After 120 days, 122,000 pages of evidence and dozens of hearings, the commission on the space shuttle Challenger concluded Monday in its report to President Reagan that the ”faulty design” of a simple seal on a booster rocket caused the shuttle accident that killed seven astronauts.
But the commission also concluded that flawed management practices at the National Aeronautics and Space Administration, driven by ”relentless”
schedule and budget pressures, were just as much to blame.
And commissioners said they were ”surprised” to find NASA`s safety oversight practices had become a ”silent safety program” plagued by gaps in communication that kept crucial information from top launch managers.
The report does not assess blame against individuals, but it comes close in identifying some testimony from the booster project manager, Lawrence Mulloy, which commissioners found erroneous. Mulloy has since been reassigned. Commissioners said they found it ”disturbing” that the history of concern over the rocket seal was not adequately communicated to top agency officials, despite Mulloy`s testimony to the contrary.
And panel members also said NASA initially ”appeared to be withholding information about the accident from the public,” suggesting this was due to
”the trauma resulting” from the tragedy.
The glossy, 256-page report of the 13-member presidential commission capped an exhaustive 120-day investigation with a detailed description of how NASA failed to fix the defective joint even though its problems had been documented in internal memos since 1977.
Illustrated with dramatic color photographs of the Jan. 28 accident, the panel makes nine recommendations, including calls for a redesign of the rocket joint, a reorganization of NASA management and communications, revamped internal safety procedures with a greater role for astronauts, a study of ways for future crews to bail out in emergencies and a flight schedule consistent with the space agency`s resources.
”Our objective has been not only to prevent any recurrence of the failure related to this accident, but to the extent possible, to reduce other risks in future flights,” said Commission Chairman William Rogers in a cover letter to Reagan.
”However, the commission did not construe its mandate to require a detailed evaluation of the entire shuttle system,” he added. ”The nation`s task now is to move ahead to return to safe space flight and to its recognized position of leadership in space.”
Rogers briefed congressional leaders on the report before heading to the White House for a signing ceremony with Reagan in the Rose Garden.
”Let me give my heartfelt thanks to the members and staff of the Rogers Commission,” Reagan said. ”They have performed their task with distinction and it was an arduous one. To a nation still suffering from the trauma of the loss of the Challenger and a brave crew it was often a painful duty.”
Reagan vowed to continue the shuttle program.
”We`ll simply do what has to be done to make our space program safe and reliable and a renewed source of pride to our nation,” he said. ”We`ve suffered a tragedy and a setback but we`ll forge ahead wiser this time and undaunted, as undaunted as the spirit of the Challenger and her seven heroes.”
Emerging from the earlier meeting with Rogers, Sen. Donald Riegle (D., Mich.) called for a special task force made up of members from Congress and the administration to ensure that the recommendations are implemented.
”I think the commission has done an exceptional job. I think they did get to the bottom of what happened,” Riegle said. But he said now that the problems have been highlighted, Congress had to move quickly to correct them. Rep. Manuel Lujan Jr. (R., N.M.) said he found the recommendations ”very good” but ”rather subdued.” In some respects, the commission didn`t go far enough, he said, noting, ”I believe there was some negligence involved inasmuch as NASA knew about problems with those joints.”
”There was negligence on the part of the contractor and NASA,” Lujan said, but he added that he did not see any basis for criminal action.
Morton Thiokol, Inc., makes the shuttle`s booster rockets. The report found that the firm`s managers reversed their own decision and overruled their own engineers when they recommended launching Challenger in dangerously cold weather in order ”to accommodate a major customer.”
NASA Administrator James Fletcher welcomed the report and pledged to carry out its recommendations, calling the findings and criticisms ”not unexpected and certainly not entirely undeserved.”
Fletcher pointed out that NASA works ”under the severe budget limitations and restrictions of our time” but, he vowed, ”we cannot and will not sacrifice safety concerns to budget limitations.”
The report opens with a dedication page titled ”In Memoriam” with a photograph of the Challenger crew and a Jan. 31 statement by Reagan beginning, ”The future is not free.”
The report does not resolve the question of when the crew died, stating merely that, ”All seven crew members perished.”
Also not in the final report was some of the more harsh language proposed for criticizing NASA, and a controversial 10th recommendation calling for continued support for NASA by the administration and the public was reduced to a ”concluding thought.”
Some commissioners argued that the observation, which includes praise of NASA`s ”spectacular achievements,” was not part of the commission`s mandate. To ensure their recommendations are followed, commissioners ordered the administrator of NASA to report to the President in a year on the agency`s progress.
The two most extensive recommendations dealt with the rocket joint and management of the shuttle program. First, commissioners said that NASA must change the design of the joint on the shuttle`s solid-fuel booster rockets.
The cause of the accident, the panel concluded, ”was the failure of the pressure seal in the aft field joint of the right solid-rocket motor. The failure was due to a faulty design unacceptably sensitive to a number of factors. These factors were the effects of temperature, physical dimensions, the character of materials, the effects of reusability, processing and the reactions of the joint to dynamic loading.”
Specifically, while the panel did not pinpoint the exact reason for the joint failure, the report concluded that a puff of smoke detected at the joint .678 seconds after the rockets ignited was burning grease, joint insulation and rubber O-rings. The O-rings are giant washer-like rings 12-feet in diameter that are supposed to keep 5,800-degree gases from escaping.
Commissioners did not explain how the seal apparently held for about a minute after the brief puff of smoke was seen, but they said Challenger went through ”several high-altitude wind-shear conditions,” starting at 37 seconds, that ”created forces on the vehicle with relatively large fluctuations.”
At 58.788 seconds after launch, ”a flickering flame” first appeared on the right booster at the same joint that grew in size until it burned the surface of the giant external tank, ultimately causing the structural collapse of that tank in a ”massive, almost explosive, burning.”
At this point, the shuttle disintegrated in a fireball while traveling 1.92 times the speed of sound at an altitude of 46,000 feet and the orbiter broke into several large sections.
Photographs in the report identify pieces of the tail section with the main engines still burning, one of the wings and the crew compartment in the nose, ”trailing a mass of umbilical lines pulled loose from the payload bay.”
As for the shuttle`s management structure, the report criticized a tendency of NASA employees to feel more accountable to managers at the center where they work than to headquarters program managers. It called for a redefinition of the shuttle program manager`s job and strengthening of his authority and urged a stronger role for astronauts in management.
It also ordered NASA to establish an internal shuttle Safety Advisory Panel reporting to the program manager to review launch, operations and flight decisions.
Briefly, the other seven recommendations urge NASA to:
— Review all critical shuttle components whose failure could lead to a catastrophe and get an audit panel appointed by the National Research Council to approve them bfore resuming flights.
— Establish an Office of Safety, Reliability and Quality Assurance that would be headed by an associate administrator, have agencywide authority, ensure adequate oversight and be independent of other shuttle program responsibilities.
— Eliminate a tendency toward ”management isolation” at Marshall Space Flight Center, Huntsville, Ala., which oversees shuttle propulsion systems. Such a tendency resulted in failure of the center to provide ”full and timely information bearing on the safety” of the Challenger flight to top launch managers.
— Fix problems that concern astronauts in the tire, brake and nosewheel steering systems before attempting landings at Kennedy Space Center, Fla.
— Make every effort to provide a crew escape system to allow astronauts to bail out with parachutes during a controlled, low-altitude glide if they are forced to ditch on the ocean or when an emergency landing is not possible. — Establish a flight rate that is consistent with the agency`s resources to limit ”relentless pressure” on NASA to meet schedules and attract customers.
— Establish a system to spot dangerous trends in critical items and ensure safe maintenance and inspection, and also to stop the practice of cannibalizing one orbiter for spare parts.
