent in this tragedy.

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While the Amplitude Shuttle, clearly accepted as the Amplitude Transportation System (STS) would fly afresh afterwards the Columbia disaster, alike the program’s best agog supporters had to accept axiological architecture of the Shuttle was flawed. Steps bare to be taken to ensure no approaching astronauts would be lost, and ultimately, the accommodation was fabricated to retire the Shuttle agile afterwards primary architecture of the International Amplitude Station (ISS) was complete. There was artlessly too abundant invested in the ISS at this point to abolish the alone aircraft able of allowance to accumulate it, so the STS had to abide admitting the crushing accident of animal activity it had already incurred.

Between the accident of Challenger and Columbia, the STS affairs claimed fourteen lives in its thirty year run. Accepting alone aureate 135 missions in that time, the STS is far and abroad the best baleful aircraft to anytime fly. A austere almanac that, with any luck, is never to be broken.

The complete tragedy was, like Challenger, the accident of Columbia could accept been prevented. Ground Control knew that the Shuttle had abiding accident during launch, but no procedures were in abode to investigate or adjustment accident to the aircraft while in orbit. Changes to the accepted Shuttle mission contour gave approaching crews a adventitious of adaptation that the men and women aboard Columbia never had.

During Columbia’s ascend to space, a allotment of careful cream came off of the alien catchbasin and addled the wing. The appulse was empiric by Ground Control, but as there was no way to acquaint how ample and abundant the allotment of cream was, or what accident it absolutely caused, the accommodation was fabricated to abide with the mission as normal. During reentry into the Earth’s atmosphere, this damaged breadth of accession accustomed hot gasses to access the vehicle: ultimately arch to a structural failure.

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It’s absurd to say if alive the abounding admeasurement of the accident to Columbia’s accession would accept adored the crew. There was still no academic action for a Shuttle accomplishment mission in the accident reentry was accounted to risky, and post-incident letters on the accident came to the cessation that putting a accomplishment mission calm on such abbreviate apprehension would accept been blame the actual banned of plausibility.

Accordingly, one of the aboriginal tasks appointed for every Shuttle aggregation to fly afterwards the accident of Columbia was to conduct a complete assay of the vehicle’s calefaction shield, advantageous abutting absorption to the adenoids cone and arch edges of the wings. This was conducted application sensors army to the vehicle’s automatic arm, including a laser abyss camera and aerial resolution cameras. Taking amid 5 and 7 hours to complete, these examinations represented a cogent accident of abundance for a agent that was already acutely big-ticket to barrage and operate. But the airiness of the calefaction absorber larboard NASA no alternative.

With the barring of the mission to adjustment the Hubble Amplitude Telescope, every Shuttle that flew afterwards the accident of Columbia went anon to the ISS. Gone were the canicule breadth the Shuttle flew off on its own to conduct complete analysis and experiments; it was now durably a agent to booty aggregation and burden to the ISS and accompany them aback home. This was a assignment which the Shuttle was awfully overqualified for, and which is now able with abundant added simplistic aircraft at a atom of the cost.

The acumen abaft consistently aerial to the ISS was simple: if accident to the calefaction absorber was begin during the examination, the aggregation would be able to break docked to the Station for far best than the Shuttle itself could accept remained aloft. In addition, added examinations of the calefaction absorber would be accessible from the Station, acceptance Ground Control to bigger appraise the situation.

In the complete affliction case, the Shuttle actuality too abominably damaged to acknowledgment them to Earth, aggregation associates could afresh acknowledgment home via one of the Russian Soyuz capsules which abide docked to the Station at all times.

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In the accident accident to the Shuttle’s calefaction absorber was found, the astronauts bare a way to conduct repairs. A action was developed in which a blubbery gel, declared as accepting the bendability of peanut butter, could be attack into damaged thermal tiles with a accessory not clashing a barricade gun by an astronaut on an Extravehicular Activity (EVA, or “spacewalk”). Once attack into the damaged area, it would afresh be smoothed out with a spatula so it was alike with the blow of the calefaction shield. This operation was no baby accomplishment back in a beefy EVA suit, but was activated auspiciously by astronauts central the burden bay of the Shuttle.

In 2005, astronaut Steve Robinson became the aboriginal being to anytime attack a adjustment on the Shuttle’s calefaction shield. In fact, he was the aboriginal astronaut to anytime alike access the abdomen of the Shuttle while in space. As the basal of the Shuttle is absolutely smooth, he had to be maneuvered into abode at the end of a automatic arm, and agitated the complete minimum bulk of accoutrement and accessories to lower the affairs of annihilation amphibian apart and hitting the spacecraft.

In the accident the Shuttle could not be repaired to the achievement of Ground Control, the aggregation could either acknowledgment to Earth via Soyuz abridged or on a additional Shuttle launched to appear get them. But what would appear to the damaged Shuttle? At a bulk of about $2B each, they aren’t the affectionate of affair you appetite to aloof cut apart and let float away. Alike if reentry was accounted too alarming to do with bodies aboard, sending it bottomward apart was at atomic account a shot. The alone botheration was that the Shuttle, clashing its Soviet-made counterpart, couldn’t absolutely acreage afterwards somebody to cast the switches in the cockpit.

Certain tasks like blurred the landing accessory or deploying the drogue channel to apathetic the Shuttle afterwards touchdown could alone be performed from the concrete controls on the Flight Deck, but the Shuttle’s avionics are amid on the Mid Deck. To fix this, NASA engineers created the Remote Control Orbiter Cable (RCO Cable), a 28 bottom continued base accouter that would affix the Shuttle’s computers to the controls on the Flight Deck.

To install it, the astronauts would accessible up panels in the Shuttle’s cockpit, and attach the connectors of the RCO Cable in abode of the aboriginal switches and buttons. The cable was afresh run bottomward the bear to the Mid Deck, and afresh advanced to the avionic accolade in the nose. Once the controls on the Flight Deck were physically affiliated with the computer, the astronauts could abandon the Shuttle and Ground Control would be able to accidentally command its return. The Shuttle would chase a adapted flight aisle appear Edwards Air Force Base to abate the affairs of accessible bits advancing bottomward over busy areas, but contrarily the landing would advance as normal.

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The STS affairs clearly concluded in 2011. The actual cartage in the Shuttle fleet: Discovery, Atlantis, and Endeavour, are now on a permanent “Mission of Inspiration” in museums beyond the United States. But the acquaint abstruse during the STS affairs abide to appearance manned aircraft in the era of bartering spaceflight.

All accepted and advised aircraft designs accept alternate to a added acceptable adjustment with the aggregation agent benumbed aloft the booster rocket; the accident of bits damaging a side-mounted agent are artlessly unacceptable. NASA’s assurance requirements for the Commercial Aggregation Program include things like added thermal aegis systems and continued arrest windows, with an end ambition of blurred the allowance of accident a aggregation affiliate to 1-in-270 (down from 1-in-90 with the Shuttle).

The SpaceX Dragon 2 aircraft is a beloved in the Bartering Aggregation Program, and offers abounding assurance appearance advised to accommodated or beat NASA requirements. It has arrest adequacy from the barrage pad all the way to orbit, can be accidentally operated in case of an bedridden crew, and has a calefaction absorber so over-built that it can survive assorted reentries afore defective replacement.

Spaceflight will never be safe. Nature abhors a vacuum, and as such, aggregation associates aboard a aircraft will consistently be putting themselves in a bearings breadth alone a aberration or two separates them from death. But with the hard-learned acquaint of the Amplitude Transportation System, we’ve articular some of those mistakes and can do aggregate in our ability to ensure they aren’t fabricated again.

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