Richard Lawrence - The Mammoth Book of Space Exploration and Disaster

The Commission concluded that other factors contributed to the accident.

The decision to launch the Challenger was flawed. Those who made that decision were unaware of the recent history of problems concerning the O-rings and the joint and were unaware of the initial written recommendation of the contractor advising against the launch at temperatures below 53 degrees Fahrenheit and the continuing opposition of the engineers at Thiokol after the management reversed its position. They did not have a clear understanding of Rockwell’s concern that it was not safe to launch because of ice on the pad. If the decision makers had known all of the facts, it is highly unlikely that they would have decided to launch 51-L on January 28, 1986.

The Commission made the following findings:

1. The Commission concluded that there was a serious flaw in the decision-making process leading up to the launch of flight 51-L. A well-structured and managed system emphasizing safety would have flagged the rising doubts about the Solid Rocket Booster joint seal. Had these matters been clearly stated and emphasized in the flight readiness process in terms reflecting the views of most of the Thiokol engineers and at least some of the Marshall engineers, it seems likely that the launch of 51-L might not have occurred when it did.

2. The waiving of launch constraints appears to have been at the expense of flight safety. There was no system which made it imperative that launch constraints and waivers of launch constraints be considered by all levels of management.

3. The Commission is troubled by what appears to be a propensity of management at Marshall to contain potentially serious problems and to attempt to resolve them internally rather than communicate them forward. This tendency is altogether at odds with the need for Marshall to function as part of a system working toward successful flight missions, interfacing and communicating with the other parts of the system that work to the same end.

4. The Commission concluded that the Thiokol Management reversed its position and recommended the launch of 51-L at the urging of Marshall and contrary to the views of its engineers in order to accommodate a major customer.

The Commission is concerned about three aspects of the ice-on-the-pad issue.

1. An analysis of all of the testimony and interviews establishes that Rockwell’s recommendation on launch was ambiguous. The Commission finds it difficult, as did Mr Aldrich, to conclude that there was a no-launch recommendation. Moreover, all parties were asked specifically to contact Aldrich or other NASA officials after the 9:00 Mission Management Team meeting and subsequent to the resumption of the countdown.

2. The Commission is also concerned about the NASA response to the Rockwell position at the 9:00 a.m. meeting. While it is understood that decisions have to be made in launching a Shuttle, the Commission is not convinced Levels I and II appropriately considered Rockwell’s concern about the ice. However ambiguous Rockwell’s position was, it is clear that they did tell NASA that the ice was an unknown condition. Given the extent of the ice on the pad, the admitted unknown effect of the Solid Rocket Motor and Space Shuttle Main Engines ignition on the ice, as well as the fact that debris striking the Orbiter was a potential flight safety hazard, the Commission finds the decision to launch questionable under those circumstances. In this situation, NASA appeared to be requiring a contractor to prove that it was not safe to launch, rather than proving it was safe. Nevertheless, the Commission has determined that the ice was not a cause of the 51-L accident and does not conclude that NASA’s decision to launch specifically overrode a no-launch recommendation by an element contractor.

3. The Commission concluded that the freeze protection plan for launch pad 39B was inadequate. The Commission believes that the severe cold and presence of so much ice on the fixed service structure made it inadvisable to launch on the morning of January 28, and that margins of safety were whittled down too far.

Additionally, access to the crew emergency slide wire baskets was hazardous due to ice conditions. Had the crew been required to evacuate the Orbiter on the launch pad, they would have been running on an icy surface. The Commission believes the crew should have been made aware of the condition; greater consideration should have been given to delaying the launch.

The Commission concluded that the causes of the accident were rooted in the Shuttle’s original design.

The Space Shuttle’s Solid Rocket Booster problem began with the faulty design of its joint and increased as both NASA and contractor management first failed to recognize it as a problem, then failed to fix it and finally treated it as an acceptable flight risk.

Morton Thiokol, Inc., the contractor, did not accept the implication of tests early in the program that the design had a serious and unanticipated flaw. NASA did not accept the judgment of its engineers that the design was unacceptable, and as the joint problems grew in number and severity NASA minimized them in management briefings and reports. Thiokol’s stated position was that “the condition is not desirable but is acceptable.”

Neither Thiokol nor NASA expected the rubber O-rings sealing the joints to be touched by hot gases of motor ignition, much less to be partially burned. However, as tests and then flights confirmed damage to the sealing rings, the reaction by both NASA and Thiokol was to increase the amount of damage considered “acceptable.” At no time did management either recommend a redesign of the joint or call for the Shuttle’s grounding until the problem was solved.

Finally the Commission concluded that:

The genesis of the Challenger accident – the failure of the joint of the right Solid Rocket Motor – began with decisions made in the design of the joint and in the failure by both Thiokol and NASA’s Solid Rocket Booster project office to understand and respond to facts obtained during testing.

The Commission has concluded that neither Thiokol nor NASA responded adequately to internal warnings about the faulty seal design. Furthermore, Thiokol and NASA did not make a timely attempt to develop and verify a new seal after the initial design was shown to be deficient. Neither organization developed a solution to the unexpected occurrences of O-ring erosion and blow-by even though this problem was experienced frequently during the Shuttle flight history. Instead, Thiokol and NASA management came to accept erosion and blow-by as unavoidable and an acceptable flight risk. Specifically, the Commission has found that:

1. The joint test and certification program was inadequate. There was no requirement to configure the qualifications test motor as it would be in flight, and the motors were static tested in a horizontal position, not in the vertical flight position.

2. Prior to the accident, neither NASA nor Thiokol fully understood the mechanism by which the joint sealing action took place.

3. NASA and Thiokol accepted escalating risk apparently because they “got away with it last time.” As Commissioner Feynman observed, the decision making was:

“a kind of Russian roulette… (The Shuttle) flies (with O-ring erosion) and nothing happens. Then it is suggested, therefore, that the risk is no longer so high for the next flights. We can lower our standards a little bit because we got away with it last time. You got away with it, but it shouldn’t be done over and over again like that.”

4. NASA’s system for tracking anomalies for Flight Readiness Reviews failed in that, despite a history of persistent O-ring erosion and blow-by, flight was still permitted. It failed again in the strange sequence of six consecutive launch constraint waivers prior to 51-L, permitting it to fly without any record of a waiver, or even of an explicit constraint. Tracking and continuing only anomalies that are “outside the data base” of prior flight allowed major problems to be removed from and lost by the reporting system.