...EH&S Leadership At All Levels It Starts With You Workshop Pre-Reading The Fatal Flaw In Flight 51-L Contents Instructions 3 Study Questions 3 The Fatal Flaw In Flight 51-L 5 Challenger's final hours 6 The history of the flawed joint 7 Certified in spite of the flaws 8 Accepted as acceptable 9 The lesser of two evils 9 The problems grow worse 9 Anatomy of a tragedy 10 Why wasn't the design fixed? 11 Why wasn't erosion seen as a danger sign? 11 Operational and then what? 12 Why no second sources? 12 How did NASA and Thiokol view the odds? 12 What role did NASA's safety office play? 13 Was NASA or Thiokol pressured to launch? 14 Why didn't they talk to each other? 14 How about NASA's past success? 15 What lessons have been learned? 15 Defining terms 16 Figures Figure 1: The Launch Decision Chain 17 Figure 2: Anatomy Of A Booster Field Joint 18 Figure 3: Joint Rotation 18 Figure 4: Titan Joints vs. Shuttle Booster Joints 19 Figure 5: Joint Putty 19 Figure 6: O-Ring Distress 20 Figure 7: Joint Distress vs. Temperature At Launch 20 Figure 8: 7/31/85 Memo, Boisjoly 21 Figure 9: 10/1/85 Memo, Ebeling 22 Figure 10: 10/1/85 Memo, Stein 24 Figure 11: 10/4/85 Activity Report, Boisjoly 25 Instructions On the first day of the workshop, we will discuss the management system failures associated with the Space Shuttle...
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...Organizational Dynamics, Vol. 33, No. 2, pp. 128–142, 2004 ß 2004 Elsevier Inc. All rights reserved. www.organizational-dynamics.com ISSN 0090-2616/$ – see frontmatter doi:10.1016/j.orgdyn.2004.01.002 Lessons in Organizational Ethics from the Columbia Disaster: Can a Culture be Lethal? RICHARD O. MASON ‘‘Houston We Have a Problem.’’ A Message Never Sent or Received. On February 1, 2003, the Space Shuttle Columbia, on its way to its landing site in Florida, blew apart in the skies of East Texas. Its seven-member crew perished. The $2 billion ship was lost; some destruction occurred on the ground, and considerable cost was incurred to recover debris scattered over several states. The disaster sounded an eerie echo from the past. Seventeen years earlier the shuttle Challenger exploded 73 seconds into flight due to an O-ring malfunction. All seven crewmembers were also lost. And, about 11 years before that, the cabin of Apollo 1 burst into flames on its pad. Three crewmembers were killed. Within a day, as NASA policy requires, an internal investigation team of six ex officio members was formed. Harold Gehman Jr., a retired admiral who was NATO supreme allied commander in Europe, was appointed to chair it. A veteran of several military investigations, including the bombing of the U.S. Cole, Gehman, in an initially unpopular move, broadened the inquiry to include the agency’s organization, history and culture. Sean O’Keefe, NASA’s administrator, was incensed that the investigation...
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...concerns to management about the reliability of the O-Rings being used on the space shuttles but a review committee concluded that they were safe to use and if a problem did arise there were secondary O-rings in place. In the flights leading up to the challengers departure, there was evidence that there were serious problems with the O-rings. On the eve of the launch, the weather forecast was unusually cold for Florida weather, with temperatures in the low twenty’s. Thiokol expressed concern that the O-rings would not work properly in the cold weather. But the communication was unsuccessful because the engineers had no data to quantify their concerns. There was two telephone conferences were held between Thiokol, Marshall SFC and Kennedy Space Center, where the engineers expressed their concerns however there was a breakdown in communication when Kilminster asked for the Thiokol engineers and managers to go off line. While...
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...NASA Ill-Equipped For Disasters NASA was ill-equipped to deal with the problems that led to these disasters because of its organizational structure, organizational culture, and lack of support from POTUS. NASA’s established merit system of being known as a “civil service” created a since of duty. This duty in its recent years was greatly wanted because of the Apollo mission to the moon. Thus, scientist were willing to work not for what they are worth but, for the position and status it represented. In the later years NASA’s merits system crumbled because people were no longer interested in NASA. This organizational structure along with the “turning the blind eye to technical failures” culture that was emerging in NASA made it ill-equipped to deal with problems that arose during the Challenger and Columbia missions. NASA without the full backing of POTUS in their missions would be doomed from the start because it also lacked public and congressional approval. Thus, being susceptible to the OMB for more slicing and dicing of the budget. Leaving NASA to make the best product with what they had. It was like Mcguever building the six-million dollar man off a paper clip and duct tape. This coalition with the decentralization of duties where each industry would have a job to do but no communication was given within the infrastructure. Created a Sisyphean task of overlapping duties. The duties were distributed over 6 agencies that had to do with, launching, R&D, Astronomy, environmental...
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... When I was four years old, I scared my mother by telling her that one day I was going to be an astronaut. I had stars that glowed in the dark scattered all around my room, I was obsessed with the idea of anything that related to going somewhere new, with the mechanics of how planes could fly, and how something could zoom off into space. I remember my dad waking me up and taking me out to see a meteor shower one cold night, asking what they were and instead of receiving the answer “shooting stars” my father explaining to me how friction causes the object to get hot and burn. When I got a little older I realized that I was in fact, too short to be an astronaut. At the same time this was happening though I was getting ever more involved with the different breeds of robotics with which I had gotten entangled. I had done FIRST Lego League in elementary school before moving to VEX and finally to FIRST robotics. I loved it the whole time, entranced with the little moving parts and the idea that they all worked together to create something that could fly. I started building cars with my school’s Electric Race team. I looked at the Aerodynamics and saw how the wind was flowing over. It was through FIRST and race team in which I learned CAD and got to see flow design - a wind tunnel simulator. I spent a week drawing up airfoils because I thought it was cool to be able to see the pressures above and below the wing and was excited to study fluid dynamics in my physics class this year because...
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...equipment and eliminates disturbances in the power such as spikes, undervoltages (dips and sags), outage flicker, and transient noise which can affect system performance. This significantly increases reliability of electronic equipment using AC power. Programs Which Certify Use: Crawler Transporter, Orbiter Processing Facilities, Launch Processing System. Center to Contact for More Information: Kennedy Space Center (KSC) Implementation Method: UPS can be used where loss of power during an operation is considered critical or where loss of power may cause extensive equipment damage or data loss. Technical Rationale: An UPS typically does two things: (1) It either provides power to enable the safe shutdown of equipment and saving data to a nonvolatile medium, or (2) it provides power to equipment over the duration of fault/failure, enabling equipment to operate continuously. Safe shutdown is completed through embedded programming that communicates KENNEDY shutdown protocol to the user and/or initiates shutdown procedures automatically SPACE at the point of fault/failure. Continuous operation is primarily a function of load CENTER draw and battery type and size. PRACTICE NO. GSE-3009 PAGE 2 OF 10 Uninterruptable Power Supply (UPS) Systems There are a variety of end-user UPS...
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...Jordan Jones Cady 1A ENGL 101 CC 8 March 2013 The Power in Words Speeches can be one of the most difficult things to write and present. Anyone can give a speech about anything, but not all of them are going to be amazing. Actually, speeches are one of those things that not everyone is going to feel the same about. One person could think that the speech was great and it changed their life, while another person could absolutely hate that same speech. Most speeches are given to persuade your audience to believe whatever it is that you believe. The speaker wants them to agree with what they are saying. The President of the United States has a huge job when it comes to public speaking. They are addressing a whole country that is looking to them for their opinion, advice, or guidance. Even though not every citizen in the country is going to agree with what the president is saying, it is usually over an important issue, so the president is completely aware that everyone will be listening. On January 28, 1986, while Ronald Reagan was serving as president, the country experienced a huge tragedy when the Challenger space shuttle exploded on live television. It wasn’t really an event that words could describe, but as the president, Reagan had to try. Through the use of ethos and pathos, President Reagan’s speech attempts to persuade America and the viewers of the Challenger explosion that despite the tragedy, the United States and its space program will continue to move forward...
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...October 14, 2015 OSCM 3322 Midterm Challenger Disaster On the morning launch of the challenger on January 28th, 1986, at approximately 9:41am an unexpected event happened. The shuttle, within 75 seconds of taking off, exploded in the air. Citizens and NASA staff were shocked and confused as to what they had just seen, but there was a small group knew this type of problem could occur. They had little evidence but still chose to launch that day, now worrying about the events that will transpire thereon. Many questions as to why the shuttle had exploded arose such as, “What caused it to malfunction?” “Was there any known facts before the incident?” And if so, “why was there no action taken?” Unfortunately, some of these questions were addressed and brought to a few personnel in top management positions such as managers, vice presidents, supervisors, and engineers. One of the main issues was the failure to communicate the problem of the O-rings in a timely manner. The fact that they waited until the night before the launch to discuss the problems that the seals were causing, was an obvious point leading us to believe that the organization of communication within the chain of command was faulty. Another issue was that Larry Mulloy saw the data that Roger Boisjoly and Arnold Thompson provided, lacked details to support their theories. In all retrospect, they were the ones who had done the research and work that lead them to their conclusions. It was obvious that they knew...
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...so specific, it has to be calculated exactly to match the constant movement of other objects in space. That serves multiple reasons. First, to avoid collisions and, second, to take the gravity of other objects in space into account to make sure the spacecraft is following the predetermined path [trajectory] exactly right. Much of the path determining is done at the launching process; the rocket that delivers a satellite into space sets its future trajectory which can only be altered minimally at the later stages. “Preparing for the flight was a long and complicated process that took several stages, and years of research before we even started talking about the execution of the mission,” says the operations director of the mission control center. “Additionally to calculating the safe orbital path which the exploration shuttle would follow, we also had to take into consideration what is called space weather which can be summarized as conditions in space characterized by the levels of electromagnetic radiation and the number of charged particles emitted as a result of solar activity or incoming from outside of our solar system. [4] Such conditions can take form of a solar wind, i. e. the stream of charged particles coming off of the sun’s surface. [5] As a result of twisting of the sun’s magnetic field triggered by the differential rotation of the field, the magnetic field lines can form loops lead to breakouts of plasma off the chromosphere. Alternatively, it can be galactic cosmic...
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...and Roger Boisjoly to whom we are thankful. Many lessons can be learned from this disaster to help prevent further disasters and to improve on organizations ethics. One of the many key topics behind the Challenger disaster is the organizational culture. One of the aspects of an organizational culture is the observable culture of an organization that is what one sees and hears when walking around an organization. There are four parts to the observable culture, stories, heroes, rites and rituals and symbols. The first one is stories, which is tales told among an organization’s members. In the Challenger Space Shuttle incident there were mainly four organizations thrown together to form one, Morton Thiokol, Marshall Space Flight Center, Johnson Space Center and NASA Headquarters. All of these organizations had the same type of stories to be told. At Morton Thiokol, they talked about their product and their big deal, which they received from NASA. At NASA, it’s members retold stories of the previous space missions and being the first people to have landed on the moon. Second are their heroes. At Morton Thiokol, their heroes might have been the founders of the organization or it’s top executives like Charles Locke or Jerry Mason. At NASA, their heroes might have been Neil Armstrong, staff or any members of the organization. All of these people that were chosen to be heroes set the standards for that organization and conducted themselves for others to follow. Third are the rites and...
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...Before or during a disaster, it is a challenge and important to communicate correct information clearly to the target audience. Such efforts are taken for granted because we communicate every day. Communicating is very important in the prevention of disasters and reaction to an emergency. Often time’s communication plays a big part, but is placed in a small window of opportunity to gain a response from a small or large group. When lives are at stake, communication should take lead focus in the efforts to prevent disaster. Communication is a two way street. A speaker usually focuses on the information they want to get across. A listener may understand the message, understand a portion, or miss the message all together. This occurrence played out in the disaster of spaceship Challenger and Columbia. In comparison, the communication issues that happened in both Challenger and Columbia are very similar. Even with NASA’s advanced technology, engineers and political backing failed in communicating flaws of productions elements. A contractor in the Challenger camp, Thiokol failed to address flaws in the O –rings in 1977 and engineers disregarded potential launching in colder temperatures. Many years later NASA disaster struck the space program again. Space shuttle Columbia went down in flames over Texas. The disaster was debated because in multiple meetings before launch, potential problems were not communicated or the frequency in which the problem were occurring...
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...Introduction Sometimes disasters happen without any of the control of others. These are what is labeled as natural disasters. Others happen under the control of the leadership of those involved. These are what is known as accidents. I will be analyzing the leadership and control of that of the devastating Columbia space shuttle disaster, as it pertains to the lack of leadership and communication of those involved. Relevancy of Leadership Leadership is necessary in all situations. It is especially essential in the case of accidents. The question I have to ask is why did this incident become an accident? What could have been done to prevent this disaster from happening? Was NASA aware of the possibilities of this space shuttles’ vulnerability? Throughout the course of this analysis, I will attempt to find these answers within the referenced article “Self-evaluation tool: Key lessons from the Columbia Shuttle disaster (adapted to the process industries).” Throughout the report from the article, the Columbia Accident Investigation Board (CAIB) is mentioned in the discussion regarding the evidence of the space shuttle catastrophe. In fact, they organization was formed specifically for this case. There are several mentions of the space shuttles vulnerabilities that possibly could have been prevented with a more thorough process and leadership from within the development team of the space shuttle and procedures. The article specifically mentions this as one of keys to maintaining...
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...the accident. 3. NASA managers had known contractor Morton Thiokol’s design of the SRB contained a potentially catastrophic flaw in the o-rings since 1977. 4. NASA disregarded warnings from engineers about the dangers of launching posted by the low temperature of that morning. 5. The ROGER”S commission offered NASA 9 recommendations that were to be implemented before shuttle flight resumed. 6. The o-rings had no test data to support any expectation of successful launch in such conditions. 7. Challenger was originally set to launch from Kennedy space center in Florida at 2:42 EST Jan 22. 8. Launch was delayed 1st to Jan 23 then 2nd to Jan 24, 3rd to Jan 25 due the bad weather at the TAL site in Senegal. NASA decided to use Casablanca as TAL site but it wasn’t equipped for night landings so they had to move it to the morning to Florida. 4th to Jan 27 9:37 as of unaccepted weather at Kennedy space center and5th to Jan 28 as by problems with the exterior access hatch. 9. Delayed 5 times shows lack of good decision making and management of NASA’s managers. 10. Morton Thiokol is the contractor responsible for the construction and maintenance of the shuttle’s SRBs. 11. Rockwell international is the shuttle’s prime contractor. 12. Jan 28th forecast predicted an unusual cold morning with temps close to 31f (-1 c) , that’s the minimum temp. Permitted for launch. 13. Roger Boisjoly and some engineers of Morton Thiokol expressed their concern about...
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...TABLE OF CONTENT Executive Summary…………………………………….. 3 Introduction……………………………………………… 4 Mechanical Problems……………………………………. 4 Administrative or Management Problems………………. 5 Weather conditions and delays…………………………... 5 Communication Problem ……………………………….. 6 Organizational Pressure…………………………………. 6 Using of reusable part…………………………………… 7 Recommendations………………………………………. 8 Conclusion………………………………………………. 9 Bibliography…………………………………………….. 10 Executive Summary This Report attempts to unfold the management flaws and terrible decision making that marked the morning of the 28th of January 1986 as a terribly tragic disaster. What it sadder is that this disaster was mainly due to inhumane practices conducted by the NASA and the management bodies of companies associated with this project than natural reasons. The whistleblowing led to the loss of billions of dollars and more importantly loss of 7 innocent lives. The space shuttle was propelled by the two attached Solid Rocket Boosters (SRBs) and an external fuel tank. The SRBs were joined to the External Tank. aOnce the SRBs ignited, hot gases heated the rubber O rings and they eroded to seal the joints. SRB joint design had a serious flaw in it and the engineers knew it meant a catastrophe and yet they passed the design for flight. The O rings worked only down to a temperature limit of 12 ̊ C, but the morning of the launch saw temperatures as low as -1 ̊ C which was much lower than the prescribed limit. Many engineers voiced to...
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...MK 620 Yafei Liu 11/16/2014 A Lesson from American Apparel On July 3, 2014, American Apparel, an American clothing brand posted an image of the 1986 space shuttle Challenger’s explosion on its Tumblr account with tags of “smoke” and “clouds”. The photo was supposed to be a celebratory post of the Independence Day, but it became a social media crisis of American Apparel since the image of the explosion was mistaken for fireworks by the one who edited and posted the image (Kleinberg, 2014). Observers on Twitter and Tumblr immediately recognized the photo and blamed the insensitivity of the brand. Some people even speculated about whether the company intentionally stoked the controversy, which it has done before in order to make people talking about the brand (Torossian, 2014). Within an hour after the photo was posted, American Apparel removed it and issued an official apology on its Twitter account. According to its post, the photo was mistakenly reblogged by an international social media employee, who is too young to remember the Challenger’s explosion. The reactions from public were mixed with both positive and negative responses. However, most people didn’t think the apology was acceptable, especially the excuse of why the photo was showed on the account (Torossian, 2014). Many people argued that the photo’s origin should have been investigated before being posted, and claimed the age of the social media manager was not an excuse for unknowing the tragedy...
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