When the first of many loud alarms sounded on the space shuttle Columbia, the seven astronauts had about a minute to live, though they didn't know it.
The pilot, William McCool, pushed several buttons trying to right the ship as it tumbled out of control. He didn't know it was futile. Most of the crew were following NASA procedures, spending more time preparing the shuttle than themselves for the return to Earth.
Some weren't wearing their bulky protective gloves and still had their helmet visors open. Some weren't fully strapped in. One was barely seated.
In seconds, the darkened module holding the crew lost pressure. The astronauts blacked out. If the loss of pressure didn't kill them immediately, they would be dead from violent gyrations that knocked them about the ship.
In short, Columbia's astronauts were quickly doomed and most likely never knew what was happening.
If certain safety measures had been taken, the crew could have lived longer, but ultimately the Feb. 1, 2003, accident was not survivable, a NASA report released Tuesday concludes.
Even though parts of the 400-page report were redacted to protect the sensitivities of the astronauts' families, it represents the most graphic and harrowing account of the fliers' final moments as Columbia disintegrated over Texas.
The point of the analysis was to figure out how to make NASA's next spaceship more survivable. The report targeted problems with the spacesuits, restraints and helmets of the Columbia crew.
Astronaut Pam Melroy, deputy study chief, said the analysis showed the astronauts were at their problem-solving best trying to recover Columbia, which was starting to crack up as it re-entered Earth's atmosphere with a hole in its left wing, damage that had occurred at liftoff. "There was no way for them to know that it was going to be impossible."
The crew had lost control of the motion and direction of the spacecraft. It was pitching end-over-end, the cabin lights were out, and parts of the shuttle behind the crew compartment — including its wings — were falling off.
"It was a very disorienting motion going on," NASA deputy associate administrator Wayne Hale said in a telephone conference call. "There were a number of alarms going off simultaneously. The crew was trying very hard to regain control. We're talking about a brief time in a crisis situation."
The NASA study team is recommending 30 changes based on Columbia, many of them aimed at the spacesuits, helmets and seat belts for both the shuttle and the next space capsule NASA is building. Since the accident, NASA has quietly made astronauts put more priority on getting their protective suits on, Melroy said.
NASA's suits don't automatically pressurize, "a basic problem of suit design and it is one we intend to fix with future spacecraft," Hale said. And wearing the suit's gloves makes it difficult or impossible to perform many required tasks.
The report lists events that were each potentially lethal to the crew: loss of cabin pressure just before or as the cabin broke up; crew members, unconscious or already dead, crashing into objects in the module; exposure to a near vacuum at 100,000 feet; and crashing to the ground.
Killed in the Columbia disaster along with pilot McCool, were commander Rick Husband, Michael Anderson, David Brown, Kalpana Chawla, Laurel Clark, and Israel's first astronaut, Ilan Ramon.
Columbia was the second space shuttle NASA has lost. The hole in its wing was caused by a piece of foam insulation that broke off the fuel tank and slammed into it at launch. The shuttle Challenger blew up shortly after liftoff on 1986, also claiming seven lives. Investigators in both accidents pointed to a NASA culture of ignoring problems that later turned fatal.
Dr. Jonathan Clark, a former NASA flight surgeon and husband of Laurel Clark, praised NASA's leadership for the report "even though it says, in some ways, you guys didn't do a great job."
"I guess the thing I'm surprised about, if anything, is that (the report) actually got out," said Clark, who was a member of the team that wrote it. "There were so many forces" that didn't want to produce the report because it would again put the astronauts' families in the media spotlight.
NASA officials said the four years spent on the current report was due to many of its investigating members having other jobs, including ensuring the shuttle continues to fly safely.
Its release during a holiday week also was by design so that the children of deceased astronauts could absorb the report during a vacation week, said Pam Melroy, an astronaut and investigator.
"This is one of the hardest things I've ever done, technically and emotionally," she said.