Disaster Blamed on O-Rings, Pressure to Launch

Another failure of the safety program cited in the report is the continuing uncertainty surrounding the "criticality" -- the potential risk -- of the booster joint.

Though the joint had been officially categorized as posing the highest possible risk to mission and crew as early as 1982, most of the paper work on the problem done by Thiokol and Marshall listed it as Criticality 1R -- meaning there was backup hardware, or redundancy, in the system to reduce the risk, although there was not.

"As a result," the report says, "informed decision-making by key managers was impossible." As late as March 7, five weeks after the accident, the problem assessment system operated by Rockwell contractors at Marshall still listed the joint as Criticality 1R.

Jesse W. Moore, chief of the shuttle program at the time of the accident, was "misinformed" about what Marshall was doing to fix the joint problem and about the issue of joint risk, the report says.

In establishing the flight schedule after President Reagan declared the shuttle operational on July 4, 1982, the report says, "NASA had not provided adequate resources for its attainment." As a result, the capabilities of the system were strained even by the modest nine-mission rate of 1985, and the evidence suggests that NASA would not have been able to accomplish the 15 flights scheduled for 1986.

The panel urges NASA to develop firm new ground rules for flight rates based on "a realistic assessment of what NASA can do safely and well."

NASA was allowing disruptions to build up, which meant that the "end of the production chain: crew training," was getting increasingly squeezed, the report says. It quoted astronaut Henry Hartsfield as saying, "Had we not had the accident, we were going to be up against a wall . . . . For the first time, somebody was going to have to stand up and say we have got to slip the launch because we are not going to have the crew trained."

Among the disruptions were those caused when shuttle customers requested changed launch dates because of "development problems, financial difficulties or changing market conditions. NASA generally accedes to these requests and has never imposed the penalties available" against the customers, the report says.

Even small cargo changes take a lot of time if they are made late, Johnson Space Center official Harold Draughon told the commission.

"Accomplishing the more pressing immediate requirements diverted attention from what was happening to the system as a whole," the report says. "In many respects, the system was not prepared to meet an 'operational' schedule."

"At Kennedy Space Center, numerous contract employes have worked 72 hours per week or longer and frequent 12-hour shifts," the report says. "The potential implications of such overtime for safety were made apparent during the attempted launch of mission 61C on Jan. 6, 1986, when fatigue and shiftwork were cited as major contributing factors to a serious incident involving a liquid oxygen depletion that occurred less than five minutes before scheduled liftoff."

The spare parts problem also was coming to a head at the time of the accident. By last January, "only 32,000 of the required 50,000 items (65 percent) had been delivered." Funding cuts "necessitated major deferrals of spare parts purchases."

It became an "essential modus operandi" for NASA to cannibalize spares, that is, to remove parts from one shuttle orbiter for installation in another. "This practice is costly and disruptive and introduces opportunities for component damage . . . and is a potential threat to flight safety."

"I think we would have been brought to our knees this spring by this problem if we had kept trying to fly," Horace Lamberth, director of shuttle engineering at Kennedy, told the commission in an interview.

As of spring 1986, the shuttle logistics program was approximately one year behind, the report says. "Unless logistics support is improved, the ability to maintain even a three-orbiter fleet is in jeopardy."

A "serious problem" among shuttle technicians is a perception that they might be "punished" or even lose their jobs if they report accidental damage to the space craft, the report says. Consequently, "accidental damage is not consistently reported."

In an appendix to the report, the panel is harshly critical of NASA's system of documenting shuttle processing problems and concludes that the system itself is a problem. "The amount of flawed paper work -- approximately 50 percent -- is unacceptable," it says.