WHY DIDN’T THEY LISTEN???
— DOOMED FROM THE BEGINNING–
What were the key events leading up to the “The Space Shuttle Challenger Disaster”?
1974: Morton-Thiokol awarded contract to build solid rocket boosters.
1976: NASA accepts Morton-Thiokol booster design.
1977: Morton-Thiokol discovers joint rotation problem. The test showed rotation of joints causes loss of secondary O-rings.
1980: SRB joint classification described as criticality 1R (1R = Redundant hardware element, failure of which could cause loss of vehicle).
1981-82: Anomalies in O-rings found in initial flights.
November 1981: O-ring erosion discovered after second shuttle flight.
December 1982: Tests proved secondary O-rings no longer functional under 40% maximum operating pressure.
- Criticality changer to 1(1 = loss of life or vehicle).
- Paperwork after this time showed SRB joint still as 1R.
|Criticality 1||Loss of life or vehicle if the component fails.|
|Criticality 2||Loss of mission if the component fails.|
|Criticality 3||All others.|
|Criticality 1R||Redundant components, the failure of both could cause loss of life or vehicle.|
|Criticality 2R||Redundant components, the failure of both could cause loss of mission.|
January 24, 1985: STS 51-C launched in lowest ever temperature: 53° degrees. Shuttle flight that exhibited the worst O-ring blowby.
February 8 1985: Analysis by Morton-Thiokol noted risk of O-ring failure.
Concluded risk should be accepted because of secondary O-ring.
April 29 1985: STS 51 – B:
Primary O-ring never sealed, second eroded beyond predicted limits.
Marshallplaced a launch constraint on 51- F and all subsequent flights.
Morton-Thiokol was unaware of constraint (which was waived for each subsequent flight.
July 1985: Morton-Thiokol orders new steel billets for new field joint design. Morton-Thiokol engineers set up task force to solve O-ring problem.
October 1985: Task force complains of lack of cooperation from management.
October/November 1985: 61– A & 61– B both experience O-ring problems.
December 1985: Morton-Thiokol management 1) believes problem is so severe that they will not ship anymore engines with current design 2) recommends closure of O-ring problem.
August 19, 1985: NASA Level I management briefed on booster problem.
January 27, 1986: Night teleconference to discuss effects of cold temperature on booster performance.
January 28, 1986: Challenger explodes 73 seconds after liftoff.
Morton-Thiokol, a Utah based NASA contractor was awarded the contract to design and build the Solid Rocket Boosters (SRB) in 1974. Howard Berke described it as producing, “The solid rocket motors that lifted space shuttles from their launch pads. The rockets were like stacked metal cans stuffed with highly explosive propellant. The forces of liftoff tended to pull the cans apart slightly where they joined. Rubber O-rings lined those joints and kept burning propellant from leaking out.” NASA accepted the design in 1976.
Alan McDonald, director of the Solid Rocket Motor Project at Morton-Thiokol, was convinced that there were cold weather problems with the solid rocket motors. It had been communicated by two of the engineers working on the project, Robert Ebeling and Roger Boisjoly that leaking gas was already known to occur. His analysis proved that the hot gases went past the primary and secondary O-rings to the outside. Morton-Thiokol knew there was a dilemma with the boosters as early as 1977.
Leon Ray documented his visits to two O-ring manufacturers, both of whom expressed concerns relative to the O-ring performing properly in the joint design. During that time proposals were written suggesting the relaxation of clevis joint O-ring acceptance and the use of standard thickness for clevis joints allowing O-ring compression to fall below minimum industry accepted values, the office stated opposition
to these proposals. On January 9, 1978 John Miller, The chief solid motor branch at Marshall Space Flight Center, discussed the summary findings as, “We believe that the facts presented in the preceding paragraphs should receive your most urgent attention…high quality O-rings are mandatory to prevent hot gas leaks and resulting catastrophic failure.”
A Nasa memorandum written on February 6, 1979 acknowledged, “Parker experts would make no official statements concerning the reliability and potential risk factors associated with the present design; however, their first thought was that the O-ring was being asked to perform beyond its intended design and that a different type of seal should be considered.” Planning for mission 51-L Challenger began in 1984. Lynn Fraser (2004) described it as, “The aim of the mission was to deploy the second tracking and data relay satellite and the Spartan Halley’s Comet observer.” McDonald had commenced a redesign effort in 1985 regarding the O-rings.
On January 27, 1985, one year before launch, NASA announced the names of the astronauts assigned to mission 51-L: Commander: Francis R. Scobee; Pilot: Michael J. Smith; Mission Specialist One: Ellison S. Onizuka; Mission Specialist Two: Judith A. Resnik and Mission Specialist Three: Ronald E. McNair. On board there were seven people, five professional astronauts, one industrial client, and one civilian teacher. Captain Scobee and copilot Smith commanded the mission. Finally, there were Christa McAuliffe (a payload specialist) and Greg Jarvis (a payload specialist) from NASA client Hughes Aircraft. Not only did this crew contain the first civilian, but it had two women and two minorities (Onizuka was Hawaiian of Japanese descent, and McNair was black). This was to be the 25th shuttle into space from Cape Canaveral: Mission 51-L, the 10th flight of the orbiter Challenger.
The responsibilities for the payload specialists were to be: Ms. McAuliffe was going to perform a series of classroom lessons and experiments from orbit, who was assigned to the 51-L crew in July, 1985. Mr. Jarvis was going to perform a series of fluid dynamics experiments that would support satellite redesign and was last to be added to the crew on October 25, 1985.
NASA Level I organization had been briefed on the O-ring problem on August 19, 1985. Approximately half of the shuttle flights had experienced O-ring erosion in the booster field joints. Ebeling and Boisjoly had expressed to Morton-Thiokol that management was not behind the redesign task force. A memo went out from J.E. Kingsbury of NASA September 5, 1985 expressing his concerns. Kingsbury informed Lawrence Mulloy that he placed high priority on the O-ring seal problem and required supplementary information on a strategy for improving the circumstances “I consider the O-ring seal problem on the SRM to require priority attention of both Thiokol/Wasatch and MSFC….please arrange such a briefing no later than September 13, 1985, from my point of view, this can be accomplished by telecom with Morton-Thiokol.”
The crew began training 37 weeks before launch. All NASA crew members exceeded the number of training hours required and were certified in all mission tasks. All flight controllers were also certified and ready for flight.
The time frame during the day when a flight could be launched had many factors to consider. There were requirements of the Orbiter and the payloads. The Challenger was limited due to providing the best lighting conditions for Spartan’s observations of Halley’s Comet. There were three postponements of the launch date that was discussed during a late afternoon management conference on January 25, 1986 in which members reviewed the weather forecast for the Kennedy area. Since the forecast was unacceptable during the launch window the countdown actions were terminated.
The day before the anticipated launch, January 27 1986, the minimum temperature was 46.0°F with an average was 51.8° F. and NASA began with fueling of the external tank at 12:30 a.m. and the Challenger crew was awakened at 5:07 a.m.; the events proceeded in a normal fashion with the crew in the shuttle by 7:56 a.m.; but around
9:00 a.m. the countdown was terminated when there appeared to be a problem with the exterior hatch handle. When the crew corrected the situation the wind had changed in turn, cancelling the flight and rescheduled for January 28, 1986.
The night before the launch had been a cold one, and frost had formed on the O-ring in question, freezing it and making it brittle with ice accumulating on the launch pad causing considerable concern for the launch team. The weather forecasted to be clear and very cold, with temperatures dropping into the low twenties overnight. In reaction, the ice inspection team was sent to the launch pad at 1:35 a.m., January 28 and returned to the Launch Control Center at 3:00 a.m.
Also, during the night, prior to fueling, a problem developed with a fire detector in the ground liquid hydrogen storage tank. Though it was ultimately tracked to a hardware fault and repaired, fueling was delayed by two and half hours. By continuing past a planned hold at launch minus three hours, however, the launch delay was reduced to one hour. The Crew was awakened at 6:18 a.m. and rescheduled. Yet, after a meeting to consider the team’s report, the Space Shuttle program manager decided to continue the countdown. Another ice inspection was scheduled at launch minus three hours.
This mission had been postponed a number of times due to irregular weather and mechanical issues. There were many reasons NASA was pressured to launch, one being the need to launch the Challenger without any delays so the launch pad could be restored in time for the next mission. It was scheduled to carry a probe that would observe Halley’s Comet. If it had launched on time, this probe would have gathered data a few days before a similar Russian probe was scheduled to be launched. NASA had much to gain from the success of flight 51-L. The “Teacher in Space” mission had generated much more press interest than other recent shuttle flights. This was an important tool which NASA used to help ensure its funding. The recent success of the Space Shuttle program had left NASA in a Catch 22 type situation. Victorious shuttle flights were no longer news since they were almost commonplace. However, launch aborts and delayed landings were more news worthy because they were much less frequent.
In addition to general publicity gained from flight 51-L, NASA undoubtedly was aware that a successful mission would play well in the White House. President Reagan had a mutual love of publicity as did NASA and was about to give a State of the Union speech.
The Challenger disaster came in an era of tighter budgets, smaller labor forces and a steady need for the space agency to validate the shuttle program. NASA had hoped sending a teacher into space to give a lesson would win back some public attention and show the routine nature of shuttle flights. Pressures developed because of the need to meet client commitments, which translated into an obligation to launch a certain number of flights per year and on time.
To retain Shuttle funding, NASA was forced to make a series of major concessions. First, facing an extremely controlled budget, NASA sacrificed the research and development essential to produce a truly reusable shuttle. Instead they accepted a design which was only partially reusable, eliminating one of the features which made the shuttle attractive in the first place. Solid rocket boosters (SRB’s) were used instead of safer liquid fueled boosters since they required a much smaller research and development effort. Numerous other design changes were made to reduce the level of research and development required.
Before the decision to launch the Challenger, NASA held many meetings to discuss the low temperature performance of the boosters. The meeting(s) took place throughout the day and evening from 12:36 p.m., January 27, 1986 following the decision to not launch the Challenger due to high crosswinds at the launch site. Discussions continued through about 12:00 midnight via teleconferencing and Telefax systems connecting the Kennedy Space Center in Florida with engineers and management, Morton-Thiokol in Utah with several engineers and managers that were present at the table in corporate headquarters, Johnson Space Center in Houston, and the Marshall Space Flight Center in Alabama who was responsible for all rocket and propulsion systems.
Boisjoly and another engineer, Arnie Thompson, knew this would be another opportunity to express their concerns about the boosters, but they had only a short time to prepare their data for the presentation. No organization in the history of NASA has ever tried to stop a launch before.
The discussion surrounded the grease and the O-rings that could not handle the low temperatures and that both the primary and secondary seals would not function properly. They advised that no launches should take place below 53°F. Morton-Thiokol engineers debated for an hour presenting a persuasive argument that the cold weather would exaggerate the problems of joint rotation and delayed O-ring seating. The lowest temperature experienced by the O-rings in any previous mission was 53°F. With a predicted temperature of 26°F at launch, the O-rings were anticipated to be 29°F. After the technical presentation, Morton-Thiokol engineering Vice President Bob Lund presented the recommendations. His main focus was that 53°F was the only low temperature data Morton-Thiokol had regarding the effects of cold on the operational boosters. The boosters had experienced O-ring erosion at this temperature. Since his engineers had no low temperature data below 53°F, they could not prove that it was unsafe to launch at lower temperatures. He read his recommendations and commented that the predicted temperatures for the morning’s launch was outside the data base and NASA should delay the launch, so the temperature could rise and the O-ring temperature was at least 53°F.
This puzzled NASA managers since the booster design specifications called for booster operation as low as 31°F. Because of this, dynamic tests of the boosters had never been performed below 40°F. Marshall’s Solid Rocket Booster Project Manager, both the NASA engineers and engineers from Morton-Thiokol disagreed that under the current freezing weather conditions, it would be unsafe to launch.
During that period of time NASA’s had a safety policy in place that they called the “burden of proof.” This recognized that if someone could substantiate there is a problem, flaw, or if something is unsafe then in order to carry on they must first prove without a reasonable doubt that there is no foreseen predicament. In other words, NASA felt that an individual doesn’t have to establish that anything is unsafe, but one has to verify it was safe, before any launch was made.
This policy was distorted the night before the launch of the Challenger. Morton- Thiokol had mentioned to NASA that it was dangerous to launch under the current weather conditions because of the cold weather. NASA having never being told by a contractor not to launch became skeptical of the sudden announcement by Morton-Thiokol engineers and questioned why they were bringing up the safety issues of the O-rings.
A heated debate went on for several minutes before Joe Kilminster was asked for his opinion. Kilminster was in management, although he had an extensive engineering background and stood by his engineers. Several other managers at Marshall expressed their doubts about the recommendations, and finally Kilminster asked for a meeting off of the net, so Morton-Thiokol could review its data. Boisjoly and Thompson tried to convince their senior managers to stay with their original decision not to launch. A senior executive at Morton-Thiokol, Jerald Mason, commented that a management decision was required. Stanley Reinartz, the manager of the shuttle project office at the Marshall Spaceflight Center made the decision not to take engineer’s concerns about O-ring seals to the highest reaches of NASA management. The data presented to them showed no correlation between temperature and the blow-by gasses which eroded the O-rings in previous missions. Chris Bergin (2007) reported that according to the testimony by Kilminster and Boisjoly, Mason finally turned to Bob Lund and said, “Take off your engineering hat and put on your management hat.” Joe Kilminster wrote out the new recommendation and went back on line with the teleconference.
Morton-Thiokol was harshly chastised by NASA for expressing a launch delay. Marshall mentioned to the group that they have been flying for 5 years, with the knowledge of the conditions of the joints at cold temperatures. Things became heated between Morton-Thiokol and NASA. Morton-Thiokol provided fourteen charts at the conference trying to prove why there should not be a launch. But, to no avail and it was considered inconclusive. Faced with this extreme pressure, Morton-Thiokol management asked its engineers to reconsider their position. When the engineers stuck to their original recommendations not to fly, Morton-Thiokol management overruled them and gave NASA its approval to launch.
William H. Starbuck and Frances J. Milliken described the situation as, “…no consensus was reached, so a “management risk decision” was made. Managers voted and engineers did not. When a Marshall administrator asked, “Does anyone have anything to add to this? No one spoke.” NASA heard silence on the phone after that, which was interpreted by them to be the green light to launch. It was actually the silence that became the sound of looming death. At 11:15 P.M. the recommendation was finalized to launch. There were no procedures to guide their dialogue; the participants automatically reverted to the centralized, hierarchical method used in Flight Readiness Reviews. The entire discussion and decision making process to launch began and ended with this group of 34 individuals.
On January 28, 1986 the skies were clear and the sun shone brightly on an uncharacteristically cold morning at Kennedy Space Center. Roger Boisjoly questioned the feasibility of launching at these low temperatures because he knew of the effect that the cold temperature would have on the O-rings. Rockwell International primary contractor told NASA they could not guarantee the safety of the flight. The people on the launch pad explained what they saw as a scene right out of Dr. Zhivago….everything was covered with icicles. One potential problem was that if an icicle removed any of the thermal protection tiles on the orbiter, the vehicle would bum up and the astronauts would die during re-entry. From the weather situation alone and the scene at the launch pad, it was obvious that there was enough proof to stop the launching of the Challenger.
The management team directed engineers to assess the possible effects of temperature on the launch. No critical issues were identified to management officials, and while the assessment continued, it was determined that there was no sufficient evidence to prevent the proceeding of the countdown. With an extra hour, the team had more than sufficient time to consume breakfast, obtain a weather briefing and put on their flight gear. At the weather meeting, the temperature and ice on the pad were discussed, but neither then nor in earlier weather deliberations was the crew told of any apprehensions about the effects of the low temperatures. The seven crew members left the quarters and rode the astronaut van to launch pad B, arriving at 8:03 a.m.; they were in their seats in the Challenger at 8:36 a.m. The temperature at launch time was 36° degrees.
At T-6 seconds, the shuttle engines were ignited, followed by the vehicle’s solid rocket boosters. As the Challenger ascended, it encountered tremendous wind shears after liftoff. They were the worst wind shears any shuttle had ever faced. Already weakened by the cold weather the O-rings eroded; the field joint came completely out of alignment. A gap had opened through which blow-by gases could come in contact with Challenger’s external tank. The potentially fatal failure sequence was known to NASA officials before liftoff had begun.
At 56 seconds the super hot flame was burning a big hole. At 58.32 seconds, an unusual plume in the lower part of the right Solid Rocket Booster was recorded; at 58.72 seconds the first indication of smoke became visible from the right SRB. A fraction of a second later, at 58.77, the first flickering flame appeared on the right SRB in the area of the aft field joint. By 59.26, the flickering flame had grown into a continuous, well-defined cloud. At 64.66 seconds, the hydrogen tank was punctured and the hydrogen began to burn. Meanwhile, the crew was given the command to give the shuttle more power: “You are go at throttle up…” The next words heard from Challenger, was: “Roger, go at throttle up” At 72.3 seconds, it burned through the booster support. At 72.5 seconds the booster swung out from lack of support. At 73 seconds into the mission, a response was spoken from someone… most likely the pilot, Mike Smith speaking the words: “Uh-oh”. David Ellis stated in an article from Time Magazine, “The last response a NASA investigator has confirmed suspicions that the astronauts were conscious of their fate, and that among the last words from the craft were those of one astronaut saying to another, “Give me your hand.”
The crew at that moment knew of the impending danger of what lied ahead. At 73.6 seconds, everything ignited as the hydrogen and oxygen mixed and exploded. The explosion blasted the shuttle skyward at more than 1,000 MPH, but the sudden stress tore it apart as the world watched the doomed Challenger and mourned for the seven individuals who gave their lives in the name of progress.
It is in my opinion that the individuals involved in this fatal decision making process were considered a cohesive group (self-managing team) consisting of Socio-emotional and instrumental factors and there was a sense of esprit de corps within the group dynamics. They had been employed collectively for many years working toward a common goal and were familiar with each other moving up in their positions within the space shuttle program. Kreitner-Knicki (2006) described a cohesive group as being , “…a process whereby a sense of “we-ness” emerges to transcend individual differences and motives…a sense of togetherness based on emotional satisfaction…mutual dependency needed to get the job done.” (p.352) Esprit de corps is defined by Wikipedia as, “A state of mind, morale, a united sense, or feeling, of direction, conviction, spirit, and enthusiasm toward a generally positive cause or purpose.”
The organizational culture was one factor at NASA, Morton-Thiokol, Marshall Space Flight Center and Rockwell which contributed to the disaster as well as the communication patterns leading to the flawed decision making process. A second factor would be the role that leadership played in the destruction of the spacecraft and the loss of the crew member’s life.
Rockwell, the company which manufactured the Orbiter also had concerns about launching in cold and icy conditions. Their major concern was the possibility of ice from either the shuttle or the launch structure striking and damaging the vehicle. Like Morton-Thiokol, they recommended against the launch, and they too were pressed to explain their reasoning. Instead of sticking with their original strong recommendation against launch, the Rockwell team carefully worded their statement to say that they could not fully guarantee the safety of the shuttle.
In its desire to fly out its manifest, NASA was willing to accept this as a recommendation. The final decision to launch, however, belonged to Jesse Moore who was in charge of the Flight Readiness Review for NASA. He was informed of Rockwell’s concerns, but was also told that they had approved the launch. Somehow, as the warnings and concerns were communicated up each step of the latter of responsibility they became diminished.
The decision to suggest for a launch was made by lower level management officials over the objections of skilled individuals who opposed the launch under the environmental circumstances that existed on the launch pad at the time. Furthermore, the lower level managers who made this decision, both NASA and contractor personnel chose not to report the objections of the technical experts in their recommendations to higher levels in the management chain of authority to continue with the launch. Finally, it seems that the lower level managers had also received out of the ordinary demands from higher levels of management to continue with the launching of the shuttle.
This type of dysfunctional operational view of the organizations portrayed many opportunities for failure. The basic fundamentals of this process were the beginnings of failure as the groups searched for conformity and unity sacrificing everything in order to maintain peace within the groups. It is perceived that management wanted the organizations process to run without any type of questions.
I believe that Groupthink played a significant factor and major contributor to the Challenger disaster. This term referred to the preference of group members to have the same opinions and beliefs which, in this case lead to numerous errors. I.L. Janis defined Groupthink as, ”A mode of thinking that people engage in when they are deeply involved in a cohesive in-group, when members striving for unanimity override their motivation to realistically appraise alternative courses of action.” It is the sharing of false beliefs that everyone in the group agrees with its judgments. In the Report of the Presidential Commission there was a comment stating, “Morton-Thiokol became highly susceptible to Groupthink when they requested a break from the GDSS. At this point they became insulated, conducted private conversations under high stress and were afraid of losing potential future revenue should they disagree with NASA.” All these factors are considered prime to the formulation of Groupthink.
Some of the symptoms of Groupthink that lead up to this tragedy were: Overestimations of the group’s power and unquestioned morality such as believing that the group’s position is ethical/moral and that all others are inherently malevolent, closed-mindedness, mind guarding, inherent morality, rationalization, self-censorship, illusion of unanimity, pressure dissent and stereotype actions within the group. These symptoms lead to a faulty decision process among all of the organizations involved.
During the conferences concerning the option to launch appeared to be a rejection of the engineers opinions along with management’s bias of the facts presented to them. This was indicated when most of the group viewed themselves as invincible which caused them to make decisions that were at a high risk. Irving Janis described this occurrence as the illusion of invulnerability by summarizing this attitude as ‘‘Everything is going to work out all right because we are a special group.” The group had an enormous amount of confidence and authority in their decisions as well as in themselves. Two of the top three NASA officials responsible for the launch displayed a stereotyped view of the situation. They felt that they completely understood the nature of the joint problem and never seriously considered the objections raised by the MTI engineers. In fact they degraded and badgered the opposition bases on their information and opinions.
These same two officials pressured MTI to change its position after they originally recommended that the launch not take place. These two officials pressured MTI personnel to prove that it was not safe to launch, rather than to prove the opposite. This was a total reversal of normal preflight procedures. It was this pressure that top MTI management was responding to when they overruled their engineering staff and recommended launch. Pressure on dissent group members were considered direct pressure to anyone who questioned the validity of the arguments supporting a decision favored by the majority.
The self censorship group members censored themselves when they had opinions that deviated from the apparent group consensus. Janis felt that this reflected each member’s inclination to minimize their importance of the doubts and counterarguments.
The most obvious evidence of self censorship occurred when the Vice President of MTI, who had previously presented information against launch, bowed to pressure from NASA and accepted their rationalizations for launch.
Illusion of the unanimity group members were victim to Groupthink sharing an illusion of unanimity concerning judgments made by members who spoke in favor of the majority view. This symptom was caused by the false assumption that any participant who remained silent is in agreement with the majority opinion. No participant from NASA ever openly agreed with or even took sides with MTI in the discussion. The silence from NASA was amplified by the fact that the meeting was a teleconference linking the participants at three different locations. The group leader and other members supported each other by playing up points of union in their thinking at the expense of fully exploring points of divergence that might reveal unsettling problems. The group ignored obvious danger signals, being overoptimistic, and taking extreme risks.
Mind guarding group members assumed the role of guarding the minds of others in the group. They attempted to shield the group from adverse information that might destroy the majority view of the facts regarding the appropriateness of the decision. The top management at Marshall knew that the rocket casings that had been ordered to be redesigned were to correct a flaw 5 months prior to this launch. This information and other technical details concerning the history of the joint problem were withheld at the meeting. It was obvious that this group was protecting the group from negative, threatening information.
Even though there existed broad protection programs consisting of interdependent safety, reliability and quality assurance functions, I believe they were intentionally overlooked when reviewing any prospective safety issues with the Challenger. Preceding the accident however, the program became ineffective. The Report of the Presidential Commission stated, “This loss of effectiveness seriously degraded the checks and balances essential for maintaining flight safety.”
The group considered only two alternatives. No initial survey of all possible alternatives occurred during the decision making process. The Flight Readiness Review team had a launch – no launch decision to make. Other possible alternatives might have been to delay the launch for further testing, or to delay until the temperatures reached an appropriate level. The group failed to reexamine alternatives that may have been initially discarded based on early unfavorable information. Top NASA officials spent time and effort defending and strengthening their position, rather than examining the MTI position.
Members of the group tended to focus on supportive information and ignored any data that might have cast a negative light on their preferred alternative. MTI representatives repeatedly tried to point out errors in the rationale the NASA officials. Even after the decision was made, the argument continued until a NASA official told the MTI representative that it was no longer his concern.
NASA faced a variety of external and internal risks factors such as strategic risks, operational risks, financial risks, environmental risks and individual loss regarding the launch. The inherent risks in the management of these companies involved the failure in the control system. Since they were built on risks of management and control systems due to agency problems the managers were ignoring them or possibly were unaware of their existences.
The real cause of the space shuttle Challenger accident 1986 was the flawed decision making process leading to the launch of the shuttle. The flawed decision making process was not a result of an individual mistake but a multitude of individuals within a Groupthink setting.
To be successful, both task and social-emotional roles had to be filled, but many people could have helped fill these leadership positions. It is my opinion that the functional roles performed by the group members could have been conducted better to prevent the loss of seven lives and the shuttle. The initiators (Morton-Thiokol engineers; Bob Lund, Joe Kilminster, Jerald Mason, Alan McDonald, Robert Ebeling and Roger Boisjoly should have held their ground and not backed down to peer pressure, in this sense becoming an ethical dilemma. The evaluators (NASA; George Hardy, Stan Reinartz) even though it appeared understaffed, should have had a task force in place, a group of on site engineers to test certain theories such as the effects of erosion on O-rings since this had been a problem for many years. The energizers (top level managers of NASA) should have reflected on the pertinent information given by the information givers (Morton-Thiokol, Marshall Space Flight Center and Rockwell) and not manipulated the decisions of these organizations to push for making a defective decision. Mulloy, believing in the previous Flight Readiness Review assessments, unconvinced by the engineering analysis, and concerned about the schedule implications of the 53-degree temperature limit on launch the engineers proposed, was quoted in the Report of the Presidential Commission, “My God, Morton-Thiokol, when do you want me to launch, next April?” The compromiser (NASA) regarded all members of the group decision process should have lived up to the “norms” of the group. Although the Morton-Thiokol engineers were firm on their recommendation to scrub the launch, they changed their presentation of objections once threatened with the possibility of being expelled from the program. NASA gave no indication of resolving the conflict or to meet them half way. At this stage of the meeting NASA had a responsibility to the crew of the Challenger to consider other options before agreeing to launch.
Cultural beliefs about the low risk O-rings, backed by years of Flight Readiness Review decisions and successful missions, provided a frame of reference against which the engineering analyses were judged. When confronted with the engineering risk assessments, top Shuttle Program managers held to the previous Flight Readiness Review assessments.
The recorder (NASA) had documented the events of prior missions failing and yet, refused to take into account and incorporate the incidents regarding the forecasting of the Challenger’s outcome. The followers (many engineers) did not voice their opinions regarding the danger involved in launching in low level temperatures; if more had taken the initiative the end result might have been more successful with the crew surviving the launch.
It appeared that the missing elements of the maintenance/socio-emotional roles in the decision making process which would have kept the group harmonious. NASA (encourager) was not willing to accept the engineer’s point of view regarding the dangers involved in the launching of the Challenger. The harmonizers (managers) within this organization were not willing to keep the communication channels open. NASA (gatekeeper) was non-existent in encouraging all individuals to participate in the discussion to come up with a mutual consensus.
In conclusion, within the shuttle program there were continuous safety measures which were supposed to focus on the potential hazards while assessing the acceptable risks. This was to include the preparation and execution of plans for accident avoidance, flight system protection and industrial safety requirements. During the teleconference it was apparent that none of the individuals involved with the group decision making process considered incorporating the advice from a safety representative or a quality assurance engineer. Similarly, there was no representative of safety on the Mission Management Team.
Many problems were apparent such as the following of procedures regarding the reporting requirements which were not concise and failed to get critical information to the proper levels of management. Through all of the research done little or no trend analysis was performed on O-ring erosion and blow-by problems. As the flight rate increased, the Marshall safety, reliability and quality assurance work force was decreasing, which adversely affected mission safety. .
Many procedures and errors were overlooked prior to the launching of the Challenger. At the time of launch, all items called for by the Operational Maintenance Requirements and Specifications Document were to have been met, waived or accepted. A forward avionics bay closeout panel was not verified as installed. Landing gear voids were not replenished and crew module meters were not verified during final vehicle closeouts. During External Tank propellant loading in preparation for launch, the liquid hydrogen 17-inch disconnect valve was opened prior to reducing the pressure in the Orbiter liquid hydrogen manifold, through a procedural error by the console operator. The three requirements that verify the main engine pneumatic isolation valve actuation were not met as specifically called for in the Operational Maintenance Requirements and Specifications Document. A main engine pneumatic regulator functional test, which checks the redundancy of individual regulators, was not verified under flow conditions. The leak check steps for test port Number 4, after installation of the plug, were inadvertently omitted from the Operations & Maintenance Instructions. Main engine protective covers were not installed at times required. The humidity indicator inspection requirement was not met because the engines were not in the controlled environment.
The managerial structure and chain of command blocked effective communication of technical problems. Red flags were overlooked, people’s opinions were suppressed and important information on technical issues did not surface at higher levels. What was communicated to parts of the group was that O-ring erosion was not a problem to be considered. Every decision that was made on that day to launch the Challenger is precisely what I.L. Janis discussed and fits perfectly into the model of the eight characteristics of Groupthink.
In retrospect, this was undoubtedly a Groupthink decision making process. It was one of the worst tragedies in both the U.S. and NASA history. Therefore, every measure should be taken to stop Groupthink before it begins, and with any luck stop another tragedy like this from ever occurring again. Virginia McCullough described the group of individuals who lost their lives as, “Almost a perfect James Watt “Rainbow Coalition” went to their graves. One black, a classmate of Jesse Jackson, one Buddhist-Japanese, one Jew and two women.“ The lesson to be learned is: VALUE HUMAN LIFE.
Morton-Thiokol – Contracted by NASA to build the solid rocket booster Morton-Thiokol was the subcontractor directly responsible for the development of the SRB “O” rings.
Marshall Space Flight Center – In charge of booster rocket development.
Rockwell International – The company which manufactured the Orbiter and also had concerns about launching in cold and icy conditions.
NASA – National Aeronautics and Space Administration.
Larry Mulloy – NASA manager who challenged the engineer’s decision not to launch.
Morton-Thiokol – Contracted by NASA to build the solid rocket booster.
Alan McDonald – Director of the Solid Rocket Motors project.
Bob Lund – Morton-Thiokol VP in engineering.
Robert Ebeling – Morton-Thiokol engineer who worked under McDonald.
Roger Boisjoly – Morton-Thiokol engineer who worked under McDonald.
Arnie Thompson – Morton-Thiokol engineer.
Joe Kilminster – Morton-Thiokol VP in boosters, also engineer in a management position.
Jerald Mason – Senior executive who encouragedLund to reassess his decision not to launch.
Jesse Moore – Was in charge of the Flight Readiness Review for NASA.
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