Challenger disaster case

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). 

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

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. 

The Challenger disaster was framed by Starbuck and Milliken (1988) as a case where the decision-makers believed that the chain of successful launches prior to the one in January 1986 could be explained by one of three models. One model suggests that the probability of success was improving with each launch. A second model made the assumption that the launches represented a series of independent trials and that the probability of success on a given launch was independent of the probability of prior launches. A third model assumed that the probability of success declined with each launch. According to Starbuck and Milliken, the third model bore no resemblance to the mental model of the majority of NASA s decision-makers. 

Probably the most famous of seal failures ever was the Challenger disaster which has been described in some detail by Lewis (71). This resulted from the effect of overnight low temperature on Viton elastomer. Perhaps most shocking is that this was a case where there had been several warnings of potential failure. 

Accident rates are frequently themselves used as a criterion. However, safety is not necessarily the same as an absence of accidents. Dictionary.com defines safety as freedom from danger, risk, injury. Conditions are easily conceived in which there is no history of injury but great risk of future injury. Of course this appears to be the case with shuttle flights up to the time of the Challenger disaster. Even though there was no history of injury, even the lowest estimates of danger would have indicated that shuttle flights were quite risky. 

The Shuttle Challenger disaster represents a real-world example in which an organization, NASA, allowed the bridge between systems engineering and safety that had existed throughout NASA s history, from Mercury to Gemini to Apollo and on to the early development of the shuttle, to collapse. The Safety Breakdown Theory in this case was the result of several biases that contributed to the failure. As described in Chapter 6, The Glismann Effect—in the form of Pressure bias. Feedback bias, and Availability bias—was obviously present ... 

As a part of control measure assessment it is necessary to demonstrate all control measures such as physical control (say barrier), engineering control (say process control, relief valve), and administrative control such as defined procedure, etc. During demonstration the operator needs to challenge the control measure to improvise the process. In this way, alternative controls could be taken into account, especially in those cases where all risks are not in SFARP. Helpful guidance toward both additional control measures and past disaster issues are highlighted in the following ... 

Refugee camps or feeding centers are used to provide food to those who are either affected by natural disasters or have been displaced by conflicts. In these cases, the main challenge is to provide those affected with the proper nutritional requirements as they may not have access to any other food (Sphere Project 2004 UNHCR and WFP 1999). 

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