****Report of the PRESIDENTIAL COMMISSIONon the Space Shuttle Challenger Accident****
****Recommendations****

 

[**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 -****
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**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 -****
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[**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.

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**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.

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**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.

 

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**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 -****

 

[**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.

- 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. 

 

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**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. 

 

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**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 -****

 

[**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.

 

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**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****
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*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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