Panel Blames Shuttle Disaster on Poor Design, Management : Agency Held Mesmerized by Successes

A blue-ribbon presidential commission Monday blamed a fatally flawed rocket design and the failure of NASA management to recognize or fix it for the Challenger space shuttle tragedy that claimed the lives of seven crew members last January.

Concluding one of the most intensive government inquiries since the Warren Commission’s investigation of President John F. Kennedy’s assassination, the commission headed by former Secretary of State William P. Rogers found--as expected--that the failure of a thin, rubbery O-ring seal between two sections of the shuttle’s right solid booster rocket was the immediate cause of history’s worst space accident.

“The cause of the accident,” it said, “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 reaction of the joint to dynamic loading.”

The investigation concluded, however, that weaknesses in the National Aeronautics and Space Administration’s decision-making process had been a heavily contributing secondary cause.

In both long-term direction and in short-term decision making, the commission concluded that at critical points space agency officials were ill-informed and mesmerized by the agency’s long run of success.

Customer Commitments

“Pressures developed,” the commission said, “because of the need to meet customer commitments, which translated into a requirement to launch a certain number of flights per year and launch them on time. Such considerations may have occasionally obscured engineering concerns.

“Managers may have forgotten--partly because of past success, partly because of their own well-nurtured image of the program--that the shuttle was still in a research and development phase.”

Thus the report, far from portraying the Challenger’s fiery explosion as an aberration, described it as rooted in a space program plagued with enormous management failings and technical flaws, traveling an inexorable course into trouble.

The 13-member panel called for far-reaching reforms of space agency management, more realistic shuttle flight schedules and reinvigorated safety precautions. It also said that NASA should no longer rely exclusively on the shuttle for future space launches.

Formally accepting the report in a brief ceremony in the White House Rose Garden, President Reagan praised the investigation as a testament to an open society. “We’ve learned in these past few months that we’re frail and fallible,” he said. “But we have also learned that we have the courage to face our faults and the strength to correct our errors.

“Because we don’t hide our mistakes, we’re not condemned to repeat them,” he said. “Because we’re an open society, we have room to grow.”

NASA Administrator James C. Fletcher, who before returning to the agency criticized the investigation as a witch hunt, praised the commission for its work. He agreed with the report’s thrust that “the whole agency needs a major re-examination,” but he refused to indicate what he will do on several specific recommendations.

Poorly Informed

Although the shuttle had flown successfully 24 times before disaster struck, the commission found that the design flaw had long been known to engineers but that senior officials responsible for managing the program were poorly informed and did not appreciate the significance of the problems.

“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,” the commission said in its report to President Reagan.

“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.’ ”

Massive Fireball

The Challenger was torn apart in a massive fireball 73 seconds after it was launched, killing all seven crew members without their knowing that the shuttle was doomed from the moment of ignition.

Among them was Sharon Christa McAuliffe, a New Hampshire school teacher selected in a nationwide competition to be what she termed the first “ordinary citizen” in space.

As anticipated, the 256-page report focused most sharply on NASA’s Marshall Space Flight Center and the role its officials played in pressing ahead with the Jan. 28 launch even though Morton Thiokol engineers had urged a delay because of extraordinarily cold weather.

Mulloy Accused

In effect, the report accused Lawrence B. Mulloy, the director of the solid rocket booster program at Marshall, of giving misleading testimony when he asserted that NASA’s top management had been made aware of concerns about the O-ring seals in flight readiness meetings before the launch.

“It is disturbing to the commission,” the report said, “that contrary to the testimony of the solid rocket booster project manager, the seriousness of concern was not conveyed in flight readiness review to Level 1. . . . “

After analyzing the deliberations that took place between NASA and Morton Thiokol the evening before the launch, the commission said it was “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.”

Rockwell Misgivings

In addition to Thiokol engineers’ fears that the O-rings would not function properly in the cold weather, NASA was confronted by strong misgivings on the part of officials of the space division of Rockwell International, the shuttle’s prime contractor.

Rockwell officials, including space division President Rocco Petrone, a longtime NASA executive before joining the aerospace firm, were concerned that ice hanging from the launch structure around the shuttle would do serious damage to the fragile tiles that protect the orbiter from extreme re-entry temperatures.

But the commission concluded that Rockwell’s recommendation on launch was ambiguous. It said it agreed that it would have been difficult for NASA officials to take Rockwell’s comments as a no-launch recommendation. But it added: “However ambiguous Rockwell’s position was, it is clear that they did tell NASA that the ice was an unknown condition.”

It was a case, the commission said, in which “NASA appeared to be requiring a contractor to prove that it was not safe to launch, rather than proving it was safe.”

‘Reversed Its Position’

There was no such ambiguity about the debate between Marshall officials and Morton Thiokol engineers, however, and it ended with the company giving its approval to go ahead with the launch. The commission concluded that the company’s 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.”

Among the commission’s major recommendations was that NASA “take energetic steps to eliminate” what it called “a tendency at Marshall to management isolation.”

Major shifts had taken place at the troubled center even before the report was completed. Mulloy was transferred out of the solid rocket booster project, as was Stanley R. Reinartz, the Marshall official who made the decision not to advise top officials of the dispute with Thiokol engineers over the launch.

Last week, Marshall Center Director William R. Lucas announced his retirement.

During the course of the investigation, the commission amassed more than 120,000 pages of materials, interviewed 160 people and conducted 13 days of hearings.

Presented to Reagan

The report was informally sent to Reagan last Friday and officially presented to him Monday afternoon.

NASA Administrator Fletcher, coaxed in the middle of the crisis to return to the NASA job he held for six years in the 1970s, responded to the commission’s findings with a pledge to consider them “with an open mind and without reservations.”

“The report,” he said in a prepared statement, “deserves that kind of thoughtful treatment. To give it less is to insult a distinguished group of citizens who are serious and concerned about what went wrong . . . who have spent several months dealing with difficult questions. It was a task which they undertook as public servants whose sole purpose, I believe, was to seek the truth and to help our national space program.”

“They are determined, as is NASA, to ensure that this program will become as good as it ever was and as good as it ever can be. Their report, I am also sure, was not and is not intended to sound the death knell of this agency, or the space explorations that distinctively mark the ingenuity of this century and the next.”

Doubts Raised

In the immediate aftermath of the accident, many feared that it might be impossible to determine beyond doubt what caused Challenger to be destroyed in the fireball 10 miles above the Florida coast.

But in the report made public Monday, the commission was able to re-create the short trip to destruction millisecond by millisecond, using NASA’s engineering photography, telemetry returned from the shuttle during flight, detailed analysis of wreckage recovered from the ocean floor and laboratory tests.

In sum, the shuttle was destroyed when the failure of the O-ring allowed hot gases from the booster rocket to cut like a welder’s torch through the rocket joint, then burn their way into the nearby hydrogen fuel tank and trigger the explosive fire.

Fell in Large Pieces

In televised pictures of the horror, it appeared that Challenger was blown to bits in a massive explosion. But the investigation disclosed that the fireball had broken the external tank, the solid boosters and the orbiter apart, and that the Challenger had in fact plunged to the sea in large pieces, including the crew cabin which hit the water intact.

Contributing to the breakup of the orbiter was an inferno inside the craft created by the ignition of the fuel in its reaction control system used to maneuver in orbit.

“Separate sections that can be identified on film include the main engine/tail section with the engines still burning, one wing of the orbiter and the forward fuselage trailing a mass of umbilical lines pulled loose from the payload bay,” the report said.

The commission considered and eliminated other potential failures within the booster rocket system, the orbiter and the external fuel tank.

Sabotage Ruled Out

It considered and unequivocally ruled out the possibility of sabotage.

Shortly after the accident, persistent rumors circulated that the White House had put pressure on NASA to get the launch off on schedule because President Reagan wanted to mention McAuliffe in his State of the Union speech, then scheduled for Jan. 28.

Commission investigators questioned officials who took part in the launch decision as well as “a large number of other witnesses,” the report said. “No evidence was reported to the commission which indicated that any attempt was ever made by anyone to apply pressure on those making the decision to launch the Challenger.”

Safety Standards Hit

The commission said NASA allowed its safety standards to decline.

“There was no representative of safety on the mission management team that made key decisions during the countdown on Jan. 28, 1986,” it said.

“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 program (to send men to the moon),” the report declared. At both Marshall and NASA headquarters, the commission found, safety and reliability functions had been reduced by cutbacks in the work force assigned to quality assurance.

And at the Kennedy and Marshall centers, the report said, “organizational structures have placed safety, reliability and quality assurance offices under the supervision of the very organizations and activities whose efforts they are to check.”

Besides McAuliffe, those killed in the Challenger disaster were Francis R. (Dick) Scobee, the commander; Michael J. Smith; Judith A. Resnik; Ronald E. McNair; Ellison S. Onizuka, and Gregory B. Jarvis.