This is an addendum to the official Rogers Commission report on the cause of the explosion and catastrophic disintegration of the shuttle.
From science.ksc.nasa.gov (Kennedy Space Center):
Appendix F - Personal observations on the reliability of the Shuttle by R. P. Feynman"For a successful technology, reality must take precedenceover public relations, for nature cannot be fooled."
It appears that there are enormous differences of opinion as to the probability of a failure with loss of vehicle and of human life. The estimates range from roughly 1 in 100 to 1 in 100,000. The higher figures come from the working engineers, and the very low figures from management. What are the causes and consequences of this lack of agreement? Since 1 part in 100,000 would imply that one could put a Shuttle up each day for 300 years expecting to lose only one, we could properly ask "What is the cause of management's fantastic faith in the machinery?"
We have also found that certification criteria used in Flight Readiness Reviews often develop a gradually decreasing strictness. The argument that the same risk was flown before without failure is often accepted as an argument for the safety of accepting it again. Because of this, obvious weaknesses are accepted again and again, sometimes without a sufficiently serious attempt to remedy them, or to delay a flight because of their continued presence.
There are several sources of information. There are published criteria for certification, including a history of modifications in the form of waivers and deviations. In addition, the records of the Flight Readiness Reviews for each flight document the arguments used to accept the risks of the flight. Information was obtained from the direct testimony and the reports of the range safety officer, Louis J. Ullian, with respect to the history of success of solid fuel rockets. There was a further study by him (as chairman of the launch abort safety panel (LASP)) in an attempt to determine the risks involved in possible accidents leading to radioactive contamination from attempting to fly a plutonium power supply (RTG) for future planetary missions. The NASA study of the same question is also available. For the History of the Space Shuttle Main Engines, interviews with management and engineers at Marshall, and informal interviews with engineers at Rocketdyne, were made. An independent (Cal Tech) mechanical engineer who consulted for NASA about engines was also interviewed informally. A visit to Johnson was made to gather information on the reliability of the avionics (computers, sensors, and effectors). Finally there is a report "A Review of Certification Practices, Potentially Applicable to Man-rated Reusable Rocket Engines," prepared at the Jet Propulsion Laboratory by N. Moore, et al., in February, 1986, for NASA Headquarters, Office of Space Flight. It deals with the methods used by the FAA and the military to certify their gas turbine and rocket engines. These authors were also interviewed informally.
Solid Rockets (SRB)
An estimate of the reliability of solid rockets was made by the range safety officer, by studying the experience of all previous rocket flights. Out of a total of nearly 2,900 flights, 121 failed (1 in 25). This includes, however, what may be called, early errors, rockets flown for the first few times in which design errors are discovered and fixed. A more reasonable figure for the mature rockets might be 1 in 50. With special care in the selection of parts and in inspection, a figure of below 1 in 100 might be achieved but 1 in 1,000 is probably not attainable with today's technology. (Since there are two rockets on the Shuttle, these rocket failure rates must be doubled to get Shuttle failure rates from Solid Rocket Booster failure.)
NASA officials argue that the figure is much lower. They point out that these figures are for unmanned rockets but since the Shuttle is a manned vehicle "the probability of mission success is necessarily very close to 1.0." It is not very clear what this phrase means. Does it mean it is close to 1 or that it ought to be close to 1? They go on to explain "Historically this extremely high degree of mission success has given rise to a difference in philosophy between manned space flight programs and unmanned programs; i.e., numerical probability usage versus engineering judgment." (These quotations are from "Space Shuttle Data for Planetary Mission RTG Safety Analysis," Pages 3-1, 3-1, February 15, 1985, NASA, JSC.) It is true that if the probability of failure was as low as 1 in 100,000 it would take an inordinate number of tests to determine it ( you would get nothing but a string of perfect flights from which no precise figure, other than that the probability is likely less than the number of such flights in the string so far). But, if the real probability is not so small, flights would show troubles, near failures, and possible actual failures with a reasonable number of trials. and standard statistical methods could give a reasonable estimate. In fact, previous NASA experience had shown, on occasion, just such difficulties, near accidents, and accidents, all giving warning that the probability of flight failure was not so very small. The inconsistency of the argument not to determine reliability through historical experience, as the range safety officer did, is that NASA also appeals to history, beginning "Historically this high degree of mission success..."
Finally, if we are to replace standard numerical probability usage with engineering judgment, why do we find such an enormous disparity between the management estimate and the judgment of the engineers? It would appear that, for whatever purpose, be it for internal or external consumption, the management of NASA exaggerates the reliability of its product, to the point of fantasy.
The history of the certification and Flight Readiness Reviews will not be repeated here. (See other part of Commission reports.) The phenomenon of accepting for flight, seals that had shown erosion and blow-by in previous flights, is very clear. The Challenger flight is an excellent example. There are several references to flights that had gone before. The acceptance and success of these flights is taken as evidence of safety. But erosion and blow-by are not what the design expected. They are warnings that something is wrong. The equipment is not operating as expected, and therefore there is a danger that it can operate with even wider deviations in this unexpected and not thoroughly understood way. The fact that this danger did not lead to a catastrophe before is no guarantee that it will not the next time, unless it is completely understood. When playing Russian roulette the fact that the first shot got off safely is little comfort for the next. The origin and consequences of the erosion and blow-by were not understood. They did not occur equally on all flights and all joints; sometimes more, and sometimes less. Why not sometime, when whatever conditions determined it were right, still more leading to catastrophe?
In spite of these variations from case to case, officials behaved as if they understood it, giving apparently logical arguments to each other often depending on the "success" of previous flights. For example. in determining if flight 51-L was safe to fly in the face of ring erosion in flight 51-C, it was noted that the erosion depth was only one-third of the radius. It had been noted in an experiment cutting the ring that cutting it as deep as one radius was necessary before the ring failed. Instead of being very concerned that variations of poorly understood conditions might reasonably create a deeper erosion this time, it was asserted, there was "a safety factor of three." This is a strange use of the engineer's term ,"safety factor." If a bridge is built to withstand a certain load without the beams permanently deforming, cracking, or breaking, it may be designed for the materials used to actually stand up under three times the load. This "safety factor" is to allow for uncertain excesses of load, or unknown extra loads, or weaknesses in the material that might have unexpected flaws, etc. If now the expected load comes on to the new bridge and a crack appears in a beam, this is a failure of the design. There was no safety factor at all; even though the bridge did not actually collapse because the crack went only one-third of the way through the beam. The O-rings of the Solid Rocket Boosters were not designed to erode. Erosion was a clue that something was wrong. Erosion was not something from which safety can be inferred.
There was no way, without full understanding, that one could have confidence that conditions the next time might not produce erosion three times more severe than the time before. Nevertheless, officials fooled themselves into thinking they had such understanding and confidence, in spite of the peculiar variations from case to case. A mathematical model was made to calculate erosion. This was a model based not on physical understanding but on empirical curve fitting....MORE