Challenger space shuttle disaster

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. 

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. 

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. 

For hazard and associated risk issues and problems, the regular chain of command may not respond fast enough to respond to the critical nature of the issue. Historical examples of these issues are the Challenger and Columbia space shuttle disasters. An open door policy and procedures that allow unresolved high hazard and risk information to move rapidly to senior leadership should be in place. Essentially, a way to short circuit and bypass normal communication channels is needed. Refer to Chapter 9, Risk Perception—Defining How to Identify Personal Responsibility . 

The importance of a safety culture cannot be understated. Safety culture has been identified as a contributory factor in many catastrophic incidents occurring within the hazardous industries in recent times, including the Ladbroke Grove and Southall rail crashes, Texas BP refinery explosion, the Challenger and Columbia space shuttle disasters, and the Piper Alpha oil platform disaster (Hendershot, 2007). 

In 1984, the AMPTE mission launched the first carbon-foil TOF-MS into space, which would have been the second, had the Challenger shuttle disaster not delayed the Ulysses launch until 1991 (Fig. 11.2) [23]. The photons were filtered out by a traditional blackened deflection system, which directed the ions toward the 2 p,g/cm2 thick foil mounted on an 85% transparent grid almost a square centimeter in area. The grid provided the support needed to survive the launch. The foil thickness permitted >2keV/nuc ions to pass through and hit a SSD some 10 cm away. To ensure that the ions made it through the foil and also through the dead layer on the SSD (caused by the upper electrode), the foil and the entire TOF section were floated at 20 kV to post-accelerate the ions. Electrons sputtered off the carbon foil became the start, whereas electrons sputtered off the SSD became the stop pulse for the TOF. 

Sleep deprivation was determined to play a role in the 1989 Exxon Valdez oil tanker disaster, the 1986 decision to launch the Space Shuttle Challenger which exploded shortly after takeoff, and numerous deadly commercial airline crashes. 

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). 

Is it time to rethink the manned space program Despite the Columbia, Challenger, and Apollo disasters, NASA has called for the shuttle program to continue. President Bush s January 2004 initiative for a moon base and manned flights to Mars has led to much discussion about cost, safety, and priorities. 

FIGURE 13-2 An unmitigated disaster the horrible explosion of the space shuttle Challenger (Source NASA). 

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. 

About 14 months after the Bhopal disaster, on January 28, 1986, the US space shuttle Challenger exploded and disintegrated 73 seconds after launch from Kennedy Space Center in Florida. The entire crew perished six astronauts and Christa McAuliffe, the first Teacher in Space. 

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 ... 

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. 

The Chernobyl reactor, like the Titanic, was a technological masterpiece, but both had inherent and serious flaws in their design. Another technologically advanced design that failed disastrously was the NASA Space Shuttle Challenger. Other technological disasters, such as at Bhopal and Seveso, were more related to simple carelessness in design and operation. 

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