SELECTED ROGERS COMMISSION RECOMMENDATIONS

"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:

"The joints should be fully understood, tested and verified."

"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."

"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."

"NASA should encourage the transition of qualified astronauts into agency management positions."

"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."

"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 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 [the Challenger mission] 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."

"The nationʼs reliance on the Shuttle as its principal space launch capability created a relentless pressure on NASA to increase the flight rate … NASA must establish a flight rate that is consistent with its resources."5 disaster cost the country $12 billion, which included the cost of building the replacement Orbiter Endeavour.7

¶It took NASA 32 months after the Challenger accident to redesign and requalify the Solid Rocket Booster and to return the Shuttle to flight. The first post-accident flight was launched on September 29, 1988. As the Shuttle returned to flight, NASA Associate Administrator for Space Flight

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¶Richard Truly commented, "We will always have to treat it [the Shuttle] like an R&D test program, even many years into the future. I donʼt think calling it operational fooled anybody within the program … It was a signal to the public that shouldnʼt have been sent."8

¶The Shuttle Program After Return to Flight

¶After the Rogers Commission report was issued, NASA made many of the organizational changes the Commission recommended. The space agency moved management of the Space Shuttle Program from the Johnson Space Center to NASA Headquarters in Washington, D.C. The intent of this change was to create a management structure "resembling that of the Apollo program, with the aim of preventing communication deficiencies that contributed to the Challenger accident."9 NASA also established an Office of Safety, Reliability, and Quality Assurance at its Headquarters, though that office was not given the "direct authority" over all of NASAʼs safety operations as the Rogers Commission had recommended. Rather, NASA human space flight centers each retained their own safety organization reporting to the Center Director.

¶In the almost 15 years between the return to flight and the loss of Columbia, the Shuttle was again being used on a regular basis to conduct space-based research, and, in line with NASAʼs original 1969 vision, to build and service a space station. The Shuttle flew 87 missions during this period, compared to 24 before Challenger. Highlights from these missions include the 1990 launch, 1993 repair, and 1999 and 2002 servicing of the Hubble Space Telescope; the launch of several major planetary probes; a number of Shuttle-Spacelab missions devoted to scientific research; nine missions to rendezvous with the Russian space station Mir; the return of former Mercury astronaut Senator John Glenn to orbit in October 1998; and the launch of the first U.S. elements of the International Space Station.

¶After the Challenger accident, the Shuttle was no longer described as "operational" in the same sense as commercial aircraft. Nevertheless, NASA continued planning as if the

¶Shuttle could be readied for launch at or near whatever date was set. Tying the Shuttle closely to International Space Station needs, such as crew rotation, added to the urgency of maintaining a predictable launch schedule. The Shuttle is currently the only means to launch the already-built European, Japanese, and remaining U.S. modules needed to complete Station assembly and to carry and return most experiments and on-orbit supplies.10 Even after three occasions when technical problems grounded the Shuttle fleet for a month or more, NASA continued to assume that the Shuttle could regularly and predictably service the Station. In recent years, this coupling between the Station and Shuttle has become the primary driver of the Shuttle launch schedule. Whenever a Shuttle launch is delayed, it impacts Station assembly and operations.

¶In September 2001, testimony on the Shuttleʼs achievements during the preceding decade by NASAʼs then-Deputy Associate Administrator for Space Flight William Readdy indicated the assumptions under which NASA was operating during that period:

The Space Shuttle has made dramatic improvements in the capabilities, operations and safety of the system. The payload-to-orbit performance of the Space Shuttle has been significantly improved – by over 70 percent to the Space Station. The safety of the Space Shuttle has also been dramatically improved by reducing risk by more than a factor of five. In addition, the operability of the system has been significantly improved, with five minute launch windows – which would not have been attempted a decade ago – now becoming routine. This record of success is a testament to the quality and dedication of the Space Shuttle management team and workforce, both civil servants and contractors.11

5.2 THE NASA HUMAN SPACE FLIGHT CULTURE

¶Though NASA underwent many management reforms in the wake of the Challenger accident and appointed new directors at the Johnson, Marshall, and Kennedy centers, the agencyʼs powerful human space flight culture remained intact, as did many institutional practices, even if in a modified form. As a close observer of NASAʼs organizational culture has observed, "Cultural norms tend to be fairly resilient … The norms bounce back into shape after being stretched or bent. Beliefs held in common throughout the organization resist alteration."12 This culture, as will become clear across the chapters of Part Two of this report, acted over time to resist externally imposed change. By the eve of the Columbia accident, institutional practices that were in effect at the time of the Challenger accident – such as inadequate concern over deviations from expected performance, a silent safety program, and schedule pressure – had returned to NASA.