Investigation of the Challenger Accident
TABLE I1 PRINCIPAL PARTICIPANTS IN THE TELECONFERENCE
TABLE I1 PRINCIPAL PARTICIPANTS IN THE TELECONFERENCE
¶ON JRNUARY 27. 1986 e.tKennedvwm.Florlda Th I okol A1 I an McDonal d D t r e c t o r , Sol I d Rocket Motor Program
¶Offfce Th f okol Jack Buchanan Manager, KSC Resldent O f f l c e MSFC Lawrence Mu1 I oy Manager, Sol 1 d Rocket Booster P r o j e c t
¶Offfce MSFC Stan1 ey Relnartz Manager, S h u t t l e ProJects O f f f c e MSFC Judson Lovfngood Deputy Manager, S h u t t l e P r o j e c t s O f f l c e
¶MSFC George Hardy Deputy D l r e c t o r f o r Sclence and
¶Engl neerf ng
¶AtJhlokdKaza.mODeratfons,Ytatr Th I okol J e r a l d Mason Senlor V f c e Presfdent, Wasatch
¶Operatlons Th I okol C.G. Wlggins V l c e P r e s l d e n t and General Manager,
¶Space D i v l s f o n Th lokol Robert Lund V f c e P r e s l d e n t f o r Englneerfng Th I okol Joseph K l l m l n s t e r V l c e Presldent, Space Booster Programs Th l o k o l Roger Bols j o t y S t a f f Engineer, Appl l e d Mechanics Th I okol Robert Ebel I n g Manager, SRM lgnf t l o n System, F f nal
¶Assembl y, Spec1 al ProJects and Test Th I okol Arnold Thompson Supervlsor, S t r u c t u r e s Deslgn
223¶Mr. Houston then called Dr. Judson Lovingood, Deputy Shuttle Project Manager at Marshall, to inform him of the concerns about the O-rings. Mr. Houston asked Dr. Lovingood to set up a telecon- ference with senior project management personnel, including Mr. George Hardy, Deputy Director of Science and Engineering at Mar- shall, and with Thiokol personnel. Dr. Lovingood called Mr. Stan- ley Reinartz, Marshall's Shuttle Project Office Manager, a few min- utes later and informed him of the planned teleconference.
¶The first phase of the teleconference began at 5:54 p.m. EST and included Messrs. Reinartz, Lovingood, Hardy, and others at Kenne- dy, Marshall and Thiokol's Wasatch plant. Concerns about the effect of low temperature of the O-rings and the joint seal were presented by Thiokol personnel, along with an opinion that launch should be delayed.
¶A recommendation was also made that Arnold Aldrich, the Space Transportation System Program Manager, be told of the up- coming telecon and that the fact that Thiokol had expressed some concerns. Mr. Reinartz testified before the Commission that "we did not have a full understanding of the situation as I understood it at that time, and felt that it was appropriate to do before we in- volved the Level I1 into the system."63
¶Testifying before the Rogers Commission, Dr. Lovingood was asked whether the possibility of a launch delay had been men- tioned in this telcon on January 27. Dr. Lovingood replied:
That is the way I heard it, and they were talking about the 51-C experience and the fact that they had experi- enced the worst case blow-by as far as arc and the soot and so forth. And also, they talked about the resiliency data that they had. So it appeared to me-and we didn't have all the people there. That was another aspect of this. It appeared to me we had better sit down and get the data so that we could understand exactly what they were talking about and assess that data. And that is why I suggested that we go ahead and have a telecon within the center, so that we can review that.64
¶Dr. Keel, the Staff Director for the Rogers Commission, asked,
Dr. KEEL."So as early as after that first afternoon con- ference at 545, it appeared that Thiokol was basically saying delay. Is that right?" Dr. LOVINGOOD. "That is the way it came across to me. I don't know how other people perceive it, but that's the way it came across to me." Dr. KEEL."Mr. Reinartz, how did you perceive it?" Mr. REINARTZ."I did not perceive it that way. I per- ceived that they were raising some questions and issues which required looking into by all the parties, but I did not perceive it as a recommendation to delay." Dr. KEEL."Some prospect for delay?"
¶63 Rogers Commission Report, Volume V, p. 919 84 Ibid., p. 923.
224Mr. REINARTZ."Yes, sir, that possibility is always there." Dr. KEEL."Did you convey that to Mr. Mulloy and Mr. Hardy before the 8:15 teleconference?" Mr. REINARTZ."Yes I did. And as a matter of fact, we had a discussion. Mr. Mulloy was just out of communica- tion for about an hour, and then after that I got in contact with him, and we both had a short discussion relating to the general nature of the concerns with Dr. Lucas and Mr. Kingsbury at the motel before we both departed for the te- lecon that we had set up out at the Cape."65
¶At approximately 8:45 p.m. EST, the second phase of the telecon- ference commenced, Thiokol's charts and written data having ar- rived at the Kennedy Space Center by telefax. The charts present- ed a history of the O-ring erosion and blow-by in the Solid Rocket Booster joints of previous flights, presented the results of subscale testing at Thiokol and the results of static tests of Solid Rocket Motors.
¶Mr. Boisjoly testified:
I expressed deep concern about launching at low temper- ature. I presented Chart 2-1 with emphasis-now, 2-1, if you want to see it, I have it, but basically that was the chart that summarized the primary concerns, and that was the chart that I pulled right out of the [August 191 Washington presentation without changing one word of it because it was still applicable, and it addresses the highest concern of the field joint in both the ignition transient con- dition and the steady state condition, and it really sets down the rationale for why we were continuing to fly. Ba- sically, if erosion penetrates the primary O-ring seal, there is a higher probability of no secondary seal capability in the steady state condition. And I had two sub-bullets under that which stated bench testing showed O-ring not capable of maintaining contact with metal parts gap opening rate to maximum operating pressure. I had another bullet which stated bench testing showed capability to maintain O-ring contact during initial phase (0 to 170 milliseconds of transient). That was my comfort basis of continuing to fly under normal circumstances, normal being within the data base we had. I emphasized, when I presented that chart about the changing of the timing function of the O-ring as it at- tempted to seal. I was concerned that we may go from that first beginning region into that intermediate region, from 0 to 170 being the first region, and 170 to 330 being the intermediate region where we didn't have a high probabili- ty of sealing or seating.66
¶66 Ibid. 60 Ibid., Volume IV, p. 790.
225¶Mr. Boisjoly then presented Chart 2-2 with his added concerns related to the timing function. He mentioned in his testimony to the Rogers Commission:
We would have low O-ring squeeze due to low tempera- ture which I calculated earlier in the day. We should have higher O-ring Shore hardness. . . . Now, that would be harder. And what that material really is, it would be lik- ened to trying to shove a brick into a crack versus a sponge. That is a good analogy for purposes of this discus- sion. I also mentioned that thicker grease, as a result of lower temperatures, would have higher viscosity. It wouldn't be as slick and slippery as it would be at room temperature. And so it would be a little bit more difficult
¶to move across it.
¶We would have higher O-ring pressure actuation time, in my opinion, and that is what I presented. . . . These are the sum and substance of what I just presented. If action time increases, then the threshold of secondary seal pressurization capability is approached. That was my fear.
¶If the threshold is reached, then secondary seal may not be capable of being pressurized, and that was the bottom line of everything that had been presented up to that point.67
¶Asked by Chairman Rogers, "Did anybody take issue with you?." Mr. Boisjoly responded:
¶Well, I am coming to that. I also showed a chart of the joint with an exaggerated cross section to show the seal lifted off, which has been shown to everybody. I was asked, yes, at that point in time I was asked to quantify my concerns, and I said I couldn't. I couldn't quantify it. I had no data to quantify it, but I did say I knew that it was away from goodness in the current data base. Someone on the net commented that we had soot blow-by on SRM-22
¶[Flight 61-A, October, 19851 which was launched at 75 degrees, I don't remember who made the comment, but that is where the first comment came in about the disparity between my conclusion and the observed data because SRM22 had blow-by at essentially a room temperature launch.
¶I then said that SRM-15 [Flight 51-C, January, 19851 had much more blow-by indication and that is was indeed telling use that lower temperature was a factor. This was supported by inspection of flown hardware by myself. I was asked again for data to support my claim, and I said I have none other than what is being presented, and I had been trying to get resilience data, Arnie [Thompson] and I both, since last October, and that statement was mentioned on the net.68
¶This second phasse of the telecon on the evening of January 27 concluded with statements from Robert Lund, Thiokol's Vice Presi- dent of Engineering. His conclusion at that time was that the Shut67 Ibid., p. 791. 88 Ibid.
226¶tle should not fly outside Thiokol's database; that, is, that the 0- ring seals should be above 53 degrees Fahrenheit before lift-off.
¶NASA participants in the telecon were not pleased with these conclusions and recommendations, according to Mr. Boisjoly and Mr. McDonald. Mr. Hardy, when asked what he thought about Thiokol's recommendation, was quoted to the effect that he was "appalled" at Mr. Lund's decision.69
¶Boisjoly also testified that Mr. Hardy said, "No, not if the con- tractor recommended not launching, he would not go against the contractor and launch."70
¶Shortly thereafter, Mr. Joseph Kilminster, Thiokol's Vice Presi- dent for-Space Booster Programs, was asked-by NASA if he would launch and "he said no because the engineering recommendation was not to l a ~ n c h . " ~
¶Then, according, to Mr. Boisjoly, someone in Thiokol manage- ment asked for a five-minute caucus, and at that point Thiokol cut their speakerphone off.
¶Chairman ROGERS."Mr. Boisjoly, at the time that you made the-that Thiokol made the recommendation not to launch, was that the unanimous recommendation as far as you knew?"
¶Mr. BOISJOLY. "Yes. I have to make something clear. I have been distressed by the things that have been appearing in the paper and things that have been said in general, and there was never one positive, pro-launch statement ever made by anybody. There have been some feelings since then that folks have expressed that they would support the decision, but there was not one positive statement for launch ever made in that
¶Asked for his recollection of these incidents, Mr. McDonald com- mented,
¶. . . And the bottom line was that the engineering people would not recommend a launch below 53 degrees F. The basis for that recommendation was primarily our concern with the launch that had occurred about a year earlier, in January of 1985, I believe it was 51-C.73
¶Mr. Mulloy testified:
¶The bottom line of that, though, initially was that Thiokol engineering, Bob Lund, who is the Vice President and
¶Director of Engineering, who is here today, recommended that 51-L not be launched if the O-ring temperature predicted at launch time would be lower than any previous launch, and that was 53 degrees. . . .7 bid. 4
¶At 10:30 p.m. EST, the teleconference between NASA and Thio- kol was recessed. The off-net caucus of Thiokol personnel lasted ap70 Ibid.
¶bid. 72 bid. 7s Ibid., Volume IV, p. 717. 7' bid., Volume IV, p. 604.
227¶proximately thirty minutes at the Wasatch office. Jerald Mason, Senior Vice President for Wasatch Operations, remembered that the conversation during the caucus centered around O-rings and the history of eroosion of the O-rings. Mr. Mason testified:
¶Now, in the caucus we revisited all of our previous discussions, and the important things that came out of that was, as we had recognized, we did have the possibility that the primary O-ring might be slower to move into the seating position and that was our concern, and that is what we had focused on originally. . . . The fact that we couldn't show direct correlation with the O-ring temperature was discussed, but we still felt that there was some concern about it being colder.75
¶Ten engineers participated in the caucus, along with Mr. Mason, Mr. Kilminster, Mr. Lund and Mr. C.G. Wiggins (Vice President and General Manager for Thiokol's Space Division). Arnold Thomp- son 7 6 and Mr. Boisjoly voiced very strong objections to launch, and the suggestion in thieir testimony was that Lund was also reluc- tant to launch.
¶Mr. Boisjoly, in testifying before the Rogers Commission, stated:
¶Okay, the caucus was started by Mr. Mason stating that a management decision was necessary. Those of us who opposed the launch continued to speak out, and I am specifically speaking of Mr. Thompson and myself because in my recollection he and I were the only ones that vigorously continued to oppose the launch. And we were attempting to go back and rereview and try to make clear what we were trying to get across, and we couldn't understand why it was going to be reversed. So we spoke out and tried to explain once again the effects of low temperature. Arnie actually got up from his position which was down the table, and walked up the table and put a quarter pad down in front of the table, in front of management folks, and tried to sketch out once again what his concern was with the joint, and when he realized he wasn't getting through, he just stopped.
¶I tried one more time with the photos. I grabbed the photos, and I went up and discussed the photos once again and tried to make the point that it was my opinion from actual observation that temperature was indeed a discriminator and we should not ignore the physical evidence that we had observed.
¶And again, I brought up the point that SRM-15 [Flight
¶51-C, January, 19851 had a 110 degree arc of black grease while SRM-22 [Flight 61-A, October, 19851 had a relatively different amount, which was less and wasn't quite as black. I also stopped when it was apparent that I couldn't get anybody to listen.71
¶'6 Kid., p. 759. '6 Supervisor of Structures Design, Thiokol. '7 Rogers Commission Report, Volume IV, pp. 792-93.
228¶Commissioner Walker asked, "At this point did anyone else speak up in favor of the launch?" Mr. Boisjoly replied:
No, sir. No one said anything, in my recollection, nobody said a word. It was then being discussed amongst the man- agement folks. After Arnie and I had our last say, Mr. Mason said we have to make a management decision. He turned to Bub Lund and asked him to take off his engi- neering hat and put on his management hat. From this point on, management formulated the points to base their decision on. There was never one comment in favor, as I have said, of launching by any engineer or other nonman- agement person in the room before or after the caucus. I was not even asked to participate in giving any input to the final decision charts. I went back on the net with the final charts or final chart, which was the rationale for launching, and that was presented by Mr. Kilminster. It was hand written on a note pad, and he read from the notepad. I did not agree with some of the statements that were being made to sup- port the decision. I was never asked or polled, and it was clearly a management decision from that point. . . . I left the room feeling badly defeated, but I felt I really did all I could to stop the l a ~ n c h .7 bid. ~
¶In testimony before the Committee on June 18, 1986, concerning the caucus and the decision to overrule engineering recommenda- tions, Boisjoly said:
When we went off the line and caucused-one of the first statements that was made was that we would have to make a management decision by management people. And we continued very strongly to oppose that and we argued as vigorously as we could argue, and when you look up into people's eyes you know you have gone about as far as you can go. And so both Mr. Thompson and I just plain frankly backed off. You had to be there and you had to see the looks and feel the experience that it didn't really make any difference what further you were going to say, you were just not going to be heard.79
¶At approximately 11 p.m. EST, the Thiokol/NASA teleconference resumed, with Mr. Kilminster stating that they had reassessed the problem, that the temperature effects were a concern, but that the data were admittedly inconclusive. He read the rationale recom- mending launch and stated that to be Thiokol's recommendation. Mr. Hardy of NASA requested that it be sent in writing by telefax both to Kennedy and to Marshall, and it was.8o
¶713bid.
¶lS Cmte Hgs, Transcript, June 18, 1986, p. 85.
¶no The Committee has learned that (apparently due to an error in duplicating the relevant chart) the copy of this telefax that was sent to the Rogers Commission did not contain the stand- ard caveat that was printed below the company logo on the original telefax. The caveat reads, "Information on this page was prepared to support an oral presentation and cannot be consid- ered complete without the oral discussion." At the Committee hearings on June 18, 1986, Mr.U. Continued
229¶Having heard the debate and this decision, Mr. Reinartz accepted the conclusion and ended the teleconference. He asked whether anyone had any further concerns. None were expressed. Commis- sioners then asked what steps he had taken after the decision was made.
¶Chairman ROGERS."I guess the question that still lingers in my mind is, in the Navy we used to have an expression about going by the book, and I gather you were going by the book. But doesn't the process require some judgment? Don't you have to use common sense? Wouldn't common sense require that you tell the decisionmakers about this serious problem that was different from anything in the past?
¶Mr. REINARTZ."In looking at that one, Mr. Chairman, together with Mr. Mulloy when we looked at were there any launch commits, any Level 11, as I perceived during the telecon, I got no disagreement concerning the Thiokol launch between any of the Level I11 elements, the contractor, with Mr. McDonald there. I felt that the Thiokol and
¶Marshall people had fully examined that concern, and that it had been satisfactorily dispositioned based upon the evidence and the data that was supplied to that decision process on that evening, from that material, and not extraneous to what else may have been going on within Thiokol that I had no knowledge of."
¶Chairman ROGERS."Okay. Thank you. I'm sorry for the long interruption."
¶Mr. REINARTZ. "Based upon-and as we skipped over it is only a point to illustrate, Mr. Chairman, that in our discussion about the parachute with KSC and Mr. Aldrich, was to indicate that there was a clear area there where we had a very direct responsibility to inform them of the situation, which Mr. Mulloy did. And after a discussion of that issue, Mr. Aldrich concluded that the launch should proceed in that nature. Based on the results of the meeting and the conclusions out of the meeting, Mr. Mulloy and I informed the Director of Marshall, Dr. Lucas, and the Director of Science and Engineering, Mr. Kingsbury, on the
¶28th of January-about 5:OO-of the initial Thiokol concerns and engineering recommendations, the final Thiokol launch recommendation, that I felt had led to a successful resolution of this concern."
¶General KUTYNA."Could I interrupt for a minute? You informed Dr. Lucas. He is not in the reporting chain?"
Mr. REINARTZ. "NO,sir." General KUTYNA. "If I could use an analogy, if you want
¶to report a fire you don't go to the mayor. In his position as center director, Dr. Lucas was cut out of the reporting chain, much like a mayor. If it was important enough to
¶Edwin Garrison, President of the Aerospace Group at Thiokol, testified that the caveat at the bottom of the paper in no way". . . insinuates. . . that the document doesn't mean what it says." (Cmte H the Committee r&Transcript, June 18, 1986, p. 43.) After further investigation of this deletion, concluded that it was not significant.
230report to him, why didn't you go through the fire depart- ment and go up your decision chain?" Mr. REINARTZ."That, General Kutyna, is a normal course of our operating mode within the center, that I keep Dr. Lucas informed of my activities, be they this type of thing or other." General KUTYNA. "But you did that at 5 o'clock in the morning. That's kind of early. It would seem that's impor- tant. Why didn't you go up the chain?" Mr. REINARTZ."NO,sir. That is the time when we go in, basically go into the launch, and so it was not waking him up to tell him that information. It was when we go into the launch in the morning. And based upon my assess- ment of the situation as dispositioned that evening, for better or worse, I did not perceive and clear requirement for interaction with Level 11, as the concern was worked any dispositioned with full agreement among all reasona- ble parties as to that agreement." Chairman ROGERS. "Did I understand what you just said, that you told Dr. Lucas that all the engineers at Thiokol were in accord? Mr. REINARTZ. "No, sir. What I told him was of the ini- tial Thiokol concerns that we had and the initial recom- mendation and the final Thiokol recommendation and the rationale associated with that recommendation, and the fact that we had the full support of the senior Marshall engineering and, as George has testified, to the exten- siveness of the group of people we had involved in that te- lecon with the various disciplines, that those three ele- ments made up the final recommendation." Mr. HOTZ."Mr. Reinartz, are you telling us that you in fact are the person who made the decision not to escalate this to a Level I1 item?" Mr. REINARTZ. "That is correct, sir."8 Ibid. Ibid. ' 0 bid. I 1bid. Morton Thiokol, "Program Plan, Protection of Space Shuttle SRM Primary Seals," TWR- 14359,May 4, 1984. s Ibid. Discussions with Allan McDonald and Carver Kennedy, Thiokol (Wasatch Operations), Brigham City, Utah,, September 4, 1986. 2
¶According to NASA's Program Directive SFO-PD 710.5A, Mr. Reinartz may have been required to report the matter to the Asso- ciate Administrator for Space Flight. A portion of that directive reads as follows:
Significant items occurring subsequent to the FRR will also be reported to the AA-SF. Actions that can be easily accomplished without safety, mission, or launch impact and do not violate flight vehicle or launch complex config uration integrity or cause basic changes to launch commit criteria, flight rules, flight plan, or abort and alternate mission plans, need not be reported.83
¶Was this telecon, and the decision reached, "significant?" NASA's request that the Thiokol decision be put in writing indi-Staff review of teleconference materials used by Marshall engineers Wilbur Riehl (Chief, Nonmetallic Materials Division) and John Miller (Technical Assistant to the SRM Mana er) in- dicates that some of the Marshall engineering staff shared the concerns expressed by 'fhiokol engineers.
¶Rogers Commission Report, Volume V, pp. 917-18.
¶8s SFO-PD 710.5A, p. 3.
231¶cates that MSFC personnel felt the situation was significant, since in effect Thiokol was reconfirming the flight readiness of the SRM.
¶It is also interesting to note, in light of the directive, that Mr. McDonald testified before the Commission to the effect that Mr. Mulloy had made some "fairly strong comments . . . about trying to institute new launch commit criteria."84 NASA, documents on the SPC contract, sup lied to the Committee in July, 1986. Rogers Commission Report, Volume IV. p. 721
¶Mr. Mulloy responded to this by explaining what he had at- tempted to say.
Mr. MULLOY. "The total context, I think, in which those words may have been used is, there are currently no Launch Commit Criteria for joint temperature. What you are proposing to do is to generate a new Launch Commit Criteria on the eve of launch, after we have successfully flown with the existing Launch Commit Criteria 24 previ- ous times. With this LCC, i.e., do not launch with a tem- perature greater than [sic] 53 degrees, we may not be able to launch until next April. We need to consider this care- fully before we jump to any conclusions. It is all in the context, again, with challenging your interpretation of the data, what does it mean and is it logical, is it truly logical that we really have a system that has to be 53 degrees to fly? . . ," General KUTYNA."Mr. Mulloy, if in fact the criteria were 53 degrees, it would have an impact not only on this launch, but on the shuttle program. . . . It is a fairly im- portant decision to say you can't launch below 53 degrees, isn't it? Mr. MULLOY. "Yes, sir, I agree with that. I cannot de- scribe the impacts, but, as I say, based upon our previous experience and our actions in flying subsequent vehicles after 51C,I found that to be a surprising conclusion. . . ." Mr. SUITER.' I . . . [Ilnstead of saying you have to wait until next April to launch, the thing that you do is you go and there were three different levels of improvements that were discussed. The thing to do then was to put those im- provements in the program, not infer that these engineers are saying, we're throwing a ringer a t you that says don't launch until next April. I think that is putting those engi- neers into a little bit of a hot seat. And if they're trying to do their job and say, hey, we ought to do something about this, there ought to have been more attention paid."8 Ibid. Ibid. ' 0 bid. I 1bid. Morton Thiokol, "Program Plan, Protection of Space Shuttle SRM Primary Seals," TWR- 14359,May 4, 1984. s Ibid. Discussions with Allan McDonald and Carver Kennedy, Thiokol (Wasatch Operations), Brigham City, Utah,, September 4, 1986. 5
¶The Rogers Commission report included the statement, "It is clear that crucial information about the O-ring damage in prior flights and about the Thiokol engineers' arguments with the NASA telecon participants never reached Jesse Moore or Arnold Aldrich, the Level I and I1 program officials, or J. A. Thomas, the Launch Director for 51-L."86
¶Based on the available evidence, the Committee is unable to con- clude whether or not Mr. Moore or Mr. Aldrich, with the information available to them that day, would have reached a decision to stop the launch had they been informed of this meeting. It does appear, however, that a three-hour telecon, in which arguments are raised about launch commit criteria and the contractor is asked to reconfirm the flight readiness of his hardware fall under the definition of the policy directive. At the very least, the STS Program Manager should have been presented the new declaration of flight readiness with a n explanation of why it had been devel- oped. This should have been a necessary addition to the Certificate of Flight Readiness prepared after the Flight Readiness Review.
232¶The Committee also reviewed tapes and transcripts of conversa- tions that took place in the Firing Room on January 28th involving discussions of the threat posed by ice on the Fixed Service Struc- ture. Kennedy Space Center managers, in response to the predicted low temperatures that would be seen in the hours before the launch of STS-SlL, took action to protect Launch Complex 39B and the Shuttle from freezing and ice buildup. This involved imple- menting the "freeze protection plan" for launch pad facilities. Ac- cording to a post-accident report:
Two actions within the PLAN were intended to limit the ICE DEBRIS which potentially could cause damage to the Shuttle Vehicle during launch. The first action involved adding approximately fourteen hundred gallons of anti- freeze into the overpressure water troughs. The water troughs in both SRB exhaust holes have a total capacity of 6,580 gallons. The resultant antifreeze to water ratio was calculated to be 21.3%. According to the manufacturer's specifications, solution protected against freezing down to a n ambient temperature of 16 degrees F. The second action involved the draining, where practical, of all water systems. Several systems, such as Firex [fire extinguish- ing], Deluge, and emergency shower and eyewash, were not drained. These systems were opened slightly and al- lowed to trickle into drains. The trickling water was found to cause drain overflows. High wind gusts then spread the water over large areas and it then froze.87
¶Soon after the call-to-stations on 28 January, at approximately midnight, cameras on the pad allowed engineers in the Firing Room to see that the gantry was heavily encrusted with ice. Over the Engineering Support Room communications loops, the follow- ing conversation took place:8 Ibid. Ibid. ' 0 bid. I 1bid. Morton Thiokol, "Program Plan, Protection of Space Shuttle SRM Primary Seals," TWR- 14359,May 4, 1984. s Ibid. Discussions with Allan McDonald and Carver Kennedy, Thiokol (Wasatch Operations), Brigham City, Utah,, September 4, 1986. 7 NASA, Kennedy Space Center, "STS-33 (51-L) IceIFrost Team Evaluation Report ESS/ RSS/MLP Deck/Pad Apron Icing," January 30, 1986, 1.
¶Conversations were recorded from the Kennedy ipace Center Operational Intercommunica- tion System (OW, which permits members of the launch crew to discuss problems that occur during the countdown, and permits them to contact various mission support facilities around the country. The transcripts provided to the Committee do not indicate the exact times at which the referenced conversations occurred, and so the flow of conversations has been reconstructed in an attempt to provide logical consistency.
¶Most of the transcripts in this section are drawn from OIS Channel 245, identified as the co- ordination channel for JSC/MSFC/KSC Engineering personnel in the Engineering Support Area at Kennedy Space Center. Conversations among Rockwell International personnel were obtained from 01s Channel 216, described as the coordination channel for JSC personnel at Johnson and Kennedy centers and Rockwell engineers in Downey, California. Tranacript page numbers a re those supplied by NASA.
¶Continued
233¶BL. This is Bob on 245.
¶DIRECTOR. Go ahead, Bob.
¶BL. Did you ever find out any more about that water?
¶DIRECTOR. No, no I haven't.
¶BL. Okay, I guess the thing, they don't know yet where that water's coming from and the NTDs [NASA Test Director] got some folks looking into it. I guess the thing you guys need to do is see if you can get certain cameras to look a t the vehicle and to determine if there's any water getting on the vehicle that might freeze and cause problems.
¶DIRECTOR. I think what we need to do, Bob, we need to decide do we feel comforta- ble enough to let it keep running and forming ice up there, or we ought to stop and send somebody in there and try to shut it off.
¶BL. Yeah, okay.
¶DIRECTOR. Do you guys think we could form enough ice there to cause us any problem on liftoff or anything?
¶BL. I think you've already done that, Horace.
¶DIRECTOR. Well, then, we ought to stop and go out there and get the water shut Off.
¶BL. Yeah, we're worried about a n icicle up high-well, see, camera 108's on the 155 foot. . . .
¶ITL. 155? Yeah. So you're already getting high up, you know. And if the winds going to be out of the north-northwest. . . .
¶DIRECTOR. All right, let's stop them and send the people out there and see if they can shut the water off.
¶ITL. I think what it is, is the fire hose-if you look right over, if you go to 108 and go like you're going to the elevator, you'll see a fire hose, looks like a fire hose draped across there ...
¶DIRECTOR. Yeah.
¶ITL. . . . And I think they take the fire hose and carry it over to the shower, the eye shower. And evidently the drains that they're draining into is frozen off, or either the hose has fallen off the drain, one or the other.
¶DIRECTOR. Okay, we gotta work this in. We're going to tell them to go out there and shut the water off.
¶The ice/frost team was dispatched to the pad and arrived at ap- proximately 1:45 a.m. What they found during their inspection of the Fixed Service Structure was not very encouraging to the team leader. He reported back to the Firing Room:
¶ITL. Horace, this is Charlie on 245.
¶BL. Hello, this is Bob. I think he may still be in that HIM (Hardware Interface Module] meeting [on the fire detector problem]. What do you see out there?
¶ITL. Okay, starting on about the 235 foot level where the top hose is, the fire hose that was draining into the shower, the hose is not really, the drain is in the shower, the hose is not really draining into the little bowl on the shower and it was spilling over. So we have a lot of hard solid ice from the 235 feet down to 195 feet where I am now. Most of it's on the west side and the north side, and about halfway in- between, the floor is one solid sheet of ice about an inch and a half thick. And down on 195 foot level, the water's on the pipe and plumbing and structure and beams all the way over to the Orbiter Access Arm [OAA]. That's as far down as we got so far.
¶BL. Copy.
¶ITL. We have some icicles about 18 inches long.g*
¶The Ice Team leader later reported that ice was covering part of the floor on the 195 foot platform where the crew would enter the Orbiter. Part of this discussion follows: Significant participants in these conversations include: DIRECTOR: Director of Engineering, Kennedy Space Center. B L Chief, Mechanical Systems Division, Shuttle Engineering Directorate. LD: Launch Director, STS 51-L. ITL Ice Team Leader. w 9 01s Channel 245, p. 570.
¶mid., pp. 570-72.9 Rogers Commission Report, loc. cit. 1 h i d . , p. 573.
234¶BL. Charlie, is that ice going to be any kind of impediment to the crew?
¶ITL. Uh, not to the crew. I don't see any out here where the crew walks.
¶BL. HOW'bout to the baskets [the emergency escape system]?
¶ITL. . . . Up to the what?
¶BL. If they had to go to the baskets for any reason, do they have a clear path through that ice?
¶ITL. Oh, no. When you get over that way, we got ice.
¶BL. SOthey had to get out in a hurry in order to get to the baskets, they've got to go over a sheet of ice.
¶ITL. Oh, yeah. On the north side, that's all one hard sheet of ice. Now, they could get to the two baskets on the south side, probably three baskets on the south side. Hold on just a minute, I'll go take a look. . . .9 Rogers Commission Report, loc. cit. 2
¶ITL.Okay, Bob, I'm back.
¶BL. Okay. What's it look like over there?
¶ITL. Okay-some right a t the elevator, right where the camera is, going back toward the baskets, we got ice on the floor. And the ice goes all the way across the west side of the facility, all the way over to the north corner on the floor. So it is slippery. Once you get past the west-most part of the FSS, the ice on the floor ceases, and you got a clear walkway, 90 all five baskets are, uh, six baskets do have a clear walkway right around the baskets. But to get between the elevator and the camera where you're looking at, there's some ice on the floor.
¶BL. Okay.
¶ITL. And including the handrails that they would be holding on to. But out here from the Orbiter Access Arm over to the camera is clear.
¶BL. What's your Safety guy there think about that? You got a Safety guy with you, don't you?
¶ITL. Yes, he's concerned. Matter of fact, there's some ice right under my feet now that I look.
¶BL. Charlie, Horace is back with us now. Why don't you start up your review from the 235 foot level on down again.
¶ITL. Okay. From the 235 foot level is where we had these litle Firex systems-the hose, the rubber hose which we ran over to the shower back on the northwest corner of the FSS, so we ran it on to the eyewash shower the level below, the 235 foot level, and it was running out of the drain, you know, the little basin-it was overflowing the little basin. So we have over in that area, down to the 195 foot level on the north side of the FSS, icicles that are about 18 inches or so long, about one inch in diameter or more at their maximum diameter. This floor, the grating, over on the north side paralleling the showerway and the elevator in some places are frozen solid about two inches thick. You know, the area is like 10 [by] 10 or more.
¶DIRECTOR. On the floor, which floors, Charlie?
¶I T L The floor of the grating, on like the 215 and there's a level between 215 and right under, between 215 and 195; there's a half-level that you go out to the hatch on the north side.
¶DIRECTOR. Okay.
¶ITL. And there's a lot of icicles hanging, you know, under the floor. As far as the east side goes, on the 195 foot level where we are now, we have about one-quarter inch or one-half inch ice. On the beam structures themselves, they go all the way over to the-right at the hinge where the Orbiter Access Arm goes out. I don't see any on the Orbiter Access Arm itself, but there is some here where I'm standing and a little bit on the floor. Just before you came on, we were talking about the slidewire-the baskets. The floor from the Orbiter Access Arm over to, back where the camera is, is fairly clean. And from the camera back to the west side, is some ice on the floor to the west edge of the FSS.
¶DIRECTOR. Okay.
¶ITL. So the crew would have to walk across one slick spot. Around the baskets themselves. it's fairly clean. But to the northwest corner of the FSS where the bas- kets are, there's h e a h concentration of ice on the floor.93
¶The discussion concluded:
¶DIRECTOR. Do you see anything out there that makes it unsafe for the crew?
¶ITL. At this time, I'd say from the elevator to the Orbiter Access Arm would be fairly good; the floor's in good shape. The elevator's got a little bit of-the doors are real hard to work but everything seems to work in that neighborhood. If they had to go to the slidewire, it'd be very slippery from the camera that you're looking a t to the slidewire itself. There's a n area about ten feet long where the handrails have ice on them, as well as the floor.94
235¶This discussion is of concern to the Committee. The slidewire re- ferred to is the means by which the Shuttle crew would evacuate the launch pad if an emergency were to occur that required a rapid exit from the pad area. Crew safety concerns should dictate that the ice situation described by the Ice Team leader is unacceptable, and that some effort to remove the ice from the floor and handrails should be made. There is no indication that this was done. If the ice could not be removed, the mission should have been delayed until the danger represented by the ice could be eliminated.
¶This situation, admittedly, had nothing to do with the accident that destroyed STS-51-L. However, had this been the one time that use of the pad escape system was required, the crew would very likely have been impeded in their attempt to reach the escape bas- kets, and the lost time might have proven fatal. This system must be operated with the expectation that it will be used, and the countdown procedure should require that no barriers to its use be present before launch.
¶As the Ice Team continued its inspection, the discussion in the Firing Room involved the possible threat posed by the ice problem.
¶BL. We're just going to ask your opinion on the debris concern. If Charlie thinks we have a concern with debris, and I guess I would find it hard to believe that we'd be concerned about it from the FSS, but if we do have a concern, can we go out there and try to clean it up a little bit?
¶DIRECTOR. Yeah, I think we could. I think when he gets through here, if we think there's some areas that we need to clean up a little bit, we probably could.
¶BL. I think Safety would probably have to make a call, myself, on the floor if they think it's, that's a concern, but. . . .
¶DIRECTOR. Okay, he's [ITL] on 108 now.
¶BL. I see him on camera 108, next to the 155 foot level.
¶LD. Hey, what kind of debris are you guys talking about?
¶BL. The icicles on the FSS.
¶LD. Yeah, and how is that going to hurt you?
¶BL. Well, that's what I'm saying, I don't think it-personally, I don't think it would, but I just wanted to. . . .
¶DIRECTOR. [garbled] by there, you're not gonna hit the Orbiter, but Charlie's wor- ried about it, Gene-the acoustics releasing it and it being free when the Orbiter comes by.
¶LD. Boy, he's really stretching it.
¶DIRECTOR. Oh no, I don't know whether that's stretching it too much or not.
¶LD. Well, I mean if we can ignore it, we need to feel comfortable about it.
¶P. All right, Gene, remember the wind is coming from the northwest.
¶LD. We need to all know if we don't get back into tanking as soon as possible, we could possibly blow it just for that.
¶DIRECTOR. Yeah, we understand, Gene. . . .9 Rogers Commission Report, loc. cit. 5
¶The Ice Team leader's next report was no more encouraging. Water had spilled over the platform as the drains were unable to cope with the volume of water they were asked to manage. Icicles were found on the platform handrails that could easily be knocked off.
236¶As the team leader was explaining that the water could not be completely cut off for fear of making the situation worse.s7 the fol- lowing conversations occurred:
¶L D Hey, we gotta come out of there when you guys telling us you're pretty sure that water system's gonna work.
¶DIRECTOR. Yeah, you feel comfortable with what you see out there, Charlie, now?
¶ITL. We have a lot of ice, if that's what you mean. I don't feel comfortable with what's on the FSS.
¶DIRECTOR. Then what choices we got?
¶ITL. Well, I'd say that only choice you got today is not to go. We're just taking a chance of hitting the vehicle.
¶LD. You see that much ice?
¶ITL. Well, the problem we have is we hve a lot of icicles hanging, you know, even on the west side of the FSS here, which is on1 60 feet or more from the Orbiter wing. And I'm sure that stuff is going to fall o x as soon as the acoustics get to it. And you got a northwest wind, so you know, somebody will have to make that as- sessment. If we're worried about that little bit of ice that comes off the hydrogen vent arm, and the O X [gaseous oxygen] vent arm, what we have over here is con- siderably more than that, you know-it's a hundred-fold.
¶DIRECTOR. You got enough ice that's over there that's big enough and got enough density to it that if it hits the Orbiter it could do some significant damage?
¶ITL. Yes, we do. . . . It's on the east side of the FSS.On the northeast corner of the FSS,which puts you about 65 feet or so from the vehicle. But it comes right to about where this camera is, it's right on the center thin line of the FSS,it comes that far over.
¶BL. Charlie, I would doubt the wind could blow that over. Are you concerned about during-afkr engine start, that things should kinda blow around?
¶ITL. Uh, yes. And the problem is it's so high, too. You know, it's way up to the top. If it were all the way down here to the bottom, it probably wouldn't be any problem.
¶BL. Can we go along the east side handrails and knock it off now? Isn't that the biggest concern-the east side?
¶ITL. Well, it's on the handrails and its on the floor underneath, too. You know, I guess it could probably be done but it'd be a job.
¶BL. It would take a long time, wouldn't it?
¶ITL. All the FACS pipes, and all the conduit and all the cable trays and then hanging down underneath the floor, you know, everywhere, on all the pieces of grat- ing, you got little icicles hanging down.
¶DIRECTOR. Who do you have out there with you?
¶ITL. B.K., as far as my oup goes.
¶DIRECTOR. Okay, why g n ' t you guys go ahead and walk everything down and quick as you get-come on back, let's get with Gene and we'll sit down and talk about what we got.Os
¶LD. Okay, why don't you do like Horace said, come on back and we'll go ahead and tank and we'll have you look at it when you go back.
¶ITL. Okay, and I think- ou know, the Rockwell people have a program which says it probably would be aE right, so contact them and let them put it in the ma- chine and see what they g e t s s
¶As the Ice Team returned from its initial inspection, the launch director spoke to KSC's Director of Engineering about the ice situa- tion:
¶LD. Yeah, we really need to do some head scratching on this ice thing and what we gonna do once we get back in. We've just about used all our hold.
¶DIRECTOR: Okay.
¶LD. What we're gonna do-we're not gonna opt to have a hold, we'll let the ice team go in just like normal, but we gonna keep counting the clock, and if we have to get ourselves into eating some of our launch window, we'll do it late.
¶DIRECTOR. Okay. We can do the ice inspection parallel with counting.
¶LD. Okay, but we need to have Rockwell in there where we need to ready to talk.
¶DIRECTOR. We can get Don in and we'll do that.
¶97 Ibid.9 Rogers Commission Report, loc. cit. s Bid. pp. 579-81.9 Rogers Commission Report, loc. cit. Ibid., pp. 581-82.
237¶LD. I don't see how in the world-we need to worry about that ice. I don't know what's going to knock it off. It's going to freeze and stay there.
¶DIRECTOR: I don't think it will hit the Orbiter, Gene. It'll probably come off just from the acoustics, but. . . .
¶LD. Yeah, as you go by, I would think . . . I would think after we start the en- gines, if it starts breaking loose then, I don't know how it would travel that far until, you know, the six seconds or so we are on the ground.
¶DIRECTOR. Yeah. We'll get everybody here; we'll talking before-while we're tank- ing before they go out, then we'll be ready to help make an assessment.100
¶The Ice/Frost Team returned to the launch pad during the scheduled countdown hold at T-3 hours. The crew was somewhat larger than usual, since their primary objective was to clear ice from the water troughs on the launch pad. The team would also be making a follow-up assessment of ice on the FSS.
¶According to the post-accident report, "the team arrived at Pad B at 0654 hours and departed at 0844." A summary of their activity during this time stated:
Ice in the troughs had thickened and was found to be solid. All secondary troughs except the northern most one
¶in each hole now had ice. The two inboard primary hole troughs were also forming ice. . . . The "shrimp net" was employed to break up the ice and remove it. Approximately 95% of the ice was removed. The ice and unfrozen antifreeze solution was measured using an infra-red pyrometer and found to have a temperature between 8 and 10°F. . . .
¶The pyrometer measured the MLP deck surface temperature as 12°F. On the FSS the quantity of ice had increased but the overall extent of icing was generally the same. In most cases, sheet ice was firmly adhered to the structure.
¶Icicles could very easily be "snapped" off. Water continued to trickle down the facility-including the RSS [Rotating
¶Service Structure]. O
¶NASA launch team members were continuing their debate over the risk represented by the ice at this time.
¶LD. What do you think about the ice now?
¶DIRECTOR. Well, I don't know, Gene. I keep thinking there is a n answer if we can find it, but we got people out talking it and I think we can make a decision on the SRB things [troughs]. I think we have the data there that we can make the right decision on that. The tower is what's going to be the one that is going to be hard to come to a decision on.
¶LD. But do we have any data that shows a mechanism for moving that ice across there?
¶DIRECTOR. That's what we're trying to see if we can come up with some kind of rationale why it won't. Charlie says we've got some data that we have moved some pieces across from basically the tower to the vehicle but we're-[Marty Ciofoletti, Vice President for Space Transportation System Integration, Rockwell Internation- al] and the guys are working with Downey to see how they feel if they come up with anything on the acoustics and things like that.
¶LD. Okay. O 2
¶KSC's Engineering Director then called the Rockwell liaison. 02a
238¶DIRECTOR. John, on 245.
¶RI. Go ahead, Horace.
¶DIRECTOR. You guys still talking to Downey?
¶RI. Yeah, we haven't go anything new since I last talked to you. Larry Williams just called in. He wants to talk to Bill Hovath [?I so they are getting ready to make a call to his now.
¶DIRECTOR. Okay.
¶RI. But we haven't got anybody. You know Jack McTimmons [McClymondsI-I talked to him and all he had to offer was his old program data of how far ice would go at various wind speeds, you know, from the FSS that's not our primary concern, obviously, right now.
¶DIRECTOR. No, that's right.Io3
¶In the Mission Support Room in Downey, California, Rockwell support personnel were expressing the same concerns as the Ice Team Leader, and were not confident their computer model could remove the uncertainty presented by the ice. Rockwell's Kennedy Space Center liaison was asked for information.
¶RTI. KSC, MSR [Mission Support Room]
¶RI. Go.
¶RTI. Good morning, John. Uh . . .
¶RI. It's been a busy morning!
¶RTI. I bet-looks bad, eh?
¶RI. Ice does look bad, eah. The situation we've got right now is that they're working the bags in the JRB hole; they reported slush in those bags and we were watching on TV and some of that slush was pretty big and pretty heavy. But I think we can take care of that part-I think they re gonna get that cleared up. There's a crew out there working on those right now. One of the concerns [Richard] Colonna [Orbiter Project Manager, JSC] had was reflected pressure wave problems if there was a film of ice across those bags, but i t looks like they're breaking that up. The big concern is gonna be the mass of ice that is on the FSS, from the 235 foot level all the way down to the MLP [mobile launcher platform]. Ever platform had had water running on it all night and they're just a-some of the cLseups of the stair- wells looks like, uh, something out of Dr. Zhivago. There's sheets of icicles hanging everywhere. We've had reports, back on the northwest corner, of ice, icicles-this is a couple hours ago, the crew are up there walking it down right now, so we'll prob- ably get some updates here shortly-but the initial walkdown said icicles up to two feet long by a n inch in diameter. On the northwest corner, kind of graduating down to about three inches by one-quarter inch diameter on the east side, with periodic one-foot icicles on the east side on some of the cross beams.
¶RTI. Sounds grim.
¶RI. The big concern is that nobody knows what the hell is going to happen when that thine lights off and all that ice gets shook loose and come tumbling down and- what d o d it-do then? Does it ricoch&, does it get into some turbulent condition that throws it against the vehicle? Our general input to date has been basically that there's vehicle jeopardy that we've not prepared to sign up to. . . .
¶RTI. Okay. We didn't see this when we had icing conditions before?
¶RI. No, and they didn't run the showers all damn night,before. They ran the showers this time and ran'em, pretty heavily by the look of it, the drains froze up and the all overflowed.
¶RTI. 6 h . . . .
¶RI. And I guess nobody watched it all night or, if the did, they didn't say any- thing. But, uh-is John [Peller, Rockwell Vice President &r Engineering] in yet?
¶RTI. No. RI. Okay. We need to-you know, somebody at his level needs to get in and try to get up to speed as fast as they can. They're oing to be looking for a final position from Rockwell here very shortly. We got-Bit Frohoff is right now talking to Larry Williams of JSC. I've got Colonna and Bobola sitting here with A1 Martin and myself and we're probably going to be the forcing factor on this decision. Until
¶RSD Site Director for Launch Support Operations. RTP: Thermal Protection Project Manager. RDE Vice-president for Engineering. RVP Vice President and Program Manager for Orbiter Operations Sup rt. R S R Senior Re resentative, Mission Evaluation Room, Johnson Space Enter somebody can come up and tell us that the potentia! flow path is to the objects on the FSS at liftoff-you know, we're going to have to assume the worst case-but I don't think anybody is going to have that sort of data.
239¶RTI. This is going to be a tough one. O 4
¶The Ice Team Leader reported that efforts to clear out the water troughs under the SRBs were meeting with success, and that the team was managing to clear the ice that had formed on the left SRB aft skirt. O 5
¶As this occurred, Rockwell's Site Director for Launch Support Operations was reporting from KSC to Downey. He said,
¶RSD. . . . [Tlhe situation here is that-very quickly-when Charlie gives his report, then they are gonna want to reconvene a top level management meeting here, so whatever we want to say in that meeting we're gonna have to come up with it here and now in order to be ready to say it and I guess the situation is that there are icicles all over the stand, that's the fixed service structure, all up and down it, various levels-some of the icicles are two feet long, an inch or two a t the base, there are lots of small icicles hanging all over the place. What they say is that when they touch them gently that they break off and for that reason I don't think there is any doubt about the fact in my mind that when we start the SSMEs a lot of these icicles are going to break off and they're going to-and when they do break off, then what's going to happen is that they're gonna come tumbling down, they can ricochet off of the service structure and they can-then some of them wind up on top of the MLP. ' 0 8
¶The discussion was interrupted at this point by another report from the ice team, indicating that the lower levels of the FSS had ice coverage equal to the levels already discussed. The decision was made to bring the team leader back for a report to managers, in order to decide whether the threat was sufficient to stop the launch. O
¶The discussion at Rockwell then resumed:
¶RSD Okay. He was just reporting on one of the levels. As he, as Charlie Steven- son, of NASA, moves up and down with the ice team, they're reporting on each level and on that particular level he was reporting a signficant amount of ice as the result of the overflow from the shower. You know, they left the water running in order to keep the pipes from freezing and then, I guess, some of the drains have frozen so then the water's overflowing and that's what's creating a lot of the big icicles. But at any rate, what I was getting around to, it just appears to me that when these icicles break off when they start the SSMEs some of them are very likely-in fact, 1'11 tell you, almost for sure-are gonna wind up on top of the MLP and then when we launch it seems to me it would be very difficult for anybody to predict where that debris would go and it appears to me that there would be a possi- bility of some of that debris impacting the Orbiter tiles and I don't know how our aerodynamista or analysts or anybody you know could really say that that wouldn't happen. They can predict what happens when you drop a piece of ice in the wind. They can also predict what happens due to aspiration when you start the Solid Rocket Motors and SSMEs.The real question is how do you predict what happens to ice chunks that are on top of the MLP at launch and where they go. So, at any rate, that's how we see it here at launch.
¶RTI. Well, one thing I guess we can see, from the view that we have, is ice on top of the MLP right now.
¶RSD. Yes, there is ice on top of the MLP right now.
¶RTI. That's unacceptable. Anything in the trough is unaccepatable and any ice that would impact the vehicle during ascent is unacceptable and we can't predict what's going to happen to all that massive ice on the towers, so I think we're in a critical situation. . . .
¶104 01s Channel 216, pp. 340-41.
¶1O5 01s Channel 245, pp. 600-601.
¶lo8 01s Channel 216, p. 345.
¶lo' 01s Channel 245, pp. 603-604.
240¶RTP. Most of the ice on the tower is going to end up on a n MLP, probably right before SRB ignition anyway-right, Al? You think?
¶RTI. Well, it's going to end up looking like snow, though, isn't it?
¶RTP. No, this is hard ice.
¶RTI. Once it hits that tower it's not going to be hard ice. What we're worried about is the aspiration effects of the motion of the ice into the vehicle.
¶RTP. You're still going to have large chunks of ice, ice cubes. Like a n ice cube.
¶RTI. That's unacc . . . question is, how high is, is the highest elevation of ice, what was the. . . .
¶RTP. I think they're saying it's all the way to the top of the tower, like the 235 foot level has icicles forming and all the way down from there.
¶RTI. Okay.
¶RSD. Bob, would you say again what you were saying about the ice on the tower and the concern about that?
¶RTI. We really don't have a data base to know what's going to happen to the ice. We do have some information that we can get horizontal movement of the ice into the vehicle. Obviously, since it's very tenuous, it's going to be bouncing all over the place. It'll be bouncing off the J-boxes and everything else. So you're going to have some horizontal velocity of ice.
¶RTP. Hey, Bob, you're breaking up again.
¶RTI. Okay. Let me try once more. Our data base does not allow us to scientifically tell you what's going to happen to the ice. Therefore, we feel we're in a no-go situa- tion right now.
¶RSD. Okay. That, Bob, is a consensus down here, too-that there's no way, that is for Rockwell, the consensus down here for Bill Frohoff and ourselves, that there's no way to predict what's going to happen, and I think that when we get into this next meeting, we need to state that as Rockwell's position and I think that's going to come up fairly soon, here. Now, I have told Dick Colonna that I suspect that's going to be the Rockwell position, I haven't told them officially. I've also told Horace that, but I haven't told him that officially, and I guess, or, uh, do you think we're ready now to, uh, for Rockwell to state that position and do you want to go back to the MER with that or how do you want to handle it?
¶RTI. Well, what I would like to do is get ahold of [Bob] Glaysher-we're not sup- posed to overrule him-and talk to him about it. Is he there?
¶RSD. We woke him up a t 4:OO this morning. He called in about a n hour ago. We understood he was on the way and he's not here yet.
¶RTI. Okay, I'd like to stonewall it until he gets here.lo8
¶At about this time, Mr. Bill Fleming, the senior representative of Rockwell International, reported from the Mission Evaluation Room at JSC that "ice on MLP, tower and trough not acceptable to MSR [Rockwell's Downey facility]." O 9
¶Just prior to attending the meeting called by Arnold Aldrich, the Vice President and Program Manager for Orbiter Operations Sup- port at Rockwell held the following teleconference with their Chief Engineer at Downey.
¶RDE. Hey, we've gone over this again. Colonna called me and wanted to see if there is a way we could give it a go. But, when all the experts have looked at it, we still have concerns with three mechanisms. One, direct transport of falling ice into the vehicle at SSME ignition and the wind is adequate to make that happen. The ten-knot wind can move it laterally like twenty feet and a fifteen-knot gust could take it laterally forty feet. So even though you might be able to placard it, it's very close with the wind you've got. Secondly, you've got a rebound mechanism, where ice falls down into the lower part of the platform and goes out. Some pretty sizeable chunks and sometimes all it does is break a n icicle in two, that's clearly enough to cause significant tile damage. And, finall the ice ends up on the MLP and in the trough is all potential debris sources a t JRB ignition and liftoff and the trajectory those things take are highly unpredictable and we just note in films tended to go in different directions. So we are not in the position to, uh. . . . So we've been through the three mechanisms, none of which we can completely clear. Dr. Petrone's here; we've discussed it with him. We still are of the position that it's still a bit of Rus108 01s Channel 2 1 6 , ~ ~ .
¶345-48.
¶logNASA, Johnson pace Flight Center, "Presidential Commission Action Item (A-301) Re- sponse," DDATF-86-36, April 7, 1986, p. 1.
¶24 1 sian roulette; you'll probably make it. Five out of six times you do playing Russian roulette. But, there's a lot of debris. They could hit direct, they could be kicked up later by the SRBs, and we just don't know how to clear that.
¶RVP. Okay. Our position fundamentally hasn't changed. We'll just go in now, we got a 9:00, we'll go in and express it. I'll let you know what happens.
¶RDE. And obviously, uh, you know, it's their vehicle and they can take the risk, but our position is as stated.
¶RVP. Okay, you got it. l o
¶No recording exists of the meeting at 9:00 a.m. on January 28. In testimony before the Commission, Mr. Robert Glaysher stated that he told Mr. Aldrich that "Rockwell cannot assure that it is safe to fly."1 For the purpose of this report, a procedure is a formal set of instructions designed to guide and assist in the performance of a technical or management function. g8 mid., July 24, 1986, p. 11. 1 1
¶Mr. A1 Martin testified that:
I also added that we do not have the data base from which to draw any conclusions for this particular situation with the icicles on the tower, and also, we had no real ana- lytical techniques to predict where the icicles might go at lift-off. The other thing that I did was review the fact that prior to each launch there is great care taken to assure that there is no debris out on the launch pad. A day or two before launch a crew goes out and they walk down the entire tower and walk down the mobile launcher surface, and also the concrete apron around the launch pad for the purpose of removing any debris such as nuts, bolts, rocks or anything else that might be there. . . . So I was drawing a corollary between the care that is normally taken for debris and painting a picture that the icicles appeared to me to be in that same category.
¶Mr. Marty Cioffoletti testified that "I felt that by telling them we did not have a sufficient data base and could not analyze the trajectory of the ice, I felt he understood that Rockwell was not giving a positive indication that we were for the launch."' '
¶Mr. Aldrich, conversely, told the Commission that:
Glaysher's statement to me as best as I can reconstruct it to report it to you at this time was that, while he did not disagree with the analysis that JSC and KSC had reported, that they would not give a n unqualified go for launch as ice on the launch complex was a condition which had not previously been experienced, and thus posed a small addi- tional, though unquantifiable, risk. l 4
¶Aldrich concluded the meeting by deciding to recommend that the countdown continue until the ice team could return to the pad just prior to launch and make a final assessment. Aldrich testified that he told Jesse Moore about Rockwell's reservations, explained his decision, and recommended that the launch proceed unless the ice team discovered that the situation had badly deteriorated. '' ' lo01s Channel 216, p. 353. 111 Rogers Commission Report, Volume V, p. 1013 112 Ibid.
¶Ibid., p. 1014.1 For the purpose of this report, a procedure is a formal set of instructions designed to guide and assist in the performance of a technical or management function. g8 mid., July 24, 1986, p. 11. 1 4 Ibid., p. 1025. 115 Ibid.
242¶The results of the meeting were reported back to Rockwell over the communications system:
¶RSR: MSR, this is MER.
¶UKN: Go ahead.
¶RSR: We just got a report in from Arnie and they're going to go ahead and go into the count. They're going to go out, sweep down the pad as best they can and remove as much ice as they can and go for the launch today.
¶UKN. We copied that. '
¶In their final report, the Ice Team found that ice on the MLP in direct sunlight had begun melting. They also found that icicles had begun to fall from the upper FSS levels. Ice cube sized pieces of these icicles were found within 10 feet of the left-hand SRB hole. The west MLP deck was swept clean of ice/icicles. The water troughs were checked and found to be forming ice, which was again removed using the "shrimp net."
¶In analyzing launch films after the accident, NASA found that, contrary to expectations and analysis, ice from the Fixed Service Structure did reach and impact the Shuttle vehicle during liftoff. The report stated:
¶Numerous launch films were viewed regarding FSS and
¶RSS ice debris. A film (E-43) [Engineering Camera 431 looking directly in at the vehicle and FSS shows some ice falling straight down in the period between SSME ignition and vehicle ascent through approximately 20 feet. It shows that very many particles fell at approximately a 45" angle during the vehicle rise through 20 to 40 feet. This ice included sheet ice particles up to 6 in. x 6 in. and flowed down into the plumes at a point directly below the engine nozzles. Some of this struck the LH SRB. One downward looking camera (E-36) on the FSS clearly showed that a small amount of FSS ice debris reached the area of the LH
¶SRB exhaust hole. Particles numbered 50-100 and were approximately ice-cube size. None of these or any other debris was observed to be ejected upward toward the Orbiter. Another film (E-18) looks upward from the SSME pit.
¶This shows that after a vehicle rise of 10 ft. hundreds of ice particles flowed in below the main engine at a 45"
¶angle. No Orbiter impacts are observed. Camera E-26 . . .
¶reveals many small pieces of falling ice striking the LH2
¶TSM [liquid hydrogen tail service mast] in the period between SSME ignition and vehicle rise through approximately 25 feet. Due to aspiration, 50-100 small ice particles flowed into the LH SRB plume directly below the SRB nozzle as the vehicle rose through 4 to 25 ft. These films and others show fairly clearly that there was little or no debris damage to the oribiter [sic] during liftoff due to
¶FSS/RSS icing for the conditions observed.
¶In the summary and conclusions section of this report, the fol- lowing statements appear:
¶01s Channel 216, p. 355.
¶117 "Ice/Frost Team Evaluation Report," 5.
¶NASA, "Hazard to Orbiter Tiles Posejby the Vertical Structure Ice: Mission 51-L," Janu- ary 30, 1986, p. 3.
243On STS-33 (51L) the actual F§S/RSS ice movement, as proven by the photographic documentation did not con- form to the predictions in two important respects: 1. The ice generally did not release until after SSME ig- nition. 2. The ice translated several times farther toward the vehicle than predicted. To do meaningful predictions of ice movement, the ef- fects of aspiration must be considered. Similarly, the re- lease time of the ice must be known. Until the above capability is available, it should be as- sumed that FSS/RSS ice would be released early and pulled by aspiration into contact with the vehicle. FSS/ RSS ice thereby could be judged as a potential high risk to flight safety.1 For the purpose of this report, a procedure is a formal set of instructions designed to guide and assist in the performance of a technical or management function. g8 mid., July 24, 1986, p. 11.
¶The Committee has proceeded at some length to develop the con- versations regarding ice that occurred on the morning of 28 Janu- ary because they illuminate tendencies that are at variance with the careful attention to safety the Nation has come to expect from NASA. It is the Committee's view that the information developed by the discussions between members of the ice team and those that took place between Rockwell personnel on this subject should have led to the conclusion that "FSS/RSS ice . . . could be judged a po- tential high risk to flight safety."
¶The Committee also notes that, in his presentation to the STS Program Manager at the 9:OO a.m. Mission Management Team meeting, the ice team leader apparently did not inform Mr. Aldrich that he had earlier recommended that the launch be held due to the ice in the pad area. There is no indication in testimony to the Commission that Mr. Aldrich knew of the team leader's comment, "Well, I'd say the only choice you got today is not to go." Had it been presented to him in those terms, the later reluctance of Rock- well to recommend a launch might have been sufficient to cause Mr. Aldrich to recommend a launch scrub. In any event, the uncer- tainly present in connection with this discussion should have been sufficient to cause a delay in the lauch until the ice melted off the gantry. The unknown risk represented by the ice would then have been removed.
¶These conversations also indicate that the launch director was not operating in a manner the Committee would expect. Given his position as the senior official responsible for the preparation of the Shuttle for launch, the Committee would expect a healthy skepti- cism to underlie discussions he had with members of the launch crew. In contrast to these expectations these tapes demonstrate that the director was often reminding the engineering team about time, and spent much time questioning the ice team leader's analy- sis of the ice on the pad. There is also no indication that he took steps to see that the pad escape system was ready for use by the flight crew, if necessary.
¶l9 bid., p. 4.
244¶Finally, Congressman Ron Packard discussed with witnesses at the Committee's hearings on July 25, 1986, ways to improve con- tractor participation in preparing the Shuttle for launch.
¶Mr. PACKARD. "Mr. Davis, you spoke regarding the companies having a voice in the decisionmaking, I presume, after the FRRs-that two week interim between launch and the readiness review system. Do you believe that the companies should have more voice, less voice, or have they had any voice in whether its a go or no-go?"
Mr. D A V I S . ~ ~ ~ I can tell you how it runs now. Up "Well,
¶to and including the Lminus-one day review, there's no doubt that every company has a very strong voice; and, as a matter of fact, at the Gminus-one review, they are required to stand up and commit their hardware as go or nogo. And those are very unequivocal commitments, also.
¶After that time, then the reviews are more mission management meetings that are held, and as you get down into the countdown, it turns into more of a real time polling of the people that are actually controlling the launch. In those latter meetings, we are not, I would say, formally involved in those unless there is some problem with the hardware itself, the External Tank hardware. We are in
¶Firing Room 2 in a very significant presence; we are aware of what is happening in some of the consoles. We sit behind them; we do not operate them. We are polled by the Director of Engineering prior to the launch actually proceeding, so we are sort of polled in an informal manner. We are not asked at any time after the Lminusone for a formal go or no-go. I believe it would probably be appropriate, in terms of the Commission's desires, that indeed we be more formally involved in the mission management meetings, and that at some appropriate late time in the launch count-and I would leave that to NASA to decide-that indeed the companies be asked to declare go or no-go."
¶Mr. PACKARD. "A quick answer, Mr. Murphy. Do you agree?"
Mr. M U R P H Y . ~ ~I~agree with what Rick has said. I "Yes,
¶think that we have found out that we commit ourselves, I guess, at 20 minutes and 9 minutes by the people who are manning the consoles, but it does not rise to the management level which it should, in accordance with what Mr. Davis has stated. We would like that opportunity also."
¶Mr. DAVIS."I'd like to make one other comment on that.
¶I have never felt that if I needed to stop a launch, I could not stop it. While I have not been asked for a positive go or no-go, the ability is always there if I decide no, to stop the launch."
¶Mr. PACKARD. "Mr. Jeffs, do you feel the same?"
¶lZoMr. Richard Davis, President, Martin Marietta Michoud Aerospace.
¶121Mr. George Murphy, Executive Vice President and General Manager, United Technologies Booster Production Company.
245Mr. J E F F S . ' ~ ~ "Yes, I think the system should be formal-
¶ized more. We have great visibility as to the problems and real times, being on the net and having CRTs [console displays] and people that are involved in depth, both at
¶Downey and at Houston, who support it, even though it's at the Cape. But especially, when you have holds or delays and what have you, it needs to be-again-upgraded in real time with, I believe, the contractor's participation with NASA management right up to the launch decision point, and a little more formal process involved in the polling of the contractors."
¶Mr. PACKARD. "Mr. Murphy, if you'd had that system set up prior to the accident, would the flight-would it have still gone?"
¶Mr. MURPHY."It would not have influenced our position at all. Our hardware-we had stipulations on what we required on the hardware during the whole period. They were met, and so we were in a 'go' posture as far as we were concerned. It would not have affected our position." z 3
¶The Committee believes that had the hardware contractors been required by NASA to formally declare their flight readiness, it would have removed the ambiguity in Rockwell's recommendations involving the ice on the Fixed Service Structure.