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