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Kurt_Steiner: That's all right, Kurt.

El Pip: What's striking about the Apollo 1 disaster is that the command module had so many problems and design flaws, and yet NASA management thought, "Eh, it's good enough. Let's use it." Clearly "Safety First" was not a priority for them, so it was only a matter of time before tragedy struck.

The decision to use pure oxygen is something I explore in this update. Of all the bad decisions NASA made concerning the command module, giving the astronauts pure oxygen to breathe might top them all, as you will see.

That's another striking thing. After defeating their country in war and destroying their government, the Nazis found the Americans only too eager to recruit them. "We don't want you to work for that crazy man Hitler; we want you to work for us. Now grab your suitcase, because you're moving to America."

DensleyBlair: Believe me, I know exactly what you mean. "I will read this AAR later." *months go by* I do read other peoples' AARs...eventually.

Thank you very much for climbing aboard, @DensleyBlair. The post-Vietnam War period is shaping up to be not any easier for America than the Vietnam War period had been.

I kind of look at this AAR as being "Echoes of A New Tomorrow's" cousin. We have two different storylines going on, but they are taking place in the same 1960s timeframe.

Rensslaer: Thank you for following my series, @Rensslaer. Like @El Pip and his Butterfly epic, I am still chugging away at my storyline. When I first started writing the original Presidents AAR way back in 2008, I didn't think it would turn into an ongoing trilogy covering almost 40 years of alternate history.

John Sparkman wasn't someone I was aware of until I got to the 1952 Presidential election. Doing research on him gave me the idea of having him become President through an assassination in 1954, right before the Supreme Court issued its' landmark Brown v. Board of Education of Topeka decision, which naturally enraged segregationists like Sparkman.

Hearing the actual audio of when the Apollo 1 crew discovered their command module was on fire is very chilling. There's a YouTube video featuring the last half-hour of Apollo 1 audio that is gripping to hear, knowing that the three astronauts are going to die at the end of it.
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The Apollo 1 Fire
“I suppose that someday we are going to have a failure. In every other business there are failures, and they are bound to happen sooner or later. However, you sort of have to put that out of your mind. There’s always a possibility that you can have something go wrong, of course. This can happen on any flight; it can happen on the last one as well as the first one. So, you just plan as best you can to take care of all these eventualities, and you get a well-trained crew and you go fly.”
-Virgil “Gus” Grissom, April 1966

“This is a CBS News Special Report”
On the evening of Friday, May 27th, 1966, television viewers watching “The Wild Wild West” on CBS suddenly found the Robert Conrad-led Western interrupted by a CBS News Special Report title card and announcement. A few seconds later, the title card was replaced by a live shot of Mike Wallace sitting behind a desk at the CBS news studio in New York City. At age 48, Wallace had been with the network since the late 1940s, hosting a string of game shows and appearing in numerous commercials before becoming a full-time journalist in 1962. He looked directly into the television camera, his face looking like that of a man who had bad news to deliver. “America’s first three Apollo astronauts,” Wallace matter-of-factly began, “Were trapped and killed by a flash fire that swept their spaceship tonight during a launch pad test at Cape Canaveral in Florida.”
Television viewers became stunned to learn that Virgil “Gus” Grissom, Edward White, and Roger Chaffee, the crew of the first manned Apollo mission, which was scheduled to be launched next month for a two-week test of the new command and service module, were now dead. “These three astronauts were aboard their spaceship, ten minutes from a simulated liftoff at Cape Canaveral,” Wallace reported, “When the fire hit at about 6:30 tonight. They were inside their spaceship, pressurized, buttoned-up inside their spacesuits, when the fire hit. A closed-circuit television camera was relaying pictures of the astronauts, laying on their backs inside the spacecraft atop a two-stage Saturn I. ‘There was a flash, and that was it,’ according to a NASA spokesman watching the television screen in the block house a few hundred yards away from Launch Pad 34. The screen went blank, and he says there were no communication from the astronauts. They died silently and apparently swiftly.”
What Wallace was telling his television viewers was unprecedented. While the country’s space program had already lost a few astronauts through vehicle accidents, never before had an entire crew perished inside their spacecraft. Exactly what had caused the fatal fire was unknown at that hour. As the native of Brookline, Massachusetts spoke, he was handed a piece of paper, which he quickly scanned with his eyes. “The White House has put out a statement about the disaster. It says that President Forbes mourns the deaths of the three astronauts and he asks that all Americans join him in mourning their tragic loss. In his words, ‘They gave their lives in the service of the nation, and we should stand together to honor them for it.’
Vice President Dirksen, in his role as the man in charge of the space program, will visit Cape Canaveral tomorrow to meet with top space officials concerning the fire.”

Wallace was soon joined in the broadcast by “CBS Evening News” anchor Walter Cronkite. Cronkite himself was a veteran of the space program, having covered every single manned Mercury and Gemini mission – sometimes being unable to contain his own enthusiasm at what he was seeing. His dedication was such that “The New York Times” called him “a one-man phenomenon in space coverage.”
Given his close association with the space program, Cronkite told Wallace that the shocking news “hits me hard. I knew Gus Grissom personally. He was a friend of mine.”
“This is a time for great sadness,”
the veteran anchor solemnly reflected, “But it is also a time for courage. This is a test program. We knew something could go wrong in this test program, and these guys who went into it knew something could go wrong. Whenever you are testing equipment of this nature, whether it is airplanes or boats or submarines, anything where you are operating in a hostile environment, which space is, you are going to encounter problems that could be deadly. This test program was bound to claim its victims.
These fellows, every one of them, were test pilots. They have flown highly sophisticated aircraft, and they have seen their buddies go down. They knew they could die flying those aircraft, and they flew anyway. They knew they could die if they became astronauts, and they became astronauts anyway and became a part of the space program.
The accident that happened tonight in Cape Canaveral should not be a cause for our turning back or having any questions of faltering in our progress forward towards the landing on the Moon. We are probably going to be delayed. It may be for a couple months, or it may be for longer. It could push us from ’67 to ’68 or even to ’69, if something else happens. But certainly, it shouldn’t in any way damage our national resolve to press on with the program to which these men gave their lives.”

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(Mike Wallace)
Early the next afternoon, Vice President Everett Dirksen arrived in Cape Canaveral. When the United States formally established her space program in 1957, it was put under the supervision of the Vice President as a way to empower an office long known for giving its’ occupants not much to do (John Nance Garner, who served as Vice President from March 1933 to January 1941, had famously derided his office as being “not worth a bucket of warm piss”).
Under the chain of command, the Administrator of NASA reported directly to the Vice President. Therefore, it was Dirksen who got the fateful phone call from James E. Webb about the fire. He in turn called President Malcolm Forbes to break the terrible news. Upon the Vice President’s arrival at Cape Canaveral, he was greeted by Webb and other key NASA officials. Seeing the NASA Administrator up close, Dirksen noticed that the 59-year-old North Carolinian looked terrible. “Are you all right, Mr. Webb?” he inquired. Webb shook his head. “I didn’t get much sleep last night, Mr. Vice President. All I could think about was the fire.”
In talking to Webb and the other officials, Dirksen saw that they were all in a state of shock. None of them had expected what happened the previous night to occur. “Who would have thought that the first tragedy, the first loss of one of our crews,” an astounded Webb remarked to Dirksen, “Would have been on the ground?”
While the American people knew about the disaster, NASA had yet to publicly release pictures of the scene of the accident. The Vice President told the officials that he wanted to see the command module for himself. “So far, I have only been told about the fire. Now I want to see exactly what the fire did.”
Obliging, Webb and a few others escorted Dirksen to Launch Complex 34. As he approached the site, he was struck by the massive height of the red steel structure housing the rocket. Boarding an elevator, the group began the ride to the top. Knowing that the Apollo 1 crew had been in the same elevator the day before, Dirksen couldn’t help but wonder what went through their minds as they made their way up, not knowing that death was awaiting them at the top. Right before the elevator door opened, Donald “Deke” Slayton, one of the original Mercury 7 astronauts who was now in charge of giving astronauts their crew assignments as Director of Flight Crew Operations, placed a cautionary hand on the Vice President’s shoulder. “I want to warn you, sir, that what you are going to see is pretty bad.”
Slayton had been in the blockhouse control room at the time of the fire. Once it had ended, the heavy smoke had cleared, and the three hatches had been removed, Slayton became the first official to see the inside the command module. Dirksen looked over at him and nodded his head in understanding. The 70-year-old was no stranger to death and destruction. During World War One, he had dropped out of the University of Minnesota to fight in France as a member of the 85th Infantry Division. The second lieutenant had seen men get killed and wounded, and the French countryside be blasted by field artillery bombardments, at the Battle of Saint-Mihiel (September 12th – 15th, 1918). As they approached the scene of the disaster, there was a strong odor lingering in the air. Dirksen later described it to Forbes (himself a veteran of World War Two) as “the unmistakable smell of death. You smell it once, and you can recognize it anywhere.”
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Walking up to the command module, the Vice President got his first glimpse of the damage. There were large burn marks scarring the outside of the spacecraft. At the climax of the pure oxygen-fed fire, the internal pressure reached 29 psi, rupturing the inner wall. Flames then shot out of every opening they could find, forming an intense barrier that kept rescuers away from the astronauts who were burning alive inside. The fire extinguished itself after it had consumed the command module’s supply of oxygen. As bad as the outside looked, it was nothing compared to what the inside looked like. Standing before the open hatch, Dirksen tilted his head downward and peered into the crew cabin. Through his black-rimmed glasses, he saw that the fire had completely gutted the inside of the command module. Where the three astronauts had sat on their backs was nothing but charred rubble. Everything had been burned to a crisp; there wasn’t a single inch of the cabin which had been spared. The Illinoisan closed his eyes, trying to imagine the living nightmare that Grissom, White, and Chaffee had suffered through. Opening his eyes, he said out loud to nobody in particular:
“These brave gallant men, to die in a manner such as this.”
Slayton walked up to Dirksen, standing right next to him as he kept his eyes fixated on the carnage. “We know, based on the position of the bodies, that Ed tried to turn the inner hatch release handle with help from Gus, but...”
The 42-year-old Director of Flight Crew Operations paused, prompting Dirksen to glance at him curiously. “But?”
“But the fire spread so quickly that Ed didn’t have time to fully turn it. He probably had only 30 seconds or so to try to open the hatch before he was overwhelmed.”

For men struggling to escape the raging inferno they now found themselves in, 30 seconds offered little in the way of hope. In fact, it took the recovery crew five minutes to remove the hatches from the outside. When they tried to pull the bodies out, they discovered that the fire wasn’t going to make it easy. It had melted the astronauts’ nylon space suits, fusing them to the interior of the spacecraft. The grim process of fully extracting the remains of Grissom, White, and Chaffee from their metal tomb took 90 minutes. Having seen enough, the Vice President turned away from the burned-out command module and moved towards Webb. “Mr. Webb, you need to distribute pictures of this to the media as soon as possible. The American people are not going to fully understand the magnitude of what happened here until they have seen what I have seen.”
Dirksen then cast one last look at the scene of horror before walking back to the elevator.
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The Apollo 1 disaster shocked the country. The American public had, by the spring of 1966, taken the space program for granted. They just assumed that the astronauts were safe inside their spacecraft; the fact that the Apollo 1 crew had perished in a fire right there on the launchpad was unbelievable. In the immediate aftermath, the President ordered flags to be flown at half-staff nationwide in their honor. He attended Grissom and Chaffee’s funeral services and burial at Arlington National Cemetery in Virginia, while the Vice President attended White’s burial at West Point Cemetery in New York. Forbes met with the families of the three fallen astronauts, offering his condolences “on behalf of the American people, who are grieving your loss along with you.”
Once the three men had been laid to rest, investigations into the disaster began. How did a routine test on the ground end up killing the entire crew? NASA established a nine-member review board to investigate what caused the deadly fire and recommend corrective measures to be taken in order to prevent another one from happening. The command module was completely disassembled, every part being thoroughly looked at. Witnesses were extensively interviewed, each one shedding light on exactly what happened and when. On August 3rd, nearly ten weeks after the catastrophe at Launch Complex 34, the review board issued its final report. According to the report, the three astronauts had died from a combination of severe third-degree burns and asphyxiation caused by breathing in a high concentration of carbon monoxide. As for what had caused the fire, investigators had traced the source to faulty wiring below the astronauts’ seats which had sparked. Those sparks ignited the pure oxygen atmosphere of the crew cabin, creating a fire which quickly intensified as it consumed combustible materials, like Velcro, which were spread throughout the cabin. The heat caused the internal pressure to rapidly swell from 16.7 psi (which is 2 psi higher than normal atmospheric pressure) to 29 psi, making it impossible for the astronauts to open the hatch, due to the fact that it was sealed by high pressure inside the command module. Grissom, White, and Chaffee were in effect sitting ducks, strapped to a ticking time bomb waiting to go off.
While NASA investigated the fire, the space agency itself was investigated by Congress. On Capitol Hill, Republican Speaker of the House Gerald Ford promised reporters a vigorous Congressional investigation into NASA’s conduct. “We owe it to the families of those three astronauts to get to the bottom of this matter. We need to find out what went wrong, who is responsible for this, and what needs to be done in order to make sure that this fire never happens again.”
Webb and other top NASA management officials appeared before House and Senate Committees, where they were grilled by Republicans and Democrats alike. They all wanted to know how NASA, who had a good track record of safety during Projects Mercury and Gemini, had allowed the first Apollo crew to die…before they had even gotten off the ground. Webb, as the man in charge of NASA, sincerely told the questioning Congressmen that as the fire had taken place on his watch, “I take full responsibility for everything we did and, more importantly, did not do to ensure the safety of the crew. We failed them. We failed Gus Grissom, we failed Ed White, and we failed Roger Chaffee. For those failures, I blame no one but myself.”
It was during the Congressional investigation that Walter Mondale first attracted national attention. A Democrat from Minnesota, he had been elected to the Senate in 1964. While being questioned by the House, Webb and the other members of upper management claimed that NASA didn’t know that having a 100% pure oxygen atmosphere inside the command module would make it much more flammable should there be an ignition of some sort. When Mondale heard this testimony, he was skeptical. NASA, after all, had the best and brightest minds working for it. “You mean to tell me,” he thought to himself, “That no one in the whole agency knew what would happen in case of a fire with all that oxygen?”
Fritz, as he was called, reached out to someone he knew at NASA and asked if what upper management said in their testimony was true. The answer he got back was stunning: it wasn’t true at all. Not only was NASA aware of the danger, upper management had in its’ possession an internal report detailing it. Mondale then asked for and received a copy of the report. “When I read it,” he later said, “It became obvious to me that the leaders of NASA had been lying to Congress – under oath, I should add – about not knowing it was dangerous to give those three astronauts nothing but oxygen to breathe. There was no way they could not have known when they had this document which made the danger as clear as day.”
When upper management (below) appeared before the Senate, Mondale asked the NASA Administrator when it became his turn for questioning, “Mr. Webb, you said the other day before the House committee that your agency did not know of the danger of pure oxygen prior to the fire on May 27th. How, sir, do you explain this report, made within your agency, which says that using pure oxygen is in fact dangerous?”
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In dramatic fashion, the 38-year-old Minnesotan proceeded to take out the report and hold it up in the air for everyone to see. There were murmurs in the room as Mondale proceeded to publicly disclose the content of the report. Shortly before the Apollo 1 fire, a pair of United States Air Force airmen underwent testing in a pure oxygen chamber at the School of Aerospace Medicine at Brooks Air Force Base in San Antonio, Texas. The purpose of the test was to simulate how two men would function in a space environment. They were taking care of laboratory rabbits when an electrical spark occurred, causing a flash fire which killed them. The report, which was passed along to upper management, stated that pure oxygen in an enclosed space had proven to be highly flammable and recommended following North American Aviation’s suggestion of using a mixture of oxygen and nitrogen that would reduce the risk of a fire. When the Senator finished speaking, he looked straight at the upper management sitting in front of him to see their reaction. One of the managers was squirming in his seat, while Webb was visibly surprised. “I ask you once again, Mr. Webb: how do you explain this report?”
Webb replied that this was the first time he had heard about the report, as it was never passed up the chain of command to him. “I did not know about the fire that took place in Texas prior to the fire at Cape Canaveral. I did not know that a pure oxygen atmosphere had been cited as the cause of it. I did not know any of it until just now.”
“But Mr. Webb, someone below you saw this report and knew about it. They knew it was dangerous to use pure oxygen. Even North American Aviation knew it was dangerous and suggested an alternative. Someone read this report and decided to use pure oxygen anyway, even though they knew it had killed two men already.”

The manager who had been squirming in his seat spoke up, “suddenly remembering” that he had read the report in question. He explained that NASA had chosen to use pure oxygen because they had found it to be more comfortable for the astronauts to breathe and was lighter in weight, which reduced the pressure load on the spacecraft. While using a mixture of oxygen and nitrogen did indeed reduce the risk of fire, NASA had found downsides to using nitrogen that kept them from pumping it into the command module. One of those downsides was that breathing in too much nitrogen had a tendency to give astronauts decompression sickness. Another problem was that if you didn’t get the mixture just right and there was more nitrogen in the air than oxygen, the person breathing it would pass out. “It is for those reasons, Senator, that we believed pure oxygen would be safer to use.”
“But you knew pure oxygen can catch on fire,”
Mondale retorted in his dry Midwestern accent. “You knew you were putting the astronauts in a dangerous situation.”
The manager attempted to defend the decision by stating that “there is an inherent risk to everything that we do. The astronauts will always face a degree of danger when they travel to space. That is the nature of things.”
“But they did not face a ‘degree of danger’ in space, sir. They faced it at sea level.”

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(Walter Mondale)
Mondale’s revelation sent shockwaves across the country. NASA had been caught not telling the truth in regards to, to paraphrase Republican Senator Howard Baker of Tennessee, what she knew about the danger of giving the Apollo 1 crew pure oxygen and when she knew it. Anger over the glaring contradiction between what upper management had told the House and what they had told the Senate damaged NASA’s credibility. The space agency’s reputation took a further hit when Congress released its’ scathing final report on October 1st. In it, Congress found that NASA officials had been complacent about the state of their spacecraft. They had allowed Apollo astronauts to use the command and service module even though it was riddled with multiple mechanical problems and safety issues. In addition, NASA had been so determined to get to the Moon as quickly as possible – and before the Soviets got there first – that they dismissed safety concerns raised by the astronauts themselves. As Walter Schirra, who was the commander of the Apollo 1 backup crew, testified to Congress:
“We never felt comfortable with the ship. It wasn’t in good shape. We tried talking to people about it, but we couldn’t get anyone to listen.”
After the Congressional report came out, there were demands for Webb to resign in disgrace. Some people even called for Project Apollo to be cancelled altogether, saying that it was just too costly and dangerous to go to the Moon, and that the United States would be better off focusing her considerable resources elsewhere. With America’s space agency tarnished and the future of her space program now in doubt, the President was faced with a domestic crisis that fall. He responded to it the way he had responded to the NATO crisis: he moved quickly to repair the damaged ship. Forbes summoned the embattled NASA Administrator to the Oval Office and asked him to resign. “Mr. Webb, you have served this nation well, but I think it would be in the best interest of the nation for you to step down.”
Webb complied, reiterating in his letter of resignation that he took full responsibility for the tragedy. With Webb out, the President appointed James C. Fletcher to be NASA’s new Administrator. Born in Millburn, New Jersey in June 1919, Fletcher had an educational background in physics. After working for a number of aerospace and defense contractors, he became the President of the University of Utah in 1964. Forbes chose Fletcher because he believed that the best way to restore confidence in NASA was to put an outsider in charge who would have new ideas on how to do things. Fletcher arrived at NASA with a mandate to turn the troubled agency around. His first act as the third Administrator was to clean house, sacking upper management and installing new managers who would be more safety-conscious. “We are still going to send astronauts to the Moon,” he told them, “But we are going to be more careful about it. We are not going to put them in any more danger than they need to be in.”
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(James C. Fletcher)
Adopting the recommendations of the two final reports, Fletcher oversaw the implementation of numerous reforms to improve NASA from the top down. Astronauts who had previously been dismissed by management over their safety concerns were now openly encouraged to provide input on how to improve not only their spacecraft but the organization in general. The command module underwent a complete overhaul. The hatch, which the astronauts couldn’t open during the fire, was the first thing to go. A new hinged hatch was installed, which the astronauts could open outward in just five seconds. The next thing to go was all the flammable materials inside the cabin; anything that could burn easily were replaced by materials that wouldn’t. The faulty wiring was completely redone, with all the wires now being encased in protective insulation. The cabin atmosphere, after rigorous testing, was given a mixture of 60% oxygen and 40% nitrogen that would help the astronauts breathe well while greatly reducing the chances of a flash fire. Even the spacesuits the astronauts wore underwent revision, with the flammable nylon being replaced by a fireproof cloth coated with Teflon. “Safety First” became the driving principle at NASA. To ensure that everyone in the space agency understood that the safety of the astronauts would from now on take priority over everything else, Fletcher ordered photographs of the Apollo 1 crew to be displayed at every NASA facility. The now-haunting photos of White, Grissom, and Chaffee cheerfully posing with a model of their command module were there to serve as a daily reminder that “We failed to protect these astronauts. Failure to protect the other astronauts is not an option.”
Among those who saw their photo everyday was Gene Kranz. At age 32, Kranz had been with NASA management since the early days of Project Mercury. He was appointed Flight Director for Project Gemini, overseeing the operation of missions from his command post at the Mission Control Center in Houston, Texas. Known for having a close-cut flattop hairstyle and wearing dapper vests made by his wife, Kranz, like everyone else in NASA management, had grown complacent heading into Project Apollo. The shock of the Apollo 1 fire shattered his complacency and made him self-critical. Recognizing right away that NASA had fallen into a deadly mindset, the Ohioan resolved to snap his team at Mission Control out of it. Calling for a mandatory meeting in the aftermath of the disaster, Kranz spoke to his people with sobering frankness:
“Spaceflight will never tolerate carelessness, incapacity, and neglect. Somewhere, somehow, we screwed up. It could have been in design, build, or test. Whatever it was, we should have caught it. We were too gung-ho about the schedule and we locked out all of the problems we saw each day in our work. Every element of the program was in trouble and so were we. The simulators were not working, Mission Control was behind in virtually every area, and the flight and test procedures changed daily. Nothing we did had any shelf life. Not one of us stood up and said, ‘Damn it, stop!’”
Everyone sat silently in the room, all eyes staring directly at the Flight Director as he proceeded to not pull any punches.
“We were not ready for the mission! We did not do our job. We were rolling the dice, hoping that things would come together by launch day, when in our hearts we knew it would take a miracle. We were pushing the schedule and betting that the Cape would slip before we did.
From this day forward, Flight Control will be known by two words: ‘Tough’ and ‘Competent’. ‘Tough’ means we are forever accountable for what we do or what we fail to do. We will never again compromise our responsibilities. Every time we walk into Mission Control, we will know what we stand for. ‘Competent’ means we will never take anything for granted. We will never be found short in our knowledge and in our skills. Mission Control will be perfect. When you leave this meeting today you will go to your office and the first thing you will do there is to write ‘Tough and Competent’ on your blackboards. It will never be erased. Each day when you enter the room these words will remind you of the price paid by Grissom, White, and Chaffee. These words are the price of admission to the ranks of Mission Control.”

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(Gene Kranz)
May 27th, 1966 became one of the darkest days in the history of NASA. Gus Grissom, Edward White, and Roger Chaffee, who were to have opened the door directly to the Moon with their Apollo 1 mission, instead died in a devastating fire at Launch Complex 34. The fire had been the result of NASA having convinced herself that nothing could go wrong in getting a man on the Moon by the end of the 1960s. The space agency cut corners, overlooking problems and ignoring warnings that the command and service module wasn’t ready yet to do what she wanted it to do. NASA management had rested on their laurels with the success of Projects Mercury and Gemini…and they paid a heavy price for it when the very first mission of Project Apollo turned into a total disaster before it had even gotten off the ground. The grisly deaths of Grissom, White, and Chaffee forced NASA to face her own failures; in doing so, the space agency was changed forever. Never again could success be taken for granted; it had to be earned everyday through hard work and due diligence. Under Fletcher’s leadership, NASA set out to show that she could learn lessons and improve herself, which in time would restore public and political confidence in the space agency. While NASA couldn’t fully eliminate the potential for disaster, Fletcher’s much-needed reforms and the extensive overhaul of the command module would help greatly reduce that potential going forward. Looking back at the Senate hearing which would propel him to the national stage, Mondale told an interviewer in 2001 that he was very proud of what he did:
“I think that by forcing a public confrontation with the management of NASA about what they really knew in regards to the safety of the space program, it forced a restructuring of management and a reorganizing of the program in a way that made everything much safer.”
 
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A fine update as always, even if the subject matter is grim.

The sad thing is that NASA seemed trapped in a cycle. You look at the Challenger disaster there are echoes of Apollo 1 - warnings were made about an known issue but the engineers were over-ruled by a management that wanted to get things done. Then after the Columbia disaster the inquiry said that NASA had failed to properly implement the Challenger recommendations and still had the same ineffective safety culture.

I think the lesson is that you need that imposed safety culture from the top, because otherwise it is just human nature to get complacent after years of nothing going dramatically wrong.