The NASA Space Shuttle Disasters

A summary of the presentation given by Stephen Carver to the IOSH London Metropolitan Branch on Tuesday 11th November 2012

About the Speaker

Stephen Carver is rated as one of the top 3 lecturers at one of Europe's top MBA Business Schools. He has a reputation of taking complex management concepts such as Projects, Programme and Crisis Management and being able to distil them down, into highly informative and fun lectures - often using "storytelling" techniques.

Stephen has spent most of his working life in real business and still runs his own, highly successful, Project Management Company.

Stephen is an unusual blend of Academic, Businessman and Teller of Tales. He has taught in almost every country in the World and has appeared regularly on National Radio and Television.

The Challenger

Space Shuttle Disaster

Presentation

On the 28th January 1986 at 11:38am Challenger launched from Kennedy Space

Centre Florida for the shuttle programs 25th flight.

73 seconds after liftoff there was an explosion that destroyed Challenger and killed all 7

crew members.

The crew consisted of 7 astronauts

Commander Francis `Dick’ Scobee (46)

Pilot Mike Smith (40)

Judy Resnick (36)

Ellison Onizuka (40)

Ron McNair (35)

Greg Jarvis (41)

Christa McAuliffe (37)

This was not an accident

This had been foretold, people in NASA (National Aeronautics and Space Administration) knew of

the dangers, but unfortunately the right people did not listen.

It all started with the then President John F. Kennedy (JFK) he said in 1963 "we will go to the moon

before the end of this decade” (WordPress, 2009). The `space race' to the moon against the then

Union of Soviet Socialist Republics (USSR) also known as the Soviet Union had begun.

In order to achieve this NASA needed a lot of money and at this point were given a blank cheque,

400,000 people were employed to work on the space programme, and they did it on the 20th July

1969, beating the Russians.

Now the goal had been achieved, NASA had a huge workforce that they could not just get rid of, as

part of the space race was about politics and votes, in order to get the votes you need to provide

employment. NASA found a new project - Mars.

NASA realised that in order to get to Mars they will need a lot of fuel and to send a space shuttle

from earth was impossible due to weight of the amount of fuel that was required. Engineers

estimated that the space shuttle would weigh in excess of three Statues of Liberty with all the fuel

that was required to thrust it into space.

This NASA realised was an impossible feat so they decided to build a space station. In order to

build a space station they were going to need some form of transportation to deliver the men and

materials into space where they were going to build the rocket to go to Mars - a space truck, which

is what the space shuttle was first called.

NASA consisted of four main divisions - John F. Kennedy Space Centre in Cape Canaveral,

Florida, Washington, Johnson Space Centre in Houston Texas and the Marshall Space flight

Centre based in Huntsville Alabama.

JFK Cape Canaveral was where they did the assembly and launching

Johnson Space Centre Houston was mission control

Washington was head quarters mainly politics and government

Marshall Space Centre was where the rocket scientists were

Marshall Space Flight Centre was first run by a German/American

Rocket Scientists, Werner Von Braun who designed the V2 rocket

that was used by the Germans during the WWII to rein terror down

on Europe. His management style was very autocratic, ie "my way

or the highway". The culture in this section of NASA was not a

listening one, but just telling, a quality Von Braun adopted as an

officer in the German army. Von Braun did not communicate with

any of the other divisions of NASA and as a result the Marshall

Space Centre became almost cut off from the other sections of NASA, it was known for its

arrogance and just did things their way and did not listen to the rest of NASA.

Having had an open cheque book for many years it became apparent that costs would need some

consideration, as the design parameters of weight, safety and performance were of paramount

importance

The shuttle craft was powered by liquid fuelled engines; the reason for this was that they could be

turned off easily if something went wrong. But these engines were not big enough to propel the

shuttle craft into space because of its payload there was no room for additional fuel, so extra fuel

tanks were fitted to the outside of the craft.

One main tank which was roughly 14 storeys high

was fitted containing 5 million litres of liquid oxygen

and hydrogen, a highly flammable explosive

dangerous material. This fuel tank on its own was

not powerful enough, so anther two tanks were

added - solid rocket boosters (SRB) which were

packed with several thousand kilos of high explosive which was 5 times more potent than TNT.

These three tanks of highly explosive fuel now had the power of a small atomic weapon and were

able to propel the shuttle into space.

The sequence of launch would be that once the SRB's were ignited they would launch the shuttle

into the atmosphere then they would fall off, shortly followed by the main tank at which time the

shuttle craft would have been despatched into space. Once the SRB's have been ignited you

cannot turn them off.

Marshall Space Centre were concerned about who got the contract, as the usual politics were

involved but eventually Morton Thiokol based in Utah were given the contract to build the SRB's.

The next challenge was to get the 14 storey SRB's from Utah to Florida.

The SRB's were then constructed in sections pre-loaded full of high explosive and assembled on

site in Florida, as it would have been too big to go by road or rail in one piece, not to mention the

controversy of transporting such a large amount of explosive across America.

Once in Florida the pieces were put together, welding was not possible so they used bolts and

flange connections. This meant they had to have an O-ring seal which in simple terms would act

like a gasket on a car, or a washer in a tap, to seal the joint between the two metal parts.

The O-rings were critical, if they failed the whole SRB would explode which would mean total loss

of the mission ie crew and loss of the vehicle caused by burn through, as it would burst resulting in

fire and explosion.

Morton Thiokol knew there were problems with the O-ring as many of them had failed during

testing, so they decided to put in a secondary O-ring as backup in case the first one failed.

Bolt and Flange with rubber ring

Engineers putting together two pieces of the SRB

The first shuttle was launched in 1981 and then again 24 more times after that.

NASA wanted to portray an image of them being environmentally friendly, so after each launch

they would collect the parts that fell away including the SRB's and reuse them. The recovered

parts were examined by the engineers who were horrified by their condition as they were battered

and twisted. They also realised that the O-rings were not performing in the way that they were

designed to, compounded with the fact that each take off was different as there were burn marks

and blow by marks around the O-rings.

The space shuttle twin solid rocket boosters separate from the orbiter and external tank at an altitude of approximately 24 miles. They descend on parachutes and land in the Atlantic Ocean off the Florida coast, where they are recovered by ships, returned to land, and refurbished for reuse.

Roger Boisjoly was the chief engineer of the O-rings, he told NASA that they would fail

eventually, NASA were not concerned. Roger continued looking and examining all the O-rings on

return, he decided the one factor that could be the problem was the temperature. He found that

the lower the temperature was on the day of launch the higher the O-ring erosion was.

In 1985 a group of engineers were tasked with solving this problem. Later investigations

showed that this effort however, had become hindered by paperwork, procurement delays

and hampered by the rush to launch the shuttle.

As they had already made a lot of successful flights through the winter, the managers did

not believe Boisjoly's theory and told him he was wrong. Boisjoly went to Dr Lucas who

had taken over from Von Braun as the head of the Marshall Centre to plead his case.

Boisjoly said "when people go in front of Dr Lucas they know if they use words like think,

feel or judgement to explain something that they would be shot down in flames". Boisjoly

was unable to convince Dr Lucas and the flights continued. The engineers kept telling the

managers at Morton Thiokol that there were problems, but management just told them that

`they had to make this thing work, and keep to schedule'.

Six months before the space shuttle Challenger exploded over Florida on Jan. 28, 1986,

Roger Boisjoly wrote an important memo to Morton Thiokol, his employer, he warned them

that if the weather was too cold, seals connecting sections of the shuttle’s huge rocket

boosters could fail. “The result could be a catastrophe of the highest order, loss of human

life,” (Times, New York, 2012)

Roger Boisjoly, SRB Engineer, Morton Thiokol

On the evening of the 27th January 1986 the engineers and managers convened for a

conference call to discuss the weather conditions with NASA managers from Kennedy

Space Centre and Marshall Space Flight Centre. Boisjoly and Arnold Thompson again

voiced their concern about the effect of the low temperature on the rubber O-rings that

sealed the joints on the SRB's, and asked again that the launch be postponed. The

engineers said that they did not have enough data to confirm that the O-rings would

perform if the outside temperature was colder than 53°F.

Thiokol management initially supported its engineers' recommendation to postpone the

launch, but NASA staff opposed a delay saying that they were appalled by Thiokol's

recommendation to postpone launch. "Larry Mulloy, Marshall Space Centre Manager said,

"My God, Thiokol, when do you want me to launch — next April?"

NASA management suggested that if the primary O-ring failed, then the secondary O-ring

would still seal. The engineers contested saying that it was unproven. Mulloy quoted data

from a previous successful launch in April 1985, where the association of low temperature

with blow-by on a field joint was a condition that was considered "an acceptable risk".

With this Mulloy accused Morton Thiokol of attempting to establish new Launch Commit

Criteria at 53°F the night before a launch. Bob Lund an engineer was then asked to "take

off his engineering hat and put on his management hat" by one of the vice presidents of

NASA. Boisjoly tried again with charts and pictures to plead his case, but to no avail.

Four managers made the unanimous decision to go ahead and launch Challenger.

After several abortive launches instead of bringing Challenger back from the launch pad it

was left out for total of 27 days.

These are the pictures taken on the day Challenger launched; it turned out to be the

coldest launch day ever. Temperatures' were at 53°F (11.6°C).

On Tuesday 28th January 1986 at 11.38 Challenger STS-51L (STS = Space

Transportation Systems) was launched. As the vehicle cleared the tower Bob Ebeling

whispered "we've just dodged a bullet" the engineers thought that the failure of the O' ring

would result in an explosion immediately after ignition. 73 seconds of glory.... that was all

NASA had before they witnessed the horror of the destruction visible for all to see high in

the sky. . An explosion occurred as a result of a leak in one of two Solid Rocket Boosters

that ignited the main liquid fuel tank.

NASA as an organisation had failed, they did not listen!

The major problem with NASA was that there was:-

Too much management and not enough leadership

Too little empowerment and people felt as though they were bullied

There were appalling communications within NASA, there was fear of escalation

people were scared of whistle blowing

There was not one vision, everyone just protected their own backs and their own

department

Complacency

Looking at the various factors that have been highlighted, had the temperature not been as

low as 53°F, perhaps the O-rings would not have failed.

Had there been more discussion at a higher level regarding the decision to launch or not to

launch been taken this would not have happened.

Had higher management listened to the engineers about the problem with the O-ring this

would not have happened

A combination of the active failures of management coupled with the latent failure of the

equipment resulted in the lost off seven lives.

The Swiss cheese model of how defences, barriers, and safeguards may be penetrated by an accident trajectory

Failures in communication... resulted in a decision to launch STS 51-L based on

incomplete and sometimes misleading information, a conflict between engineering data

and management judgments, and a NASA management structure that permitted internal

flight safety problems to bypass key Shuttle managers (Rogers Report, 1986)

As well as poor communication, there was poor technical decision making over several

years between NASA and Morton Thiokol who failed to act decisively to solve the

problems with the O-rings in the SRB's

The culture within NASA was such that when decisions are made, they are made by

groups of individuals in order to avoid accountability, a shared rather than individual risk

taking, this attitude damaged the organisations management system so much so that

irresponsible decisions were made which cost not only lives but reputations.

In the words of Grace Hooper, the Navy's grand speaker for innovation said "one should

act and avoid knowledge of the consequences; and remember it is easier to ask for

forgiveness, than it is to get permission.

After the accident NASA embarked upon major management reforms. Sadly the changes

made the launches look almost too safe and as a result over the subsequent years quality

and relationships slipped once more.

Then in February 2003 - Space Shuttle Colombia burns up on re-entry and the entire crew

perish. The chilling fact was that this was a management repeat of the Challenger disaster

- NASA had not truly learned the lessons of the past!