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Challenger Tragedy: Presidential Report Continued

By Marty McDowell/NASA

An Accident Rooted in History

Early 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.

Findings

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.

5. The O-ring erosion history presented to Level I at NASA Headquarters in August 1985 was sufficiently detailed to require corrective action prior to the next flight.

6. A careful analysis of the flight history of O-ring performance would have revealed the correlation of O-ring damage and low temperature. Neither NASA nor Thiokol carried out such an analysis; consequently, they were unprepared to properly evaluate the risks of launching the 51-L mission in conditions more extreme than they had encountered before.

The Silent Safety Program

The Commission was surprised to realize after many hours of testimony that NASA's safety staff was never mentioned. No witness related the approval or disapproval of the reliability engineers, and none expressed the satisfaction or dissatisfaction of the quality assurance staff. No one thought to invite a safety representative or a reliability and quality assurance engineer to the January 27, 1986, teleconference between Marshall and Thiokol. Similarly, there was no representative of safety on the Mission Management Team that made key decisions during the countdown on January 28, 1986. The Commission is concerned about the symptoms that it sees.

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. An extensive and redundant safety program comprising interdependent safety, reliability and quality assurance functions existed during and after the lunar program to discover any potential safety problems. Between that period and 1986, however, the program became ineffective. This loss of effectiveness seriously degraded the checks and balances essential for maintaining flight safety.

On April 3, 1986, Arnold Aldrich, the Space Shuttle program manager, appeared before the Commission at a public hearing in Washington, D.C. He described five different communication or organization failures that affected the launch decision on January 28, 1986. Four of those failures relate directly to faults within the safety program. These faults include a lack of problem reporting requirements, inadequate trend analysis, misrepresentation of criticality and lack of involvement in critical discussions. A properly staffed, supported, and robust safety organization might well have avoided these faults and thus eliminated the communication failures.

NASA has a safety program to ensure that the communication failures to which Mr. Aldrich referred do not occur. In the case of mission 51-L, that program fell short.

Findings

1. Reductions in the safety, reliability and quality assurance work force at Marshall and NASA Headquarters have seriously limited capability in those vital functions.

2. Organizational structures at Kennedy and Marshall have placed safety, reliability and quality assurance offices under the supervision of the very organizations and activities whose efforts they are to check.

3. Problem reporting requirements are not concise and fail to get critical information to the proper levels of management.

4. Little or no trend analysis was performed on O-ring erosion and blow-by problems.

5. As the flight rate increased, the Marshall safety, reliability and quality assurance work force was decreasing, which adversely affected mission safety.

6. Five weeks after the 51-L accident, the criticality of the Solid Rocket Motor field joint was still not properly documented in the problem reporting system at Marshall.

Pressures on the System

With the 1982 completion of the orbital flight test series, NASA began a planned acceleration of the Space Shuttle launch schedule. One early plan contemplated an eventual rate of a mission a week, but realism forced several downward revisions. In 1985, NASA published a projection calling for an annual rate of 24 flights by 1990. Long before the Challenger accident, however, it was becoming obvious that even the modified goal of two flights a month was overambitious.

In establishing the schedule, NASA had not provided adequate resources for its attainment. As a result, the capabilities of the system were strained by the modest nine-mission rate of 1985, and the evidence suggests that NASA would not have been able to accomplish the 14 flights scheduled for 1986. These are the major conclusions of a Commission examination of the pressures and problems attendant upon the accelerated launch schedule.

Findings

1. The capabilities of the system were stretched to the limit to support the flight rate in winter 1985/1986. Projections into the spring and summer of 1986 showed a clear trend; the system, as it existed, would have been unable to deliver crew training software for scheduled flights by the designated dates. The result would have been an unacceptable compression of the time available for the crews to accomplish their required training.

2. Spare parts are in critically short supply. The Shuttle program made a conscious decision to postpone spare parts procurements in favor of budget items of perceived higher priority. Lack of spare parts would likely have limited flight operations in 1986.

3. Stated manifesting policies are not enforced. Numerous late manifest changes (after the cargo integration review) have been made to both major payloads and minor payloads throughout the Shuttle program.

Late changes to major payloads or program requirements can require extensive resources (money, manpower, facilities) to implement.

If many late changes to "minor" payloads occur, resources are quickly absorbed.

Payload specialists frequently were added to a flight well after announced deadlines.

Late changes to a mission adversely affect the training and development of procedures for subsequent missions.

4. The scheduled flight rate did not accurately reflect the capabilities and resources.

The flight rate was not reduced to accommodate periods of adjustment in the capacity of the work force. There was no margin in the system to accommodate unforeseen hardware problems.

Resources were primarily directed toward supporting the flights and thus not enough were available to improve and expand facilities needed to support a higher flight rate.

5. Training simulators may be the limiting factor on the flight rate: the two current simulators cannot train crews for more than 12-15 flights per year.

6. When flights come in rapid succession, current requirements do not ensure that critical anomalies occurring during one flight are identified and addressed appropriately before the next flight.

Other Safety Considerations

In the course of its investigation, the Commission became aware of a number of matters that played no part in the mission 51-L accident but nonetheless hold a potential for safety problems in the future.

Some of these matters, those involving operational concerns, were brought directly to the Commission's attention by the NASA astronaut office. They were the subject of a special hearing.

Other areas of concern came to light as the Commission pursued various lines of investigation in its attempt to isolate the cause of the accident. These inquiries examined such aspects as the development and operation of each of the elements of the Space Shuttle -- the Orbiter, its main engines and the External Tank; the procedures employed in the processing and assembly of 51-L, and launch damage.

This chapter examines potential risks in two general areas. The first embraces critical aspects of a Shuttle flight; for example, considerations related to a possible premature mission termination during the ascent phase and the risk factors connected with the demanding approach and landing phase. The other focuses on testing, processing and assembling the various elements of the Shuttle.

Ascent: A Critical Phase

The events of flight 51-L dramatically illustrated the dangers of the first stage of a Space Shuttle ascent. The accident also focused attention on the issues of Orbiter abort capabilities and crew escape. Of particular concern to the Commission are the current abort capabilities, options to improve those capabilities, options for crew escape and the performance of the range safety system.

It is not the Commission's intent to second-guess the Space Shuttle design or try to depict escape provisions that might have saved the 51-L crew. In fact, the events that led to destruction of the Challenger progressed very rapidly and without warning. Under those circumstances, the Commission believes it is highly unlikely that any of the systems discussed below, or any combination of those systems, would have saved the flight 51-L crew.

Findings

1. The Space Shuttle System was not designed to survive a failure of the Solid Rocket Boosters. There are no corrective actions that can be taken if the boosters do not operate properly after ignition, i.e., there is no ability to separate an Orbiter safely from thrusting boosters and no ability for the crew to escape the vehicle during first-stage ascent.

Neither the Mission Control Team not the 51-L crew had any warning of impending disaster.

Even if there had been warning, there were no actions available to the crew of the Mission Control Team to avert the disaster.

Landing: Another Critical Phase

The consequences of faulty performance in any dynamic and demanding flight environment can be catastrophic. The Commission was concerned that an insufficient safety margin may have existed in areas other than Shuttle ascent. Entry and landing of the Shuttle are dynamic and demanding with all the risks and complications inherent in flying a heavyweight glider with a very steep glide path. Since the Shuttle crew cannot divert to any alternate landing site after entry, the landing decision must be both timely and accurate. In addition, the landing gear, which includes wheels, tires and brakes, must function properly.

In summary, although there are valid programmatic reasons to land routinely at Kennedy, there are concerns that suggest that this is not wise under the present circumstances. While planned landings at Edwards carry a cost in dollars and days, the realities of weather cannot be ignored. Shuttle program officials must recognize that Edwards is a permanent, essential part of the program. The cost associated with regular scheduled landing and turnaround operations at Edwards is thus a necessary program cost.

Decisions governing Space Shuttle operations must be consistent with the philosophy that unnecessary risks have to be eliminated. Such decisions cannot be made without a clear understanding of margins of safety in each part of the system.

Unfortunately, margins of safety cannot be assured if performance characteristics are not thoroughly understood, nor can they be deduced from a previous flight's "success."

The Shuttle program cannot afford to operate outside its experience in the areas of tires, brakes and weather, with the capabilities of the system today. Pending a clear understanding of all landing and deceleration systems, and a resolution of the problems encountered to date in Shuttle landings, the most conservative course must be followed in order to minimize risk during this dynamic phase of flight.

Shuttle Elements

The Space Shuttle Main Engine teams at Marshall and Rocketdyne have developed engines that have achieved their performance goals and have performed extremely well. Nevertheless the main engines continue to be highly complex and critical components of the Shuttle that involve an element of risk principally because important components of the engines degrade more rapidly with flight use than anticipated. Both NASA and Rocketdyne have taken steps to contain that risk. An important aspect of the main engine program has been the extensive "hot fire" ground tests. Unfortunately, the vitality of the test program has been reduced because of budgetary constraints.

The number of engine test firings per month has decreased over the past two years. Yet this test program has not yet demonstrated the limits of engine operation parameters or included tests over the full operating envelope to show full engine capability. In addition, tests have not yet been deliberately conducted to the point of failure to determine actual engine operating margins.

Next page

Source: NASA.

 

Share Your Memories!

What do you remember about Challenger Presidential Report? Have you any compelling stories to share? Share your stories with the world! (We print the best stories right here!)

Your Memories Shared!

"I find it VERY hard to believe that the shuttle launch decision-making party was unaware of the problems that made the launch of Challenger so very dangerous. Was there no communication between NASA officials and engineers and experts screaming for a launch postponement? It became well known, through the extreme coverage of this event, that NASA was under pressure to meet a deadline to justify its enormous spending before the US Government. It does not take a lot of brains to see that the findings of their UNAWARENESS of the then recent Challenger history were no more than a big COVERUP. I rest assured that the persons who disregarded the safety of those seven souls aboard Challenger will meet their justice some day."

--Tom in Florida



Space References (Books):
Dickinson, Terence. Nightwatch: A Practical Guide to Viewing the Universe. Firefly Books, 1998.
Greene, Brian. Elegant Universe: Superstrings, Hidden Dimensions, and the Quest for the Ultimate Theory. Vintage, 2000.
Hawking, Stephen. Illustrated Brief History of Time, Updated and Expanded Edition. Bantam, 1996.
Hawking, Stephen. Theory of Everything: The Origin and Fate of the Universe. New Millenium, 2002.
Hawking, Stephen. The Universe in a Nutshell. Bantam, 2001.
Kaku, Michio. Hyperspace: A Scientific Odyssey Through Parallel Universes, Time Warps and the Tenth Dimension.
Kranz, Gene. Failure Is Not an Option: Mission Control from Mercury to Apollo 13 and Beyond. Berkley Pub Group, 2001.
Sagan, Carl; Druyan, Ann. Comet, Revised Edition. Ballantine, 1997
Sagan, Carl. Cosmos, Reissue Edition. Ballantine, 1993
Sagan, Carl. Pale Blue Dot: A Vision of the Human Future in Space. Ballantine, 1997

Space References (Videos):
Cosmos. PBS, 2000.
Stephen Hawking's Universe. PBS, 1997.
Hyperspace. BBC, 2002.
Life Beyond Earth PBS, 1999.
The Planets
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Understanding The Universe. A&E, 1996.

 

SPACE SPECS

This is a close-up photograph of the O-ring in the top of the aft segment of the right solid rocket booster (SRB) flown on Space Shuttle Challenger.

Courtesy of NASA


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