[206] An Overview

President Reagan, seeking to ensure a thorough and unbiased investigation of the Challenger accident, announced the formation of the Commission on February 3, 1986. The mandate given by the President, contained in Executive Order 12546, required Commission members to:

(1) Review the circumstances surrounding the accident to establish the probable cause or causes of the accident; and

(2) Develop recommendations for corrective or other action based upon the Commission's findings and determinations.

Following their swearing in by Chairman Rogers on February 6th, Commission members immediately began a series of hearings during which NASA officials outlined agency procedures covering the Shuttle program and the status of NASA's investigation of the accident.

Shortly thereafter, on February 10th, Dr. Alton G. Keel, Jr., Associate Director of the Office of' Management and Budget, was appointed Executive Director. Dr. Keel began gathering a staff of 15 experienced investigators from various government agencies and the military services, and administrative personnel to support Commission activities.

During a closed session on February 10, 1986, the Commission began to learn of the troubled history of the Solid Rocket Motor joint and seals. Moreover, it discovered the first indication that the contractor, Morton Thiokol, initially recommended against launch on January 27, 1986, the night before the launch of 51-L, because of concerns regarding low temperature effects on the joint and seal. To investigate this disturbing development, additional closed sessions were scheduled for February 13th and 14th at Kennedy. The February 13, 1986, session was an extensive presentation of film, video and telemetry data relating to the Challenger accident. It provided the Commission the first evidence that the Solid Rocket Motor joint and seal may have malfunctioned, initiating the accident.

The session on February 14th included NASA and contractor participants involved in the discussion on January 27, 1986, not to launch 51-L. After testimony was received, an executive session of the Commission was convened. The following statement was subsequently issued by the Chairman on February 15, 1986, reflecting the conclusion and view of the Commission:

"In recent days, the Commission has been investigating all aspects of the decision making process leading up to the launch of the Challenger and has found that the process may have been flawed. The President has been so advised.

"Dr. William Graham, Acting Administrator of NASA, has been asked not to include on the internal investigating teams at NASA, persons involved in that process.

"The Commission will, of course, continue its investigation and will make a full report to the President within 120 days."

The role of the Commissioners thus changed from that of overseers to that of active investigators and analysts of data presented by NASA and its contractors.

[207] The Commission itself divided into four investigative panels:

1. Development and Production, responsible for investigating the acquisition and test and evaluation processes for the Space Shuttle elements;

2. Pre-Launch Activities, responsible for assessing the Shuttle system processing, launch readiness process and pre-launch security;

3. Mission Planning and Operations, responsible for investigating mission planning and operations, schedule pressures and crew safety areas; and

4. Accident Analysis, charged with analyzing the accident data and developing both an anomaly tree and accident scenarios.

By February 17th, the panel organization had been finalized and, on February 18th, Chairman Rogers described the Commission's new approach before Congress. Working groups were sent to Marshall, Kennedy and Thiokol to analyze data relating to the accident and to redirect efforts. NASA's investigation was also reorganized to reflect the structure of the Commission's panels.

A series of public hearings were planned on February 25th, 26th and 27th to assure an orderly and fair presentation of all the facts that the Commission had discovered concerning the launch decision making process for flight 51-L. At these hearings, additional information about the launch decision was obtained from the testimony of Thiokol, Rockwell and NASA officials. Details about the history of problems with the then suspect Solid Rocket Motor joints and seals also began emerging and served to focus the Commission's attention on a need to document fully the extent of knowledge and awareness about the problems within both Thiokol and NASA.

Following these hearings, a substantial portion of the investigative efforts of the Commission was conducted by the separate panels in parallel with full Commission hearings.

The Accident Analysis Panel, chaired by Major General Donald Kutyna, made several trips to both Kennedy and Marshall and traveled to Thiokol facilities in Utah to review photographic and telemetric evidence as well as the results of the salvage operation and to oversee the tests being conducted by NASA and Thiokol engineers.

The Accident Analysis Panel followed standard investigative procedures. An extensive effort was needed to establish the design, manufacturing and processing baseline configuration of the Shuttle vehicle for STS 51-L. A data base was established for the examination and analysis of information related to all flight elements and segments. From these data and a compilation of possible and observed deviations from the norm, scenarios that might have led to the accident were developed. Tests and analyses were then performed to determine the specific scenarios most likely to have caused loss of Challenger.

Early in March, at the request of the Chairman, this group assembled and directed the Commission's independent team of technical observers with extensive experience in Solid Rocket Motor technology and accident investigation to validate and interpret the tests and analyses performed on the Thiokol motor by NASA and Thiokol.

The Development and Production Panel, chaired by Joseph Sutter, centered its investigation on the production and testing activities of the Shuttle element contractors. Starting at Johnson, the panel and staff investigators looked at how these contractors and their NASA counterparts interact.

They next traveled to the Wasatch plant of Thiokol in Promontory, Utah. Thiokol personnel briefed the group on the details of the design, manufacturing, verification and certification of the Solid Rocket Motors. Similar sessions took place in April in Downey, California, at the headquarters of Rocketdyne, Inc., the Shuttle main engine contractor; in Canoga Park, California, at the facilities of Rockwell International, the Orbiter contractor; in Michoud, Louisiana, at the plant of Martin Marietta, the External Tank contractor; and in Berea, Kentucky, at the facilities of Parker Seal Company, the manufacturers of the O-ring seals of the Thiokol Solid Rocket Motors.

In addition, the panel traveled to Marshall to learn about Marshall's interaction with Thiokol and to discuss issues that had been raised during the visits to the contractors' plants.

The Pre-Launch Activities Panel, chaired by David Acheson, centered its investigation at Kennedy where the Shuttle elements are assembled and all other final launch preparations are completed. This panel, in conjunction with the Mission Planning and Operations Panel, chaired by Dr. Sally Ride, met with its NASA counterparts in early March. This series of meetings identified for the Commission the various aspects of the pre [208] launch process that required thorough review, not only for the purpose of the Challenger accident investigation but also to increase safety margins for the future.

Later in March the Pre-Launch Panel again met at Kennedy to receive the NASA Team's preliminary reports and to focus on the spare parts issue and Solid Rocket Booster assembly operations. Panel members also met with contractor personnel involved in Shuttle processing and Kennedy security work.

After the joint meeting at Kennedy with the Pre-Launch Activities Panel, the Mission Planning and Operations Panel traveled to Johnson to begin working with its NASA counterparts and to initiate its own investigative efforts. A specific focus of its work was the mission planning and crew preparation for STS 51-L and details of NASA's safety, reliability and quality assurance programs. Later meetings at both Johnson and Marshall dealt with range safety, weather criteria for launch, flight delays and hardware testing.

While the work of the individual panels and their investigative staffs was ongoing, a general investigative staff began a series of individual interviews to document fully the factual background of various areas of the Commission's interest, including the telecon between NASA and Thiokol officials the night before the launch; the history of joint design and O-ring problems; NASA safety, reliability and quality assurance functions; and the assembly of the right Solid Rocket Booster for STS 51-L. Subsequent investigative efforts by this group were directed in the area of the effectiveness of NASA's organizational structure, particularly the Shuttle program structure, and allegations that there had been external pressure on NASA to launch on January 28th.

More than 160 individuals were interviewed and more than 35 formal panel investigative sessions were held generating almost 12,000 pages of transcript (Table 1 and Table 2). Almost 6,300 documents, totaling more than 122,000 pages, and hundreds of photographs were examined and made a part of the Commission's permanent data base and archives. These sessions and all the data gathered added to the 2,800 pages of hearing transcript generated by the Commission in both closed and open sessions.

In addition to the work of the Commission and the Commission staff, NASA personnel expended a vast effort in the investigation. More than 1,300 employees from all NASA facilities were involved and were supported by more than 1,600 people from other government agencies and over 3,100 from NASA's contractor organizations. Particularly significant were the activities of the military, the Coast Guard and the NTSB in the salvage and analysis of the Shuttle wreckage.

Table 1

Commission Investigative Interviews
.
Interviews of January 27, 1986 Teleconference (8:15 PM EST) Participants
.
Ben Powers	John Schell	William Macbeth	Jerry E Mason
Frank Adams	Keith Coates	Brian Russell	Robert Lund
Larry Wear	George Hardy	Jack Kapp	Joseph Kilminster
James Smith	Jud Lovingood	Ron Ebeling	Roger Boisjoly
Boyd Brinton	Jack Buchanan	Calvin Wiggins	Arnold Thompson
Robert Schwinghamer	Allan McDonald	Larry Sayer	Jerry Peoples
William Reihl	Carver Kennedy	Joel Maw	James Kingsbury
Wayne Littles	Cecil Houston	Kyle Speas
John Q Miller	Lawrence Mulloy	Jerry Burn
John McCarty	Stanley Reinartz	Don Ketner

[209] Interviews of Personnel Involved in Stacking of Right SRB for Flight 51-L
.
Howard Fichtl	Ed O'Neal	Mike Sestile	Jim Gardner
Jack Roberts	Leslie Lake	Granville Goad	John Taris
Curtis J. Newsome	Buddy Rogers	David Mumpower	Kenneth Koby
Mark Vigil	Mario Duran	Robin Nix	Allen R. Hyde
Bob Heinbaugh	Jim St. John	Glenn Charron	Jerry Wilkerson
Howard Christy	Billy Massey	Stewart Dalton	Alex McCool
Jackie Walden	Mike Sieglitz	Sharron Whitaker	Charles D. Newman
Alvie Hicks	Jim Jordan

Interviews on Ice on Pad

Thomas Moser

John Peller

Interviews on Security

Marvin Jones

Herbert Weisner

Interviews on History of SRB Joint Design and Problem
.
Leon Ray	Robert Lindstrom	James Kingsbury	Ben Powers
Alex McCool	James Brier	Sam Lowry	Michael Mann
Jerry Peoples	Jesse Moore	Stanley Reinartz	Richard Kohrs
Glenn Eudy	Joseph Kilminster	Calvin Wiggins	Maurice Parker
Ben Powers	Arnold Thompson	Mark Salita	Keith Coates
John Miller	Irving Davids	Joe Pelham	John Schell
Bill Rice	Arnold Aldrich	Phillip Dykstera	James W. J homes
Bill Horton	Hans Mark	Ed Dorsey	Boyd Brinton
Jerry Cox	Glynn Lunney	Roger Boisjoly	James Abrahamson
Bill Bush	Walt C. Williams	Brian Russel	Jerry Mason
Paul Wetzel	George Hardy	Jack Kemp	Jack Kapp
David Winterhalter	Larry Mulloy	Robert Lund	Ronald Ebeling
William Hamby	Fred Uptagrafft	Howard McIntosh	Arnold Aldrich
Michael Weeks	Richard Cook	Glenn Eudy	Hazel Saunders
Paul Herr	Walter Dankhoff	Robert Gaffin

Interview on Launch Coverage Camera Failures

Charles Alsworth

Interviews on Outside Pressure To Launch
.
Michael Weeks	Phil Culbertson	Jerry E. Mason	Karen Ehlers
Jesse Moore	George Hardy	Arnold Aldrich	George Johnson
Charles Kupperman	Larry Mulloy	Lawrence Wear	James Beggs
Shirley Green	Joseph Kilminster	John Q. Miller	William R. Graham
Vera Herschberg	Stanley Reinartz	James Smith	Richard Cook
Richard Smith	Robert Lund	Norman Terrell	Ben Powers

[210] Interviews on Safety, Reliability and Quality Assurance
.
David Brown	Jackie C. Walker	Howard Gittens	Wayne Frazier
Richard M. Henritze	Benny Nunnelly	Brian Russell	Norman R. Schulze
James 0. Batte	George Butler	Haggai Cohen	Stanley Reinartz
Arthur M. Carr	Henry P. Smith	Harry Quong	Milton Silveira
Wiley C. Bunn	Wesley Hawkins	Dallas N. Vickers
David Austin	John Maxson

Interviews on Management Structure
.
Dick Kohrs	James Smith	Jerry Cox	Richard A. Colonna
Jesse Moore	Arnold Aldrich	Jerry Griffin	Walt C. Williams
Dr. Hans Mark	John J. McCarty	Stanley Reinartz	George Bridwell
William Hamby	Scott Simpkinson	James Kingsbury	George Johnson
Michael Weeks	James Brier	Thomas J. Lee	Richard Cook
Lawrence Wear	Jud A. Lovingood	William F. Taylor	Michael Mann
John Q. Miller	Bill Bush
William Lucas

Interviews on Human Factors
.
Louis E. Toole	Jenny Howard	Ray Hallard	Gregory Haywood Williams
James B. Hill	Greg Oliver	Ken McCrary	Robert L. Brayant
Leonard J. Riche	Robert Yackovetsky	Joe Kenneth Patterson	Keith Coates
Heather M. Mitchell	Morton O'Hare

Interview on Wreckage Reconstruction

Terry Armentrout

Interview on Crew Activities

George Abbey

[211] Table 2. Commission Panel Sessions
.
Date	Location	Subject
.
Accident Analysis Panel
.
March 3, 4, 5	Marshall	Accident Data Review, Fault Tree Analysis
March 6, 7	Kennedy	Film & Wreckage Review
March 11	Kennedy	Coordination with NASA Task Force
March 12, 13	Marshall	Accident Data Review, Fault Tree Analysis, Test Requirements
March 19	Thiokol-Utah	Test Coordination
March 26	Marshall	Test Review
April 10, 11	Marshall	Test Review
April 14, 15, 16, 17	Marshall	Final Review
.
Design, Development and Production Panel
.
March 5	Johnson	Preliminary Briefing
March 17	Thiokol-Utah	Fact-Finding Session
March 18	Thiokol-Utah	Design-Production
April 2	Rocketdyne-California	Main Engines
April 3	Rocketdyne & Rockwell-California	Development-Orbiter
April 4	Rockwell-California	Orbiter
April 7	Marshall	Development and Production
April 8,9	Martin Marietta-Louisiana	Development-External Tank
April 11	Parker Seal-Kentucky	O-rings
.
Pre-Launch Activities Panel
.
March 4, 5, 6	Kennedy	Training, Workload, Schedule, Spares, Pre-launch Investigation Update, Security
March 17, 18, l9	Kennedy	Manpower, Spare Parts, Shuttle Processing, Security, Hold-down Post Spring 51-L, Booster Flow, Salvage Status, SRB Recovery, Launch Readiness Process
.
Mission Planning and Operations Panel
.
March 4, 5	Kennedy	Preliminary Briefing
March 11, 12	Johnson	Crew Activity Planning, Training, Abort Modes, Safety, Manifesting
March 20	Johnson	Objectives Review
March 24, 25	Johnson	Range Safety, Mission Operations, Landing Operations, Weather, Tile Damage, Main Engines, Safety, Reliability and Quality Assurance
March 31, April 1	Johnson	Payload Safety, Hardware Testing, Training, 51-L Flight Design
April 7	Marshall	Safety, Reliability and Quality Assurance
April 8, 9	Johnson	Workload, Software, Manifesting, Landing Considerations
April 14, 15	Johnson	Ascent/Entry Envelope, Abort Option History, Safety, Reliability and Quality Assurance

[212-213] Executive Order 12546, dated February 3, 1986, which established the Presidential Commission on the Space Shuttle Challenger Accident.