The Commission was surprised to realize after many hours of testimony that NASA's safety staff was never mentioned. No witness related the approval or disapproval of the reliability engineers, and none expressed the satisfaction or dissatisfaction of the quality assurance staff. No one thought to invite a safety representative or a reliability and quality assurance engineer to the January 27, 1986, teleconference between Marshall and Thiokol. Similarly, there was no representative of safety on the Mission Management Team that made key decisions during the countdown on January 28, 1986. The Commission is concerned about the symptoms that it sees.
The unrelenting pressure to meet the demands of an accelerating flight schedule might have been adequately handled by NASA if it had insisted upon the exactingly thorough procedures that were its hallmark during the Apollo program. An extensive and redundant safety program comprising interdependent safety, reliability and quality assurance functions existed during and after the lunar program to discover any potential safety problems. Between that period and 1986, however, the program became ineffective. This loss of effectiveness seriously degraded the checks and balances essential for maintaining flight safety.
On April 3, 1986, Arnold Aldrich, the Space Shuttle program manager, appeared before the Commission at a public hearing in Washington, D.C. He described five different communication or organization failures that affected the launch decision on January 28, 1986. Four of those failures relate directly to faults within the safety program. These faults include a lack of problem reporting requirements, inadequate trend analysis, misrepresentation of criticality and lack of involvement in critical discussions. A properly staffed, supported, and robust safety organization might well have avoided these faults and thus eliminated the communication failures.
NASA has a safety program to ensure that the communication failures to which Mr. Aldrich referred do not occur. In the case of mission 51-L, that program fell short.
1. Reductions in the safety, reliability and quality assurance work force at Marshall and NASA Headquarters have seriously limited capability in those vital functions.
2. Organizational structures at Kennedy and Marshall have placed safety, reliability and quality assurance offices under the supervision of the very organizations and activities whose efforts they are to check.
3. Problem reporting requirements are not concise and fail to get critical information to the proper levels of management.
4. Little or no trend analysis was performed on O-ring erosion and blow-by problems.
5. As the flight rate increased, the Marshall safety, reliability and quality assurance work force was decreasing, which adversely affected mission safety.
6. Five weeks after the 51-L accident, the criticality of the Solid Rocket Motor field joint was still not properly documented in the problem reporting system at Marshall.