The Space Shuttle Challenger disaster occurred on January 28, 1986, when Space Shuttle Challenger broke apart 73 seconds into its flight, leading to the deaths of its seven crew members. The spacecraft disintegrated over the Atlantic Ocean, off the coast of central Florida at 11:38 EST. Disintegration of the entire vehicle began after an O-ring seal in its right solid rocket booster (SRB) failed at liftoff.

1. Reality and Nature…
The Challenger Disaster Revisited
Kurt D. Hamman
May 5, 2014

2. 2
Presentation Summary
• High Reliability Organizations
– Background
– Examples/Case Studies
• Challenger Disaster
– Space Shuttle Program
– Major Components (Shuttle)
– Challenger’s Final Flight
– Rogers Commission
• Perspectives
– Insider & Outsider
– Lessons Learned
• Discussion
– 15+ minutes
Deepwater Horizon Oil Spill: the oil slick
as seen from space by NASA’s Terra satellite
on May 24, 2010 (Wikipedia.org)
“Never downplay safety to save cost or
meet deadlines.”
- Dr. Norman Swazo,
(ethics in international affairs expert)

3. 3
High Reliability Organizations (HROs)
• HRO Characteristics
– high risk technology
– sensitivity to operations
– complex processes to manage work
– preoccupation with failure
– avoid “explaining away” problems
• Learning from Mistakes
– USS Thresher (SSN-593)
– Deepwater Horizon
– Bhopal Chemical Leak
– SL-1/TMI/Chernobyl/Fukushima
– Space Shuttles Challenger/Columbia
• HROs have no choice but to function reliably…
Fukushima Nuclear Plant 2008

4. 4
HROs Must Constantly Assess
Their Responsibility and
Behavior… Why?

5. http://wikimapia.org/6554825/Approximate-location-of-the-USS-Thresher-SSN-593www.history.navy.mil/photos/sh-usn/usnsh-t/ssn593.htm
www.oilspillcommission.gov/final-report
www.history.navy.mil/photos/sh-usn/usnsh-t/ssn593.htm
Deepwater Horizon
The nuclear Navy. Turning from the skies to the sea, between 1915 and 1963, the U.S. Navy lost about one submarine every
three years to noncombat causes.71 In 1963, when the nuclear-powered USS Thresher was lost during a deep test dive, 112
naval personnel and 17 civilians perished.72 The Navy investigation found that a deficient silver-braze joint in a piping system
had failed, flooding the engine room.73 The investigation went far beyond immediate causes and “found deficient
specifications, shipbuilding practices, and maintenance practices, along with inadequate documentation of construction and
maintenance actions and deficient operational procedures.”74 After the Thresher loss, Admiral Hyman Rickover then head of
the nuclear Navy told his staff to establish a system to ensure that such an accident would never recur.75 The new SUBSAFE
system was established within 54 days of the loss of the Thresher, and no SUBSAFE-certified submarine has since been lost.76

6. National Aeronautics and Space Administration
6
Kennedy Space Center
Johnson Space Center
Marshall Space Flight Center

7. 7
NASA Space Shuttle Program
• Program History
– Authorized in 1972
• ~13,400 employees (2011)
– Total Cost → $196B (2011 $)
• $54M → $450M per flight
– Shuttle Contractors
• Rockwell (Orbiter)
• Martin-Marietta (External Tank)
• Morton-Thiokol (SRB)
– Five Shuttles (135 missions)
• Columbia (STS-1) / April 1981
• Atlantis (STS-135) / July 2011
– Two Shuttle Disasters
• Challenger (STS-51L) / Jan. 1986
• Columbia (STS-107) / Feb. 2003

8. 8
Solid Rocket Booster Assembly
Assembling Two Booster Segments
(Kennedy Space Center)
Manufacture & Preliminary Assembly
(Morton-Thiokol)

9. 9
Solid Rocket Booster Segment Assembly
Assembling Two Booster Segments
(Kennedy Space Center)
SRB Field Joint and O-rings
0.25 inch OD / 38 feet circumference

10. HISTORY OF SRB/O-RING PROBLEMS
10
Report of the Presidential Commission on the Space
Shuttle Challenger Accident, Volume I, pp. 145-146, 1986.

11. 11
Key Events – Eve of Launch (Challenger)
January 27, 1986
• 1:00 p.m. NASA concerned about cold forecast
– temperatures predicted ~ 30 F
– NASA (Marshall) initiates call to Morton Thiokol, Inc. (MTI) in Utah
• 8:45 p.m. Formal teleconference
– 34 managers and engineers
– Thiokol recommends launch only if T>53 F
– NASA challenges this recommendation.
( “My God, Thiokol, when do you want me to launch, next April?” )
• 10:30 p.m. Thiokol wants off-line caucus
•11:00 p.m. Thiokol reassessed their position
– they now recommend shuttle launch
– based on the inconclusive nature of the data
(Top Marshall managers were informed of the Thiokol conference.)

12. • Weather Tower T = 36 F
• Aft Field Joint T ≈ 28 F
12
The Morning of the Launch
Launch Platform

13. 13
Ellison Onizuka, Christa McAuliffe, Gregory Jarvis, Judith Resnik
Michael J. Smith, Dick Scobee, Ronald McNair
Space Shuttle Challenger Crew

14. 14
January 28, 1986 11:38 a.m.
Space Shuttle Challenger
(NASA photo and video link)

15. 15
Rogers Commission
William P. Rogers (FMR Sec. State)
Neil A. Armstrong (Apollo 11)
David Acheson (FMR U.S. Attorney)
Dr. Eugene Covert (Science)
Dr. Richard Feynman (Physics)
Robert Hotz (Air Force Veteran)
Maj. General Donald Kutyna (USAF)
Dr. Sally Ride (Physics)
Robert Rummel (Aerospace Engineer)
Joseph Sutter (Aeronautical Engineer)
Dr. Arthur Walker, Jr. (Physics)
Dr. Albert Wheelon (Physics)
Brigadier General Charles Yeager (Test Pilot)
Dr. Alton Keel, Jr. (Engineering Physics)
Members of Rogers Commission
(NASA photo)

16. 16
Richard Feynman
• Physicist
• Teacher
• Professor
• Musician
• Author
• Nobel laureate
• Manhattan Project
• Challenger Disaster
( 1918 - 1988 )

17. Rogers Commission Investigation
• The physical cause of the loss of the Challenger and
its crew was a failure in the O-rings sealing the aft
field joint on the right solid rocket booster….
17

18. Rogers Commission Investigation
• The Rogers Commission found a flawed decision-making
processes had been a key contributing factor to the
accident…
– failures in communication resulted in a decision to launch
51-L based on incomplete and sometimes misleading
information
– a conflict between engineering data and management
judgments
– a NASA management structure that permitted internal flight
safety problems to bypass key Shuttle managers
18

19. Decision-Making Structure
… is the shuttle ready and safe to fly?
19

20. Rogers Commission Investigation
• The “Silent Safety Program” findings…
– Reductions in the safety, reliability and quality assurance
work force at Marshall and NASA Headquarters have
seriously limited capability in those vital functions.
– Organizational structures at Kennedy and Marshall have
placed safety, reliability and quality assurance offices under
the supervision of the very organizations and activities
whose efforts they are to check.
– Problem reporting requirements are not concise and fail to
get critical information to the proper levels of management.
20

21. PERSPECTIVE…
21

22. Roger Boisjoly’s Perspective
• July 1985 Memo
“This letter is written to ensure management is
fully aware of the seriousness of the current O-ring
erosion problem...”
“It is my honest and very real fear… we stand in
jeopardy of losing a flight along with all the launch
pad facilities.”
• January 27, 1986 → Recommended No Launch
• January 2001 Interview→ Decision-Making…
– This was “teacher in space” launch (publicity)
– Thiokol was negotiating follow-on $1B booster contract
22
Roger Boisjoly
(1938-2012)
MTI Memo (1985)
(1988 – AAAS Award for Scientific Freedom and Responsibility )

23. Jesse Moore’s Perspective
• Authority to approve/scrub the launch
– All of the people involved in the program, to
my knowledge, felt Challenger was quite
ready to go and I made the decision, along
with the recommendation of the team
supporting me, that we launched.
(New York Times, January 29, 1986)
– Informed the Presidential commission… that
he had not known about a history of
problems with seals at the joints of the
shuttle's solid-fuel boosters.
– February 1987, Resigned from NASA
23
Jesse Moore
‘NASA Associate
Administrator for Space Flight’

24. Controversy - Media Perspective
– “It appears that there are enormous
differences of opinion as to the
probability of a failure with loss of
vehicle and human life. …
– The higher figures come from
working engineers, and the very low
figures from management.”
– “What is the cause of management’s
faith in the machinery?”
24
Richard Feynman
(video time: 44:20 - 45:45)
*Appendix F
‘Personal observations on the reliability of the Shuttle’
*Rogers Commission Report

25. 25
Diane Vaughan’s Perspective
… Risky Technology, Culture, and Deviance at NASA
• RESEARCH GOES BEYOND THE
CONVENTIONAL FAULT FINDING…
(e.g. media, economic, and political pressure)
• NORMALIZTION OF DEVIANCE
– Signals of potential danger
– Official act acknowledging escalated risk
– Review of evidence
– Official act of accepting the increased risk
– Launch
• WHY DID NASA ACCEPT INCREASING
DEVIATION?
– Culture of Production
– Work Group Culture
– Structural Secrecy
• 2003 COLUMBIA ACCIDENT TESTIMONY… Professor of Sociology
Columbia University“I want to make the point that, in fact,
Challenger was not just an O-ring failure but it
was the failure of the organizational system.”

26. 26
PERSPECTIVE: “CHALLENGER LESSONS”
• A Top Notch Organization can make Tragic Errors
• There were Cultural and Organizational Causes
– Normalization of Deviance
– Cultural Aspects
– Production Pressures
– Structural Secrecy
• A Flawed Decision Process was evident…
– Management and Engineers unprepared and ineffective
• The Quality of Technical Work is Paramount
– Poor Work Cannot be overcome by the “System”
Excerpts from “The Challenger Accident Re-Examined,” Naval Reactors Seminar, circa 1998.

27. 27
QUESTIONS ?
“For a successful technology, reality must take precedence
over public relations, for nature cannot be fooled.”
- Richard Feynman, theoretical physicist & Nobel laureate, (1918-1988)

28. 28
Discussion…
What could NASA management have done differently?
What, if anything, could their subordinates have done differently?
What should Roger Boisjoly have done differently (if anything)?
What should Richard Feynman have done differently (if anything)?
What did NASA and Morton Thiokol engineers see as their professional
responsibility to being loyal to management and protecting the public welfare?
Roger Boisjoly
(1938-2012)
Jesse Moore Richard Feynman
(1918-1988)

29. 29
References
1. Martin, M.W. and Schinzinger, R., “Ethics in Engineering,” 4th ed.,
McGraw-Hill, 2005.
2. Harris, C.E., Pritchard, M.S., and Rabins, M.J., “Engineering Ethics,
Concepts & Cases,” Wadsworth, 2009.
3. Committee on Science, Engineering, and Public Policy, National
Academy of Sciences, National Academy of Engineering, and
Institute of Medicine, “On Being a Scientist: A guide to Responsible
Conduct in Research,” 3rd Ed., 2009.
4. Davis, Michael. “Thinking Like an Engineer: the Place of a Code of
Ethics in the Practice of a Profession.” Philosophy and Public Affairs
20:2 (Spring 1991) 150-167.
5. Vaughn, D., “The Challenger Launch Decision: Risky Technology,
Culture, and Deviance at NASA,” University of Chicago Press, 1996.
6. Cabbage, M. and Harwood, W., “Comm Check…: The Final Flight of
Shuttle Columbia,” Free Press, 2004.
7. “The Challenger Accident Re-Examined,” Naval Reactors Seminar
presented at Puget Sound Naval Shipyard, circa 1998.

30. 30
References
8. Great Images in NASA Photo Gallery, Accessed: 1/17/2011
http://grin.hq.nasa.gov/BROWSE/space-shuttle.html .
9. Marshall Space Flight Center Photo Gallery, Accessed: 1/17/2011
http://www1.nasa.gov/centers/marshall/home/index.html .
10. Moore, C., “Thinking Like an Engineer: The Place of a Code of Ethics
in the Practice of a Profession,” University of Texas Presentation,
http://apps.engr.utexas.edu/ethics/instructor/DavisArticle-
PRiME.ppt#256,1 Accessed 1/17/2011.
11. “Memo from Roger Boisjoly on O-Ring Erosion” Online Ethics Center
for Engineering 8/29/2006 National Academy of Engineering
http://www.onlineethics.org/Topics/ProfPractice/Exemplars/Behaving
Well/RB-intro/Erosion.aspx Accessed: 1/19, 2011.
12. The Space Shuttle Challenger Disaster (Case Study), Department of
Philosophy and Department of Mechanical Engineering, Texas A&M
University, Accessed: 7/20/2012
http://ethics.tamu.edu/Portals/3/Case%20Studies/Shuttle.pdf
13. “Deep Water, The Gulf Oil Disaster and the Future of Offshore
Drilling,” National Commission Final Report to the President,
http://www.oilspillcommission.gov/ , Accessed: 1/30/2011.
14. Leveson, Nancy, “Engineering a Safer World,” MIT Press, 2011,
http://sunnyday.mit.edu/safer-world/index.html , Accessed 2/5/2011.

31. 31
References
15. Innovations in Newspapers, Accessed: 3/6/2012
http://www.innovationsinnewspapers.com/index.php/2011/03/12/first-
pictures-from-fukushima-nuclear-disaster/.
16. Marshall Space Flight Center Photo Gallery, Accessed: 1/17/2011
http://www1.nasa.gov/centers/marshall/home/index.html.
17. Feynman Online, Accessed: 3/7/2012
http://www.feynmanonline.com/ .
18. “Jesse Moore, A Top NASA Aide quits,” Accessed: 3/8/2012
http://www.nytimes.com/1987/02/06/us/jesse-moore-a-top-nasa-aide-
quits.html
19. Christianson, et al., “Becoming a High Reliability Organization,”
Critical Care 2011, 15:314, Epub 2011.
20. Armenakis, A.A., “Boisjoly on Ethics: An Interview With Roger
Boisjoly,” Journal of Management Inquiry, Vol. 11 No. 3, September
2002, pp. 274-281. http://jmi.sagepub.com/content/11/3/274.abstract
21. Space Shuttle Quotes, Accessed: 7/1/2012
http://www.spacequotations.com/spaceshuttlequotes.html
22. “With NASA’s Shuttle Era Ending, Layoffs Loom for Space Workers,”
Accessed: 7/2/2012 http://www.space.com/12133-space-shuttle-
program-nasa-future-layoffs.html

32. 32
References
23. “A Catastrophe of the Highest Order: The Tragic Legacy of Roger
Boisjoly,” Accessed: 7/1/2012
http://www.americaspace.org/?p=13357
24. “Report of the Presidential Commission on the Space Shuttle
Challenger Accident,” Accessed: 7/1/2012
http://science.ksc.nasa.gov/shuttle/missions/51-l/docs/rogers-
commission/table-of-contents.html
25. Weick, K. E. and Sutcliffe, K. M., “Managing the Unexpected,
Assuring High Performance in an Age of Complexity,” University of
Michigan Business School Management Series, Jossey-Bass, 2001.
26. Columbia Accident Investigation Board (August 2003). "Chapter 7
The Accident’s Organizational Causes,” Accessed: J7/1/2012.
http://caib.nasa.gov/news/report/pdf/vol1/chapters/chapter7.pdf.
27. Hamman, K. D., “Reality and Nature . . . The Challenger Disaster
Revisited,” NS&T Seminar Series, INL/MIS-12-26729, Idaho National
Laboratory, July 23, 2012.

33. 33
Presenter Notes:
1. Presentation Time: 45 minutes
2. Q&A / Discussion: 15 minutes
3. Internet Links / Video Time:
• "Reality and Nature... The Challenger Disaster Revisited," including video links.
(The same links can be found by showing the presentation in "Slide Show" and clicking
on the individual picture.)
• SLIDE #14 (Challenger launch): (video time: 0:00 to 2:04)
http://www.youtube.com/watch?v=EssKzOj-kME
• SLIDE #16 (Richard Feynman):
http://www.youtube.com/watch?v=Sl8UjQ6yx_Y
• SLIDE #17 (Physical Cause/O-ring failure): (video time: 6:50 to 8:40)
http://www.youtube.com/watch?v=rdeWTeei1S4
• SLIDE #22 (Roger Boisjoly):
http://www.youtube.com/watch?v=On9p0Q9eKr4
• SLIDE #24 (Media Perspective): (video time: 44:20 to 45:45)
https://www.youtube.com/watch?v=Mn4_40hAAr0

34. 34
Suggested Readings:
(Diane Vaughan testimony)
http://jmi.sagepub.com/content/11/3/274.abstract
http://www.nasa.gov/columbia/caib/PDFS/VOL6/H08.PDF
http://caib.nasa.gov/

35. 35
Solid Rocket Booster Joint
RE-DESIGNED JOINT

36. 36
Columbia Accident Investigation Board (CAIB)
• The Accident’s Organizational Causes (Chapter 7)
– "While the Board (CAIB) appreciates that
organizations dealing with high-risk technology
cannot sustain accident-free performance indefinitely,
evidence suggests that there are effective ways to
minimize risk and limit the number of accidents."
– The Board compares NASA to three specific
examples of independent safety programs that have
strived for accident-free performance and have, by
and large, achieved it:
• Aerospace Corporation's Launch Verification
Process (supports USAF space launches)
• U.S. Navy Submarine Flooding Prevention and
Recovery (SUBSAFE)
• Naval Nuclear Propulsion Programs
(Naval Reactors)
Columbia - 2003