CASE STUDY 1: THE CHALLENGER DISASTER

REPORT

BY GROUP 7:
Aadil Faiz
Angel Omar López Bautista
Luis Angel López Bautista
Midhath Nigar Shaik Markhoom
Mike Winterbottom

(November 10, 2016)

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Contents

Introduction...........................................................................................................................................3

The proximate cause of the Challenger disaster....................................................................................5

The Technical Cause of the Challenger Disaster....................................................................................5

In-detail Findings of the Cause..............................................................................................................7

Analysis..................................................................................................................................................9

Remedial Steps Taken..........................................................................................................................12

Lessons Learnt.....................................................................................................................................13

Long Term Lessons Leant.....................................................................................................................14

Conclusion...........................................................................................................................................15

Reference List......................................................................................................................................17

Appendix………………………………………………………………………………………………………………………………………….19

Signatures............................................................................................................................................23

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 Introduction

Since long time ago, the human being has been curious to understand what happens to his
surroundings and to be able to use this knowledge for manipulating the environment for his
benefit. The spark of doubt, inherent to the nature of man, is so strong that he not only
would settle for understanding his immediate environment. There is always the enthusiasm
of looking up to the sky to discover the mysteries that keeps the universe, what happens
beyond what our eyes can see if we can reach for the stars.

Moved by the exponential growth of technology and science, in the 20 th-century human
being undertook the so-called “Space Race.” It would take to another level the imagination
and knowledge of engineers and scientists around the world to achieve one of the most
bold and fearless objectives that humanity has proposed to itself: lead men into space. The
winner of such race would proclaim to be the National Aeronautics and Space
Administration (NASA) when in 1968 managed to take the first man on the Moon in the
Apollo 11 mission.

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 Space Shuttle Challenger leaps from the launch pad. Photo Credit: NASA [1].

It was expected that as a result of the event space agencies would not stop. Instead, it
would be an experience full of motivation with views towards what could come if they
continued to work correctly. In this context, NASA announced an ambitious project called
“Space Shuttle” in 1976. This project presented the idea of a reusable manned spacecraft,
able to make several return trips into space. The dream was becoming a reality, conquer of
space was happening. The first trips of the Space Shuttle, although in the midst of
uncertainties and details to improve, were promising, and with such enthusiasm, NASA
dared to send continuous missions within relatively short periods of time.

However, a tragedy occurred in the tenth trip of the project, which would be an event that
marked and changed the history of space exploration forever. The catastrophe took place
on January 28th, 1986, when the spacecraft of the “Shuttle Challenger” mission was
destroyed only 73 seconds after launching in front of the eyes of the entire organization and
a huge section of the American population.

The Shuttle Challenger mission, which numbering was STS-51-L [2], had as objectives to take
to orbit the second Tracking and Data Relay Satellite for American communication services.
In addition to the placing in orbit of the SPARTAN-Halley, which was an astronomical
platform that would carry out observations of the Comet Halley, which at that time was
close to the Earth. The accident claimed the lives of the seven members of the crew,
including a teacher of basic education who designated for teaching children about space
when returning from the mission [3]. The impact that it caused on the population and the
enthusiasm of the scientific community was so significant that many media named it as “the
largest accident on the conquer of space” [4].

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 The crew of the Space Shuttle Challenger. Photo Credit: History.com

In this essay, we will make a thorough study of the technical and administrative factors that
contributed to the failure of the Shuttle Challenger project. Starting from paying attention
from the planning stage, the implementation of the project, and even the consequences and
further investigations, to be able to identify the lessons to be learned in both areas. It is
expected that by completing this task, we can notice the critical factors that we need to pay
particular attention to approaching ourselves as students that can develop projects
successfully.

The proximate cause of the Challenger disaster

The proximate cause of the Challenger disaster was the leakage of two rubber O-rings in a
segmented solid rocket booster. The rings lost their capability to stop hot gas blow-by
because they were icy cold on the day of launch (anticipated at 20 degrees F, well below
freezing). The ambient temperature at launch was in the low 30s.

Amazingly the exact reason for the mishap was wrangled for a considerable length of time
the night before the launch between Morton Thiokol engineers, administrators and NASA
supervisors. Given the anticipated temperatures of 26 degrees F, the engineers stressed
that the O-rings will not be so strong and that there was a background marked by O-ring
destruction on the STS amid frosty climate launches.

This launch was the first no launch commendation from Morton Thiokol in the memory of
the STS. At first, the Thiokol chiefs upheld the engineers. In any case, under distrusting
addressing by the NASA directors, the Thiokol supervisors put on their administration caps,
altered their opinions and changed the Thiokol proposal to launch. The NASA chiefs in this
manner assuaged and felt legitimized in favoring a launch with the necessary result that
Challenger exploded.

The Technical Cause of the Challenger Disaster

Months of examination uncovered the excellent reason for the mishap and the greater part
of its nuances. The official Rogers Commission report peruses, "The accord of the
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Commission and taking an interest investigative offices is that the loss of the Space Shuttle
Challenger created by a disappointment in the joint between the two lower sections of the
right Solid Rocket Motor. The particular disappointment was the demolition of the seals that
are proposed to keep hot gasses from spilling through the joint amid the fuel blaze of the
rocket engine. The confirmation gathered by the Commission demonstrates that no other
component of the Space Shuttle framework added to this disappointment.".

The commission individuals inferred that the "obliteration of the seals" was connected with
two things: poor outline, which did not take into account repetition if the essential O-ring
fizzled, and the chilly temperatures experienced at launch.

The encompassing temperature at the season of Challenger's dispatch was 2.2 degrees
Celsius. In correlation, reported the commission, a compacted O-ring at 24 degrees Celsius is
five times more responsive in coming back to its uncompressed shape than a cold ring at -
1.1 degrees.

Due to the cold, the two O-rings utilized as a part of the lowermost field joint of the right
strong rocket promoter had turned out to be robust and lost their capacity to seal the joint.
Amid take-off, thermal propulsion gasses blazed through the primary O-ring and started to
get away, as for proving by puffs of smoke caught on video footage seconds after lift-off.
Before long, aluminum oxides from the heavy blazed fuel began to heap up in the secondary
O-ring, making a transitory seal that evaded disaster on the launch platform.

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 Retrieved from: http://choo.fis.utoronto.ca/FIS/Courses/LIS2149/challenger.gif

In any case, somewhere around 32 and 62 seconds after liftoff, Challenger crossed a robust
and unpredicted jet stream that shook it off course, shaking free the aluminum slag that had
gathered. Quickly a fire showed up on the right strong rocket supporter toward the outer
tank, the biggest and heaviest segment of the space shuttle that contains a liquid oxygen
tank, electrical parts, and a liquid hydrogen tank.

The blowtorch impact dissolved the metal on the outer tank until the liquid hydrogen inside
the supply started to spill out, and the connection between the supporter and the external
tank broke free. That is the point at which the whole base area of the tank gave way,
pushing the hydrogen tank upward into the oxygen-filled compartment, quickly combusting
two million liters of fuel. The Challenger orbiter was torn separated by centrifugal
aerodynamic forces, and the crew team compartment began its free-fall descent toward the
Atlantic.

In-detail Findings of the Cause

An ignition gas leak through the right Solid Rocket Motor aft field joints initiated at or
shortly after ignition eventually weakened and infiltrated the external tank that is
commencing vehicle physical breakup and loss of the space shuttle.

Retrieved from: http://i0.wp.com/leganerd.com/wp-content/uploads/2014/09/5a.gif

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The development prompted to a condition at the time of launch wherein the most extreme
gap between the tang and clevis in the area of the joint's O-rings was close to .008 inches,
and the normal hole would have been .004 inches. With a tang-to-clevis hole of .004 inches,
the O-ring in the joint would compress to the degree that it squeezed against every one of
the three dividers of the O-ring accepting channel. The absence of roundness of the
fragments was to such an extent that the smallest tang-to-clevis freedom happened at the
initiation of the assembly operation at places of 120 degrees and 300 degrees around the
outline of the toward the backfield joint. It is dubious if this steady condition and the
resultant more prominent pressure of the O-rings at these focuses endured to the time of
launch.

The encompassing temperature on the date of launch was 36 degrees Fahrenheit, or 15

degrees lower than the following coldest past launch. The temperature at the 300-degree
shape than a cold O-ring at 30 degrees Fahrenheit. The temperature on the opposite side of
the right Solid Rocket Booster confronting the sun was assessed to be around 50 degrees
Fahrenheit. Different joints on the left and right Solid Rocket Boosters experienced
comparable blends of tang-to-clevis gap clearance and temperature. It is obscure whether
these joints experienced distress amid the flight of 51-L.

At the cold launch temperature encountered, the O-ring would be ease back in coming back
to its ideal adjusted shape. It would not track the opening of the tang-to-clevis gap. It would
stay in its ready position in the O-ring channel and not give a space amongst itself and the
upstream channel divider. Thus, the O-ring would not be pressure induced to seal the gap in
time to prevent joint failure due to blow-by and destruction from hot combustion gasses.

The fixing qualities of the Solid Rocket Booster O-rings improved by opportune utilization of
engine weight. Ideally, engine pressure must be applied to incite the O-ring and seal the
joint before the huge opening of the tang-to-clevis hole (100 to 200 milliseconds after
engine start). Test confirm demonstrates that temperature, humidity and different factors in
the putty compound used to seal the joint can postpone pressure application to the joint by
500 milliseconds or more. This postponement in pressure could be a variable in an
underlying joint failure.

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The leak was again manifest as a fire at roughly 58 seconds into the flight. It is conceivable
that the leak was constant however imperceptible or non-existent in parts of the
intervening period. It is practicable in either case that pushes vectoring, and typical vehicle
reaction to twist shear and additionally arranged moves reinitiate or amplified the spillage
from a degraded seal in the period preceding the observed flames. The evaluated position
of the fire, focused at a point 307 degrees around the boundary of the toward the backfield
joint, was affirmed by the recovery of two parts of the right Solid Rocket Booster.

A small leak could have been available that may have developed to rupture the joint in a
fire at a time on the order of 58 to 60 seconds after lift-off. Then again, the O-ring crevice
could have re-fixed by deposition of a delicate build-up of aluminum oxide and other
ignition debris. The re-sealed area of the joint could have been bothered by pushed
vectoring, Space Shuttle movement and flight loads actuated by changing winds aloft. The
winds aloft caused control actions in the time interval of 32 seconds to 62 seconds into the
flight that was typical of the largest values experienced on previous missions.

Commission accomplished that the cause of the Challenger accident was the breakdown of
the pressure seal in the rear field joint of the right Solid Rocket Motor. The breakdown was
due to a faulty design unacceptably sensitive to some elements. These factors were the
results of temperature, physical dimensions, the character of materials, the effects of
reusability, processing, and the response of the joint to dynamic loading.

Analysis

While technical reasons influenced the Challenger Disaster definitively to occurred, the
analysis must go beyond that. Indirect causes acted like a snowball that ended in the
accident. With the analysis, a quick review of some of the report of the Rogers Commission
is to do.

The commission was established by President Reagan and its members emphasized William
P. Rogers, Neil Armstrong, Richard Feynman, among others. After working for some months,
the Commission published an excellent worldwide report of its findings. In summary, and
just as mentioned in the chapter above, it found that the Challenger accident caused by a

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failure in the O-rings, failure which then attributed to a faulty design, whose performance
could too easily compromise by factors including the low temperature on the day of launch.
Propulsion gasses melted metals that made up the rocket booster and caused the explosion
of the external tank [9].

The Rogers Commission in session. Photo Credit: popularmechanics.com

However, as said before, there were a bunch of other sources of the problem: Failures in
communication and management could have avoided the disaster. The Rogers Commission
reported that managers at Marshall had known about the mechanical and thermal
weaknesses of the O-rings because, after previous flights, engineers performed inspections
to them. Instead of redesigning the joint, a decision was made to consider the problem as
an acceptable flight risk without further consulting [10]. Therefore, there was a poor vertical
communication (maybe because channels of communication were not well established or
the project management followed didn’t allow workers to communicate directly with them)
and an inadequate down the line leadership skills and development. It would have been
ideal to establish a system of locks (very popular nowadays among companies where
multidisciplinary teams are the basis of production, such as petrochemical, and, of course,
aeronautics). This safe production system allows that, if part of the multidisciplinary team
does not agree with any operating condition because of being considered to be unsafe, the
process cannot continue or start until the problem is solved or parts involved reach an
agreement. Now, this agreement must base on issues of industrial safety, and technical and
economic problems in a bottom, if it not done like that, then the system would prevent

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nothing. Besides this lack of communication from the bottom to the top, there was also a
lack of communication from the managers to the crew of the Challenger. According to the
report of the Rogers Commission, the seven members of the crew were not notified about
the concern of the O-rings failure. Any other failure that could have happened due to the
low temperatures of that morning, so they could not at any time give their point of view
about the situation, even when managers knew their life were at risk.

The problem with the O-rings is a serious issue of professional ethics, as not having been
tested at temperatures as low as that morning, they could not in any way guarantee a
desirable operation, so it was just like rolling the dice. Faced with this unexpected event,
engineers had to adjust the way to attack the problem, not approved the launch, despite the
pressures of executives.

The professional ethics irresponsibility was such that nowadays it is part of the required
readings for engineers looking for a professional license in Canada and other countries [11].
In courses like Engineering Management, students taught on how to do risk matrices but, at
the end of the day, as engineers, we must have enough criteria and responsibility to state
that project has to remain paused until safe conditions achieved.

The night before the launch they had alerted Marshall Officials that the expected cold
weather could freeze the rubber O-rings and trigger tragedy, but company executives and
Marshall Project managers had disallowed calls for a launch delay. An interesting factor to
consider is the urge NASA to launch the Challenger after about a week of delay. Like any
other project, these days’ delay meant a considerable economic loss. It is because of the
change in the daily logistics to be done to complete the mission (i.e. as the movement of
earth and satellites do not follow stationary characteristics, but dynamics, every day lost
meant moving away from the initial calculations for the route of the Challenger). Senior
managers of the project felt forced to hasten the launch despite the conditions of that
morning were not favorable at all.

It can say then that the priorities were not hierarchized correctly, conflict of priorities is
clear: They put the economic aspect before safety. Today almost all big business in the
world follow a strict policy of not to perform work unless it ensured that there will be no

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incidents or accidents (operations of it would damage, i.e., neither the assets of the
company or its employees or people outside the enterprise).

Remedial Steps Taken

The Rogers Commission prescribed nine steps that NASA ought to take to diminish the
likelihood of another Challenger disaster. The steps included huge changes. All of them had
numerous parts. They tended to specific issues (redesign of the troublesome O-ring seals)
and additionally "human factors" issues, for example, communication. The commission
found that an excessive number of chiefs had a tendency to stuck in their desk areas and did
not see the master plan. President Reagan asked NASA to arrange for a scheme to carry out
the report’s commendations.

In response to these commendations:

• NASA had the solid rocket booster remodeled. Engineers made variations in the
segment joints and case-to-nozzle joints, the nozzle, propellant grain form, ignition
system, and ground support apparatus. The O-rings replaced by new rings made of a
better-performing material called nitrile rubber.
• NASA added an orbiter to the fleet to lighten the burden of a heavy flight schedule
on too few spacecraft; the agency also distributed some tasks to unmanned
spacecraft.
• NASA reorganized the shuttle program’s management structure to ensure that
dissenting voices got a say in launch decisions. It also strengthened its support for its
safety staff.
• The space agency ordered improved communication among managers and an end to
the isolation of executives from one department to the later.
• NASA reinforced the flight readiness review—the pre-launch process that had given
Challenger its green light in 1986. Staff members now record reviews and take
minutes (a regular kind of note-taking).

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 • NASA committed to “criticality review and hazard analysis.” The consideration and
analysis involved looking at every shuttle component to see which ones needed
upgrades to make them reliable.
• The agency’s scientists developed new systems to allow astronauts to escape in the
case of another faulty lift-off. NASA also improved the orbiters’ landing systems—
tires, wheels, and the like—so that in the event of an aborted mission, the shuttle
crews would have further options for landing.

Lessons Learnt

The well-known interpretation of the Rogers Commission discoveries is that the flawed
choice to launch Challenger was an aftereffect of production pressures and governmental
wrongdoing. Such a conclusion is alluring and basic. It permits fault to be assigned and
makes the outside impression that the issue can be in huge part solved by expelling the
relevant, responsible people. The clarification encourages further to the feeling that central
administration, in their willful quest for execution targets, conspires to make such
calamities.

Operationally, NASA's concentration is an endless supply of mission objectives while

guaranteeing group and vehicle wellbeing. Authoritatively, in any case, launch frequency
turned into a deliberately checked execution pointer and this added to pressures to launch
on time. At the point when specialists raised worries over the security of the launch of STS-
51L, particularly referring to the uprightness of the O-ring seals, NASA's organizational
culture allowed this articulated risk to ignored.

The issue, of tolerating conditions which would commonly view as aberrant, is referred to
as the 'standardization of deviance.' The idea of standardized aberrance is not particular to
NASA but rather generalizable, as a potential issue, over every single present day
establishment in which hazard, innovation, and authoritative chain of importance match.

The lesson learned from the Challenger disaster is that: an association may make numerous
balanced governance to moderate hazard, may manage serious emergencies skillfully,
however, in any case, be fit for making an operational culture in which catastrophic

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disasters can occur. The culture of regularized deviance permits this to happen concealed,
with no core principles broken or any obvious or cognizant wrongdoing on administration or
specialized specialists in frontline operations.

The clarification is less basic than blaming managers and the progressive managerial system
for catastrophic failures. The failure is a result of the way of life of which the chiefs,
managers, and experts work as opposed to their activities. The explanation is more intricate
and unattractive as a conclusion because the reason for disappointment lies not with an
individual or convention or arrangement of poor choices however at the heart of the
association, installed in its culture. Moreover, this sort of orderly disappointment cannot be
perceived unless it effectively looked for and can't be remedied unless the association's
working standards inspected and in a general sense adjusted. There are no straightforward
answers; an affirmation (or thought) that there may be an issue is a vital initial step

The organizational analogy drawn here is a long way from great. Almost no consideration
paid to the hierarchical culture in which the individuals work; maybe because of the
association, in general, appears to be monolithic and unchangeable; or changeable just by
powers that lie outside the ability to control of the online team. However, the lesson
learned from NASA is that individual operational capacities, or those of the little groups of
work, are unimportant if the authoritative culture and way to deal with risk are
fundamentally flawed.

Long Term Lessons Leant

• Knowing the limitations of the product or apparatus

• Knowing the validity of documentations and warranties

• Knowledge of past complications and irregularities

• To not let agenda pressure outweigh mission security

• Demand proof of mission safety and to not prove it will not collapse

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 • Maintain commercial memory and lessons learned catalog

• Significance of correct and clear-cut statement

• Maintain a non-threatening managerial atmosphere

• To never be frightened to ask questions and not to be afraid to speak up and offer

the professional opinion

• Engineers need “permission” to go with “accountability.”

• To take individual possession

• To never assume anything

• To challenge conventions and basis for study with simple calculations

Conclusion

In reverse engineering’s training courses throughout the world, it is taught to us, the
students, that processes must be cost-effective, flexible and inherently safe. The feature of
cost-effective is because every business must generate profits to survive, the flexibility is
needed to adapt to such a dynamic and changing environment that the world is facing, and
safeness, which even accompanied by an adjective that emphasizes its importance. It has
become an obligation and a requirement to be able to implement any project.

To achieve the three characteristics listed above it is necessary to have a solid foundation in
technical knowledge of engineering, complemented by good practices in administration.
That is why modules like this, Engineering Management, are so important for the new
generations of engineers who aspire to achieve high goals in their professional life.

In the development and analysis of the present work, we could see that many of the actions
committed in the Shuttle Challenger disaster could have corrected with the implementation
of various of the data that we have acquired in the lectures so far. For example, the quality
management systems, knowledge on how to manage teams, effective communication,
management theories suited to the nature of the company, decision making, among others.

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In fact, much of this content arises in NASA as a consequence of the accident, and it
reflected in the study of the lessons to be learned.

It is important always to do this kind of feedback exercises. As we have presented above,

much learning got from historical events, but we also need to make this feedback for every
project that we undertake to distinguish what went well, what went not so well, and which
are the opportunity areas to improve. We must always have the courage and determination
to take actions when pertinent, because, as we have studied in this case, if failures or errors
ignored, these can accumulate and lead to dangerous unwanted situations. The report gives
us a teaching about being proactive in our projects, and to always prioritize the preventive
actions over the corrective ones.

Also, it is important to know how to take advantage of the technological resources that we
have today compared with those existing in the times of the case study. Today, specialized
simulation software allows us to measure the permissible limits within a project can work
safely, and it can even generate reliable estimates of economic profiles, supporting
engineers to improve not only their technical practices but also the managing skills with
which the project can develop successfully.

We would like to complete this task by quoting a statement by the United States’ Ex-
President Ronald Reagan in his speech of 1986 after the accident of the Shuttle Challenger:

“Sometimes when we reach for the stars, we fall short, but we must pick ourselves up again
and press on despite the pain” [15].

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Number of words written until this point: 4250

Reference List

1) NASA. (Recovered on November, 2016). Space Shuttle Overview: Challenger (OV-099).

Available at:
http://www.nasa.gov/centers/kennedy/shuttleoperations/orbiters/challenger-info.html
2) NASA Administrator. (December, 2005). NASA - STS-51L Mission Profile. Available at:
http://www.nasa.gov/mission_pages/shuttle/shuttlemissions/archives/sts-51L.html
3) NASA. (October, 2004). The Crew of the Challenger Shuttle Mission in 1986. Available at:
http://history.nasa.gov/Biographies/challenger.html
4) El Mundo. (2011). Challenger's catastrophe, 25 years later. Available at:
http://www.elmundo.es/elmundo/2011/01/27/ciencia/1296137118.html
5) Sarah Pruitt. (January, 2016). 5 Things You May Not Know About the Challenger Shuttle
Disaster. History. Available at: http://www.history.com/news/5-things-you-might-
not-know-about-the-challenger-shuttle-disaster
6) Presidential Commission on the Space Shuttle Challenger Accident. (1986, January 31).
Retrieved November 9, 2016, from NASA, http://history.nasa.gov/rogersrep/genindex.htm
7) Lewis, S. R. (1988). Challenger The Final Voyage. New York: Columbia University Press.
8) Hastings, D. (2003, September). The Challenger Disaster. Retrieved November 9, 2016,
from https://ocw.mit.edu/courses/engineering-systems-division/esd-10-introduction-to-
technology-and-policy-fall-2006/readings/challenger.pdf

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9) Rogers Commission. (June 6th, 1986). Report to the President by the Presidential
Commission on the Space Shuttle Challenger Accident. [Online]. Available:
http://spaceflight.nasa.gov/outreach/SignificantIncidents/assets/rogers_commission_report
.pdf
10) Jenab, K., & Moslehpour, S. (December, 2016). Failure Analysis: Case Study Challenger
SRB Field Joint. International Journal of Engineering and Technology, Vol. 8.
11) Wikipedia. (Last modified: November, 2016). Space Shuttle Challenger Disaster. [Online].
Available: https://en.wikipedia.org/wiki/Space_Shuttle_Challenger_disaster
12) Fong, K. J. (2010). Risk management, NASA, and the national health service: Lessons we
should learn. British Journal of Anaesthesia, 105(1), 6–8. doi:10.1093/bja/aeq139

13) McDonald, A. J., & Hansen, J. R. (2012). Truth, lies, and o-rings: Inside the space shuttle
“challenger” disaster. Gainesville: University Press of Florida.

14) Lessons Learned: Challenger and Columbia. Retrieved November 10, 2016, from Kailua
High School, http://kailuahs.k12.hi.us/webmaster/Files/ROTC/Exploring%20Space_The
%20High%20Frontier/ES_CH07_02_p320-335.pdf.

15) NASA Administrator. (July, 2004). Remembering the Legacy of President Ronald Reagan.
Agency News. Available at:
http://www.nasa.gov/audience/formedia/speeches/reagan_legacy.html

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Signatures of the team members:

 Angel Omar López Bautista _______________________

 Luis Angel López Bautista _______________________

 Aadil Faiz _______________________

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 Midhath Nigar Shaik Markhoom _______________________

 Mike Winterbottom _______________________

END OF REPORT

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