Loss of Signal - Aerospace Medical Association

190 Pages·2014·24.69 MB·English

National Aeronautics and
Space Administration
Loss of Signal

Aeromedical Lessons Learned from the
STS-107 Columbia Space Shuttle Mishap
Executive Editor
Philip C. Stepaniak
Editor in Chief
Helen W. Lane
Foreword
Jeffrey R. Davis
NASA/SP-2014-616

National Aeronautics and
Space Administration
Loss of Signal

Aeromedical Lessons Learned from the
STS-107 Columbia Space Shuttle Mishap
Executive Editor
Philip C. Stepaniak
Editor in Chief
Helen W. Lane
Foreword
Jeffrey R. Davis
Cover photos:
Front: An overall view of the shuttle flight control room in
Houston’s Mission Control Center (MCC) at the Johnson
Space Center (JSC). At the time this photo was taken, flight
controllers had just lost contact with the Space Shuttle
Columbia at 08:59:32 CST, February 1, 2003.
Back: The Space Shuttle Columbia is just about to clear
the tower at Launch Pad 39A for STS-107. Following a
flawless and uneventful countdown, liftoff occurred on-time
at 10:39 EST, January 16, 2003.
Spine: The United States flag, in front of the Johnson Space
Center’s (JSC) Project Management Facility (Bldg. 1), is flown
at half-staff in memory of the seven Space Shuttle Columbia
crewmembers who lost their lives on February 1, 2003.
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DEDICATED TO THE CREW OF COLUMBIA STS-107

From the left (bottom row), wearing red shirts to signify their shift’s color,

are astronauts Kalpana Chawla, mission specialist; Rick D. Husband, mission commander;

Laurel B. Clark, mission specialist; and Ilan Ramon (Israeli Space Agency), payload specialist.

From the left (top row), wearing blue shirts, are astronauts David M. Brown, mission specialist;

William C. McCool, pilot; and Michael P. Anderson, payload commander.

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Foreword
Jeffrey R. Davis
On the morning of February 1, 2003, the Space Shuttle 1986, the SLSD interfaced with the Department of
Columbia underwent a high-altitude, high-velocity Defense Manned Space Flight Program Support
breakup during the entry-to-landing phase of flight. Office (DOD DDMS), Patrick Air Force Base, Florida,
The external investigation by the Columbia Accident with preparation for launch and landing emergencies.
Investigation Board (CAIB) provided the overall causes After the Challenger accident, these efforts were
of the accident in a report that included an analysis by upgraded by enhancing crew safety including improved
the Crew Survivability Working Group to determine egress, escape, and bail-out procedures with the new
the cause of the crewmembers’ deaths and the lessons Launch Entry Suit. In preparation for return to flight
learned. The next year the Space Shuttle Program in 1988, the SLSD developed a flight surgeon training
commissioned the Spacecraft Crew Survival Integrated program, the Space Operations Medical Support
Investigation Team to perform a comprehensive analysis Training Course. These improvements led to a more
of the accident, focusing on factors and events affecting direct interface of NASA with DOD DDMS in training
crew safety and developing recommendations for medical personnel and trauma teams at landing sites
improving crew survival for future human space flight. in the United States and international locations on
This report was published in December 2008. equipment, procedures, and communications for
response, search, rescue, and recovery operations.
Loss of Signal presents the aeromedical lessons learned
In 1998, the SLSD Medical Operations Branch formed
from the Columbia accident that will enhance crew
a Contingency Medical Group, a cadre of flight
safety and survival on human space flight missions.
surgeons that specialized in preparation for any aviation
These lessons were presented to limited audiences
and spacecraft mishap. This group met with the Office
at three separate Aerospace Medical Association
of Armed Forces Medical Examiner and Armed Forces
(AsMA) conferences: in 2004 in Anchorage, Alaska,
Institute of Pathology2 in 1999 to renew and improve
on the causes of the accident; in 2005 in Kansas City,
the SLSD relationships with these organizations for
Missouri, on the response, recovery, and identification
mishap investigations. This coordination greatly
aspects of the investigation; and in 2011, again in
assisted the recovery and identification efforts during
Anchorage, Alaska, on future implications for human
the Columbia tragedy.
space flight. As we are embarking on the development
of new spacefaring vehicles through both government Loss of Signal summarizes and consolidates the
and commercial efforts, the NASA Johnson Space aeromedical impacts of the Columbia mishap process—
Center Space Life Sciences Directorate (SLSD)1 the response, recovery, identification, investigative
proceeded to make this information available to a studies, medical and legal forensic analysis, and future
wider audience engaged in the design and development preparation that are needed to respond to spacecraft
of future space vehicles. mishaps. The goal of this book is to provide an account
of the aeromedical aspects of the Columbia accident
Historically, the SLSD has always prepared for space
and the investigation that followed, and to encourage
flight mishaps. From the beginning of the Space Shuttle
aerospace medical specialists to continue to capture
Program with the launch of the first Space Shuttle
information, learn from it, and improve procedures and
mission in 1981 through the Challenger accident in
spacecraft designs for the safety of future crews.
1 The Space Life Sciences Directorate was renamed the Human Health and
Performance Directorate in 2012.
2 Armed Forces Institute of Pathology was disestablished in 2011 as part of the Base
Realignment and Closure Act.
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Preface and Acknowledgments

The editors of Loss of Signal wanted to document Our gratitude goes out to all members of the editorial
the aeromedical lessons learned from the Space board who guided us patiently through the various
Shuttle Columbia mishap. The book is intended to sections of this undertaking. We thank the NASA/
be an accurate and easily understood account of the Johnson Space Center Space and Clinical Operations
entire process of recovering and analyzing the human Division and NASA Human Research Program that
remains, investigating and analyzing what happened provided the financial resources.
to the crew, and using the resulting information to
We want to acknowledge the multitude of local,
recommend ways to prevent mishaps and provide better
state, and federal government agencies as well as
protection to crewmembers.
civilian agencies, especially citizen volunteers, whose
We organized this book into 5 sections— organizational efforts were a great achievement despite
the magnitude of this tragedy.
• The Mission
• The Response By going forward with these aeromedical lessons
• The Investigation learned to enhance crew safety and survival, we honor
the families of the crewmembers, who have lost
• The Analysis
their loved ones. We pay tribute to the crewmembers
• The Future
themselves for their courage. Their efforts and sacrifice
Our goal is to capture the passions of those who of their lives will benefit survival of future fliers in the
devoted their energies in responding to the Columbia exploration of space.
mishap. We have reunited authors who were directly
involved in each of these aspects. These authors tell the
story of their efforts related to the Columbia mishap Executive Editor
Philip C. Stepaniak
from their point of view. They give the reader an honest
description of their responsibilities and share their Editor in Chief
challenges, their experiences, and their lessons learned Helen W. Lane
on how to enhance crew safety and survival, and how to
be prepared to support space mishap investigations.
As a result of this approach, a few of the chapters have
some redundancy of information and authors’ opinions
may differ. In no way did we or they intend to assign
blame or criticize anyone’s professional efforts. All
those involved did their best to obtain the truth in the
situations to which they were assigned.
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Contents

Dedication ...........................................................................................iii

Foreword
Jeffrey R. Davis..........................................................................................iv

Preface and Acknowledgments ....................................................................... v

Editorial Board ......................................................................................viii

Introduction
Michael Barratt ..........................................................................................ix

Section 1 – The Mission ..................................................................... 1

The Mission and The Crew
Helen W. Lane, Smith Johnston, and John B. Charles ............................................................ 2

The Mishap
Stevan Gilmore and Charles Campbell ........................................................................ 8

Section 2 – The Response .................................................................17

Search and Recovery Team Operations
James D. Wetherbee ....................................................................................18

Mishap Investigation Team Medical Efforts for Crew Recovery and Identification
Philip C. Stepaniak, Michael R. Chandler, and Robert Patlach ......................................................32

Mishap Response and Lessons Learned: The Role of the Office of
the Armed Forces Medical Examiner and the Armed Forces Institute of Pathology
Craig Mallak ...........................................................................................41

Johnson Space Center Space Life Sciences Response and Crew Survival Investigation
Jeffrey R. Davis.........................................................................................49

Kennedy Space Center Operations – Commitment to Safety and Preparedness
Philip J. Scarpa ........................................................................................54

Crew Medical and Psychological Support Operations
Smith Johnston and Christopher Flynn .......................................................................65

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Section 3 – The Investigation .............................................................75

Columbia Accident Investigation Board Medical Operations and Crew Survivability Working Group
James P. Bagian........................................................................................76

The Columbia Crew Survival Investigation Report: The Five Potentially Lethal Events
and Crew Survivability
Nigel J. Packham, David J. Pogue, and Pamela A. Melroy ........................................................86

Section 4 – The Analysis ...................................................................95

Aerospace Medical Forensic Analysis
Michael Barratt, Robert Banks, Philip C. Stepaniak, and Helen W. Lane ..............................................96

Legal Analysis and Issues from Recovery and Investigation of the Columbia Accident
Donna M. Shafer and Amy V. Xenofos ......................................................................114

Section 5 – The Future .....................................................................123

Human Space Flight Incidents and Crew Survival Lessons Learned
Jonathan B. Clark......................................................................................124

The Future: Crew Survival Investigations
Karon Woods .........................................................................................134

Appendix .......................................................................................153

Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154

Selected Readings .................................................................................155

Recognition and Acknowledgments ................................................................156

Contributors’ Biographies ..........................................................................160

Index ..............................................................................................167

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Editorial Board
N. Wayne Hale, Jr. Peter W. Merlin
Editorial Board Chair Mr. Merlin is a Staff Historian and Senior Public Affairs
Specialist under contract to Jacobs Engineering at the
Mr. Hale retired from NASA in 2010 as the Deputy
NASA Armstrong Flight Research Center (AFRC),
Associate Administrator of Strategic Partnerships at
Edwards, California. He has written numerous articles,
NASA Headquarters in Washington, DC. Mr. Hale
technical papers and books, many of which were
served in the senior leadership of NASA’s Space
sponsored by NASA Aeronautics Mission Directorate’s
Shuttle Program from 2003 to 2008 including Launch
Office of Education and Communications. He was lead
Integration Manager at the Kennedy Space Center and
author of Breaking the Mishap Chain (NASA SP-2011-
then assignments as Deputy Program Manager and
594), author of Crash Course: Lessons Learned from
finally as Program Manager during the post-Columbia
Accidents Involving Remotely Piloted and Autonomous
return to flight effort. From 1988 to 2003, he was a Space
Aircraft (NASA SP-2013-600), and serves as editor for
Shuttle Flight Director for 40 Space Shuttle flights,
AFRC Public Affairs products.
and prior to that as an orbiter systems flight controller
in Mission Control for 15 early Space Shuttle flights.
Terrance A. Taddeo, MD
Dr. Taddeo is currently the Chief of the Space and
Donna M. Shafer, JD
Clinical Operations Division at the NASA Johnson
Editorial Board Legal Counsel
Space Center. Dr. Taddeo has been with NASA Space
Ms. Shafer is the Deputy Chief Counsel at the NASA and Clinical Operations since 1996.
Johnson Space Center. Ms. Shafer served as the
legal advisor to the Columbia Task Force and the David A. Tipton, MD
Spacecraft Crew Survival Integrated Investigation Dr. Tipton is the Kennedy Space Center (KSC)
Team which published the Columbia Crew Survival Chief Medical Officer. He has been with NASA at
Investigation Report. KSC for over 30 years and was involved with the KSC
aspects of both the Challenger and Columbia accident
Denise L. Baisden, MD investigations. Dr. Tipton was the Emergency Medical
Dr. Baisden is the Deputy Regional Flight Surgeon Services coordinator in the Launch Control Center at
for the Federal Aviation Administration’s Southwest KSC for the STS-107 mission.
Region. She was a NASA flight surgeon from 1989 to
2000 and served as the crew surgeon or deputy crew Laurence A. Ulissey, Colonel, USAF, MD
surgeon for 17 Space Shuttle missions. Dr. Baisden also Colonel Laurence A. Ulissey, MD is an active duty
served as the Chief of Flight Medicine at the NASA US Air Force flight surgeon assigned at NASA’s
Johnson Space Center. Johnson Space Center as a DOD Aerospace Medicine
Liaison Officer, and operational flight surgeon for
Jeffery R. Davis, MD the International Space Station Program. He was the
Dr. Davis is the Director, Human Health and Chief of Bioastronautics for the DOD Human Space
Performance and Chief Medical Officer at the NASA Flight Support Office from 2010 to 2012 in support
Johnson Space Center. of the Space Shuttle Program when he was stationed
at Patrick Air Force Base, Florida. During his active
Janet L. Kavandi, PhD duty tours with the US Air Force he has participated in
Dr. Kavandi is the Director of Flight Crew Operations Class-A aircraft mishap investigations throughout his
at the NASA Johnson Space Center, where she is assignments to Utah, Alaska, Florida, and Texas.
responsible for the NASA Astronaut Corps and the
Aircraft Operations Division at Ellington Field.

Dr. Kavandi was selected to the astronaut class of 1995,

and is a veteran of three Space Shuttle flights – STS-91,

STS-99, and STS-104. Dr. Kavandi served as the Lead

Casualty Assistance Calls Officer for the families of

the STS-107 crew.

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