Report of the PRESIDENTIAL COMMISSION on the Space Shuttle Challenger Accident



[198] 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:


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:


- II -


[199] 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.


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:

- V -


[200] 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.


- VI -


Landing Safety. NASA must take actions to improve landing safety.


- 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:


- VIII -


[201] 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:


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.


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