The Space Shuttle Challenger Disaster
Introduction to the Case
On January 28, 1986, seven astronauts were killed when the space shuttle they were piloting, the Challenger, exploded at just over a minute into the flight. The failure of the solid rocket booster O-rings to seal properly allowed hot combustion gases to leak from the side of the booster and burn through the external fuel tank. The failure of the O-ring was attributed to several factors, including faulty design of the solid rocket boosters, insufficient low-temperature testing of the O-ring material and of the joints that the O-ring sealed, and lack of proper communication between different levels of NASA management.
Organizations/People Involved
Marshall Space Flight Center - in charge of booster rocket development
Larry Mulloy - challenged the engineers' 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 - Engineering Vice President
Robert Ebeling - Engineer who worked under McDonald
Roger Boisjoly - Engineer who worked under McDonald
Joe Kilminster - Engineer in a management position
Jerald Mason - Senior executive who encouraged Lund to reassess his decision not to launch.
Key Dates
1974 - Morton-Thiokol awarded contract to build solid rocket boosters.
1976 - NASA accepts Morton-Thiokol's booster design.
1977 - Morton-Thiokol discovers joint rotation problem.
November 1981 - O-ring erosion discovered after second shuttle flight.
January 24, 1985 - shuttle flight that exhibited the worst O-ring blowby.
July 1985 - Thiokol orders new steel billets for new field joint design.
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 72 seconds after liftoff.
Key Issues
How does the implied social contract of profressionals apply to this case?
What profressional responsibilities were neglected, if any?
Should NASA have done anything differently in their launch decision procedure?
Background
Pressure to launch
NASA managers were anxious to launch the Challenger for several reasons, including economic considerations, political pressures, and scheduling backlogs. Unforeseen competition from the European Space Agency put NASA in a position in which it would have to fly the shuttle dependably on a very ambitious schedule to prove the Space Transportation System's cost effectiveness and potential for commercialization. This prompted NASA to schedule a record number of missions in 1986 to make a case for its budget requests.
The shuttle mission just prior to the Challenger had been delayed a record number of times due to inclement weather and mechanical factors. NASA wanted to launch the Challenger without any delays so the launch pad could be refurbished in time for the next mission, which would be carrying a probe that would examine Halley's Comet. If launched on time, this probe would have collected data a few days before a similar Russian probe would be launched.
There was probably also pressure to launch Challenger so that it could be in space when President Reagan gave his State of the Union address. Reagan's main topic was to be education, and he was expected to mention the shuttle and the first teacher in space, Christa McAuliffe.
Solid rocket booster
The shuttle solid rocket boosters (or SRBs), are key elements in the operation of the shuttle. Without the boosters, the shuttle cannot produce enough thrust to overcome the earth's gravitational pull and achieve orbit.
An SRB is attached to each side of the external fuel tank. Each booster is 149 feet long and 12 feet in diameter. Before ignition, each booster weighs 2 million pounds.
Solid rockets, in general, produce much more thrust per pound than their liquid fuel counterparts. The drawback is that, once the solid rocket fuel has been ignited, it cannot be turned off or even controlled. So it was extremely important that the shuttle SRBs be properly designed.
Morton Thiokol was awarded the contract to design and build the SRBs in 1974. Thiokol's design is a scaled-up version of a Titan missile, which had been used successfully for years. NASA accepted the design in 1976.
O-rings
Each SRB joint is sealed by two O-rings: the bottom ring known as the primary O-ring, and the top known as the secondary O-ring. (The Titan booster had only one O-ring. The second ring was added as a measure of redundancy since the boosters would be lifting humans into orbit. Except for the increased scale of the rocket's diameter, this was the only major difference between the shuttle booster and the Titan booster.)
The purpose of the O-rings is to prevent hot combustion gasses from escaping from the inside of the motor. To provide a barrier between the rubber O-rings and the combustion gasses, a heat-resistant putty is applied to the inner section of the joint prior to assembly. The gap between the tang and the clevis determines the amount of compression on the O-ring. To minimize the gap and increase the squeeze on the O-ring, shims are inserted between the tang and the outside leg of the clevis.
Launch Delays
The first delay of the Challenger mission was due to a weather front expected to move into the area, bringing rain and cold temperatures. Usually a mission wasn't postponed until inclement weather actually entered the area, but the Vice President was expected to be present for the launch and NASA officials wanted to avoid the necessity of the Vice President's having to make an unnecessary trip to Florida, so they postponed the launch early. The Vice President was a key spokesperson for the President on the space program, and NASA coveted his good will. The weather front stalled, and the launch window had perfect weather conditions; but the launch had already been postponed.
The second launch delay was caused by a defective microswitch in the hatch locking mechanism and by problems in removing the hatch handle. By the time these problems had been sorted out, winds had become too high. The weather front had started moving again, and appeared to be bringing record-setting low temperatures to the Florida area.
NASA wanted to check with all of its contractors to determine if there would be any problems with launching in the cold temperatures. 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 and contacted two of the engineers working on the project, Robert Ebeling and Roger Boisjoly. Thiokol knew there was a problem with the boosters as early as 1977, and had initiated a redesign effort in 1985. NASA Level I management had been briefed on the problem on August 19, 1985. Almost half of the shuttle flights had experienced O-ring erosion in the booster field joints. Ebeling and Boisjoly had complained to Thiokol that management was not supporting the redesign task force.
The Night Before the Launch
Temperatures for the next launch date were predicted to be in the low 20°s. This prompted Alan McDonald to ask his engineers at Thiokol to prepare a presentation on the effects of cold temperature on booster performance.
A teleconference was held between engineers and management from Kennedy Space Center, Marshall Space Flight Center in Alabama, and Morton-Thiokol in Utah. 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.1
Thiokol's engineers gave an hour-long presentation, presenting a convincing 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, on the January 24, 1985 flight. With a predicted ambient temperature of 26°F at launch, the O-rings were estimated to be at 29°F.
After the technical presentation, Thiokol's Engineering Vice President Bob Lund presented the conclusions and recommendations. His main conclusion was that 53°F was the only low-temperature data Thiokol had for 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 database and NASA should delay the launch, so the ambient temperature could rise until the O-ring temperature was at least 53°F. This confused NASA managers because the booster design specifications called for booster operation as low as 31°F. (It later came out in the investigation that Thiokol understood that the 31°F limit temperature was for storage of the booster, and that the launch temperature limit was 40°F. Because of this, dynamic tests of the boosters had never been performed below 40°F.)
Marshall's Solid Rocket Booster Project Manager, Larry Mulloy, commented that the data was inconclusive and challenged the engineers' logic. A heated debate went on for several minutes before Mulloy bypassed Lund and asked Joe Kilminster for his opinion. Kilminster was in management, although he had an extensive engineering background. By bypassing the engineers, Mulloy was calling for a middle-management decision, but Kilminster 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 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 Thiokol, Jerald Mason, c
ภัยกระสวยอวกาศชาเลนเจอร์ แนะนำให้กับกรณีบน 28 มกราคม 1986 นักบินอวกาศ 7 ถูกฆ่าตายเมื่อกระสวยอวกาศจะมีการนำอาวุธ ชาเลนเจอร์ ขยายที่เพียงกว่านาทีในการบิน ความล้มเหลวของบูสเตอร์จรวดแข็งโอริงซีอย่างก๊าซเผาไหม้ร้อน การรั่วไหลจากด้านของบูสเตอร์ที่เขียนผ่านถังเชื้อเพลิงภายนอกได้ ความล้มเหลวของโอริงถูกบันทึกปัจจัยหลาย รวมทั้งออกแบบผิดพลาดของ boosters จรวดแข็ง พอ อุณหภูมิต่ำการทดสอบวัสดุโอริง และรอยต่อที่ปิดผนึกโอริง และขาดการสื่อสารที่เหมาะสมระหว่างระดับต่าง ๆ ของการจัดการองค์กรนาซ่า องค์กร/บุคคลเกี่ยวข้องมาร์แชลล์ศูนย์การบิน - รับผิดชอบพัฒนาจรวดบูสเตอร์ Larry Mulloy - ท้าทายการตัดสินใจของวิศวกรไม่ให้เปิด มอร์ตัน Thiokol - ตีบ โดย NASA สร้างบูสเตอร์จรวดแข็ง Alan แมคโดนัลด์ - กรรมการโครงการมอเตอร์จรวดแข็ง บ๊อบลุนด์ - ฝ่ายวิศวกรรม โรเบิร์ต Ebeling - วิศวกรที่ทำงานภายใต้แมกดอนัลด์ Roger Boisjoly - วิศวกรที่ทำงานภายใต้แมกดอนัลด์ Joe Kilminster - วิศวกรในตำแหน่งบริหาร Jerald Mason - ผู้บริหารอาวุโสที่ลุนด์ประเมินตัดสินไม่ให้เปิดใช้การสนับสนุนให้ วันสำคัญ 1974 - มอร์ตัน-Thiokol รับรางวัลสัญญาสร้าง boosters จรวดแข็ง 1976 - NASA ยอมออกบูสเตอร์มอร์ตัน Thiokol 1977 - มอร์ตัน-Thiokol พบปัญหาหมุนร่วมกัน 1981 พฤศจิกายน - โอริงพังทลายค้นพบหลังจากมีรถสองเที่ยวบิน 24 มกราคม 1985 - รถรับส่งเที่ยวบินที่จัดแสดงเลวร้ายที่สุดโอริง blowby 2528 ก.ค. - Thiokol สั่ง billets เหล็กใหม่ร่วมออกแบบใหม่ฟิลด์ 19 สิงหาคม 1985 - NASA ระดับฉันจัดการนำเกี่ยวกับปัญหาบูสเตอร์แหล่ง 27 มกราคม 1986 - คืนประชุมเพื่อหารือเกี่ยวกับผลกระทบของอุณหภูมิเย็นบูสเตอร์ประสิทธิภาพ 28 มกราคม 1986 - ชาลเลนเจอร์ระเบิด 72 วินาทีหลังจาก liftoffเรื่องสำคัญ ว่าสัญญาประชาคมโดยนัยของ profressionals ใช้กับกรณีนี้ ความรับผิดชอบผู้เชี่ยวอะไรถูกที่ไม่มีกิจกรรม ถ้ามี จะนาซ่าทำอะไรแตกต่างกันในกระบวนการตัดสินใจเปิดตัว พื้นหลัง กดดันให้เปิดผู้จัดการนาซ่าได้กังวลเปิดชาลเลนเจอร์ที่เหตุผลหลาย รวมถึงข้อพิจารณาทางเศรษฐกิจ แรงกดดันทางการเมือง และแผน backlogs แข่งขันไม่คาดฝันจากองค์การอวกาศยุโรปใส่นาซ่าในตำแหน่งที่มันจะต้องบินในรถ dependably ตามกำหนดการทะเยอทะยานมากไปพิสูจน์ต้นทุนประสิทธิผลและศักยภาพใน commercialization ของระบบขนส่งอวกาศ นี้ให้ NASA กำหนดจำนวนระเบียนของภารกิจในปี 1986 เพื่อให้กรณีสำหรับการร้องของบประมาณThe shuttle mission just prior to the Challenger had been delayed a record number of times due to inclement weather and mechanical factors. NASA wanted to launch the Challenger without any delays so the launch pad could be refurbished in time for the next mission, which would be carrying a probe that would examine Halley's Comet. If launched on time, this probe would have collected data a few days before a similar Russian probe would be launched. There was probably also pressure to launch Challenger so that it could be in space when President Reagan gave his State of the Union address. Reagan's main topic was to be education, and he was expected to mention the shuttle and the first teacher in space, Christa McAuliffe.Solid rocket boosterThe shuttle solid rocket boosters (or SRBs), are key elements in the operation of the shuttle. Without the boosters, the shuttle cannot produce enough thrust to overcome the earth's gravitational pull and achieve orbit.An SRB is attached to each side of the external fuel tank. Each booster is 149 feet long and 12 feet in diameter. Before ignition, each booster weighs 2 million pounds.Solid rockets, in general, produce much more thrust per pound than their liquid fuel counterparts. The drawback is that, once the solid rocket fuel has been ignited, it cannot be turned off or even controlled. So it was extremely important that the shuttle SRBs be properly designed.Morton Thiokol was awarded the contract to design and build the SRBs in 1974. Thiokol's design is a scaled-up version of a Titan missile, which had been used successfully for years. NASA accepted the design in 1976.O-ringsEach SRB joint is sealed by two O-rings: the bottom ring known as the primary O-ring, and the top known as the secondary O-ring. (The Titan booster had only one O-ring. The second ring was added as a measure of redundancy since the boosters would be lifting humans into orbit. Except for the increased scale of the rocket's diameter, this was the only major difference between the shuttle booster and the Titan booster.)The purpose of the O-rings is to prevent hot combustion gasses from escaping from the inside of the motor. To provide a barrier between the rubber O-rings and the combustion gasses, a heat-resistant putty is applied to the inner section of the joint prior to assembly. The gap between the tang and the clevis determines the amount of compression on the O-ring. To minimize the gap and increase the squeeze on the O-ring, shims are inserted between the tang and the outside leg of the clevis. Launch Delays The first delay of the Challenger mission was due to a weather front expected to move into the area, bringing rain and cold temperatures. Usually a mission wasn't postponed until inclement weather actually entered the area, but the Vice President was expected to be present for the launch and NASA officials wanted to avoid the necessity of the Vice President's having to make an unnecessary trip to Florida, so they postponed the launch early. The Vice President was a key spokesperson for the President on the space program, and NASA coveted his good will. The weather front stalled, and the launch window had perfect weather conditions; but the launch had already been postponed.The second launch delay was caused by a defective microswitch in the hatch locking mechanism and by problems in removing the hatch handle. By the time these problems had been sorted out, winds had become too high. The weather front had started moving again, and appeared to be bringing record-setting low temperatures to the Florida area. NASA wanted to check with all of its contractors to determine if there would be any problems with launching in the cold temperatures. 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 and contacted two of the engineers working on the project, Robert Ebeling and Roger Boisjoly. Thiokol knew there was a problem with the boosters as early as 1977, and had initiated a redesign effort in 1985. NASA Level I management had been briefed on the problem on August 19, 1985. Almost half of the shuttle flights had experienced O-ring erosion in the booster field joints. Ebeling and Boisjoly had complained to Thiokol that management was not supporting the redesign task force. The Night Before the Launch Temperatures for the next launch date were predicted to be in the low 20°s. This prompted Alan McDonald to ask his engineers at Thiokol to prepare a presentation on the effects of cold temperature on booster performance.A teleconference was held between engineers and management from Kennedy Space Center, Marshall Space Flight Center in Alabama, and Morton-Thiokol in Utah. 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.1Thiokol's engineers gave an hour-long presentation, presenting a convincing 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, on the January 24, 1985 flight. With a predicted ambient temperature of 26°F at launch, the O-rings were estimated to be at 29°F.After the technical presentation, Thiokol's Engineering Vice President Bob Lund presented the conclusions and recommendations. His main conclusion was that 53°F was the only low-temperature data Thiokol had for 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 database and NASA should delay the launch, so the ambient temperature could rise until the O-ring temperature was at least 53°F. This confused NASA managers because the booster design specifications called for booster operation as low as 31°F. (It later came out in the investigation that Thiokol understood that the 31°F limit temperature was for storage of the booster, and that the launch temperature limit was 40°F. Because of this, dynamic tests of the boosters had never been performed below 40°F.) Marshall's Solid Rocket Booster Project Manager, Larry Mulloy, commented that the data was inconclusive and challenged the engineers' logic. A heated debate went on for several minutes before Mulloy bypassed Lund and asked Joe Kilminster for his opinion. Kilminster was in management, although he had an extensive engineering background. By bypassing the engineers, Mulloy was calling for a middle-management decision, but Kilminster 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 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 Thiokol, Jerald Mason, c
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