Space Shuttle Challenger

A company s culture can make or break even a well-designed data collection system. Essential requirements are minimal use of blame, freedom from fear of reprisals, and feedback which indicates that the information being generated is being used to make changes that will be beneficial to everybody. All three factors are vital for the success of a data collection system and are all, to a certain extent, under the control of management. To illustrate the effect of the absence of such factors, here is an extract from the report into the Challenger space shuttle disaster ... 

The Challenger space shuttle disaster (January 1986) was the culmination of a series of occurrences each with its own root cause. 

Fig. 2.7 On January 28, 1985, at 11 38 am Eastern Standard Time, Challenger space shuttle left Pad 39B at Kennedy space center in Florida for Mission 51-L, the tenth flight of Orbiter Challenger. Seventy three seconds later the space shuttle was com-...

Case 8 Challenger" Space Shuttle Specific ethical issues include ... 

A second group have looked to organizational and cultural characteristics. A classic example of this approach is Diane Vaughan s analysis of the Challenger space shuttle explosion, when safety standards were progressively eased and finally ignored to the point of disaster. Her evocative phrase the normalization of deviance perfectly captures the gradual erosion of standards, the tacit acceptance by the people concerned and the eventual loss of any sense of where the boundary of safety lies. 

One famous example of a special commission was the Kemeny Commission that investigated the Three Mile Island nuclear accident in 1979. Another is the Rogers Commission that investigated the Challenger Space Shuttle accident in 1986. 

January 28,1986, Cape Canaveral, FL. The 0-ring seal in the booster rocket eroded and blow-by burned a hole in the external fuel tank. Suddenly, mission 51 -L exploded before a world-wide audience on live television. The screens in the control room went blank only a white S remained at the top of each mission control monitor screen. Seventy seconds after launch the Challenger space shuttle fell in pieces from 50,000 ft to the ocean below. ... 

The Six Sigma program is designed to keep essentially all of a quality-controlled product within half of the variance allowed for each individual unit. This corresponds to one defect in a million possibilities. Thejanuary 28,1986, Challenger space shuttle disaster was caused by defective O-ring seals on the outboard propellant tanks that were not detected during quality checks. Their failure resulted in an explosion that destroyed the vessel and killed all aboard. Quality-control standards developed from mOitary specifications (mil-spec). Anecdotal histories suggest that these standards were established in an attempt to lessen the number of military fatalities caused by defective products. 

One of the earliest comprehensive probabilistic risk assessments conducted was borne out of the Apollo 1 fire in 1967 that killed all three astronauts on board. For the following 20 years, NASA vacillated conducting probabilistic risk assessments for human space flight, at times concerned that the numbers showed that human space flight was too risky. However, the 1986 Challenger space shuttle accident returned NASA to regular probabilistic risk assessments. 

The tendency of fluoroelastomers to lose resilience at lower temperatures is said clearly to be a major cause of the failure of the Challenger space shuttle. Redesign engineers have concluded that fluoroelastomers are still the best material available for the construction of the O-rings details are given. 

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