THE CHALLENGER LAUNCH DECISION Risky Technology, Culture, and Deviance at NASA

1. THE CHALLENGER LAUNCH DECISIONRisky Technology, Culture, and Deviance at NASA

2. Introduction Define Bureau pathology Discuss the organizational structure of the launch decision process – (Washington, D.C. – to Morton-Thiokol) Summarize the structural failures of the pre-launch findings (weather factors – what they found) Review the developments leading to Structural Failure

3. What is Bureau Pathology? Bureau pathology is – the study of the primary structure or processes of an organization and the pathologies to which organizations are prone.

4. Decision Makers Involved in The Challenger Launch Space Flight, NASA National Aeronautics and Space Administration Headquarters (Washington, D.C.) Johnson Space Center (Houston, TX) Marshall’s Space Center (Huntsville, AL) Morton – Thiokol (Utah)

5. Organizational Structure Four Tier Level of the Decision-making Process

6. Space Flight NASA Headquarters Based in Washington, D.C NASA- established in 1958 - government agency responsible for the flights Manages space flight centers, research centers, systems constituting NASA Supervises the establishment of policies, and performance criteria

7. Johnson Space Center Based in Houston, TX Arnold Aldrich, Program Manager (Level II) Accountable for the development, production and testing of spacecraft

8. Marshall Space Flight Center Based in Hunstville, Alabama Opened in 1960, made responsible for the propulsion system Responsible for the technical breakthroughs behind the success of Apollo. Marshall’s on the 3rd tier in regards to the Challenger Launch Decision Participated in both teleconference calls that took place the day before the Challenger launch. Many of Marshall’s supervisors were not available for the second conference call that took place at 8:15p.m. EST Propulsion system ( driving force, forward motion) of the system.- consisiting of the Orbiter’s Main engine, the External Tank and the SRB’s. Propulsion system ( driving force, forward motion) of the system.- consisiting of the Orbiter’s Main engine, the External Tank and the SRB’s.

9. Morton – Thiokol Acquired a $800 million contract with NASA to manufacture the SRB’s – decision to select this company was cost Contractor is responsible for the Solid Rocket Motors (SRM’s) found on the SRB’s of the Challengers Morton-Thiokol's Website Cheap is NOT ALWAYS BETTER Won contract even though it was one of the lowest ranked companies out of the four bids placed for the NASA contract Found on the SRB”s of the Challenger where the O-rings explosion occurred.The designs had technical effects that were easily correctable , according to Fletcher, Source Selection Officer, who decided what company to contract. Decision was based on cost. Cheap is NOT ALWAYS BETTER Won contract even though it was one of the lowest ranked companies out of the four bids placed for the NASA contract Found on the SRB”s of the Challenger where the O-rings explosion occurred.The designs had technical effects that were easily correctable , according to Fletcher, Source Selection Officer, who decided what company to contract. Decision was based on cost.

10. Morton - Thiokol Organizational Structure

11. Structural Failure of Pre -Launch Findings: Temperature Concerns At HUNTSVILLE, ALABAMA At 1:00p.m. January 27, 1986– Larry Wear SRM initiates initiates the first concern of the predicted low temperature factor Thiokol is advised to have their engineers review low temperature effects Thiokol engineers gather, discuss, and conclude that low temperature could affect o-ring procedure of sealing 1. LARRY WEAR SRM managerfor Marshall, based in Huntsville, Alabama- He brings up the fact that 1/85 the STS 51C launch recalled that during launch Thiokol had a major concern of low temperature affecting the o-rings. 2. Low temperature could affect o-ring procedure by hardening o-rings ant not allowing them to seal the joints. ( tang & segment clevis) 4. McDonald & Buchanan are engineers representing Thiokol at Cape Canaveral Agreed there was no SRB constraint after discussing the temp and went ahead and agreed to continue the launch. Structural Failure – Exhibit divided failure 1. LARRY WEAR SRM managerfor Marshall, based in Huntsville, Alabama- He brings up the fact that 1/85 the STS 51C launch recalled that during launch Thiokol had a major concern of low temperature affecting the o-rings. 2. Low temperature could affect o-ring procedure by hardening o-rings ant not allowing them to seal the joints. ( tang & segment clevis) 4. McDonald & Buchanan are engineers representing Thiokol at Cape Canaveral Agreed there was no SRB constraint after discussing the temp and went ahead and agreed to continue the launch. Structural Failure – Exhibit divided failure

12. Structural Failure of Pre -Launch Findings: Temperature Concerns At CAPE CANAVERAL, FL Contractors (Marshall Space Launch Center) of Main Engine, SRB’s and External Tank agreed there was no SRB constraints for the launch at 9:38am. Marshall strongly believed that low temperature was not a reason for a SRB delay Engineers for Thiokol did not express any concern for low temperature Marshall manager (L.Wear) initiates a second concern when he recalls Thiokol’s concern on low temperature during the January 1985 launch. Thiokol engineers Representatives at Cape Canaveral Thiokol engineers Representatives at Cape Canaveral

13. Structural Failure of Pre - Launch Findings: Temperature Concerns cont’d Thiokol SRB managers do not recall any concerns during the January 1985 STS-51-C launch After denying January 1985 concerns, Thiokol calls for a meeting to discuss the blow-by effects on the January 1985 launch. Thiokol concludes the possibility of it could happening again Thiokol’s O-ring Task Force meet & conclude that O-rings were not flexible to low temperature weather The predicted weather for Jan. 28th launch was 26° Not all managers/engineers were available from Thiokol- key decision makers that could have affected whether the launch being postponed. involving managers and engineers of Thiokol, Marshall and Kennedy space Center. A major key player not available was Engineer Leon Ray ( worked for Marshall) apparently no one called him because they were under the assumption he was on route to Cape, when in fact he was home. He worked closely with Thiokol and knew more than anyone, on the SRB joints. 34 managers & engineers participated in the second teleconference call. Not all managers/engineers were available from Thiokol- key decision makers that could have affected whether the launch being postponed. involving managers and engineers of Thiokol, Marshall and Kennedy space Center. A major key player not available was Engineer Leon Ray ( worked for Marshall) apparently no one called him because they were under the assumption he was on route to Cape, when in fact he was home. He worked closely with Thiokol and knew more than anyone, on the SRB joints. 34 managers & engineers participated in the second teleconference call.

14. Structural Failure of Pre - Launch Findings: Temperature Concerns cont’d At 5:45 p.m. EST, the first teleconference call took place - managers and engineers of Thiokol, Marshall and Kennedy Space Center During a 45 minute teleconference call, Thiokol recommended the launch be delayed for 12 noon or later At 8:15 p.m. EST, a second teleconference call was placed Purpose: To discuss delaying the launch – due to weather conditions To give ample time for Thiokol to fax their data to Kennedy & Marshall Space Centers

15. Structural Failure of Pre -Launch Findings: Temperature Concerns cont’d At 8:15p.m. EST second teleconference call began: Thiokol argued: o-rings ability to seal the booster joints at time of ignition would be slower due to the predicted temperature. Demonstrated several hand written charts to explain the effect of low temperatures Blow-by’s occurred at 75 degrees weather – Marshall excluded temperature as a factor 34 managers & engineers participated in the second teleconference call. This was based on the coldest launch that took place which was in 1985 at 53 degrees. Analogy used by Engineer Boijsoly( based in FL) the o-ring not being able to seal n is like placing a brick into a crack, rather than a sponge. Someone said ‘temp should not be a factor because there was a blow-by at 75 degrees, so there’s no correlation. – since Thiokol couldn’t identify or explain, then it was ruled out by Marshall. Lund mentioned launch had to be done at 53 degree or higher Lund- VP of engineering for Thiokol 34 managers & engineers participated in the second teleconference call. This was based on the coldest launch that took place which was in 1985 at 53 degrees. Analogy used by Engineer Boijsoly( based in FL) the o-ring not being able to seal n is like placing a brick into a crack, rather than a sponge. Someone said ‘temp should not be a factor because there was a blow-by at 75 degrees, so there’s no correlation. – since Thiokol couldn’t identify or explain, then it was ruled out by Marshall. Lund mentioned launch had to be done at 53 degree or higher Lund- VP of engineering for Thiokol

16. Structural Failure of Pre -Launch Findings: Temperature Concerns cont’d Marshall confronted Thiokol for a management recommendation Kilminster (VP of Thiokol) recommended to delay that launch Marshall immediately challenged data on charts Robert Lund then made a management decision (due to performance pressure – State of the Union Address – first teacher in space)

17. Structural Failure of Pre -Launch Findings: Temperature Concerns cont’d Thiokol engineers could not assess the link between cool temperatures & o-ring damage on previous flights Thiokol did not effectively present the relevant data – to show high risk Teleconference Call ended at 11:15p.m. EST – Launch was scheduled for 9:30a.m. EST

18. Positioning of O-Rings

19. Diagrams Created by Thiokol Engineers to Show Correlation of O-Rings and Temperatures for the previous launches The Chart makers did in fact reach the correct conclusion- the low temperature will effect the o-rings resiliency. However, they were not able to demonstrate in the charts they produced. Engineers had the correct theory, But didn’t display it properly. Weren’t able to show the correlation – NASA was skeptical, so therefore launch continued Show Correlation of O-Rings and Temperaturesto Show Correlation of O-Rings and Temperatures for the previous launches The Chart makers did in fact reach the correct conclusion- the low temperature will effect the o-rings resiliency. However, they were not able to demonstrate in the charts they produced. Engineers had the correct theory, But didn’t display it properly. Weren’t able to show the correlation – NASA was skeptical, so therefore launch continued Show Correlation of O-Rings and Temperatures

20. History of O-Ring Temperatures Diagrams Created by Thiokol Engineers

21. History of O-Ring Conditions on Previous Launches This data matrix reveals all the launches sorted by the temperature Those in red indicate Damage index- is the severity of the damage in the o-rings, erosion, heating and blow-by.This data matrix reveals all the launches sorted by the temperature Those in red indicate Damage index- is the severity of the damage in the o-rings, erosion, heating and blow-by.

22. Temperature of Field JointsDiagrams Created by Thiokol Engineers

23. Temperature of Field Joints at time of Launch

24. Conclusionmade by Thiokol Engineers

25. Thiokol Engineers Recommendations

26. Footage of the Actual Challenger Launch The Challenger Launch

27. Conclusion Structural Failure Oversight Failure lack of communication & understanding within the participants involved in the decision making process Production pressure came from top management to launch on schedule Structure authority was divided amongst the parties involved Oversight – top management has power & needed to address the launch of the first teacher in space program during the state of the union addressStructure authority was divided amongst the parties involved Oversight – top management has power & needed to address the launch of the first teacher in space program during the state of the union address