Challenger, disaster

Some of the cases below reflect situations that might be encountered in a typical process plant. Others are less obvious and may only appear remotely connected to an operating plant. The Concorde crash and the Challenger disaster are examples of this latter category. These clearly demonstrate loss of containment scenarios that could be encountered in any operating environment. 

While the Challenger disaster was not a process incident in the strictest sense, the nature of the failure was similar to many piping system failures that typically occur in the process industries. More importantly, organizational failure was a fundamental cause of the incident. This case study serves as a classic example of the type of loss that can occur in a large complex organization if management systems are not effective. 

The results of sleep deprivation have been linked to motor vehicle accidents, major industrial accidents such as the Exxon Valdez, and Three Mile Island, and the Space Shuttle Challenger disaster (2). The U.S. National Highway Traffic Safety Administration (NHTSA) in 1999 estimated that 56,000 police-reported crashes and 4% of all traffic crash fatalities (1550 cases) involved drowsiness and fatigue as principal causes (3). Sleepiness was a probable cause in about one third of all fatal-to-driver motor vehicle accidents involving commercial truck drivers (4). 

COMMENT. The solution to the problem of the cause ot the Challenger disaster was the final achievement, just before his death, of Richard Feynman, a Nobei prize winner in physics and a person who ioved to soive probiems. He was an outspoken person who abhorred sham, especially in science and technology. Feynman concluded his personal report on the disaster by saying, For a successful technology, reality must take precedence over public relations, for nature cannot be tooled (James Gleick, Genius The Life and Science of Richard Feynman. Pantheon Books, New York (1992).)... 

One of the most effective forms of boron sulfide was the powdered, amorphous form once available from Morton Thiokol. However, commercial supplies of this material were discontinued in the wake of the Space Shuttle Challenger disaster. Samples prepared in the laboratory are much less effective and their difficult synthesis and limited reactivity discourages usage. 

On July 4,1983, then-President Ronald Reagan declared that the US space shuttles were no longer experimental vehicles, but were well-tested aircraft, ready for routine, increasingly frequent, ultimately profit-making trips. After the Challenger disaster, former US astronaut Col. Frank Borman, commander of Apollo 8 and later CEO of Eastern Airlines, offered the following view ... 

Normalization of risk. One of the more remarkable things about the Challenger disaster is the fact that it was known that there was erosion in the 0-rings since early 1984, almost 2 years before flight 51L. But... 

The second is the space shuttle Challenger disaster. For Bucciarelli, the focus of this case is the caucus of Morton-Thiokol Inc. (MTl) senior... 

Boisjoly, Roger. (1987). Ethical Decisions - Morton Thiokol and the Space Shuttle Challenger Disaster, A5M/1, 87-WA/TS-4, pp. 1-13. 

Vaughan (1996) introduced the concept of normalization to deviance in her analysis of the space shuttle Challenger disaster in 1986. She showed how people who work together develop work patterns that make them blind to the consequences of their actions. Small... 

It serves to underscore how analyzing the wrong information, no matter how well intentioned, will result in a wrong conclusion. In this particular case, the analysis resulted in a disastrous outcome. While the circumstances leading up to the Challenger disaster are quite complex, the analysis of 0-ring thermal distress as a function of launch temperature was certainly a key element to the disaster. 

Even if disposal in space were restricted to waste from reprocessing used fuel, the economics of launch payloads would mean that this option could be considered only for the most problematic radionuclides [27], thereby requiring additional processing of the waste stream to extract these elements. The need for disposal of the other wastes would not be eliminated. Even more compellingly, this option has been all but eliminated from consideration by the risk of launch failures such as the Challenger disaster in 1986 and by the adverse repercussions of the 8 million search and clean-up exercise in northern Canada in 1978 after the breakup on re-entry of a satellite nuclear power-pack. 

As the CAIB concluded, the accident did not have simple and isolated causes. There were many contributing factors, ranging from the environment, to NASA s histoiy, policy and technology, to organizational structures and processes and the behaviors of individual employees and managers. The breadth and complexity of these factors call for a research inquiry that examines both specific factors and their combined effects. The unfortunate precedent of the Challenger disaster in 1986 provides an opportunity to compare two well-documented accidents and consider how NASA developed over time. 

January The Challenger disaster and follow-up investigation by the Rogers... 

My historical analysis underscores how early policy and technological decisions became relatively permanent features of the shuttle s working environment. The International Space Station has also played a critical role in the operation of the shuttle program. History reveals historical parallels and repeated patterns at NASA in addition to the ones associated with the Challenger disaster. Historical developments have evolved into key constraints that reproduce failures at NASA. NASA and its constituencies will find it difficult to change these constraints and they may not want to change them. ... 

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