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Challenger Tragedy: Presidential Report Concluded

Recommendations of the Presidential Commission

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 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 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 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.

NASA Actions To Implement Commission Recommendations

(Source: Actions to Implement the Recommendations of The Presidential Commission on the Space Shuttle Challenger Accident, Executive Summary, July 14, 1986, NASA Headquarters)

On June 13, 1986, the President directed NASA to implement, as soon as possible, the recommendations of the Presidential Commission on the Space Shuttle Challenger Accident. The President requested that NASA report, within 30 days, how and when the recommendations will be implemented, including milestones by which progress can be measured.

In the months since the Challenger accident, the NASA team has spent many hours in support of the Presidential Commission on the Space Shuttle Challenger Accident and in planning for a return of the Shuttle to safe flight status. Chairman William P. Rogers and the other members of the Commission have rendered the Nation and NASA an exceptional service. The work of the Commission was extremely thorough and comprehensive. NASA agrees with the Commission's recommendations and is vigorously pursuing the actions required to implement and comply with them.

As a result of the efforts in support of the Commission, many of the actions required to safely return the Space Shuttle to flight status have been under way since March. On March 24, 1986, the Associate Administrator for Space Flight outlined a comprehensive strategy, and defined major actions, for safely returning to flight status. The March 24 memorandum (Commission Activities: An Overview) provided guidance on the following subjects:

actions required prior to next flight, first flight/first year operations, and development of sustainable safe flight rate.

The Commission report was submitted to the President on June 9, 1986. Since that time, NASA has taken additional actions and provided direction required to comply with the Commission's recommendations.

The NASA Administrator and the Associate Administrator for Space Flight will participate in the key management decisions required for implementing the Commission recommendations and for returning the Space Shuttle to flight status. NASA will report to the President on the status of the implementation program in June 1987.

The Commission report included nine recommendations, and a summary of the implementation status for each is provided:

RECOMMENDATION I Solid Rocket Motor Design:

On March 24, 1986, the Marshall Space Flight Center (MSFC) was directed to form a Solid Rocket Motor (SSRM) joint redesign team to include participation from MSFC and other NASA centers as well as individuals from outside NASA. The team includes personnel from Johnson Space Center, Kennedy Space Center, Langley Research Center, industry, and the Astronaut Office. To assist the redesign team, an expert advisory panel was appointed which includes 12 people with six coming from outside NASA.

The team has evaluated several design alternatives, and analysis and testing are in progress to determine the preferred approaches which minimize hardware redesign. To ensure adequate program contingency in this effort, the redesign team will also develop, at least through concept definition, a totally new design which does not utilize existing hardware. The design verification and certification program will be emphasized and will include tests which duplicate the actual launch loads as closely as feasible and provide for tests over the full range of operating conditions. The verification effort includes a trade study which has been under way for several weeks to determine the preferred test orientation (vertical or horizontal) of the full-scale motor firings. The Solid Rocket Motor redesign and certification schedule is under review to fully understand and plan for the implementation of the design solutions as they are finalized and assessed. The schedule will be reassessed after the SRM Preliminary Design Review in September 1986. At this time it appears that the first launch will not occur prior to the first quarter of 1988.

Independent Oversight: In accordance with the Commission's recommendation, the National Research Council (NRC) has established an Independent Oversight Group chaired by Dr. H. Guyford Stever and reporting to the NASA Administrator. The NRC Oversight Group has been briefed on Shuttle system requirements, implementation, and control; Solid Rocket Motor background; and candidate modifications. The group has established a near-term plan that includes briefings and visits to review inflight loads; assembly processing; redesign status; and other solid rocket motor designs, including participation in the Solid Rocket Motor preliminary design review in September 1986.

RECOMMENDATION II Shuttle Management Structure:

The Administrator has appointed General Sam Phillips, who served as Apollo Program Director, to study every aspect of how NASA manages its programs, including relationships between various field centers and NASA Headquarters. General Phillips has broad authority from the Administrator to explore every aspect of NASA organization, management and procedures. His activities will include a review of the Space Shuttle management structure.

On June 25, 1986, Astronaut Robert Crippen was directed to form a fact-finding group to assess the Space Shuttle management structure. The group will report recommendations to the Associate Administrator for Space Flight by August 15, 1986. Specifically, this group will address the roles and responsibilities of the Space Shuttle Program Manager to assure that the position has the authority commensurate with its responsibilities. In addition, roles and responsibilities at all levels of program management will be reviewed to specify the relationship between the program organization and the field center organizations. The results of this study will be reviewed with General Phillips and the Administrator with a decision on implementation of the recommendations by October 1, 1986.

Astronauts in Management Rear Admiral Richard Truly, a former astronaut, has been appointed as Associate Administrator for the Office of Space Flight. Several active astronauts are currently serving in management positions in the agency. The Crippen group will address means to stimulate the transition of astronauts into other management positions. It will also determine the appropriate position for the Flight Crew Operations Directorate within the NASA organizational structure.

Shuttle Safety Panel A Shuttle Safety Panel will be established by the Associate Administrator for Space Flight not later than September 1, 1986, with direct access to the Space Shuttle Program Manager. This date allows time to determine the structure and function of this panel, including an assessment of its relationship to the newly formed Office of Safety, Reliability, and Quality Assurance, and to the existing Aerospace Safety Advisory Panel.

RECOMMENDATION III Critical Item Review and Hazard Analysis

On March 13, 1986, NASA initiated a complete review of all Space Shuttle program failure modes and effects analyses (FEMEA's) and associated critical item lists (CIL's). Each Space Shuttle project element and associated prime contractor is conducting separate comprehensive reviews which will culminate in a program-wide review with the Space Shuttle program have been assigned as formal members of each of these review teams. All Criticality 1 and 1R critical item waivers have been cancelled. The teams are required to reassess and resubmit waivers in categories recommended for continued program applicability. Items which cannot be revalidated will be redesigned, qualified, and certified for flight. All Criticality 2 and 3 CIL's are being reviewed for reacceptance and proper categorization. This activity will culminate in a comprehensive final review with NASA Headquarters beginning in March 1987.

As recommended by the Commission, the National Research Council has agreed to form an Independent Audit Panel, reporting to the NASA Administrator, to verify the adequacy of this effort.

RECOMMENDATION IV Safety Organization

The NASA Administrator announced the appointment of Mr. George A. Rodney to the position of Associate Administrator for Safety, Reliability, and Quality Assurance on July 8, 1986. The responsibilities of this office will include the oversight of safety, reliability, and quality assurance functions related to all NASA activities and programs and the implementation of a system for anomaly documentation and resolution to include a trend analysis program. One of the first activities to be undertaken by the new Associate Administrator will be an assessment of the resources including workforce required to ensure adequate execution of the safety organization functions. In addition, the new Associate Administrator will assure appropriate interfaces between the functions of the new safety organization and the Shuttle Safety Panel which will be established in response to the Commission Recommendation II.

RECOMMENDATION V

Improved Communications On June 25, 1986, Astronaut Robert Crippen was directed to form a team to develop plans and recommended policies for the following:

Implementation of effective management communications at all levels.

Standardization of the imposition and removal of STS launch constraints and other operational constraints.

Conduct of Flight Readiness Review and Mission Management Team meetings, including requirements for documentation and flight crew participation.

Since this recommendation is closely linked with the recommendation on Shuttle management structure, the study team will incorporate the plan for improved communications with that for management restructure.

This review of effective communications will consider the activities and information flow at NASA Headquarters and the field centers which support the Shuttle program. The study team will present findings and recommendations to the Associate Administrator for Space Flight by August 15, 1986.

RECOMMENDATION VI Landing Safety

A Landing Safety Team has been established to review and implement the Commission's findings and recommendations on landing safety. All Shuttle hardware and systems are undergoing design reviews to insure compliance with the specifications and safety concerns. The tires, brakes, and nose wheel steering system are included in this activity, and funding for a new carbon brakes system has been approved. Runway surface tests and landing aid requirement reviews had been under way for some time prior to the accident and are continuing. Landing aid implementation will be complete by July 1987. The interim brake system will be delivered by August 1987. Improved methods of local weather forecasting and weather-related support are being developed. Until the Shuttle program has demonstrated satisfactory safety margins through high fidelity testing and during actual landings at Edwards Air Force Base, the Kennedy Space Center landing site will not be used for nominal end-of-mission landings. Dual Orbiter ferry capability has been an issue for some time and will be thoroughly considered during the upcoming months.

RECOMMENDATION VII Launch Abort and Crew Escape

On April 7, 1986, NASA initiated a Shuttle Crew Egress and Escape review. The scope of this analysis includes egress and escape capabilities from launch through landing and will provide analyses, concepts, feasibility assessments, cost, and schedules for pad abort, bailout, ejection systems, water landings, and powered flight separation. This review will specifically assess options for crew escape during controlled gliding flight and options for extending the intact abort flight envelope to include failure of 2 or 3 main engines during the early ascent phase. In conjunction with this activity, a Launch Abort Reassessment Team was established to review all launch and launch abort rules to ensure that launch commit criteria, flight rules, range safety systems and procedures, landing aids, runway configurations and lengths, performance versus abort exposure, abort and end-of-mission landing weights, runway surfaces, and other landing-related capabilities provide the proper margin of safety to the vehicle and crew. Crew escape and launch abort studies will be complete on October 1, 1986, with an implementation decision in December 1986.

RECOMMENDATION VIII Flight Rate

In March 1986 NASA established a Flight Rate Capability Working Group. Two flight rate capability studies are under way:

(1) a study of capabilities and constraints which govern the Shuttle processing flows at the Kennedy Space Center and

(2) a study by the Johnson Space Center to assess the impact of flight specific crew training and software delivery/certification on flight rates.

The working group will present flight rate recommendations to the Office of Space Flight by August 15, 1986. Other collateral studies are still in progress which address Presidential Commission recommendations related to spares provisioning, maintenance, and structural inspection. This effort will also consider the National Research Council independent review of flight rate which is under way as a result of a Congressional Subcommittee request.

NASA strongly supports a mixed fleet to satisfy launch requirements and actions to revitalize the United States expendable launch vehicle capabilities.

Additionally, a new cargo manifest policy is being formulated by NASA Headquarters which will establish manifest ground rules and impose constraints to late changes. Manifest control policy recommendations will be completed in November 1986.

RECOMMENDATION IX Maintenance Safeguards

A Maintenance Safeguards Team has been established to develop a comprehensive plan for defining and implementing actions to comply with the Commission recommendations concerning maintenance activities. A Maintenance Plan is being prepared to ensure that uniform maintenance requirements are imposed on all elements of the Space Shuttle program. This plan will define the structure that will be used to document (1) hardware inspections and schedules, (2) planned maintenance activities, (3) Maintenance procedures configuration control, and (4) Maintenance logistics.

The plan will also define organizational responsibilities, reporting, and control requirements for Space Shuttle maintenance activities. The maintenance plan will be completed by September 30, 1986.

A number of other activities are underway which will contribute to a return to safe flight and strengthening the NASA organization. A Space Shuttle Design Requirements Review Team headed by the Space Shuttle Systems Integration Office at Johnson Space Center has been assigned to review all Shuttle design requirements and associated technical verification. The team will focus on each Shuttle project element and on total Space Shuttle system design requirements. This activity will culminate in a Space Shuttle Incremental Design Certification Review approximately 3 months prior to the next Space Shuttle Launch.

In consideration of the number, complexity, and interrelationships between the many activities leading to the next flight, the Space Shuttle Program Manager at Johnson Space Center has initiated a series of formal Program Management Reviews for the Space Shuttle program. These reviews are structured to be regular face-to-face discussions involving the managers of all major Space Shuttle program activities. Specific subjects to be discussed at each meeting will focus on progress, schedules, and actions associated with each of the major program review activities and will be tailored directly to current program activity for the time period involved. The first of these meetings was held at Marshall Space Flight Center on May 5-6, 1986, with the second at Kennedy Space Center on June 25, 1986. Follow-on reviews will be held approximately every 6 weeks. Results of these reviews will be reported to the Associate Administrator for Space Flight and to the NASA Administrator.

On June 19, 1986, the NASA Administrator announced termination of the development of the Centaur upper stage for use aboard the Space Shuttle. Use of the Centaur upper stage was planned for NASA planetary spacecraft launches as well as for certain national security satellite launches. Majority safety reviews of the Centaur system were under way at the time of the Challenger accident, and these reviews were intensified in recent months to determine if the program should be continued. The final decision to terminate the Centaur stage for use with the Shuttle was made on the basis that even following certain modifications identified by the ongoing reviews, the resultant stage would not meet safety criteria being applied to other cargo or elements of the Space Shuttle System. NASA has initiated efforts to examine other launch vehicle alternatives for the major NASA planetary and scientific payloads which were scheduled to utilize the Centaur upper stage. NASA is providing assistance to the Department of Defense as it examines alternatives for those national security missions which had planned to use the Shuttle/Centaur.

The NASA Administrator has announced a number of Space Station organizational and management structural actions designed to strengthen technical and management capabilities in preparation for moving into the development phase of the Space Station program. The decision to create the new structure is the result of recommendations made to the Administrator by a committee, headed by General Phillips, which is conducting a long range assessment of NASA's overall capabilities and requirements.

Finally, NASA is developing plans for increased staffing in critical areas and is working closely with the Office of Personnel Management to develop a NASA specific proposal which would provide for needed changes to the NASA personnel management system to strengthen our ability to attract, retain, and motivate the quality workforce required to conduct the NASA mission.

[END OF REPORT]

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
. BBC, 1999.
Understanding The Universe. A&E, 1996.

 

SPACE SPECS

A  9'7" x 16' segment of Challenger's right wing is unloaded at the Logistics Facility after being off-loaded from the rescue and salvage ship USS Opportune.

Courtesy of NASA


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