by Pawel Motyl
The prototype of the space shuttle was named Enterprise (in honor of the space ship in Star Trek), and in 1977, it completed its first test flights, the goal of which was to practice the landing maneuver. On the basis of what was learned from those tests, the first fully functional space shuttle was constructed. Designated OV-102, and known to all as Columbia, its maiden voyage was slated for an undisclosed date in 1978. A series of delays meant that it was actually April 12, 1981, at precisely noon, before the historic first mission, STS-1, was launched with a two-man crew, John Young and Robert Crippen. The flight lasted two days, six hours, and just under twenty-one minutes, during which time Columbia orbited Earth thirty-seven times. It landed at Edwards Air Force Base (EAFB) without any problems. President Ronald Reagan, welcoming the crew back to Earth, gave a speech in which he announced that “The first priority of the STS program is to make the system fully operational and cost-effective in providing routine access to space.” 5 However, in many experts’ opinions, flying in the space shuttle was an enormous challenge, greater even than landing on the Moon had been twelve years earlier, and they treated the announcement of numerous commercial flights with some skepticism.
In the years to come, NASA tried its best to realize President Reagan’s promise. New shuttles were put into service—in 1982, Columbia was joined by Challenger, and in later years by Discovery and Atlantis. 6 Missions were carried out increasingly frequently, and by mid-January 1986, twenty-four had already been completed. The twenty-fifth mission, STS-51L, was the Challenger flight, but it was repeatedly delayed for technical reasons. For NASA, this was a very awkward situation, as just prior to the scheduled date for the Challenger mission, an unwelcome record had been set: the liftoff of Columbia had been put back seven times, delaying the mission by twenty-five days. Information about problems with yet another shuttle was exploited to the full by the media, which mercilessly mocked NASA with comments such as “Once again a flawless liftoff proved to be too much of a challenge for the Challenger.” 7 A new launch date of January 27 was finally set for Challenger, but yet again bad luck raised its ugly head in the form of a damaged exterior access hatch. Once more, liftoff was delayed and set for the following day. On January 28, at 11:38 local time, the Challenger space shuttle was finally set to leave the launch tower and begin its mission.
On January 23, at around 1:00 pm, NASA received an unpromising weather forecast. It showed an unusually low temperature for Florida, going as low as 23°F on the night before liftoff. Air temperatures before noon the following day were expected to range between 32°F and 41°F. A shuttle had never taken off in such low temperatures before—the lowest liftoff temperature to date had been 52°F, precisely a year before in January 1985. During that mission, STS-51C, an isolating O-ring connecting element of the SRB rockets used to boost the shuttle into orbit, failed. On that occasion, the backup O-ring remained sealed, which prevented a tragedy.
Larry Wear, responsible for the solid rocket boosters on the STS program, contacted the Morton-Thiokol company, which supplied the booster rockets to NASA. He asked the vital question: Could the low temperature predicted for liftoff constitute a threat to the rockets? The contractor treated the question with the appropriate seriousness. Robert Ebeling, who was the person responsible in the company for the liftoff systems for the STS project, set up two teleconferences with engineers from Morton-Thiokol and key NASA management. The second of these, which began at precisely 8:15 pm, turned out to have grave consequences. Lawrence Mulloy, a high-ranking NASA manager, requested a liftoff recommendation from the manufacturer. To his surprise, the engineers strongly advised against it. The Morton-Thiokol vice president, Joe Kilminster, therefore informed Mulloy and the other participants in the discussion that he couldn’t guarantee the O-rings would remain operable at such low temperatures. He referenced the incident from the year before, when the O-ring became rigid at 52°F, and recommended delaying the start. NASA went ballistic. There followed a heated exchange during which Mulloy uttered the fateful words: “My God, Thiokol, when do you want me to launch, next April?” George Hardy, the deputy director of Science and Engineering, said he was appalled by the recommendation. 8 Then Kilminster asked to suspend the conference. During a thirty-minute break, another vice president of Morton-Thiokol, Jerry Mason, said, “We have to make a managerial decision,” thus excluding the Thiokol engineers from the process and ignoring concerns and questions from Arnie Thompson and Roger Boisjoly, engineers at NASA. Despite this, they still tried to make the others understand their concerns. Finally, it was put to a vote in which only the high-ranking managers could take part and which resulted in the earlier recommendation being changed. To the evident satisfaction of NASA’s management, Morton-Thiokol gave the green light for liftoff.
During the night, yet another red flag began to wave. The team that inspected the liftoff equipment at 1:30 am noted a large buildup of ice covering the surface of the tower as well as the shuttle itself and the boosters. The inspection was repeated twice more in the early morning hours, and as a result of their findings, NASA contacted Rockwell, the company that had built Challenger. Here again, the contractor’s engineers expressed their misgivings about the weather, suggesting the liftoff be delayed. The Mission Management Team (MMT) voted to continue the launch procedure. To the satisfaction of the MMT, at 11:25 am the countdown began, and liftoff went ahead, according to plan, at 11:38 am local time at a temperature of barely 36°F.
Fifty-eight seconds into the flight, small tongues of flame began to lick at the connector to the right solid-fuel rocket booster (SRB), indicating both seals had failed. Sixty-four seconds after liftoff, the casing of the liquid hydrogen tank caught fire, which was registered by the telemetry as a pressure drop in the tank. The crew was totally oblivious to the drama that was unfolding. At the sixty-eight-second point, the final communication between Mission Control and Challenger’s commander, Richard Scobee, took place. Scobee accepted and confirmed a command to increase power to the rockets—a command he ultimately could not carry out. In the seventy-third second, the connectors to the right SRB and the damaged liquid oxygen tank broke away, causing massive disruption to the flight trajectory. The resulting G-force exceeded 20, which tore the shuttle apart. The catastrophe took place at an altitude of approximately 9 miles, when Challenger was traveling at over 1,800 miles an hour.
Later analyses showed that the crew of seven probably survived the initial explosion. In photos that captured the moment of the explosion, the undamaged cabin is clearly visible, separated from the rest of the craft, still climbing for a few seconds, then falling in a gentle arc down toward the ocean. It emerged that after the breakup of the shuttle, three PEAPs (Personal Egress Air Packs), which supply oxygen in the event of an emergency, were activated. The PEAP activation demanded conscious action by the astronauts on board; it couldn’t have occurred spontaneously. Not that it mattered. Regardless of the PEAPs, the crew would have had zero chance of surviving the impact when the cabin hit the water two minutes and forty-five seconds after the explosion. The cabin fell at a rate of about 200 miles an hour, and the impact with the ocean generated about 200 Gs—a force that neither the reinforced aluminum crew module nor the astronauts themselves could have survived.
President Reagan immediately set up an investigative committee led by former attorney general William P. Rogers, whose name lives on in the commonly used name of the committee, the Rogers Commission. The aim of the investigation, which was also their mandate, was to analyze the causes of the tragedy and present a detailed report containing recommendations to avoid similar events in future, all within 120 days. The committee was composed of numerous luminaries from the world of science and technology, including, among others, the legendary Richard Feynman, winner of the Nobel Prize in Physics in 1965; the astronaut Neil Armstrong; and Charles Yeager, the renowned test pilot who, in 1947, broke the sound barrier.
This extraordinary set of experts met their deadline
, publishing the report expected of them by the president, while the investigation itself was observed closely by the media and the public. Right from the start, there were leaks, some more outrageous than others. The turning point arrived on February 9, 1986, when the New York Times published an article on the front page of its Sunday edition, under the headline “NASA Had Warning of a Disaster Risk Posed by Booster,” 9 in which an anonymous but very well-informed NASA employee revealed the shocking truth to journalists: the problems with the O-rings had been well known since at least 1982—and consistently ignored. All hell let loose, and the Rogers Commission subsequently decided to hold a closed meeting on February 10, with the managers and technicians from NASA who were responsible for the SRBs and their O-rings, as well as the contractors, Morton-Thiokol. The information released following the meeting provided a deeply disturbing view of the situation. The now-infamous teleconference the day before liftoff came to light, as well as the pressure that had been applied to the engineers and Morton-Thiokol’s management. It also brought to light historical details that revealed that the problems with the O-rings went as far back as 1977, four years before the first space shuttle flight and almost a decade prior to the Challenger disaster. Despite this knowledge, NASA took no action to avert the tragedy.
The committee’s report, published on June 6, 1986, described the blatant faults and technical shortcomings that led to the catastrophe, but it also pointed to its deeper cause: the faulty decision-making process in the Agency. In particular, the committee highlighted the ineffective procedures for reporting problems to senior managers as well as general problems with the flow of information, which rendered deeper analysis of the situation impossible. The report didn’t name and shame; instead, it placed the responsibility for the deaths of the seven astronauts of STS-51L on the organization as a whole.
The Challenger tragedy almost offers a grocery list of the classic decision-making errors described in this book, and the RCA reveals a range of additional information about its causes.
The launch conditions were the very definition of a black swan—no mission had ever been initiated at such low temperatures. The takeoff was therefore outside the zone of typical risk management, because there was no way of assessing the risk. NASA had boldly gone where no space agency had gone before and was dealing with genuine uncertainty. In this situation, an inquiry approach is essential and time needs to be bought by using salami tactics, enabling a more thorough analysis to be carried out. It would have been enough to delay liftoff to either deal with the black swan (which would essentially have simply meant waiting a few hours for the air to heat up a bit), or more thoroughly assess the degree of danger. NASA, unfortunately, decided on a typical commercial, business-oriented advocacy approach. They urgently sought out information that would show that it would be safe to lift off despite the unusual weather. They cited earlier examples of a shuttle getting back safely despite damaged O-rings (falling prey to the turkey syndrome). Another part of the advocacy approach was the pressure placed on the Morton-Thiokol engineers, who had their arms twisted to help them come around to Mission Control’s view.
If we use RCA to understand the underlying reasons for the tragedy, the answers to successive “whys” are very interesting. Why did people as experienced and professional as the NASA managers make such a fundamental error? Why did the same organization that had successfully rescued the crew of Apollo 13 several years before fail so spectacularly on this occasion? Why was liftoff allowed to proceed in such unusual conditions? Why was the wrong decision made?
Both the Rogers Commission and the other teams investigating the catastrophe have pointed to sequential pressures that may have pushed NASA’s managers into making the wrong decision.
The Space Shuttle program (generally referred to as the STS) was set up at a time when NASA was desperately fighting for funding to continue its work. The shuttles were a compromise measure that the organization decided upon after Congress refused the funding to build an orbiting space station. The fundamental argument the Agency used was that an orbiting space station would make space flights routine, which meant the STS program made commercial sense. Congress was won over by the idea of space travel becoming easy and financially viable. It was therefore of the utmost importance to NASA that they kept to the schedule for the plans presented to Congress, and that they garnered the relevant media backing for the project. This led the Agency to develop a very dangerous dual nature. While it was still carrying out extremely difficult, experimental projects using untested technologies and operating with a high degree of risk, it tried to present itself to the outside world as a commercial organization. They were on time and they delivered the measurable results they promised. In this way, the risk became downplayed, and in the growing chasm between these two sides of itself, it lost sight of the fundamental priority: the safety of the astronauts.
The project that was to be one of the driving forces behind the Agency’s new image was the Teacher in Space program, as part of which NASA intended to send the first civilian into space, thereby demonstrating that space travel was a routine and relatively simple undertaking. The culminating moment was to be a lesson conducted from space by a teacher onboard the shuttle and transmitted live to thousands of pupils across the United States. The Teacher in Space program was announced by President Reagan in 1984 and generated enormous interest—as many as eleven thousand teachers submitted applications. After a long series of medical and other tests, on July 19, 1985, a special commission selected thirty-seven-year-old Christa McAuliffe from New Hampshire.
In line with the initial plans for liftoff on Wednesday, January 22, the space class was planned for Tuesday, January 28, the sixth day of the mission. The delays to liftoff disrupted that schedule. Starting the flight on January 28 meant there was still a chance to conduct the class on Friday, January 31, though. If the liftoff had been delayed yet again, limitations on time and organization would mean it couldn’t go ahead. Many of the experts investigating the Challenger catastrophe pointed to this as one of the pressures that influenced the final decision. 10
A great many articles and commentaries also focused on the wider political context. On January 28, 1986, Ronald Reagan was to give his annual State of the Union address to the nation. The presidential administration was very keen to be able to boast of further successes in the space exploration program, including the planned space lesson. The Rogers Commission found no evidence of direct pressure being placed on NASA, but the decision-makers at the Agency were well aware of the expectations and must have been influenced by them.
There was also another significant source of pressure: the media. In NASA’s new incarnation as a commercial entity, it had to protect its image in the public arena and in Congress, because acquiring further funding for its projects depended on it. The repeated delays to Columbia’s liftoff immediately prior to Challenger’s deadly mission incited widespread sarcastic commentary about NASA. So, when new technical problems delayed STS-51L, NASA once again found itself the prime target of the media. In this situation, the pressure to launch and get the media off the organization’s back was intense, and it cast a long shadow over the objectivity of the decisions taken by even the most competent and experienced members of the team.
The results of the Rogers Commission’s work and its conclusions came as a big shock to many people. The situation as pieced together by the experts allowed for no ambiguity: The Challenger space shuttle tragedy was entirely avoidable. All that NASA had needed was somebody bold enough and high enough up the organization’s hierarchy to say “No. Don’t lift off, because the conditions are totally new and the experts with the greatest knowledge have the greatest fears.” But nobody did.
An analysis of the events that played out in January 1986, and further “why” questions, show that the seeds of the Challenger disaster were sown almost sixteen years earlier, in April 1970. That’s when, following the heroic efforts of Gene Kran
z’s team to save the three astronauts onboard Apollo 13, Congress essentially decided to punish the organization for the incident, refusing further funding for its program. As a result of this decision, NASA was pushed toward an unconscious and entirely uncontrolled process of moving from a research and development operating mode to one that was strictly commercial. Consequently, the priorities set out for and the expectations placed on the engineers and managers, their teams, and indeed the entire Agency began to change. People were required to alter their attitudes and behavior, which over the following dozen or more years led to a fatal decline in the organization’s culture, until it was ultimately utterly inappropriate for the kind of work it was involved in. As in the case of Rob Hall’s and Scott Fischer’s expeditions, an extraordinarily dangerous venture started to be treated in purely business terms, leading to an acceptance of higher and higher levels of risk. On April 28, 1986, at 11:38 am local time, this unconscious mechanism killed seven people.
Sadly, though, this isn’t the end of this terrible story.
You might think that a shock of this scale would have been a kind of catharsis for the organization, leading to profound reflection and fundamental changes in how projects were managed so that nothing like it would ever happen again. Hard as it is to believe, that didn’t happen.
After the Challenger catastrophe, the STS program was halted for over two and a half years. During this period, NASA carried out its own investigation into the cause of the tragedy and subsequently implemented the nine changes recommended by the Rogers Commission. Despite these actions, the culture and financial models of the organization didn’t change.
