NASA Managers Broke Oldest Rule in the Book

“If the decision-makers had known all of the facts, it is highly unlikely they would have decided to launch.”

With that sentence, the blue-ribbon commission investigating the explosion of the space shuttle Challenger summed up perhaps the most haunting element in the tragedy: not the fatal flaws in NASA’s ultra-sophisticated rockets but the human failure to follow one of the oldest rules in the book.

Despite the weaknesses in Challenger’s technology, its seven crew members would probably still be alive today if shuttle officials had only spoken more candidly to their superiors and if their superiors had only been willing to listen.

Bureaucratic Structure

In its final report, officially delivered to President Reagan Monday, the panel headed by former Secretary of State William P. Rogers described the problem in the language of modern management techniques. Flaws in bureaucratic structure and operations had developed over the years and ultimately figured prominently in the chain of events leading to the destruction of the spacecraft on Jan. 28, it said.

What that meant was simply that evidence of serious safety problems was played down or sometimes withheld from key NASA managers, that some program officials were misled by subordinates and became too complacent, that “ominous trends” were not detected because elementary rules were ignored and that safety programs were being cut back at the same time that “unrelenting pressure” for more shuttle flights was building.

The Marshall Space Center in Huntsville, Ala., and its solid booster rocket project manager, Lawrence B. Mulloy, were singled out for especially harsh criticism by the commission after a four-month investigation of the accident, which killed the crew and halted the nation’s space program.

Although the panel singled out the failure of a rocket booster pressure seal as the physical cause of the accident, it blamed NASA and contractor management for allowing safety problems to develop and to go uncorrected within a non-responsive bureaucratic system.

“The decision to launch the Challenger was flawed,” the commission declared. “Those who made the decision were unaware” of the recent history of problems with the pressure seal and engineers’ concerns about the effect of cold temperatures on the O-rings, it said.

In citing “incomplete and sometimes misleading information” and “a conflict between engineering data and management judgments,” the commission criticized “a NASA management structure that permitted internal flight safety problems to bypass key shuttle managers.”

Specifically, it said two critical points--the objections to launch voiced by engineers of Morton Thiokol Inc., the rocket boosters’ contractor, because of cold weather, and concerns within Morton Thiokol and the Marshall Center over erosion of seals in prior shuttle flights--were not adequately communicated to higher-level NASA officials.

For example, it said Jesse W. Moore, who, as NASA associate administrator, headed the flight readiness review panel, was unaware that Mulloy, the project manager at Marshall, had imposed and then waived launching constraints because of O-ring erosion problems. In addition, it said that “no mention appears in several inches of paper comprising the entire chain of readiness reviews.”

The report found it “disturbing” that, contrary to Mulloy’s testimony to the commission, “the seriousness of concern was not conveyed” during the review preceding the Challenger’s launching.

‘Rising Doubts’

“A well-structured and managed system emphasizing safety would have flagged the rising doubts about the solid rocket booster joint seal,” the commission concluded. “Had these matters been clearly stated and emphasized in the flight readiness processs,” the launching might not have occurred.

In describing “a tendency at Marshall to management isolation,” the commission said that the Huntsville center has “a propensity . . . to contain potentially serious problems and to attempt to resolve them internally rather than communicate them forward.”

“This tendency,” it said, “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.”

The commission called the disaster “an accident rooted in history” and traced its genesis to the design during the 1970s of the troublesome joint and “the failure by both Thiokol and NASA’s solid rocket booster project office to understand and respond to facts obtained during testing.”

‘Acceptable Flight Risk’

Rather than heeding warnings and developing a solution, the panel said, “Thiokol and NASA management came to accept” problems with the seal “as unavoidable and an acceptable flight risk.”

In a chapter headed “The Silent Safety Program,” the commission said it was concerned that safety, reliability and quality control were being downgraded while pressure was mounting to increase the number of shuttle launchings.

“The unrelenting pressure to meet the demands of an accelerating flight schedule might have been adequately handled by NASA if it had insisted upon the exactingly thorough procedures that were its hallmark during the Apollo programs,” the report said.

But the “extensive and redundant safety program” of the lunar effort “became ineffective” by 1986, the commission said, and “this loss of effectiveness seriously degraded the checks and balances essential for maintaining flight safety.”

For example, it said, the chief engineer at NASA’s Washington headquarters has overall responsibility for safety but has only two employees who work on safety, reliability and quality assurance--and then only less than one-fourth of the time.

Lack of Expertise

At the Johnson Space Center in Houston, it said, “a large number” of employees work on those programs but “needed expertise . . . is absent” on shuttle hardware because hardware is considered the responsibility of the Marshall Center. And, at Marshall, it said, the quality assurance staff answers to the official who develops the hardware.

“The clear implication of such a management structure is that it fails to provide the kind of independent role necessary for flight safety,” the commission said.

As an illustration of the well-known competition between the NASA centers, the commission said that only one copy of Marshall’s monthly “open problem list” was sent to Houston--and that that copy went to an engineer in an unrelated division.

The space shuttle program manager’s office “and the entire Johnson safety, reliability and quality assurance directorate were not on the distribution list for the problem reports,” it said.

And the commission suggested that problem-reporting procedures were too vague. “Those, in effect,” it said, “are found in numerous individual documents, and there is little agreement about which document applies to a given level of management under a given set of circumstances.”

NASA’s failure to develop “trend data” tracking the problem of erosion of the O-rings also was criticized by the commission, which said the procedure is a “standard and expected function of any reliability and quality assurance program.”

Problem Not Recognized

“Even the most cursory examination of failure rate should have indicated that a serious and potentially disastrous situation was developing on all solid rocket booster joints,” it said. “Not recognizing and reporting this trend can only be described, in NASA terms, as a ‘quality escape,’ a failure of the program to preclude an avoidable problem. If the program had functioned properly, the Challenger accident might have been avoided.”

The commission said that the O-ring erosion problems were never discussed with the Aerospace Safety Advisory Panel, a congressionally mandated group of senior scientists, or with the Space Shuttle Program Crew Safety Panel, another review group, which was disbanded in 1981.

In a chapter entitled “Pressures on the System,” the commission said that NASA was overambitious in accelerating the shuttle launching schedule. “The capabilities of the system were strained by the modest nine-mission rate of 1985,” it said, “and the evidence suggests that NASA would not have been able to accomplish the 15 flights scheduled for 1986.

Resources Diluted

“One effect of NASA’s accelerated flight rate and the agency’s determination to meet it was the dilution of the human and material resources that could be applied to any particular flight,” it said.

NASA’s legendary “can-do” attitude, ironically, became part of the problem, the panel said, because it resulted in the agency’s “worrying about today’s problem and not focusing on tomorrow’s.”

As an example, it cited the the successful efforts by shuttle crew members to retrieve two failed communications satellites. Although spectacular, the missions placed a substantial strain on resources needed for longer-term commitments.

“NASA cannot both accept the relatively spur-of-the-moment missions that its ‘can-do’ attitude tends to generate and also maintain the planning and scheduling discipline required to operate a ‘space truck’ on a routine and cost-effective basis,” the commission said. “NASA’s optimism must be tempered by the realization that it cannot do everything.”