Engineers, officials and the crew members' families provide their perspective on the 1986 Space Shuttle Challenger disaster and its aftermath.
1. Space for Everyone
The new Space Shuttle program captivates America and draws a diverse, determined crop of astronauts. But safety issues arise out of public view.
2. HELP!
To revive public interest, NASA chooses teacher Christa McAuliffe to be the first civilian on the Shuttle. Issues with the solid rocket boosters linger.
3. A Major Malfunction
After several delays, the crew prepares for launch as engineers, and NASA officials tensely discuss concerns about the O-rings and a cold weather launch.
4. Nothing Ends Here
Challenger's shocking explosion devastates the families of the crew as well as millions watching live, and an investigation puts NASA on the defensive.
Netflix’s ‘Challenger: The Final Flight’ Is a Story of Inspiration and Tragedy
The four-part documentary doesn’t reveal much new info about the space shuttle explosion that killed six astronauts and a high school social studies teacher, but it’s revealing nonetheless .
More than six months after the country caught the world’s worst case of coronavirus and some of its more sensible citizens retreated inside, the United States is still convulsing from the effects of its failed response to the pandemic. When we aren’t preoccupied by case counts and death tolls, our screens are sending us warnings of economic collapse, flashing scenes of repeated police violence, and reminding us that the leaders who are supposed to be bulwarks against chaos have, through a combination of cruelty and complacency, only exacerbated the suffering and deepened the divides. Which makes this a less than optimal time for Netflix to ask the question that its app is posing this week: Can we interest you in a four-part documentary about a devastating national tragedy?
As an alternative to the endless hours of low-stakes escapism that streaming services serve up to temporarily take our troubles away, Challenger: The Final Flight isn’t an easy sell. It’s a three-hour exhumation of a traumatic event that imprinted itself on the psyche of anyone who was watching when it went down. The new Netflix limited series, which debuted on Wednesday, chronicles the lead-up to, causes of, and fallout from the fiery disintegration of the space shuttle Challenger 73 seconds after its launch on January 28, 1986, which resulted in the deaths of its seven-member crew of six astronauts and high school social studies teacher Christa McAuliffe. The destruction of the Challenger was a horror that everyone who was watching live or on taped delay wished they could unsee. Yet The Final Flight makes a strong case for forcing oneself to see it again, even—or, perhaps, especially—at a time when we’re overwhelmed by the disasters unfolding in front of our eyes.
The Final Flight tells the alternately inspiring and dismaying story of the Challenger via archival clips, fresh footage from home movies, and new interviews with former shuttle program personnel and relatives of the fliers lost in the fatal launch. There’s no new information about how and why the catastrophe occurred; unlike some of the sensational subjects that have become fodder for Netflix nonfiction, the Challenger’s destruction is a mostly solved mystery. “Even from the pitching stage, we knew there wasn’t anything that was a huge reveal,” director Daniel Junge said in an interview conducted by Netflix and provided to the press.
Even without a huge reveal, though, the documentary is revealing, especially for those who learned about the Challenger long after the fact or never delved deeply into what went wrong. The documentary—developed by Glen Zipper and Steven Leckart, directed by Leckart and Junge, and executive produced by Zipper, J.J. Abrams, and others—examines why the shuttle program mattered so much to many Americans, and how its importance to the public intensified both the pressure that contributed to the Challenger’s loss and the crisis of confidence that followed.
In the wake of the war in Vietnam and the racial unrest and stagflation of the 1970s, “the country needed something to feel good about,” former astronaut Robert Crippen says in The Final Flight. The sleek space shuttle, a reusable successor to the Apollo program, represented progress, human mastery over orbit, and American ingenuity. “I think this epic flight of Columbia proves once again that the United States is number one,” NASA acting administrator Alan Lovelace declared when Columbia completed the program’s first fully operational mission in April 1981. If the shuttle’s triumphs were the country’s triumphs, then the shuttle’s failures would be blows to national pride.
A 1980s documentary excerpted in The Final Flight notes that the first shuttle’s inaugural launch marked the first time a U.S. space vehicle carried a crew on its maiden flight. Unlike the largely automated spacecraft of today, the shuttle, an incredibly complex machine governed mostly by manual controls, was inoperable apart from its crews. Many members of those crews came from NASA’s Class of 1978, the first post-Apollo group of astronaut recruits. That class, which was inclusive in comparison to the all-male, all-white Mercury, Gemini, and Apollo crews that preceded it, featured NASA’s first female astronauts, Black astronauts, and Asian American astronaut. STS-51-L, the 25th space shuttle mission and the Challenger’s last, carried two women (McAuliffe and Judith Resnik) and two non-white men (Ronald McNair and Ellison Onizuka) among its seven passengers.
The Final Flight gives McAuliffe and the rest of the crew their due through clips recorded in the months, weeks, and days leading up to the launch and via sit-downs with spouses, siblings, and colleagues. Some of those interview subjects dab discreetly at their eyes at emotional moments, but their wounds, while always apt to reopen, are somewhat scabbed over after 34 years. Most of the miniseries’ on-camera tears are shed by the engineers who knew there was a problem with the shuttle’s solid rocket booster (SRB) but didn’t do enough to intervene. Those are tears of remorse more than mourning, and the decades haven’t dried them.
The charismatic McAuliffe was the first civilian selected for a space mission as part of the Teacher in Space Project, which was intended to rekindle the public’s fervor for a space program that had started to seem almost mundane. NASA’s plan worked too well: McAuliffe’s quest captivated the public, ensuring that many Americans, including kids in schools with satellite setups, tuned in live for the launch or soon saw the news and gaped at the billowing curlicue that hung hauntingly in the air after the shuttle’s brief flight. “Obviously a major malfunction,” uttered a tightly controlled voice from mission control.
The mission was supposed to prove that space was accessible; “Spaceflight today really seems safe,” McAuliffe says in one old interview. Instead, it exposed NASA’s flaws. Although the three-man crew of Apollo 1 was killed in a cabin fire in a 1967 launch rehearsal test, NASA never lost an astronaut en route to space until the Challenger disaster. After putting the first men on the Moon, salvaging Apollo 13, and conceiving the futuristic shuttle, the agency was overconfident in its engineering know-how and approach to problem-solving and resistant to probabilistic risk analysis.
As The Final Flight makes clear, earlier shuttle launches had yielded evidence of dangerous degradation in the O-ring seals on the SRBs, 150-foot-tall cylinders full of combustible propellant that helped the shuttle overcome gravity in its first two minutes of flight. Some signs suggested that the O-rings were especially susceptible to failure in cold temperatures. The Challenger’s launch was rescheduled or scrubbed several times for various reasons, and the delays allowed time for a cold snap to set in and for temperatures in Florida to fall below freezing.
On a prelaunch conference call, engineers at NASA contractor Morton Thiokol, which manufactured the motor segments of the SRBs, objected to launching in those cold conditions. But NASA middle managers, prompted by pressure to keep the over-budget and behind-schedule shuttle program moving, browbeat Thiokol executives into giving their assent despite the continued trepidation of the company’s engineers. The launch went ahead, with precisely the result that the engine experts had feared. Months before his death in 2016, former Thiokol engineer Bob Ebeling was still lamenting the sequence of missteps that culminated in Thiokol giving the green light. Although Ebeling died before The Final Flight could capture his words, his daughter and a few of his fellow former engineers recount the concerns expressed at the fateful meetings leading up to the launch, which the documentary reenacts with period décor.
The Final Flight presents a stark contrast to space pablum like Away, the 10-episode series about a future crewed mission to Mars that Netflix released earlier this month. The series, which stars Hilary Swank, is an old-fashioned family drama masquerading as a thriller, which would work better if the relationships and earthbound backstories that eclipse the sci-fi weren’t so melodramatic and trite. It’s watchable, but best enjoyed with a companion who can join you in sputtering about confusing character motivations and scenes that don’t make sense.
Away is fundamentally idealistic, as are so many of the space dramas that free us from the limitations of life on Earth. When things go wrong—and things always go wrong—competent, passionate specialists rally to find a fix. Disaster strikes more because space is dangerous than because people are. In reality, both can kill you, and the latter threat is all the more insidious because it has a friendly face.
In the wake of the Challenger disaster, the agency covered up its culpability and stubbornly resisted pinpointing a cause; in one infamous press conference, a NASA briefer repeatedly referred to an apparent jet of flame in a photo of the streaking shuttle as an “anomalous plume.” Subsequent leaks revealed that NASA had ignored a memo about the O-ring threat and issued a waiver that certified the shuttle safe to fly. In June 1986, the Rogers Commission Report blamed both NASA and Thiokol for not responding appropriately to the known design flaw, and also found fault with NASA for the management structure and decision-making process that allowed the launch to proceed. Some of the parties responsible for what the commission labeled an “accident rooted in history” soon resigned.
Two of those men, former NASA officials Lawrence Mulloy and William Lucas, consented to interviews for The Final Flight. Now in their 80s or 90s, they assert that they made the best decisions they could given what they knew at the time. “I feel I was to blame, but I feel no guilt,” Mulloy states. Lucas says, “I didn’t do anything that I thought was wrong then, and I didn’t do anything that I think was wrong in retrospect,” adding that the loss of seven lives was a regrettable but unavoidable consequence of the perils of spaceflight. “How could they live with themselves for making a decision like that?” wonders June Scobee Rodgers, widow of commander Dick Scobee. Maybe maintaining and persuading themselves of their innocence was the way they went on living long after the crew perished. Neither is visibly upset when discussing the disaster, and their comments make for moments almost as chilling as Robert Durst’s apparent confession in HBO’s The Jinx.
But these men aren’t murderers, or even alleged ones. In a way, their actions (or inactions) are even more disturbing because they weren’t trying to do harm. “There’s no mustache-twirling villain,” Zipper told Netflix. “There’s no person who said, ‘We’re absolutely sure tragedy is inevitable, but launch it anyway.’ Everyone was trying to do their job and attempting to achieve a goal under enormous pressure. And sometimes when there is that kind of ambition coupled with pressure and expectation, the danger somehow gets lost in the mix.”
As The Final Flight makes clear, the footage of the Challenger’s last moments—mercifully replayed no more than necessary—is almost a snuff film, albeit one in which the crime amounts to manslaughter. It’s as agonizing to watch the Challenger ascent stop as it is to see Thích Quang Dúc set himself on fire, the Falling Man plummet from one of the Twin Towers, or George Floyd gasp for air beneath the knee of Derek Chauvin. Like those other indelible images, though, it demands our attention, lest we fail to learn from the mistakes and maliciousness that led to those deaths.
The Final Flight is hazy on certain points. It mentions complaints by some astronauts that civilians like McAuliffe constituted safety risks on space flights, but it doesn’t say whether that charge was well founded. Clearly, McAuliffe had nothing to do with NASA neglecting the O-rings, and it’s not clear from the film whether the willingness to welcome civilians on board sprang from the same lack of care that endangered the Challenger. The documentary also elides the difficulties faced by the Thiokol engineers who talked to the Rogers Commission. Most important, it underplays the persistence of systemic problems.
The Final Flight ends on an up note, covering NASA’s triumphant return to space via Discovery’s safe launch in 1988, after a two-plus-year hiatus and an SRB overhaul. “After the redesign, no solid rocket booster ever failed again,” a chyron explains, celebrating the 86 successful shuttle missions launched over the 15 years that followed STS-51-L. The 87th one wasn’t so fortunate: On February 1, 2003, the Columbia broke up on reentry, killing all seven members of its crew. “An investigation revealed a similar failure to fix a well-documented issue,” The Final Flight’s chyron concedes.
Although the specific problem that doomed The Challenger was corrected, another known problem with insulating foam was permitted to persist. A piece of that foam broke off and damaged the Columbia’s heat shield, which led to the shuttle’s demise. Again an investigation turned up organizational issues, and again the shuttle program was paused. NASA learned something from the Challenger, but not enough. And just this week, a congressional report on Boeing’s 737 Max crashes showed that the tradition of institutional failure is still with us.
The country needs something to feel good about at least as urgently in 2020 as it did in the ’70s, and spaceflight still has the capacity to uplift us figuratively as well as physically. This spring, SpaceX sent NASA astronauts to orbit from American soil for the first time since the shuttle was retired. The public-private partnership that enabled that milestone launch made space seem within widespread reach, as McAuliffe’s mission was designed to do. But it didn’t uplift us for long. The achievement of safely putting people in space only made it more galling that back on the planet’s surface, the same country rejected science and avoided taking basic steps to stop the spread of disease.
In one of The Final Flight’s interviews, McAuliffe’s sister remembers speaking to the teacher the night before the launch. McAuliffe admitted to feeling a few butterflies. “I had asked her about the ice and the coldness, and she said that she felt that they would take care of that, that she had full faith in NASA,” the sister says. At the time, that trust seemed reasonable. But as the next day’s destruction demonstrated and the events of 2020 have recently reminded us, placing full faith in any of the people, policies, or systems that are supposed to protect us is a recipe for disillusionment—and, all too often, avoidable deaths.
Click here to see diagram
The Space Shuttle solid rocket booster field joint assembly (from the Rogers
Findings :
The Space Shuttle solid rocket booster field joint assembly (from the Rogers Commission report)
The commission found that the immediate cause of the Challenger accident was a failure in the O-rings sealing the aft field joint on the right solid rocket booster, causing pressurized hot gases and eventually flame to "blow by" the O-ring and contact the adjacent external tank, causing structural failure. The failure of the O-rings was attributed to a design flaw, as their performance could be too easily compromised by factors including the low temperature on the day of launch.
"An accident rooted in history"
More broadly, the report also determined the contributing causes of the accident. Most salient was the failure of both NASA and its contractor, Morton Thiokol, to respond adequately to the design flaw. The Commission found that as early as 1977, NASA managers had not only known about the flawed O-ring, but that it had the potential for catastrophe. This led the Rogers Commission to conclude that the Challenger disaster was "an accident rooted in history".[4]
Flawed launch decision:
The report also strongly criticized the decision-making process that led to the launch of Challenger, saying that it was seriously flawed. Morton Thiokol called a meeting the night before the launch to raise concerns over the forecast temperature in regards to the O-rings. During the meeting, Morton Thiokol's engineers issued a recommendation "not to launch below 53F", the previous lowest temperature of a launch (STS-51C, a year earlier). The NASA managers challenged this and after a 30 minute offline caucus, Morton Thiokol's senior management overruled their engineers decision and gave the launch the go-ahead. The concerns were not communicated beyond the Level III Flight Readiness Review (FRR).[5] It is certain that even though members of higher FRR teams knew about the issues, there were plenty of members who could have stopped the launch but decided not to. This was done in large part because of the management structure at NASA and the lack of major checks and balances, which proved to be fatal in this scenario.[citation needed][6] The report concluded that:
... failures in communication ... resulted in a decision to launch 51-L based on incomplete and sometimes misleading information, a conflict between engineering data and management judgments, and a NASA management structure that permitted internal flight safety problems to bypass key Shuttle managers.[5]
Role of Richard Feynman
edit
Learn more
This section may be too long to read and navigate comfortably. (September 2021)
I took this stuff that I got out of your seal and I put it in ice water, and I discovered that when you put some pressure on it for a while and then undo it, it maintains, it doesn't stretch back. It stays the same dimension. In other words, for a few seconds at least and more seconds than that, there's no resilience in this particular material when it's at a temperature of 32 degrees [Fahrenheit]. I believe that has some significance to our problem.
— Richard Feynman, [7]
One of the commission's best-known members was theoretical physicist Richard Feynman. His style of investigating with his own direct methods rather than following the commission schedule put him at odds with Rogers, who once commented, "Feynman is becoming a real pain."[8] During a televised hearing, Feynman famously demonstrated how the O-rings became less resilient and subject to seal failures at low temperatures by compressing a sample of the material in a clamp and immersing it in a glass of ice water.[7] Feynman's own investigation reveals a disconnect between NASA's engineers and executives that was far more striking than he expected. His interviews of NASA's high-ranking managers revealed startling misunderstandings of elementary concepts. One such concept was the determination of a safety factor.[9]
In one example, early tests resulted in some of the booster rocket's O-rings burning a third of the way through. These O-rings provided the gas-tight seal needed between the vertically stacked cylindrical sections that made up the solid fuel booster. NASA managers recorded this result as demonstrating that the O-rings had a "safety factor" of 3. Feynman incredulously explains the magnitude of this error: A "safety factor" refers to the practice of building an object to be capable of withstanding more force than the force to which it will conceivably be subjected. To paraphrase Feynman's example, if engineers built a bridge that could bear 3,000 pounds without any damage, even though it was never expected to bear more than 1,000 pounds in practice, the safety factor would be 3. If a 1,000-pound truck drove across the bridge and a crack appeared in a beam, even just a third of the way through a beam, the safety factor is now zero: The bridge is defective, there was no safety factor at all even though the bridge did not actually collapse.[9]
Feynman was clearly disturbed by the fact that NASA management not only misunderstood this concept, but inverted it by using a term denoting an extra level of safety to describe a part that was actually defective and unsafe. Feynman continued to investigate the lack of communication between NASA's management and its engineers, and was struck by management's claim that the risk of catastrophic malfunction on the shuttle was 1 in 105, i.e. 1 in 100,000. Feynman immediately realized that this claim was risible on its face; as he described, this assessment of risk would entail that NASA could expect to launch a shuttle every day for the next 274 years while suffering, on average, only one accident. Investigating the claim further, Feynman discovered that the 1 in 105 figure was stating what they claimed the failure rate ought to be, given that it was a manned vehicle, and working backward to generate the failure rate of components.[9]
Feynman was disturbed by two aspects of this practice. First, NASA management assigned a probability of failure to each individual bolt, sometimes claiming a probability of 1 in 108, i.e. one in one hundred million. Feynman pointed out that it is impossible to calculate such a remote possibility with any scientific rigor. Secondly, Feynman was bothered not just by this sloppy science but by the fact that NASA claimed that the risk of catastrophic failure was "necessarily" 1 in 105. As the figure itself was beyond belief, Feynman questioned exactly what "necessarily" meant in this context, whether it meant that the figure followed logically from other calculations or that it reflected NASA management's desire to make the numbers fit.[9]
Feynman suspected that the 1 in 105 figure was wildly fantastical, and made a rough estimate that the true likelihood of shuttle disaster was closer to 1 in 100. He then decided to poll the engineers themselves, asking them to write down an anonymous estimate of the odds of shuttle explosion. Feynman found that the bulk of the engineers' estimates fell between 1 in 50 and 1 in 200 (at the time of retirement, the Shuttle suffered two catastrophic failures across 135 flights, for a failure rate of 1 in 67.5). Not only did this confirm that NASA management had clearly failed to communicate with their own engineers, but the disparity engaged Feynman's emotions. When describing these wildly differing estimates, Feynman briefly lapses from his damaging but dispassionate detailing of NASA's flaws to recognize the moral failing that resulted from a scientific failing: he was upset NASA presented its fantastical figures as fact to convince a member of the public, schoolteacher Christa McAuliffe, to join the crew. Feynman was not uncomfortable with the concept of a 1⁄100 risk factor, but felt strongly that the recruitment of laypeople required an honest portrayal of the true risk involved.[9]
Feynman's investigation eventually suggested to him that the cause of the Challenger disaster was the very part to which NASA management so mistakenly assigned a safety factor. The O-rings were rubber rings designed to form a seal in the shuttle's solid rocket boosters, preventing the rockets' hot gas from escaping and damaging other parts of the vehicle. Feynman suspected that despite NASA's claims, the O-rings were unsuitable at low temperatures and lost their resilience when cold, thus failing to maintain a tight seal when rocket pressure distorted the structure of the solid fuel booster. Feynman's suspicions were corroborated by General Kutyna, also on the commission, who cunningly[10] provided Feynman with a broad hint by asking about the effect of cold on O-ring seals after mentioning that the temperature on the day of the launch was far lower than had been the case with previous launches: below freezing at 28 to 29 °F (−2.2 to −1.7 °C); previously, the coldest launch had been at 53 °F (12 °C). In 2013, the BBC film The Challenger revealed that the O-ring insight had in fact come to Kutyna from the astronaut and fellow commission member Sally Ride, who had secretly provided him with NASA test results showing the O-rings became stiff when they were too cold.[11]
Feynman's investigations also revealed that there had been many serious doubts raised about the O-ring seals by engineers at Morton Thiokol, which made the solid fuel boosters, but communication failures had led to their concerns being ignored by NASA management. He found similar failures in procedure in many other areas at NASA, but singled out its software development for praise due to its rigorous and highly effective quality control procedures – then under threat from NASA management, which wished to reduce testing to save money given that the tests had always been passed.[12]
Based on his experiences with NASA's management and engineers, Feynman concluded that the serious deficiencies in NASA management's scientific understanding, the lack of communication between the two camps, and the gross misrepresentation of the Shuttle's dangers, required that NASA take a hiatus from Shuttle launches until it could resolve its internal inconsistencies and present an honest picture of the shuttle's reliability. Feynman soon found that, while he respected the intellects of his fellow Commission members, they universally finished their criticisms of NASA with clear affirmations that the Challenger disaster should be addressed by NASA internally, but that there was no need for NASA to suspend its operations or to receive less funding. Feynman felt that the Commission's conclusions misrepresented its findings, and he could not in good conscience recommend that such a deeply flawed organization as NASA should continue without a suspension of operations and a major overhaul. His fellow commission members were alarmed by Feynman's dissent, and it was only after much petitioning that Feynman's minority report was included at all. Feynman was so critical of flaws in NASA's "safety culture" that he threatened to remove his name from the report unless it included his personal observations on the reliability of the shuttle, which appeared as Appendix F.[9][13] In the appendix, he stated:
It appears that there are enormous differences of opinion as to the probability of a failure with loss of vehicle and of human life. The estimates range from roughly 1 in 100 to 1 in 100,000. The higher figures come from the working engineers, and the very low figures from management. What are the causes and consequences of this lack of agreement? Since 1 part in 100,000 would imply that one could put a Shuttle up each day for 300 years expecting to lose only one, we could properly ask "What is the cause of management's fantastic faith in the machinery? ... It would appear that, for whatever purpose, be it for internal or external consumption, the management of NASA exaggerates the reliability of its product, to the point of fantasy.[9]
"For a successful technology," Feynman concluded, "reality must take precedence over public relations, for nature cannot be fooled."[9]
Feynman later wrote about the investigation in his 1988 book What Do You Care What Other People Think?.[14] The second half of the book covers the investigation and the issues between science and politics, and includes the appendix he wrote.
Feynman later reported that, although he had believed he was making discoveries about the problems at NASA on his own, he eventually realized that either NASA or contractor personnel, in an apparent effort to anonymously focus attention on these problem areas, had carefully led him to the evidence which would support the conclusions on which he would later report.[14][15]
Result
edit
The Rogers Commission offered nine recommendations on improving safety in the space shuttle program, and NASA was directed by President Reagan to report back within thirty days as to how it planned to implement those recommendations.[16] This is a summary of the chapter of Recommendations:[17]
1.Design and Independent Oversight
2.Shuttle Management Structure, Astronauts in Management and Shuttle Safety Panel
3.Criticality Review and Hazard Analysis
4.Safety Organization
5.Improved Communications
6.Landing Safety
7.Launch Abort and Crew Escape
8.Flight Rate
9.Maintenance Safeguards
In response to the commission's recommendation, NASA initiated a total redesign of the space shuttle's solid rocket boosters, which was watched over by an independent oversight group as stipulated by the commission.[16] NASA's contract with Morton Thiokol, the contractor responsible for the solid rocket boosters, included a clause stating that in the event of a failure leading to "loss of life or mission," Thiokol would forfeit $10 million of its incentive fee and formally accept legal liability for the failure. After the Challenger accident, Thiokol agreed to "voluntarily accept" the monetary penalty in exchange for not being forced to accept liability.[18]
NASA also created a new Office of Safety, Reliability and Quality Assurance, headed as the commission had specified by a NASA associate administrator who reported directly to the NASA administrator. George Rodney, formerly of Martin Marietta, was appointed to this position.[19] Former Challenger flight director Jay Greene became chief of the Safety Division of the directorate.[20]
The unrealistically optimistic launch schedule pursued by NASA had been criticized by the Rogers Commission as a possible contributing cause to the accident. After the accident, NASA attempted to aim at a more realistic shuttle flight rate: it added another orbiter, Endeavour, to the space shuttle fleet to replace Challenger, and it worked with the Department of Defense to put more satellites in orbit using expendable launch vehicles rather than the shuttle.[21] In August 1986, President Reagan also announced that the shuttle would no longer carry commercial satellite payloads. After a 32-month hiatus, the next shuttle mission, STS-26, was launched on September 29, 1988.
After the Space Shuttle Columbia disaster in 2003, attention once again focused on the attitude of NASA management towards safety issues. The Columbia Accident Investigation Board (CAIB) concluded that NASA had failed to learn many of the lessons of Challenger. In particular, the agency had not set up a truly independent office for safety oversight; the CAIB felt that in this area, "NASA's response to the Rogers Commission did not meet the Commission's intent".[22] The CAIB believed that "the causes of the institutional failure responsible for Challenger have not been fixed," saying that the same "flawed decision-making process" that had resulted in the Challenger accident was responsible for Columbia's destruction seventeen years later.[23]
Report of the PRESIDENTIAL COMMISSION on the Space Shuttle Challenger Accident
Recommendations
[198] The Commission has conducted an extensive investigation of the Challenger accident to determine the probable cause and necessary corrective actions. Based on the findings and determinations of its investigation, the Commission has unanimously adopted recommendations to help assure the return to safe flight.
The Commission urges that the Administrator of NASA submit, one year from now, a report to the President on the progress that NASA has made in effecting the Commission's recommendations set forth below:
- I -
Design. The faulty Solid Rocket Motor joint and seal must be changed. This could be a new design eliminating the joint or a redesign of the current joint and seal. No design options should be prematurely precluded because of schedule, cost or reliance on existing hardware. All Solid Rocket Motor joints should satisfy the following requirements:
The joints should be fully understood, tested and verified.
The integrity of the structure and of the seals of all joints should be not less than that of the case walls throughout the design envelope.
The integrity of the joints should be insensitive to:
Dimensional tolerances.
Transportation and handling.
Assembly procedures.
Inspection and test procedures.
Environmental effects.
Internal case operating pressure.
Recovery and reuse effects.
Flight and water impact loads.
The certification of the new design should include:
Tests which duplicate the actual launch configuration as closely as possible.
Tests over the full range of operating conditions, including temperature.
Full consideration should be given to conducting static firings of the exact flight configuration in a vertical attitude.
Independent Oversight. The Administrator of NASA should request the National Research Council to form an independent Solid Rocket Motor design oversight committee to implement the Commission's design recommendations and oversee the design effort. This committee should:
Review and evaluate certification requirements.
Provide technical oversight of the design, test program and certification.
Report to the Administrator of NASA on the adequacy of the design and make appropriate recommendations.
- II -
[199] Shuttle Management Structure. The Shuttle Program Structure should be reviewed. The project managers for the various elements of the Shuttle program felt more accountable to their center management than to the Shuttle program organization. Shuttle element funding, work package definition, and vital program information frequently bypass the National STS (Shuttle) Program Manager.
A redefinition of the Program Manager's responsibility is essential. This redefinition should give the Program Manager the requisite authority for all ongoing STS operations. Program funding and all Shuttle Program work at the centers should be placed clearly under the Program Manager's authority.
Astronauts in Management. The Commission observes that there appears to be a departure from the philosophy of the 1960s and 1970s relating to the use of astronauts in management positions. These individuals brought to their positions flight experience and a keen appreciation of operations and flight safety.
NASA should encourage the transition of qualified astronauts into agency management positions.
The function of the Flight Crew Operations director should be elevated in the NASA organization structure.
Shuttle Safety Panel. NASA should establish an STS Safety Advisory Panel reporting to the STS Program Manager. The Charter of this panel should include Shuttle operational issues, launch commit criteria, flight rules, flight readiness and risk management. The panel should include representation from the safety organization, mission operations, and the astronaut office.
- III -
Criticality Review and Hazard Analysis. NASA and the primary Shuttle contractors should review all Criticality 1, 1R, 2, and 2R items and hazard analyses. This review should identify those items that must be improved prior to flight to ensure mission safety. An Audit Panel, appointed by the National Research Council, should verify the adequacy of the effort and report directly to the Administrator of NASA.
- IV -
Safety Organization. NASA should establish an Office of Safety, Reliability and Quality Assurance to be headed by an Associate administrator, reporting directly to the NASA Administrator. It would have direct authority for safety, reliability, and quality assurance throughout the agency. The office should be assigned the work force to ensure adequate oversight of its functions and should be independent of other NASA functional and program responsibilities.
The responsibilities of this office should include:
The safety, reliability and quality assurance functions as they relate to all NASA activities and programs.
Direction of reporting and documentation of problems, problem resolution and trends associated with flight safety.
- V -
[200] Improved Communications. The Commission found that Marshall Space Flight Center project managers, because of a tendency at Marshall to management isolation, failed to provide full and timely information bearing on the safety of flight 51-L to other vital elements of Shuttle program management.
NASA should take energetic steps to eliminate this tendency at Marshall Space Flight Center, whether by changes of personnel, organization, indoctrination or all three.
A policy should be developed which governs the imposition and removal of Shuttle launch constraints.
Flight Readiness Reviews and Mission Management Team meetings should be recorded.
The flight crew commander, or a designated representative, should attend the Flight Readiness Review, participate in acceptance of the vehicle for flight, and certify that the crew is properly prepared for flight.
- VI -
Landing Safety. NASA must take actions to improve landing safety.
The tire, brake and nosewheel steering systems must be improved. These systems do not have sufficient safety margin, particularly at abort landing sites.
The specific conditions under which planned landings at Kennedy would be acceptable should be determined. Criteria must be established for tires, brakes and nosewheel steering. Until the systems meet those criteria in high fidelity testing that is verified at Edwards, landing at Kennedy should not be planned.
Committing to a specific landing site requires that landing area weather be forecast more than an hour in advance. During unpredictable weather periods at Kennedy, program officials should plan on Edwards landings. Increased landings at Edwards may necessitate a dual ferry capability.
- VII -
Launch Abort and Crew Escape. The Shuttle program management considered first-stage abort options and crew escape options several times during the history of the program, but because of limited utility, technical infeasibility, or program cost and schedule, no systems were implemented. The Commission recommends that NASA:
Make all efforts to provide a crew escape system for use during controlled gliding flight.
Make every effort to increase the range of flight conditions under which an emergency runway landing can be successfully conducted in the event that two or three main engines fail early in ascent.
- VIII -
[201] Flight Rate. The nation's reliance on the Shuttle as its principal space launch capability created a relentless pressure on NASA to increase the flight rate. Such reliance on a single launch capability should be avoided in the future.
NASA must establish a flight rate that is consistent with its resources. A firm payload assignment policy should be established. The policy should include rigorous controls on cargo manifest changes to limit the pressures such changes exert on schedules and crew training.
- IX -
Maintenance Safeguards. Installation, test, and maintenance procedures must be especially rigorous for Space Shuttle items designated Criticality 1. NASA should establish a system of analyzing and reporting performance trends of such items.
Maintenance procedures for such items should be specified in the Critical Items List, especially for those such as the liquid-fueled main engines, which require unstinting maintenance and overhaul.
With regard to the Orbiters, NASA should:
Develop and execute a comprehensive maintenance inspection plan.
Perform periodic structural inspections when scheduled and not permit them to be waived.
Restore and support the maintenance and spare parts programs, and stop the practice of removing parts from one Orbiter to supply another.
Concluding Thought:
The Commission urges that NASA continue to receive the support of the Administration and the nation. The agency constitutes a national resource that plays a critical role in space exploration and development. It also provides a symbol of national pride and technological leadership.
The Commission applauds NASA's spectacular achievements of the past and anticipates impressive achievements to come. The findings and recommendations presented in this report are intended to contribute to the future NASA successes that the nation both expects and requires as the 21st century approaches.
No comments:
Post a Comment