An Accident Rooted in History

1. An Accident Rooted in History • NASA Culture • History of the flawed joint • Events leading up to the disaster

2. NASA • A can do mentality • Launch successes for years • Engineers • Funded by Congress

3. O Ring Joint History Upon ignition, internal pressure swells each booster section. Joints are stiffer, causing bulging. O-rings designed to fill gap. • 1977 Nasa engineers not that Primary and Secondary rings—initial tests noted that problems may occur • 1979-Management made aware “design adequacy of the joint found to be completely unacceptable” • 1980- boosters authorized for flight, rings classified as 1-R (redundant)

4. O Ring History (cont.) • 1982 joint reclassified to Criticality 1: failure effect loss of mission, vehicle and crew after blow by caused seals to erode • 1983-85 concerns escalate at MT • 1985 near disaster on flight launched at 53F in Jan., complete failure of primary in April • Fall 1985 Seal task force formed, frustrated by lack of cooperation • 1986 First launch delayed 7 times, Challenger delayed 4X • MT asked for opinion on cold launch temps night before

5. Why Wasn’t the Design Fixed Earlier? • Economics? • Cost of halting the program • Declining budget • Increased demand for shuttle to be ‘operational’ • 24 flights per year • Culture and structure of NASA? • Can’fail • Chain of command=hard communicating • Status differences emphasized between levels of managers and managers/engineers • MSFC directive that under ‘no circumstance were they to be the cause of a flight delay’

6. Why wasn’t it fixed??? • Perceptual differences between managers and engineers • Technical risk • Communication • Lack of communication between levels • Upward (eg. MTI to Marshall classified docs) • Downward(MTI not informed of joint reclassification) • Lack of attention to safety • Faith in the specifications being followed

7. What could have prompted MTI to reverse their decision Not to launch? • Customer intimidation • Follow on contract pending (>$1B) • Fear of 2nd source competition on SRM • NASA knew and accepted the risk • Uncertainty over the effects of cold- failure to have explicit references to it, substituting the phrase ‘resiliancy’ • Unethical conduct??

8. Both NASA and MTI • Failed to recognize the joint issue as a problem • Failed to fix it • Treated it as an ‘acceptable’ flight risk

9. The Flawed Decision

10. Four Frames Model • Structural perspective-what is the most appropriate organizational structure to accomplish established goals? • H/R - how well does the organization meet human needs? • Political – how does the organization handle conflict and distribute scarce resources? • Symbolic – what are the shared values of the organization and the meaning of their work? The problem is that most managers limit their effectiveness by seeing most problems from one

11. Goal To help managers stretch their perspective of “what is the problem?” Ask questions from all four frames and begin to try out strategies that are quite different from your ingrained thinking….

12. The Rogers Commission: Key Findings • Cause of the accident • The decision making process for launch • Waiving of launch constraints at the expense of safety • Accepted escalating risk because they got away with it last time • Goes back to original design acceptance • Pressures on the system

13. Rogers Commission Recommendations • Shuttle management structure • Astronauts in management • Safety panel/organization • Improved communications • Flight rate