Post on 18-Dec-2015
An Accident Rooted in HistoryAn Accident Rooted in History
NASA Culture
History of the flawed joint
Events leading up to the disaster
NASANASA
A can do mentalityLaunch successes for yearsEngineersFunded by Congress
O Ring Joint HistoryO 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.)O Ring History (cont.)
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?Why Wasn’t the Design Fixed Earlier?
Economics?– Cost of halting the program– Declining budget– Increased demand for shuttle to be ‘operational’
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 MSFC directive that under ‘no circumstance were
they to be the cause of a flight delay’
Why wasn’t it fixed???Why wasn’t it fixed???
Perceptual differences between managers and engineers– Technical risk– Communication
Lack of communication between levels– Upward (eg. MTI to Marshall classified docs)– Downward(MTI not informed of joint reclassification)
Lack of attention to safety Faith in the specifications being followed
What could have prompted MTI to reverse What could have prompted MTI to reverse their decision Not to launch?their decision Not to launch?
Customer intimidationFollow on contract pending (>$1B)Fear of 2nd source competition on SRMNASA knew and accepted the riskUncertainty over the effects of cold- failure
to have explicit references to it, substituting the phrase ‘resiliancy’
Unethical conduct??
Both NASA and MTIBoth NASA and MTI
Failed to recognize the joint issue as a problem
Failed to fix it
Treated it as an ‘acceptable’ flight risk
The Flawed DecisionThe Flawed Decision
Four Frames ModelFour Frames Model
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
GoalGoal
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 FindingsThe Rogers Commission: Key Findings
Cause of the accident– The decision making
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 RecommendationsRogers Commission Recommendations
Shuttle management structure
Astronauts in management
Safety panel/organization
Improved communications
Flight rate