NASA’S CHALLENGER DISASTER

A Business Ethics & Compliance Analysis of NASA’s Greatest Failure

Matthew Durden
Business Ethics & Compliance
November 27, 2022
 I. Introduction

On January 28, 1986, at exactly 11:38 AM Eastern Time, The National

Aeronautics and Space Administration’s (NASA) space shuttle Challenger lifted

off from the Kennedy Space Center at Cape Canaveral, Florida.1 NASA’s

Challenger launch had been repeatedly delayed for six days due to weather

concerns and technical issues.2 Seventy-three seconds after liftoff, millions of

people around the world watched in horror as Challenger broke apart in a ball of

fire, taking the lives of seven crewmembers, including Christa McAuliffe, a 37-

year-old high school teacher who won her spot aboard the shuttle in a competition

to be the first private citizen in space.3 It was the first time in history that NASA

had lost an entire crew on a mission with a public audience.4

Part II of this Report provides a background of the results and root causes of

the Challenger disaster. Parts III through VII explore the various inadequacies of

NASA’s compliance programs, how exactly those inadequacies lead to the

disaster, and whether any changes to those programs could have prevented the

Challenger disaster. Finally, Part VIII concludes that in the years leading up to the

Challenger disaster, pressure from the Congressional Committee on Science and

Technology, Congress, and NASA itself to achieve twenty-four shuttle flights per
1
History.com Editors, The space shuttle Challenger explodes after liftoff, HISTORY, (Jan. 25, 2022),
https://www.history.com/this-day-in-history/challenger-explodes.
2
History.com Editors, supra note 1.
3
Id.
4
Teitel, Amy Shira, What Caused the Challenger Disaster?, HISTORY, (Jan. 28, 2022),
https://www.history.com/news/how-the-challenger-disaster-changed-nasa.
year lead to relaxed oversight and created an environment that directly resulted in

lethal mistakes and oversights.

II. Background

The Challenger disaster occurred when NASA’s Shuttle Program was in its

tenth year, and the Challenger was the third of six space shuttles launched out of

Cape Canaveral.5 What followed after the disaster was the appointment of a

special commission by the then President Ronald Reagan to determine why exactly

this tragedy occurred.6 The Congressional Committee on Science and Technology,

after reviewing the work of the Presidential Commission on the space shuttle

Challenger Accident (hereafter referred to as the Rogers Commission) and holding

ten formal hearings involving sixty witnesses, published a 450-page report of its

findings (hereafter referred to as the Committee Report).7

Both the Rogers Commission and the Committee Report indicated that the

Challenger disaster was the result of “a failure in the aft field joint on the right-

hand Solid Rocket Motor,” which itself was the result of “a faulty design.” 8 More

troublesome, however, is that both the Rogers Commission and the Committee

5
Pittman, Travis, 7 things to know about the space shuttle on 40th anniversary of 1st launch, KHOU 11, (Apr. 12,
2021), https://www.khou.com/article/news/nation-world/space-shuttle-facts/507-7c1f05be-e7ee-4c19-886d-
dc0a17aa51a6#:~:text=Six%20space%20shuttles%20were%20built,back%20of%20a%20Boeing%20747.
6
Id.
7
H.R. Rep No. 99-1016, at 3 (1986).
8
Id. at 4.
Report concluded that the technical failure was born out of “grossly inadequate”

“safety, reliability, and quality assurance programs within NASA.”9

The “aft field joint” – the failure of which directly caused the Challenger

disaster – was a small rubber part that sealed sections of the Challenger’s solid

rocket boosters.10 This part, also known as an “O-ring,” was “known to be

sensitive to cold,” and the minimum temperature for safe operation was fifty-three

degrees Fahrenheit.11 The temperature in Cape Canaveral on the morning of the

Challenger disaster was thirty-six degrees Fahrenheit.12 In fact, four engineers

from NASA contractor Morton Thiokol raised concerns about the launch day

temperature’s impact on the O-rings the night before the launch. 13 The engineers

specifically identified the risk associated with the O-rings, but their attempts to

delay the launch were overruled by NASA and Thiokol managers.14

Additionally, in the months leading up to the Challenger disaster, NASA’s

Administrator, James Beggs, was placed on an indefinite leave of absence due to

an indictment for contract fraud.15 William Graham stepped in as acting

Administrator just eight days after joining the Agency in December of 1985, but

9
Id.
10
Teitel, supra note 4.
11
Id.
12
Id.
13
Berkes, Howard, 30 Years After Explosion, Challenger Engineer Still Blames Himself, NPR, (Jan. 28, 2016),
https://www.npr.org/sections/thetwo-way/2016/01/28/464744781/30-years-after-disaster-challenger-engineer-still-
blames-himself.
14
Id.
15
Trento, Joseph & Trento, Susan, Why Challenger Was Doomed: The story of the ill-fated space shuttle goes far
beyond O-rings, say the officials who were involved. Politics, economics, egos and ambition were also to blame.,
Los Angeles Times, (Jan. 18, 1987), https://www.latimes.com/archives/la-xpm-1987-01-18-tm-5326-story.html.
Beggs was sure that he would be placed back in charge of NASA, and the two

became hostile toward each other.16 This resulted in an additional lack of

communication and cooperation between the former Administrator and acting

Administrator, which further contributed to the Challenger disaster.17

The Committee Report ultimately concluded that the decision to launch the

following morning was “not poor communication or inadequate procedures,” but

rather “poor technical decision-making over a period of several years by top

NASA and contractor personnel.”18

III. NASA’s Written Standards of Conduct, Policies, and Procedures

Prior to the Challenger disaster, NASA largely lacked any formal risk

management or compliance program at all.19 In fact, it wasn’t until after the

disaster that NASA decided to establish an “Office of Safety, Reliability, and

Quality Assurance.”20 The few written controls that were in place prior to the

disaster were also typically ignored.21 The “quality control check points” that were

meant to be checked off by a Thiokol employee for the temperature effects on

Challenger’s O-rings were checked off.22 However, the Committee Report

concluded that “in actuality, these tests were never performed.”23

16
Id.
17
Id.
18
H.R. Rep No. 99-1016, at 4-5 (1986).
19
Id. at 138.
20
Id. at 174.
21
Id. at 177.
22
Id.
23
Id.
 NASA’s lack of written standards of conduct, policies, and procedures for

risk management certainly contributed to the unfortunate Challenger disaster. Had

written policies and procedures been in place, there likely would have been an

actual response to the concerns regarding the O-rings raised by Thiokol engineers

the night before the launch of the Challenger. Because NASA had no specific

procedure to follow, however, those concerns were quickly disregarded. In fact,

Thiokol executives initially supported the recommendation from their engineers to

delay the launch, but after pushback from NASA officials, Thiokol executives

ultimately overruled their employees and recommended the Challenger launch as

planned.24

Ultimately, however, even if written risk management policies and

procedures were in place before the Challenger disaster, it would have been

unlikely that they would have been followed. The environment within NASA in

the years leading up to the disaster was itself likely to cause mistakes and

encourage shortcuts. Internal and external pressure from NASA officials,

Congress, and the public to meet the unrealistic goal of twenty-four flights per year

“created pressure throughout the agency” that “jeopardized the promotion of a

‘safety first’ attitude throughout the Shuttle Program.”25

IV. NASA’s Compliance Governance and Infrastructure

24
Manoukian, Jean-Gregoire, 5 Risk Management Lessons From an Avoidable Disaster, Wolters Kluwer, (Jan. 28,
2021), https://www.wolterskluwer.com/en/expert-insights/5-risk-management-lessons-from-an-avoidable-disaster.
25
H.R. Rep No. 99-1016. at 3.
 Prior to the Challenger disaster, NASA employed what the Rogers

Commission referred to as “The Silent Safety Program.” 26 NASA’s “Reliability

and Quality Assurance” office did exist, but its policies were once again largely

ignored.27 NASA engineers were largely responsible for ensuring the safety of

their own projects in an individual capacity.28 In the years leading up to the

Challenger disaster, when American interest in space travel was on the decline

following the Apollo era, NASA’s workforce fell dramatically from around thirty-

six thousand people to twenty-two thousand people.29 Almost forty percent of

NASA’s workforce was reduced over this period. NASA’s Reliability and Quality

Assurance staff, however, disproportionately fell seventy-one percent from 1970-

1986, with only around 500 employees dedicated to risk management. 30 Rather

than primarily handling risk management within the agency, most risk

management functions were performed by NASA contractors along with

Department of Defense support personnel.31

Furthermore, the Committee Report concluded that prior to the Challenger

disaster, safety engineers were not involved in flight-related decisions for NASA’s

Shuttle Program.32 On top of that, the Committee’s findings indicated that the

26
Id. at 175.
27
Id. at 176.
28
Id.
29
Id.
30
Id. at 176-77.
31
Id. at 176.
32
Id. at 177.
responsibilities of NASA’s “safety engineers” were inadequately defined. 33 These

shortcomings in NASA’s compliance infrastructure lead directly to the Challenger

disaster and prevented concerns regarding Challenger’s O-rings from reaching top

NASA officials.

It almost goes without saying that an effective risk management

infrastructure could have, and likely would have, prevented the Challenger

disaster. The concerns raised by Thiokol engineers, however, were shot down.

Roger Boisjoly, one of those Thiokol engineers, stated anonymously in an

interview just three weeks after the disaster that he was “talking to the people who

had the power to stop [the Challenger] launch.”34 Boisjoly, along with another

Thiokol engineer Bob Ebeling, recalled hours of data review and arguments over

showings that the O-rings on the Challenger shuttle wouldn’t seal properly in cold

temperatures.35 Ebeling even told his wife the night before the Challenger launch

that, “It’s going to blow up.” 36 Nevertheless, in response to the Rogers

Commission, NASA did not “understand how or why the deficiencies in Solid

Rocket Motor testing and certification went undetected in spite of the very

33
Id.
34
Berkes, Howard, 30 Years After Explosion, Challenger Engineer Still Blames Himself, NPR, (Jan. 28, 2016),
https://www.npr.org/sections/thetwo-way/2016/01/28/464744781/30-years-after-disaster-challenger-engineer-still-
blames-himself.
35
Id.
36
Id.
comprehensive processes and procedures used by the agency to conduct and

oversee these activities.”37

The data supporting the Thiokol engineers’ arguments was there, and the

concerns were raised. But because NASA’s risk management infrastructure was

understaffed, improperly defined, and decentralized, however, those concerns fell

upon deaf ears. There was no channel the engineers could have utilized to send

their concerns further up the flagpole at NASA. This disorganization and lack of

any meaningful risk management structure would later be cited by both the Rogers

Commission and the Congressional Committee on Science and Technology as a

root cause of the Challenger disaster.

V. Technical Decision Making at NASA

It is difficult to argue against the education, knowledge, and capabilities of

NASA engineers. These engineers put a man on the Moon less than twenty years

before the Challenger disaster. After all, and especially in 1986 (before the days

of private space exploration), NASA employed many of the nation’s top

mechanical and aerospace engineers. After conducting its investigation, however

the Congressional Committee on Science and Technology was “not assured that

NASA has adequate technical and scientific expertise to conduct the Shuttle

Program properly.”38 Even in 1986, the Committee acknowledged the disparity

37
H.R. Rep No. 99-1016, at 6 (1986).
38
H.R. Rep No. 99-1016, at 6 (1986).
between government salaries and those in the private sector, and the Committee

Report points out that “the salary structure . . . inhibits NASA’s ability to recruit

top technical talent to replace its losses” to the higher-paying private sector. 39 The

Committee declined to publish any formal findings on this matter, however, due to

insufficient information.40

It does seem, however, that a deficiency in technical expertise played a

major role in overlooking the warning signs leading up to the Challenger disaster.

The Committee even concluded that “the failure was not the problem of technical

communications, but rather a failure of technical decisionmaking.” 41 The night

before the Challenger disaster, Thiokol engineers did not only voice concerns

about O-rings failing due to the twenty-degree, overnight drop in temperature –

they also raised additional concerns about icing.42 As it turned out, foot-long

icicles covered the launch structure on the morning of the launch, and the risks

were still deemed appropriate for launch.43 Even now knowing that the ice on the

launch pad did not cause the Challenger to explode, the ice should have been

enough on its own to delay the launch.44

39
Id.
40
Id.
41
Id. at 172.
42
Id.
43
Id.
44
Trento, Joseph & Trento, Susan, Why Challenger Was Doomed: The story of the ill-fated space shuttle goes far
beyond O-rings, say the officials who were involved. Politics, economics, egos and ambition were also to blame.,
Los Angeles Times, (Jan. 18, 1987), https://www.latimes.com/archives/la-xpm-1987-01-18-tm-5326-story.html.
 James Beggs, the head of NASA who was on administrative leave during the

Challenger disaster, could see the buildup of ice from his television set at NASA

headquarters in Washington, D.C.45 Beggs knew that a large amount of external

ice meant there was likely internal ice built up inside the Challenger itself.46

Internal ice can cause a change to the frequency of vibration, which, as Beggs put

it, can cause “a cascading effect, and you can shake yourself to pieces.” 47 Beggs

was on an indefinite leave of absence, however, and lacked the authority to delay

the launch.48

Because Beggs was “doing everything he could to sidetrack Graham’s

campaign to be named permanent administrator,” Graham left Cape Canaveral to

return to Washington, D.C. before the Challenger launched.49 Phil Culbertson,

General Manager of NASA, was therefore the senior NASA official at Cape

Canaveral on the morning of the Challenger disaster and the only person with

authority to delay the launch.50 When Graham also noticed the ice on a NASA

television in Washington, D.C., he “made the presumption that the people who

were working there knew what they were doing.”51

45
Id.
46
Id.
47
Id.
48
Id.
49
Id.
50
Id.
51
Id.
 In the years leading up to the Challenger disaster, however, NASA

significantly reduced its workforce.52 During the year of 1985 alone, roughly

fifteen hundred employees left NASA, 784 of which were engineers, technicians,

and scientists.53 This loss of technical expertise seemed to play a factor in NASA’s

failure to identify the risks associated with O-rings. During an August 1985

briefing in which Thiokol engineers briefed NASA officials on their concerns, O-

ring resiliency was listed as the Thiokol’s top concern in briefing documents.54

The briefing documents did not include data indicating that O-ring resiliency was a

function of temperature, however – a fact cited by NASA officials in explaining

why they never knew of the dangers posed by low temperatures. 55 Thiokol

engineers, however, explained to the Committee that while it was “possible” that

NASA officials did not understand temperature was a concern, it was not

“probable.”56 As Thiokol engineer Allan McDonald explained, “we put [the

resiliency issue] as the first bullet of why we thought that was our highest concern,

and if [we hadn’t run a very long range of temperatures], we wouldn’t have had

that concern.”57

The NASA officials present at the August 1985 briefing clearly lacked a full

understanding of the issues presented regarding O-ring resiliency. Following the

52
H.R. Rep No. 99-1016, at 155 (1986).
53
Id.
54
Id. at 158.
55
Id.
56
Id.
57
Id. at 158-59.
briefing, NASA officials concluded that the resiliency issue was “not an issue that

ought to ground the fleet,” and that it was safe to continue the Shuttle Program. 58

The Committee, however, after hearing testimony from Thiokol engineers present

at the briefing and reviewing the briefing documents, concluded that the data

presented at the briefing “was sufficiently detailed to require corrective action prior

to the next flight.”59

NASA contractors also lacked technical expertise related to the Challenger.

In an effort to cut costs, Beggs, while he was still Administrator, contracted with

Lockheed to prepare shuttles for launch.60 Lockheed was not involved in building

NASA’s space shuttles at all, however.61 For the first time, none of the contractors

who were involved in the construction of the space shuttles were servicing them

prior to launch.62 Rocco Petrone, who had been in charge of manned spaceflight

for NASA until 1975 and returned in 1981 as a contractor to help run the Shuttle

Program, believed that “Beggs was pushing the shuttle too hard and too fast.” 63

Petrone received complaints from NASA engineers that Lockheed was “using

unauthorized tools and small parts around the four [space shuttles].” 64 The lack of

58
Id. at 159.
59
Id.
60
Trento, Joseph & Trento, Susan, Why Challenger Was Doomed: The story of the ill-fated space shuttle goes far
beyond O-rings, say the officials who were involved. Politics, economics, egos and ambition were also to blame.,
Los Angeles Times, (Jan. 18, 1987), https://www.latimes.com/archives/la-xpm-1987-01-18-tm-5326-story.html.
61
Id.
62
Id.
63
Id.
64
Id.
engineers and technical experts within NASA, however, meant that no one was

double-checking Lockheed’s work.65

A combination of excessive cost-cutting measures, a massive reduction in

expert workforce, poor cooperation, and a general lack of technical knowledge

among top NASA officials all combined to create a dangerous situation that led

directly to the Challenger disaster. First and foremost, had top-level NASA

officials fully understood the gravity of the resiliency issue with O-rings, the entire

program would have surely been put on hold to eliminate the concerns. If Beggs

and Graham would have cooperated and combined their expertise, the launch may

have been delayed due to the buildup of ice on the Challenger’s launch structure.

If Lockheed was properly supervised by NASA engineers, poor maintenance and

corner-cutting would have been avoided. It is abundantly clear why the Committee

concluded that a failure of technical decision making was the primary cause of the

Challenger disaster.

VI. Communication within NASA

One of the main findings within the Committee Report was that “the existing

internal communication system [within NASA was] disseminating too much

65
Id.
information, often with little or no discrimination in its importance.” 66

Nevertheless, the Committee found no evidence to show that existing channels at

the time of the disaster “inhibited communication or that it was difficult to surface

problems.”67 What the Committee did find, however, was that the information that

reached top-level management at NASA was “filtered” by lower management.68

This was due to the practice of NASA managers delegating technical decisions to

lower-level managers, who were deemed to have a higher technical expertise. 69 As

previously discussed, however, the lack of technical expertise throughout NASA,

coupled with this method of delegating decision-making and filtering information,

lead to disaster.

In fact, the specific issue relating to the O-rings was “completely absent

from all the flight-readiness documents” prepared for the Challenger launch.70 The

concerns raised by Thiokol engineers were voiced during a teleconference that

took place just twelve hours before the launch, and they were still not

communicated to top-level NASA management. 71 Because the technical decisions

were delegated to lower-level managers, however, these warnings never reached

top officials. When Thiokol engineers raised their concerns the night before the

66
H.R. Rep No. 99-1016, at 6 (1986).
67
Id. at 170-71.
68
Id. at 172.
69
Id.
70
Teitel, Amy Shira, What Caused the Challenger Disaster?, HISTORY, (Jan. 28, 2022),
https://www.history.com/news/how-the-challenger-disaster-changed-nasa.
71
Id.
Challenger disaster, three NASA officials – Lawrence Mulloy, Staley Reinartz,

and George Hardy – concluded that the data linking the cold temperatures to a

failure in the O-rings was “inconclusive.”72 The next morning, the launch was

almost delayed once again, but the cause for concern was the buildup of ice on the

launch pad.73 Mulloy and Reinartz, who heard the warnings about the O-rings

themselves the night before, never once mentioned those warnings to NASA’s top-

level officials as they participated in the hours-long discussion about whether there

was too much ice to launch.74

Even without these concerns being raised on the morning of the Challenger

disaster, the concerns should have been acknowledged much earlier. Shockingly,

the Challenger disaster was not the first time the O-ring issue was brought to

light.75 O-rings used on shuttle flights in January and April of 1985 were so

damaged that NASA documents – produced after the flights – warned of the

possibility of a leak that could lead to “loss of mission, vehicle and crew.” 76 The

Committee even concluded that “the problems with the [O-rings] had been briefed

at all levels,” and specifically identified an August 19, 1985, meeting where the

issue was discussed.77 Once again, however, NASA officials blamed the oversight

72
Sanger, David, Challenger’s Failure and NASA’s Flaws, The New York Times, (Mar. 2, 1986),
https://www.nytimes.com/1986/03/02/weekinreview/challenger-s-failure-and-nasa-s-flaws.html.
73
Id.
74
Id.
75
Id.
76
Id.
77
H.R. Rep No. 99-1016, at 172 (1986).
on a communication failure – namely, that the problem was always disseminated

“in a way that didn’t communicate the seriousness of the problem; it was not

viewed as life-threatening.”78 It seems a lack of technical understanding of the O-

rings – and the dangers a failure of those O-rings posed – was the true root cause of

the Challenger disaster.

Over a year before the Challenger disaster, then-Deputy Administrator Hans

Mark ordered a review of the O-rings used on NASA’s space shuttles. 79 After

charring was noticed on an O-ring on the tenth shuttle flight – which was the

second such occurrence, first observed on the second flight – Mark issued an

“action item” seeking a complete review of the O-rings. 80 Mark soon after left

NASA, however, the review was never conducted, and the matter was dropped

completely.81 By the time of the Challenger disaster, O-rings had failed on ten out

of twenty-three flights.82

In addition to the lack of expertise highlighted by James Beggs’ and William

Graham’s decisions surrounding the Challenger disaster, their decisions also

highlight a communication deficiency.83 Beggs was NASA’s Administrator – the

head of the Agency – until he was asked to take an indefinite leave of absence due

78
Id.
79
Trento, Joseph & Trento, Susan, Why Challenger Was Doomed: The story of the ill-fated space shuttle goes far
beyond O-rings, say the officials who were involved. Politics, economics, egos and ambition were also to blame.,
Los Angeles Times, (Jan. 18, 1987), https://www.latimes.com/archives/la-xpm-1987-01-18-tm-5326-story.html.
80
Id.
81
Id.
82
Id.
83
Id.
to an indictment for contract fraud relating to a Department of Defense contract

with his previous employer.84 William Graham stepped in as acting Administrator

only eight days after joining NASA, and the Challenger launch was his second

launch as Administrator.85 Beggs retained an office at NASA headquarters to

provide “continuity and consultation,” but because Graham found Beggs to be

“aggressive and hostile,” Beggs never once asked Graham for advice.86

Graham left Cape Canaveral for Washington, D.C. to diffuse problems

caused by Beggs, despite the Challenger being just his second launch as acting

Administrator.87 For the first time in the history of the Shuttle Program, neither the

acting Administrator nor his Deputy were in either control center – in Houston or

Cape Canaveral – for a shuttle launch. 88 Both Beggs and Graham were able to see

an alarming amount of ice built up on the launch structure, but neither made their

concerns heard in Cape Canaveral.89 Beggs, who lacked authority to delay the

launch, claims he instructed two NASA officials to call Cape Canaveral and “tell

them to think hard about launching, and Graham just assumed the officials in Cape

Canaveral knew what they were doing.”90 Neither took the initiative to voice their

concerns.

84
Id.
85
Id.
86
Id.
87
Id.
88
Id.
89
Id.
90
Id.
 It is clear that NASA had a serious communications issue leading up to the

Challenger disaster. Too much information was being disseminated on all levels

from too many sources. On top of that, lower-level managers were given too much

discretion to not send concerns up the chain of command. This communication

structure at NASA directly contributed to the failure of specific concerns regarding

the Challenger’s O-rings to reach officials with the administrative capacity to

delay the launch. Had NASA had a clear channel of communication in place, or at

least a reporting structure designed to send serious concerns up the chain of

command, it is likely that the Challenger disaster would have been avoided

altogether.

VII. NASA’s Culture & Outside Pressures

The attitude that the Congressional Committee on Science and Technology

believed should have taken precedence at NASA is one putting safety above all

else.91 Clearly, however, the “safety first” attitude at NASA took a back seat to

external pressures in the years leading up to the Challenger disaster. For one,

NASA began operating not solely as a research and development agency, but also

as a “quasicompetetive business operation,” competing with private sector

aerospace engineering firms.92 Partly due to that competition, NASA aimed to

achieve a staggering twenty-four space shuttle flights per year, which the

91
H.R. Rep No. 99-1016, at 3 (1986).
92
Id.
Congressional Committee on Science and Technology found to be unattainable. 93

However, there were additional external pressures at play.

One of those pressures came from the then President Ronald Reagan. 94 The

Challenger disaster occurred on Tuesday, January 28, 1986, and President Reagan

was set to deliver his State of the Union address later that night. 95 President

Reagan planned to mention Christa McAuliffe, the civilian teacher who was abord

the Challenger, in his address.96 The President hoped to report that NASA had sent

the first private citizen into space, ushering in a new era of space travel. 97 This

placed a huge amount of pressure on NASA to launch that morning, 98 as NASA

hoped to turn the State of the Union address into an opportunity to justify more

public spending.99

NASA was so concerned with gaining public support of the space program,

that Christa McAuliffe’s plans of broadcasting a live lesson from space on the

fourth day of the Challenger mission also played a significant factor.100 If

Challenger launched on Tuesday, then that lesson would have been broadcast on

Friday, when students were in school. 101 If the launch was delayed to Wednesday,

93
Id.
94
Teitel, Amy Shira, What Caused the Challenger Disaster?, HISTORY, (Jan. 28, 2022),
https://www.history.com/news/how-the-challenger-disaster-changed-nasa.
95
Id.
96
Id.
97
Id.
98
Id.
99
Id.
100
Id.
101
Id.
however, then the broadcast would have happened on a Saturday, meaning NASA

would again miss out on a big publicity opportunity.102

NASA’s attitude – that the Challenger had to launch on Tuesday, January

28, 1986 – was echoed by the NASA officials who shot down the concerns raised

by Thiokol engineers Roger Boisjoly and Bob Ebeling.103 According to Boisjoly,

NASA’s George Hardy responded to Thiokol’s initial recommendation to delay the

launch by saying, “I am appalled. I am appalled by your recommendation.” 104

Lawrence Mulloy, another NASA Shuttle Program manager, responded to the

recommendation to delay with, “My God, Thiokol. When do you want me to

launch – next April?”105

Somewhere along the way, NASA abandoned its “safety first” attitude in

favor of something entirely different. Rocco Petrone, NASA’s former head of

manned spaceflight and a contractor assisting with the Shuttle Program, saw the

space shuttle as “more a political than a space vehicle.” 106 In fact, Petrone left

NASA in 1975 after thirty-two years in the space program because of the

compromises in safety being made during the shuttle era. 107 Rockwell, a contractor

102
Id.
103
Berkes, Howard, Remembering Roger Boisjoly: He Tried To Stop Shuttle Challenger Launch, NPR, (Feb. 6,
2012), https://www.npr.org/sections/thetwo-way/2012/02/06/146490064/remembering-roger-boisjoly-he-tried-to-
stop-shuttle-challenger-launch.
104
Id.
105
Id.
106
Trento, Joseph & Trento, Susan, Why Challenger Was Doomed: The story of the ill-fated space shuttle goes far
beyond O-rings, say the officials who were involved. Politics, economics, egos and ambition were also to blame.,
Los Angeles Times, (Jan. 18, 1987), https://www.latimes.com/archives/la-xpm-1987-01-18-tm-5326-story.html.
107
Id.
that helped build the Saturn V rocket that carried the Apollo missions to the moon,

was required to file “hundreds of thousands of documents on Apollo so that NASA

would have a history of every part.”108 The shuttles, however – a “vastly more

complicated” vehicle – were “flying without a serious paper trail to trace

responsibility.”109

James Beggs’ cost-cutting measures also placed immense pressures on the

Shuttle Program that compromised safety. Shuttle parts were being taken from one

shuttle to use on another in order to keep up with the demand of the launch

schedule.110 Also, because O-rings had already failed on ten out of twenty-three

shuttle flights conducted by NASA, special waivers were prepared and signed by

NASA officials that allowed the flights to continue despite the risks. 111 Some

shuttles were even launched on backup systems, which violated a mission rule put

in place when Alan Shepard became the first American in space in 1961.112

This pressure to cut costs and neglect safety was not solely a product of new

political pressure and decisions from Beggs. From the very beginning of the

Shuttle Program, in the early 1970s, “President Nixon, Congress, and the Office of

Management and Budget (OMB) were all skeptical of the shuttle.” 113 OMB

108
Id.
109
Id.
110
Id.
111
Id.
112
Id.
113
Bell, Trudy & Esch, Karl, The Challenger Disaster: A Case of Subjective Engineering, IEEE Spectrum, (Jan. 28,
2016), https://spectrum.ieee.org/the-space-shuttle-a-case-of-subjective-engineering.
directed NASA to hire an external contractor to conduct an economic analysis of

the shuttle’s cost-effectiveness, which marked the first time a space program was

made subject to an independent economic evaluation.114 This placed pressure on

NASA to show that shuttle launches would be “cheap and routine, rather than large

and risky, with respect to both technology and cost.” 115 This pressure, according to

Adelbert Tischler, NASA’s former director of launch vehicles and propulsion,

caused “some NASA people . . . to confuse desire with reality.” 116 For example,

many officials within NASA were estimating overall risk of catastrophic shuttle

failure in the 1980s, and those estimates ranged from one in one-hundred, to one in

one-hundred-thousand.117 The more pessimistic estimates typically came from

working engineers, with the more optimistic estimates coming from

management.118

Due to economic pressures stemming from the very beginnings of the

Shuttle Program and a need for publicity, public support, and funding, NASA

abandoned it’s “safety first” attitude of the Apollo era. This cultural shift, coupled

with external pressures, is what led to cutting costs, abandoning stringent record

keeping requirements, and a practice of decision-making that placed output above

safety.

114
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115
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116
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117
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118
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 VIII. Conclusion and Looking Ahead from Challenger

The Challenger disaster was the result of a number of factors – a general

lack of formal risk management, a lack of both internal communication and

cooperation, a deficiency of technical expertise among top NASA officials, and

economic and political pressures – all of which seemed to amplify one another.

Political pressure to remain as economical as possible led to dangerous budget cuts

and decisions to bring in new contractors that lacked expertise on space shuttles.

The budget cuts contributed to a reduced workforce and the inability to double-

check the new contractors’ work. This vast reduction in workforce also led to a

general lack of technical expertise among NASA’s top officials, with too much

highly technical information being disseminated on a regular basis. Because so

much information was being disseminated, important decision-making authority

was delegated to lower-level managers at NASA, who dismissed concerns about

O-rings and therefore did not report them to top NASA officials.

A cultural shift also occurred at NASA during the very beginnings of the

Shuttle Program. Political and economic pressures caused those within NASA to

shift their focus from “safety first” to increased output and lowering costs.

NASA’s overall lack of an effective compliance and risk management program

allowed contractors and those within NASA to work without a meaningful paper

trail. The space shuttles were built and presented to the public in 1969 as
providing crew and passenger safety “in a manner and to the degree as provided in

present day commercial jet aircraft.”119 A commercial jet is statistically the safest

mode of transportation, and this pressure to present a safe vehicle caused NASA

officials to ignore blatant risks to avoid public and political backlash.120

All of these issues within NASA only came to light after the Challenger

disaster as a result of a presidential commission investigation and numerous

Congressional hearings. As a part of the Committee’s report, recommendations

were made to remedy these issues. One of those recommendations was a complete

restructuring of Shuttle Program management “to define clear lines of authority

and responsibilities.”121 Additionally, Congress recommended that top NASA

officials should revise their communication processes, which prior to the

Challenger disaster delivered “all sorts of memoranda, such as directives, requests,

approvals for changes, etc.” across top officials’ desks, with a high possibility that

“an important piece of information could cross their desk without their

awareness.”122

NASA’s response was to establish an Office of Safety, Reliability and

Quality Assurance.123 The Shuttle Program resumed regular flights in 1988 after

roughly two hundred design changes were made to the shuttles and their

119
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120
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121
H.R. Rep No. 99-1016, at 166 (1986).
122
Id. at 171.
123
Id. at 174.
components.124 NASA’s intended changes, however, seemed to be short-lived.

With a return to regular flights came a return to the same “unrealistic launch

schedule, the same budget constraints, and the same complacency in regard to

oversight and safety.”125 In 2003, the NASA shuttle Columbia broke up upon

reentry over Texas, once again killing all seven astronauts on board.126

The Columbia disaster was caused by damage sustained to the shuttle during

takeoff, which resulted from a dislodged piece of foam insulation from the main

fuel tank.127 Once again, it was revealed that NASA had known about the risks

posed from dislodged foam insulation – shuttles had sustained debris damage from

dislodged foam insulation on at least six prior flights. 128 Wayne Hale, the deputy

program manager for the Shuttle Program at the time of the Columbia disaster,

wrote in a 2004 letter that “last year, we dropped the torch through our

complacency, our arrogance, self-assurance, sheer stupidity and through continuing

attempts to please everyone.”129 It seems as though not much had truly changed

within NASA following the Challenger disaster. NASA again fixed the insulation

problem and returned to regular flights.130

124
Hays, Brooks, Challenger disaster at 30: Did the tragedy change NASA for the better?, UPI, (Jan. 27, 2016),
https://www.upi.com/Science_News/2016/01/27/Challenger-disaster-at-30-Did-the-tragedy-change-NASA-for-the-
better/8181453843727/.
125
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126
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127
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128
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129
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130
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 Today, the Shuttle Program has ended, and NASA has turned its attention to

the Orion Program, which plans to send humans to Mars. 131 NASA’s Office of

Safety, Reliability and Quality Assurance has been replaced with OSMA, the

Office of Safety & Mission Assurance.132 According to NASA, OSMA “assures

the safety and enhances the success of all NASA activities through the

development, implementation and oversight of agencywide safety, reliability,

assurance and space environment sustainability policies and procedures.” 133 Five

different divisions of risk management and compliance functions exist within

OSMA, and their functions include establishing and ensuring compliance with

NASA Safety and Mission Assurance policies, performing independent reviews,

and improving methodologies for identifying risks.134 As NASA turns its eyes

toward Mars and beyond, however, only time will tell whether NASA has truly

reembraced its Apollo era attitude – safety first.

131
Id.
132
About OSMA, NASA, (Nov. 19, 2022), https://sma.nasa.gov/about.
133
Id.
134