Transcript Challenger

An Accident Rooted in History
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NASA Culture
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History of the flawed joint
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Events leading up to the disaster
NASA
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A can do mentality
 Launch successes for years
 Engineers
 Funded by Congress
O Ring Joint History
Upon ignition, internal pressure swells each booster
section. Joints are stiffer, causing bulging. O-rings
designed to fill gap.
 1977 Nasa engineers not that Primary and
Secondary rings—initial tests noted that problems
may occur
 1979-Management made aware “design adequacy of
the joint found to be completely unacceptable”
 1980- boosters authorized for flight, rings classified
as 1-R (redundant)
O Ring History (cont.)
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1982 joint reclassified to Criticality 1: failure effect
loss of mission, vehicle and crew after blow by caused
seals to erode
1983-85 concerns escalate at MT
1985 near disaster on flight launched at 53F in Jan.,
complete failure of primary in April
Fall 1985 Seal task force formed, frustrated by lack of
cooperation
1986 First launch delayed 7 times, Challenger delayed
4X
MT asked for opinion on cold launch temps night
before
Why Wasn’t the Design Fixed Earlier?
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Economics?
– Cost of halting the program
– Declining budget
– Increased demand for shuttle to be ‘operational’
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24 flights per year
Culture and structure of NASA?
– Can’fail
– Chain of command=hard communicating
– Status differences emphasized between levels of
managers and managers/engineers
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MSFC directive that under ‘no circumstance were
they to be the cause of a flight delay’
Why wasn’t it fixed???
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Perceptual differences between managers and
engineers
– Technical risk
– Communication
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Lack of communication between levels
– Upward (eg. MTI to Marshall classified docs)
– Downward(MTI not informed of joint reclassification)
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Lack of attention to safety
 Faith in the specifications being followed
What could have prompted MTI to reverse
their decision Not to launch?
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Customer intimidation
 Follow on contract pending (>$1B)
 Fear of 2nd source competition on SRM
 NASA knew and accepted the risk
 Uncertainty over the effects of cold- failure
to have explicit references to it, substituting
the phrase ‘resiliancy’
 Unethical conduct??
Both NASA and MTI
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Failed to recognize the
joint issue as a problem
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Failed to fix it
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Treated it as an
‘acceptable’ flight risk
The Flawed Decision
Four Frames Model
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Structural perspective-what is the most
appropriate organizational structure to accomplish
established goals?
 H/R - how well does the organization meet human
needs?
 Political – how does the organization handle
conflict and distribute scarce resources?
 Symbolic – what are the shared values of the
organization and the meaning of their work?
The problem is that most managers limit their
effectiveness by seeing most problems from one
Goal
To help managers stretch
their perspective of
“what is the problem?”
Ask questions from all
four frames and begin
to try out strategies
that are quite different
from your ingrained
thinking….
The Rogers Commission: Key Findings
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Cause of the accident
– The decision making
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process for launch
Waiving of launch
constraints at the
expense of safety
Accepted escalating risk
because they got away
with it last time
Goes back to original
design acceptance
Pressures on the system
Rogers Commission Recommendations
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Shuttle management
structure
Astronauts in
management
Safety
panel/organization
Improved
communications
Flight rate