Challenger Launch Decision

• Author: Diane Vaughan
• Publisher: University of Chicago Press
• Publication Date: 2016

Preface:

• The Challenger disaster is one of those rare events that bound together diverse people in a moment of shared anguish
• Disaster is remembered as a technical failure
  • Fault lay with rubber-like O-rings
  • O-rings were designed to seal up tiny gaps in the solid rocket boosters
  • Cold weather impaired the resiliency of the O-rings
  • When O-rings failed, hot exhaust gases from the solid rocket booster impinged on the large external fuel tank
  • Fuel tank failed causing loss of crew and orbiter
• However, the NASA organization was also implicated
  • O-ring problem had a long history at NASA
  • Documents detailing problems with the O-rings date back to 1977, 4 years before the first shuttle flight
  • Presidential commission investigating the disaster found that there was a midnight teleconference the night before the launch where Morton Thiokol (the manufacturers of the SRBs) warned against the launch
• So given that Thiokol warned against the launch and that the O-ring issue was well known, why did NASA proceed with the launch?
• House committee investigating the incident and journalists crafted a narrative explanation involving production pressure and managerial wrongdoing
  • NASA had been undergoing enormous stress
  • Managers were under pressure to stick to a launch schedule, in order to secure funding for NASA
  • Managers flouted internal NASA rules which called for information to be passed up the chain, ensuring that top administrators did not have the information they needed
• This model explains the actions of top administrators, but does not explain the actions of low and mid-level managers
  • Why did they choose to proceed with the launch, despite having all the information?
  • This question went unasked and unanswered as people came to accept the explanation in the press that production pressures caused NASA officials to withhold information that would have stopped the launch
• This book contradicts that conventional explanation
  • Presents evidence that contradicts the conventional explanation
  • Seeks to answer the question: "Why did NASA, in the years prior to the launch, choose to proceed with a design known to be flawed?"
• Books seeks to circumvent hindsight bias - tries to present technical choices as they appeared to participants at the time, not as they were seen later on
• Portrays a gradual descent into poor judgment
• Shows that signals of potential danger were normalized prior to 1986
• This normalization proceeded according to social forces and environmental contingencies which impinged upon the organizational structures and culture of NASA
• This affected the worldview of NASA engineers and managers as they were making decisions and how the processed information regarding the booster joints
• While production pressure did have a role in the tragedy, it was not the role that most press accounts assign to it
• This book shows how mistake, mishap and disaster are systematically produced by social forces
  • Shows how people doing their jobs properly can still contribute to a disaster
  • Show how scientific paradigms are constructed and how they persist even in the face of growing evidence to the contrary
  • Shows how incremental decisions in organizations can contribute to dramatic disasters
• In addition to that, the book demonstrates the macro/micro connection - showing how macroscopic forces in an organization contribute to individual day-to-day decisions that people make
• The goal of this book is to show that harmful accidents can occur in organizations specifically built to prevent them from occurring, even when everyone in the organization is honest, conscientious, and ethical

Chapter 1: The Eve of the Launch

• Challenger was originally scheduled for launch on January 22, 1986
• Crew
  • Richard Scobee - Commander
  • Michael Smith - Pilot
  • Ellison Onizuka - Mission Specialist
  • Judith Resnik - Mission Specialist
  • Ronald McNair - Mission Specialist
  • Christa McAuliffe - Payload Specialist
  • Gregory Jarvis - Payload Specialist
• Officially known as STS-51L
• Christa McAuliffe was a teacher, and was going to teach lessons from orbit, hence this mission was nicknamed as the "Teacher In Space" mission
• Although the launch was originally scheduled for January 22, it was "slipped" to January 26 to accommodate the launch of Columbia (STS-61C)
  • STS-61C set a record for launch delays by having 7 launch delays over a 25-day period
  • Originally scheduled for December, didn't actually launch until January 12
• Challenger launch was coordinated by a 4-tier management chain at NASA
  • Level 1: Jesse Moore: Associate Administrator For Space Flight (NASA HQ, Washington)
  • Level 2: Arnold Aldrich: Program Manager - Johnson Space Center (Houston)
  • Level 3:
    • William Lucas - Director - Marshall Space Flight Center (Huntsville)
    • Stanley Reinartz - Manager - Shuttle Projects Office, Marshall
    • Lawrence Mulloy - Manager - Solid Rocket Booster Project, Marshall
  • Level 4: Alan McDonald - Director, Solid Rocket Motor Project, Morton Thiokol (Utah)
• On January 26, countdown activities were terminated because the forecast showed unacceptable weather conditions
• On January 27, the countdown was terminated because of micro-switch indicators that showed that the exterior hatch locking mechanism had not closed properly
• NASA personnel first became concerned about cold temperatures at around 1:00pm on January 27
  • Forecast was unusually clear and cold for Florida, with temperatures dropping into the low 20s
  • Marshall's Larry Wear (SRM manager) asked Morton-Thiokol Wasatch (Utah) to review possible effects of cold on the performance of the SRM
  • This request was handled by Robert Ebeling, Ignition Systems Manager
  • Ebeling convened a meeting, and Thiokol engineers expressed concern that the O-rings would not be able to seal after being exposed to such cold temperatures
• A 3-way conference call was scheduled between Kennedy Space Center (KSC), Marshall and Morton Thiokol for 5:45pm EST -- during this call, Morton Thiokol expressed the opinion that the launch should be delayed until noon or later
• Another conference call was scheduled for 8:15pm EST, to allow Morton Thiokol to fax over engineering data and to allow more people to join the conference
  • In this conference call, Thiokol engineers presented their opinion that O-ring performance would be worse than the coldest launch to date (1985 mission, where the O-ring temperature was 53F)
  • On that mission, hot exhaust gases had blown past the primary O-ring, however the secondary O-ring had done its job and sealed the booster joint
  • Thiokol VP of Engineering Robert Lund's opinion was that at O-ring temperatures colder than 53F, the ability of the O-rings to seal would be compromised
  • NASA asked Thiokol management for a recommendation -- VP Joe Kilminster agreed with the engineers and said that he could not recommend launching at any temperature below 53F
  • NASA immediately began challenging this assertion
  • Mulloy argued that there had never been Launch Commit Criteria on O-ring temperatures, so Thiokol was, in essence, creating new Launch Commit Criteria on the eve of a launch
  • Reinartz asked Deputy Director of Science and Engineering George Hardy for his opinion -- Hardy concurred with Reinartz and Mulloy and said that he was "appalled" at Thiokol's recommendation
  • Mulloy asked, "My god Thiokol, when do you want me to launch? April?"
  • Reinartz asked Kilminster for his comments; Kilminster requested a 5 minute offline caucus
    • 5 minute caucus stretched to 30 minutes
    • During this caucus, Thiokol Senior Vice President Jerry Mason said, "We have to make a management decision," excluding engineers from the decision-making
    • Thiokol engineers Arnie Thompson and Roger Boisjoly presented the case against launching once again to the Thiokol management team
    • 4 Thiokol Vice-Presidents voted -- Robert Lund initially voted against the recommendation to launch, but was asked by Mason to "take off your engineering hat and put on your management hat"
    • Lund then voted for the recommendation to launch
  • After the offline caucus was over, Thiokol rejoined the conference call with KSC and Marshall
    • Kilminster said that Thiokol had reconsidered, and read a revised engineering analysis supporting launching
    • Mulloy asked Kilminster to fax the engineering analysis to Marshall and KSC
  • The second teleconference ended at around 11:15pm EST
• After the second teleconference, Mulloy and Reinartz phoned Aldrich about ice buildup on the launchpad and the status of the recovery ships for the SRBs
• Did not inform Aldrich about the teleconference with Thiokol and KSC meeting broke up around midnight EST
• At 1:30am EST the Ice/Frost inspection team assessed the ice buildup on the launchpad and alerted Rockwell to study the effects of ice buildup on the orbiter
• At 5:00am the next morning, Mulloy and Reinartz told William Lucas and James Kingsbury, head of the Science and Engineering Department, about the teleconference with Thiokol
• At 7:00am the ice inspection made a second inspection -- launch time was slipped to allow for a third round of inspections
• At 8:30am the Challenger crew were strapped in
• At 9:00am the Mission Management Team met with NASA and contractor representatives to assess launch readiness and the ice situation
  • Rockwell representatives expressed concern about the possibility of ice ricochets hitting the orbiter
  • Mission Management Team noted the concerns and voted to launch
• Terminal countdown began at 11:25am
• Orbiter was launched at 11:38am on January 28 1986
• A fireball erupted 73 seconds later and the orbiter disappeared into a huge cloud of smoke
• The SRBs careened out of control and were destroyed by an Air Force range safety officer at T+110 seconds
• All seven crew members perished

The Search For An Explanation: Creating History

• In February, President Reagan established a commission (Rogers Commission) to investigate the Challenger disaster
• NASA had already started its own investigation into the matter
• Initially, the Rogers Commission saw its role as one of collaborative oversight
• Commission began hearings on Thursday February 6, 1986
  • Initially, the commission reviewed evidence from NASA about the current state of the NASA investigation
  • Initial NASA testimony to the commission downplayed the role of the O-rings, by noting that while erosion of the primary O-rings had been observed, erosion of the secondary O-rings had never been been observed
  • However on Sunday, February 9, the New York Times published leaked documents that called the O-rings into question, stating that seal erosion had occurred 12 times, and that on one occasion the secondary O-ring had been eroded
• After the NY Times story, the Rogers Commission held a closed session
  • Questioned NASA personnel from Marshall Space Flight Center and Morton Thiokol
  • Discovered true extent of O-ring erosion
  • Found out that initially Morton Thiokol had recommended against the launch
• At this point the Rogers Commission switched from oversight to confrontation
  • Requested that no one involved in the decision to launch Challenger participate in the NASA investigation
  • Immediately shifted focus to O-rings as the primary subject of investigation
• In June the Presidential Commission revealed its report
  • Identified O-rings as the primary cause of the disaster
  • O-rings and zinc chromate putty insulation failed due to unprecedented cold temperatures at launch
  • Combustion gases blew past primary O-ring and impinged upon secondary O-ring, which in turn failed
  • Commission concluded that effects of design, re-usability, temperature and the dynamic loading of the joint combined to cause the joint to fail
  • Also identified organization factors that contributed to the failure
    • Long history of problems at NASA with O-ring joints
    • Documented NASA teleconference described above, where NASA administrators discussed the potential of problems with the SRB joints with Thiokol, but then decided to proceed with the launch anyway, and didn't notify their superiors about the teleconference with Thiokol
  • The Presidential Commission faulted the decision-making process itself rather than individuals
    • Inadequate procedures for reporting problems
    • Faulty information flows
  • However the Presidential Commission failed to answer why NASA managers who did have access to all the relevant information about the O-rings decided to proceed with the launch
• In October 1986, the U.S. House of Representatives Commission on Science and Technology published a report on the Challenger disaster
  • Echoed many of the findings of the Presidential Commission
  • However the House report placed blame on individuals, rather than the decision-making process
  • Placed blame on NASA and contractor personnel who failed to act to solve anomalies with the SRB (without naming names)
  • Suggested that these personnel were not qualified for their jobs
• However the facts and narrative in the House report and the Rogers Commission report suggested an alternative explanation: launch schedule pressure

Pressure To Launch: The Media, The Teacher in Space and The State of the Union

• In the initial aftermath of the tragedy, many analysts and journalists looked to circumstances unique to the Challenger launch to explain the disaster
• Initially they focused on the media attention on the Challenger launch
  • Media pressure
    • The previous launch, Columbia had been postponed a record 7 times
    • Every delay had received a lot of attention from the press
    • However, it makes no sense that NASA managers would push ahead with a launch and risk the worst case scenario -- loss of crew and mission -- in response to media pressure
    • In addition, media attention accompanied every shuttle launch -- by this point, NASA should have been accustomed to dealing with media attention
  • Pressure from the Reagan administration
    • The flight of the Challenger had political ramifications
      • Teacher in space was meant to show that space flight was routine enough for the US that even an "ordinary citizen" could go into space
      • State of the Union address was scheduled for January 28, the first night of the Challenger mission, and it was speculated to contain a mention of the Teacher In Space mission
    • However the Presidential Commission found no evidence that the White House contacted NASA to pressure them to launch
    • In addition NASA procedures, in general, did not allow communications hook-ups until at least 48 hours after launch, in order to give the crew time to become acclimated to space
  • Pressure from NASA PR
    • Did NASA PR pressure for a launch, in order to get the Teacher In Space mission included in the State of the Union?
    • However, the Teacher In Space mission was not slated to be in the State of the Union address
    • Even without mention of the Teacher in Space mission, all of NASA's priority items were to be mentioned
    • Moreover if the launch had gone well, the mission would have been a PR coup for NASA, more than compensating for the lack of inclusion in the State of the Union address
    • There was no evidence that NASA engineers or managers responsible for the launch knew about the PR ramifications of a successful launch
• As it became apparent that Challenger was a typical Shuttle mission, attention expanded to look at pressures on the shuttle program as a whole
  • For NASA, the desire for a positive public image was the result of a continuous struggle for funding
  • The Shuttle had suffered from economic problems throughout its history
  • Economic calculation pervaded every part of the NASA organization
  • Many sources acknowledged that economic strain translated into "production pressure"
  • Commissioner Feynman summed it up by stating that no one had to be told explicitly what to do -- everyone knew the pressures the shuttle program was under and adjusted their decision-making accordingly
  • Implied there was a causal connection between the environment of scarcity and competition and the decision to launch
  • The narrative was that NASA knowingly made a series of cost/safety trade-offs in order to gain secure and maintain funding for the Shuttle program

The Structural Origins of Disaster: Competition, Scarce Resources and the Shuttle Program

• From NASA's inception, the space agency played a central role in competition for international supremacy
• Government was dependent on NASA for military and scientific advances in space until mid-80's
• Although every administration was concerned about NASA's achievements in space, willingness to fund NASA waxed and waned with changing circumstances
• NASA secured generous funding from John F. Kennedy as the US was concerned about the political consequences of Laos, Congo, the Bay of Pigs and Sputnik
• Widespread American concern about the US "falling behind" created an environment of institutional consensus, making NASA the preferred vehicle for national and international prestige
• With the triple luxuries of generous funding, institutional consensus and a clear goal, NASA rapidly progressed and, in 1969, managed to get US astronauts to the moon
• However, even before the end of the Apollo program, there were questions being raised about the future direction of the space program
• The Vietnam War and economic issues displaced the space program as national priorities, with consequent declines in funding for NASA
• The Space Shuttle was born in this newly uncertain era for NASA, which was bereft of a clear mission after the moon landing
• In order to justify its continued existence, NASA proposed three missions, whose goal was the long-term presence of humans in space:
  • Mission to mars
  • Space station
  • Space shuttle to transfer crew and cargo from earth to the space station
• The combination of these three missions was designed to promote national interests and secure NASA's position as a powerful agency
• However, almost immediately, there was push-back on the basis of cost
• Post-Apollo funding cuts caused NASA to back off from the Mars mission and the space station and focus on the space shuttle
• Space shuttle was designed to be a reusable low-cost launch vehicle that would be the nation's sole facility for launching astronauts and satellites
  • It's so sad, in a way -- the Space Shuttle was trying to be what SpaceX is
• Space Transportation System (as the Shuttle was formally called) envisioned a set of "space buses" that would cheaply ferry astronauts and supplies to space, and lay the groundwork for permanent space stations and future space missions

Scarce Resources and Compromised Excellence

• Although NASA was a civilian agency, in order to secure support for the Shuttle, it found it expedient to secure an alliance with the military
• Positioned the Shuttle as the single launch systems for all payloads, civilian and military
• NASA and the Air Force struck a deal: in exchange for designing the Shuttle to carry Air Force payloads, the Air Force agreed to support the Shuttle program in Congress and not develop launch capability of its own
• From the outset, the shuttle was plagued by budget issues
  • NASA called for a shuttle with roughly 10 billion dollars of initial development cost and 2 billion dollars of ongoing costs
  • This was challenged by the Office of Management and Budget, which criticized NASA for designing a "Cadillac" space shuttle
  • However, the cost was necessary because the Air Force required a high-performance launch vehicle
  • In order to determine whether the Shuttle was feasible to build, NASA asked an outside think-tank to research the issue
  • Mathematica Inc determined that the Shuttle would be feasible if it had a launch rate of more then 30 flights a year -- this was considered feasible in 1971 [1]
  • The Mathematica study strengthened NASA's case for building the shuttle, but Congress allocated only half of what NASA requested
• Design trade-offs: From Cadillac to Camel
  • Power struggles between Congress, NASA, OMB and the White House directly affected the Shuttle design
  • Design process was characterized by trade-offs between development costs and operating costs
  • Trading off development costs for operational costs was justified by the fact that operating costs would be offset by revenue from commercial launches
  • Most initial ideas for lowering development costs involved the use of an expendable booster
  • However, given the large size of the Shuttle this was technically difficult
  • The breakthrough idea was to have a smaller orbiter that could be launched with two reusable Solid Rocket Boosters (SRBs)
  • Both liquid fuel and solid fuels were considered for the booster, but liquid fuels would have higher development cost and lower operating cost, cutting against the grain of the overall Shuttle program
  • In addition, liquid rocket boosters would take longer to refurbish, which would cut into the 30 flights per year that Mathematica set out as a requirement for financial viability
  • NASA's restricted budget necessitated further trade-offs, some apparently trading safety for cost
    • The Space Shuttle was the first NASA launch vehicle without escape rockets
  • The Shuttle program was pulled in contradictory directions
    • Congress: cost recovery
    • OMB: low development costs
    • Air Force: operational capabilities
    • NASA: Manned spaceflight
  • The final design of the Space Shuttle was characterized as a "camel" -- it was a compromise design that represented the best NASA could do given the constraints it had been given
• A Bitter Bargain
  • As a result of this compromised design process, NASA, ironically, had to argue for a vehicle that it really didn't want
  • Nevertheless, NASA leaders made the best case they could for the Shuttle
  • Promised 60 flights a year
  • Argued that the Shuttle would attract enough commercial launches to be mostly self-supporting
    • Pro tip: whenever a government official says that a government program will be self-supporting, they're either deluded or lying
    • If it were self-supporting, government wouldn't need to do it
    • Argued that the shuttle would be able to launch 65,000 pounds per flight at a cost of 100 dollars per pound
    • Argued that higher than forecast operating costs would be offset by a larger number of launches
  • In 1972, President Nixon authorized the development of the Space Shuttle
  • NASA divided responsibility for the Shuttle program as follows
    • Johnson Space Center in Houston got responsibility for the Orbiter
    • Marshall got responsibility for the propulsion system
      • Main engines
      • External fuel tank
      • SRBs
    • Kennedy Space Center got responsibility for final assembly and launches
  • The Shuttle program was funded, but at a cost -- program viability was dependent on the Shuttle being able to meet a launch schedule
  • This built production pressure into the program from its very inception
  • These pressures were compounded by further budget cuts pursued by OMB during the Shuttle's development phase
  • As a result of these cuts, the shuttle fleet had to be reduced from 5 to 4
  • This meant that any potential delays or problems had a much greater impact, because there was much less slack in the system to absorb potential delays
  • In another move to economize, NASA cut safety testing and other quality assurance work
  • The justification for this was that NASA had more experience with manned spaceflight, and thus the extensive and expensive checks of the Apollo program were not necessary
  • Nevertheless, in February of 1979 a National Academy of Engineering panel headed by Eugene Covert (head of Aeronautics and Astronautics at MIT) found that NASA's testing procedures for the Shuttle's main engines were not adequate
  • As a result, NASA altered testing procedures for the main engines

Operational Spaceflight: The Shuttle As Business

• NASA's bargain with OMB and Congress required them to make the Shuttle self-supporting
• The key to this was to make travel to space on the Shuttle seem "routine" and "economical"
• In order to do this, NASA emphasized two priorities
  • First, the Shuttle needed to move from being a developmental program to being an operational program as soon as possible
    • An "operational" system is one that is mature and ready for routine use
    • NASA allocated four test flights, upon successful completion of which the program would be declared "operational"
    • The fourth test flight (in 1982) went off without a hitch, and President Reagan and NASA declared the Shuttle "operational"
  • Second NASA emphasized a launch schedule that would both commercial payloads and Congressional approval
    • I think this is another key mistake. NASA should have realized that commercial payloads and Congressional approval are, to some extent, contradictory demands
    • Again, the comparison with SpaceX is telling -- SpaceX went for the commercial market first, and only afterwards did they angle for government contracts
    • However, the Shuttle was never able to reach break-even
    • In 1976 NASA forecast 49 Shuttle flights in 1984 and 58 flights in 1985, on the way to a schedule of 60 flights a year
    • By the early '80s, however, the projection of 60 flights a year seemed like pure fantasy
    • The 1971 Mathematica study forced NASA to maintain that the Shuttle was a cost-effective program, throughout the entire lifetime of the program
      • Remember, Diane Vaughan is writing about the Shuttle program up to '86, not the Shuttle program of the '90s and beyond
    • However, the Mathematica study was based off estimates provided by NASA contractors, who stood to gain valuable contracts if the Shuttle was approved
      • This isn't as obviously ridiculous as you might think
      • Aerospace is a highly specialized field, and there are only a few vendors who have the engineering capacity to build something like the shuttle
      • There really isn't an "independent" party that you would be able to ask about the costs of a complex and never-before-tried project like the space shuttle -- everyone who you would ask is going to be a potential bidder
    • Moreover, the Mathematica analysis underestimated the incremental costs of the program
    • Each shuttle launch added roughly 60 million dollars in marginal costs to a fixed cost of 1200 million dollars (1.2 billion) a year
    • Worse, the quick turnaround time required to achieve 60 flights per year never materialized
    • In 1985, NASA only achieved 9 Shuttle launches, a far cry from the 60 that were originally forecast for that year
    • In addition, the shuttle was never as capable as designed -- the Main Engines did not develop as much thrust as expected, so the actual payload was only 47,000 pounds
• The shuttle faced unexpected competition, both at home and abroad
  • Companies like ArianeSpace began offering commercial launch services that were cheaper and more reliable than the shuttle
  • Some of the Shuttle's domestic customers, such as NOAA and the Air Force began to pursue independent launch capability, as they became dissatisfied with the shuttle's lack of progress and low launch rates
  • To combat this, NASA engaged in high-profile missions which sought to highlight the unique capabilities of the Shuttle
    • In-orbit satellite repair
    • Satellite retrieval from orbit
  • However these missions only ate up more resources and drove up NASA's cost, further reducing the economic viability of the Shuttle
• Another way that NASA sought to maintain a positive public image for the shuttle in light of negative publicity was to have flights with people from outside the "traditional" astronaut corps
  • NASA was looking at non-astronaut flights as early as 1976
  • Non-astronaut flight was consistent with two of NASA's long-term goals for space:
    • Permanent occupancy of space by manned systems
    • Participation from ever-broadening walks of life
  • A NASA study team drafted a report called "Unique Personality for Space Shuttle Flights" which made recommendations regarding the sorts of civilians who would make good candidates for Shuttle flights
  • The initial consensus was for someone from the general area of popular science or a news media personality
  • While sending legislators was considered, this was seen to be fraught with the risk of partisan politics intruding into an otherwise nonpartisan activity
  • While NASA explored the possibility of sending various civilians into space, no definite action was taken until 1984
  • In that year, facing pressure on the issue of education, President Reagan announced that the first civilian passenger on the space shuttle would be a teacher
  • Meanwhile, despite initial recommendations to the contrary, the first civilian passengers aboard the Space Shuttle were legislators
    • In 1985, Senator Jake Garn (R-Utah) and Congressman William Nelson (D-Florida) flew on two separate shuttle flights
    • Both of these legislators were influential on the committees that approved funding for NASA

The Widening Gap Between Goals and Means

• 1985: NASA completes only 9 Shuttle missions
• Calls for an increase to 24 missions by 1990
• However, this increase was sought without effective conversion of the Space Shuttle into an "operational" system
• Although the Shuttle had been declared operational in 1982, the mature, operational system never emerged
• A mature system failed to develop for two reasons:
  • Personnel were diverted from long-term planning tasks to short term tasks to meet flight schedule needs, ensuring that expertise never developed
  • Budget was never high enough to support the level of development required for the emergence of a mature system
• NASA was slow to develop the resources necessary to support a mature system
  • During development, all resources were focused on a single shuttle flight
  • During the operational phase, resources were spread across many flights
  • Again, the contrast with SpaceX is telling: SpaceX, from the beginning, developed its system as an operational system
  • The attempt to reach 24 flights per year was limited by lack of spare parts, which, in turn caused led to accelerated training schedules
  • Resources became concentrated around short-term problems
  • Spare parts were often cannibalized from future launches in order to unblock the current launch
  • These parts transfers consumed personnel time, created opportunities for damage, and were wildly disruptive to launch schedules
• Another strain on resources were changes in launch manifests
  • Commercial customers often ran into issues with development, finances or market conditions, which meant that launches had to be rescheduled
  • Because the majority of the work to prepare for a launch occurred in the last three months prior to the launch, last minute changes were extremely costly and disruptive
• In 1985 Congress cut NASA's funding again
• By 1985, after accounting for inflation, NASA's budget had been cut by two thirds
• This sustained scarcity had an increasing effect on the quality of the program
• The spare parts crisis that led to cannibalization, for example, was a direct result of the budget cuts

January 1986: Production Pressures and a Disastrous Decision

• In 1986, NASA was under an enormous amount of stress
• The problems began, not in 1986, but in 1972 when NASA received the Congressional mandate to build the shuttle without Congress providing funding for the Shuttle
• Because the Shuttle was justified on the basis of cost-effectiveness, it was evaluated on solely economic criteria
• Meanwhile NASA was experiencing budget cuts and personnel departures
• 1986 was a make-or-break year for NASA, with three headline missions scheduled
  • Teacher In Space
  • Astro-1 mission to examine Halley's Comet
  • Missions with the first use of the Centaur cryogenic upper stage from the Shuttle's payload bay
• The Astro-1 Mission was especially significant, as it was meant to demonstrate the interdependence of manned and unmanned spaceflight, to insulate NASA from detractors who claimed that the Shuttle was taking away from space science research
• According to post-tragedy analysis, it was a disaster waiting to happen
• NASA prioritized production over safety
• The conventional explanation that developed was a "trickle-down" theory
  • NASA was under significant production pressure from outside forces
  • This pressure permeated the NASA organization
  • The production pressure affected decision-making on the eve of the launch
  • NASA managers knowingly violated safety requirements, taking a calculated risk that resulted in the loss of an orbiter and 7 astronauts

Chapter 2: Learning Culture, Revising History

• Initially, the Challenger disaster looked like a clear-cut case of organizational misconduct
  • Organizational misconduct: people violating rules in order to further the goals of the organization
  • Presidential commission indicated that NASA had violated industry rules and internal NASA rules designed to guarantee safety
  • These rules were apparently violated in an attempt to increase the launch rate of the Shuttle
• Three factors associated with organizational misconduct
  • Competitive pressure and resource scarcity
    • Budget cuts and launch schedule pressure
    • NASA intentionally skimped on safety in order to keep the Shuttle flying and meet production goals
  • Organizational characteristics
    • Sprawling web of contractors meant that no one really knew what was going on with the O-rings
    • "Success oriented" culture rewarded managers for correcting the joint temporarily rather than halting flights for a redesign
    • "Transactional" information exchange concealed problems rather than revealing them
  • Regulatory ineffectiveness
    • System regulating the safety of the Shuttle appeared to have suffered a massive breakdown
• There is ample precedent for this kind of organizational misconduct
  • Many documented in Charles Perrow's book, Normal Accidents
  • Ford Pinto: Ford chose to accept the risk of loss of life due to accidents over redesigning the Pinto
  • The difference between mistake and misconduct is intent: organizational misconduct has to reflect an intentional breaking of rules and taking on of risk
• The stereotype of organizational criminality portrays the organization as an amoral profit-seeking enterprise, which rationally weighs the probability and consequences of getting caught violating rules against the benefits that such rule-breaking brings
• Although NASA is not a corporation, it was subject to many of the same pressures, as it competed against other government agencies for scarce resources
• As a result, according to conventional narratives, NASA engaged in blatant and intentional rule-violation in order to meet organizational goals and secure resources
• The Challenger disaster was especially interesting from a sociological standpoint because the extensive documentation and public nature of the tragedy could shed light on the connection between "good" people and "dirty" work
  • Why do educated, law-abiding, well off people violate the law in furtherance of organizational goals?
  • We know that misconduct is associated with competition and resource scarcity, but we don't understand how competition and resource scarcity manifest in individual decisions
  • Data on this question are scarce -- often locked up in internal documents, which may be sealed or destroyed
    • We know which decision were taken, but often we don't have any written reasoning for those decisions
• While the amoral calculator hypothesis is attractive, there are many reasons to be skeptical of it:
  • Many organizations experience periods of scarcity and competition, and don't violate any rules
  • Organizations violate rules for reasons other than a careful consideration of risks and benefits:
    • Misunderstanding regulatory requirements
    • Incompetence or improper attention to regulations
    • Principled disagreement with regulations
  • Moreover, we know that's not how managers think when making decisions
    • Managers rarely formally calculate risks and benefits, because doing so is often impossible
    • Instead, they weigh a few key considerations, assess the risk that something will go wrong, and then make a judgment call
  • Finally, decision-making doesn't occur in a vacuum
    • Organizations have cultures and values
    • The choices that are available for consideration are constrained by organizational forces
  • The way organizations constrain choice is by establishing norms
    • A norm is a cultural belief or convention that originates in the environment
    • Norms create routine, taken-for-granted scripts that become part of individual world views
    • Norms don't just constrain options, they establish the criteria by which options are discovered
  • Norms are further reinforced by organizational rules on decision-making
    • In most organizations, decision-making is an example of rule-following over calculation of costs and benefits
    • Organizations and individuals are limited in their ability to search for solutions
    • As a result, decisions are made to satisfice, rather than optimize
• Had NASA administrators acted as amoral calculators, knowingly violating safety rules in order to stick to the launch schedule?
  • Need to demonstrate "macro-micro" connection
  • Show how the macro-structural forces of competitive pressure, organizational characteristics and regulatory ineffectiveness came together to influence individual decision-making
  • Unlike with many other industrial disasters, there was ample publicly available documentary evidence to show not only the decisions that were taken, but also the rationales behind those decisions
• While initially she believed that the amoral calculator hypothesis was true, after conducting her research, Diane Vaughan's understanding shifted

Early Affirmation of Amoral Calculation

• Initially, Diane Vaughan did no interviews
  • Before she could interview, she needed to know what questions to ask
  • In order to ask productive questions, she needed to be familiar with the cast of characters and the technical and bureaucratic language needed to have an intelligent conversation about the Challenger
  • The main primer for her research was Volume 1 of the Presidential Commission, published in June 1986
  • Although the Presidential Commission report was published for a lay audience, it was still tough reading
• As she studied the event in more detail, Diane Vaughan realized that some of her initial assumptions regarding the Challenger disaster were incorrect
  • Challenger did not explode
  • There was a fireball and a structural failure, but no explosion
  • Also, the dramatic public demonstrations that Commissioner Feynman gave dramatically oversimplified the issues discussed on the prelaunch teleconference
    • Everyone knew that rubber gets hard when it gets cold
    • The issues discussed in the teleconference involved matters of joint dynamics, joint rotation and ignition pressure, with millisecond-level timing
• However, as her initial misconceptions were corrected, she developed new ones
  • For a while Vaughan was convinced that the O-rings were like Nerf balls, sitting in the booster field joints
  • However, the O-rings were more like very long strings of very thin licorice, that sat in the field joints
  • It was difficult to comprehend the scales involved
    • On a booster the size of the Statue of Liberty, the field joint gap in question was 0.004"
    • When enlarged, the gap increased to somewhere between 0.0042" and 0.006"
    • The expansion occurred for 0.6 seconds, right at the beginning of the launch
• Although her understanding of technical issues changed, the evidence seemed to reinforce initial impressions of amoral calculation
• NASA management actions on the eve of the launch
  • Commission confirmed that NASA managers at Marshall played a major role in convincing Thiokol to reverse its recommendation to delay the launch
  • According to Thiokol, Marshall flipped the burden of proof -- made it incumbent upon Thiokol to show that the launch would be unsafe
  • It was also unusual that managers at Marshall requested Thiokol to send them written confirmation of their recommendation to launch
  • This was initially seen as a possible indication that NASA managers at Marshall wanted written confirmation in order to show that they were proceeding on advice from Thiokol
  • The Presidential Commission also found apparent evidence of rule-breaking on the eve of the launch:
    • NASA rules specified that NASA managers who knew about technical problems needed to transmit those problems up the hierarchy
    • In this case, however, higher-level NASA administrators were not informed about the teleconference
  • The failure to transmit information about potential problems with the O-rings up the management chain appeared to be a blatant cover-up
• Previous cost/safety trade-offs
  • NASA had a history of decision-making in which economic considerations seemed to take priority over safety
  • Reinforced suggestion of an organization culture where amoral calculation was the norm
  • 2 incidents stood out
    • Decision to eliminate the escape rockets
      • Increased payload capacity
      • However left the astronauts with no way to escape if there was a catastrophic failure early in the flight
    • Decision to award the SRB contract to Morton Thiokol
      • Although Morton-Thiokol Wasatch had previous experience designing solid rocket boosters for the Trident and Minuteman missiles, they were not seen as a leader in the field
      • Thiokol won the contract to build the SRBs even thought its design was ranked lowest out of the 4 submitted
      • James C. Fletcher, who was the NASA administrator at the time, announced publicly that the rationale for the decision was cost -- Morton-Thiokol's bid was about $100 million lower than the competition
        • Fletcher was later found to have deep political and personal ties to Utah, where Thiokol was based
        • Shuttle contract was a huge financial windfall for Morton-Thiokol and resulted in the creation of 6,500 jobs and Shuttle spending accounted for 44% of Morton-Thiokol's aerospace revenues in FY 1985
  • It seemed apparent that NASA had started building the Shuttle on the cheap
  • Even when there were problems, the solution was never to stop flights and redesign the SRB field joints, but rather to tinker with the existing design
  • A redesign could take up to two years, and would be enormously expensive
  • Moreover, revenue from all the launches during these two years would be deferred or lost entirely
• Cover-up
  • Adding to the perception of amoral calculation was the apparent cover-up of Shuttle-related information at the time of the accident
  • NASA impounded all documents related to the disaster
  • NASA began its own investigation, conducting it in "great secrecy"
  • Furthering impressions of a cover-up was the way that NASA handled the recovery of the crew's remains
    • NASA's initial transcript of the tape recovered from the Challenger wreckage showed that the last words were Commander Richard Scobee's "Go at throttle up", which implied that the crew had been killed instantly by the fireball and violent break-up
    • However a report released 11 days later said that the last words on the tape were "Uh oh", which indicated that the crew may have been aware that something was going wrong
    • Recovery of the crew's remains took six weeks, and questions were raised about why it took so long, when debris from the crew compartment had floated to the surface a month after the disaster
    • Analysis of the recovered oxygen packs and the footage of the shuttle's breakup showed that the crew may have been alive until the crew compartment hit the water
• Young, Boisjoly, Cook and Feynman
  • Further credence to the amoral calculation hypothesis came from
    • Veteran astronaut John W. Young
    • Thiokol engineer Roger Boisjoly
    • NASA resource analyst Richard Cook
    • Presidential commissioner Richard Feynman
  • Cook was responsible for assessing the budgetary impacts of the external tank, SRBs and Centaur upper stage
    • Wrote a memo in 1985 that indicated that flight safety was being compromised by the potential seal failure
    • Indicated that personnel knew of the possibility of failure and understood that failure would result in catastrophe
  • John Young was chief of NASA's astronaut office
    • Wrote on March 4 1986 that "some crews were lucky to be alive"
    • Alleged that the only reason the Shuttle had flown with such a flawed design was because of launch schedule pressure
    • Enclosed a list of other design elements of the Shuttle that were allegedly compromised due to the same factor
    • Noted that safety and flight schedule are conflicting goals and that safety didn't win when it was placed against schedule pressure
  • Roger Boisjoly brought civil and criminal charges against Thiokol
    • Charged that Thiokol had knowingly supplied NASA with defective solid rocket motors
    • Alleged that Thiokol had fraudulently signed off on the motors prior to Challenger's final launch
    • Charged NASA with collusive action based upon economic interest
    • Said that people at NASA and Thiokol knowingly withheld information about problems with the solid rocket boosters in order to meet production concerns
  • Richard Feynman -- Nobel Prize winning physicist on the Presidential Commission investigating the Challenger disaster
    • Claimed that NASA was playing "Russian Roulette" by going ahead with launches when they knew that there were issues with the boosters
    • Suggested that successful launches caused NASA administrators to knowingly downplay the risk, even though they knew that were outstanding issues
  • Together, these four individuals painted a picture of intentional managerial wrongdoing
  • Supported stereotypes from theories of organizational misconduct and amoral calculation

Puzzles and contradictions

• The hypothesis set out by the investigative commissions in the aftermath of the Challenger disaster is that safety rules were knowingly violated in order to stick to the launch schedule
• In order to prove this hypothesis, we need to show how the economic pressures affected managers' actions
• However, the Presidential Commission never asked specific questions about the connection between economic strain and managerial actions
• Therefore, the evidence, while apparently strong, was still circumstantial
• Furthermore, as she did more research, Vaughan found evidence that contradicted or added missing context to many of the statements which led many to believe that the launch was the result of organizational misconduct
• The documents that the early public narratives relied on systematically distorted the public impressions of NASA actions
• NASA management actions on the eve of the launch
  • The basic assumption of the amoral calculator hypothesis is that the launch was the result of a cost/safety trade-off
  • This posits costs and safety as competing goals, and suggests that satisfying one reduces one's ability to satisfy the other
  • While this applies to many decisions taken at NASA, it doesn't seem to apply to the decision to launch the Shuttle
  • In the decision to launch, safety and economic considerations are interdependent rather than competing goals
  • Key to the amoral calculator's decision-making is the probability of detection, and the costs of getting caught
    • For NASA, SRB failure during launch would be immediately detectable
    • The costs would be instantaneous and catastrophic
    • The manned space program was already in parlous shape -- a failure might lead to the administration giving up on manned spaceflight altogether
  • If NASA managers knowingly launched Challenger after weighing the costs of potential failure against production pressures, how could they fail to take into account the extensive costs of an O-ring failure
  • If NASA was so keen to convince the world that spaceflight was routine and economical, why would they risk failure on the first mission in which an "ordinary person", Christa McAuliffe, was scheduled to fly?
  • In a broader sense if NASA was facing pressure from its customers to launch payloads, why would it risk losing those payloads by launching them on a booster that it knew to be flawed?
  • To argue that NASA managers knowingly launched Challenger as the result of an amoral calculation is to suggest that decision-makers acted in opposition to NASA's commercial interests, rather than in concert with them
    • Well, this argument can be made -- you can argue that the decision to launch was the result of principal-agent problems
    • Everybody assumed that it was someone else's job to assure safety, and, as a result, safety was ignored as everyone pursued their own narrow interests
  • Another thing that is often missed is that none of the engineers opposing the launch were calling for the launch to be canceled
  • They were arguing for delay
  • It doesn't make any sense that NASA would risk catastrophe for a few hours of schedule
• Previous cost-safety trade-offs
  • Previous examples of cost-safety trade-offs identified by the press and astronaut John Young cannot serve as automatic verification that the decision to launch Challenger was the result of a cost-safety trade-off

References

1. Mathematica Report on the viability of the Space Shuttle

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