Assignment: 02

Subject: project management

Name: Vinay Kumar M Yevoor (19MBAR0228)

Section: 19CF - 1

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Score:

Faculty Signature:
Summary of the case:
On the night of January 27, 1986, the night before the space shuttle Challenger accident, there
was a three-hour teleconference among people at Morton Thiokol and Kennedy Space
Center. The Space Shuttle Challenger’s holes were not identified in sufficient time for
safeguards to be implemented to prevent such catastrophic loss. Moreover, there was no
active failure involved in the front end layer of defense; all decisions were made from the top
management level of the organization. With the miscommunication that occurred between
NASA and Thiokol, the administrators at NASA were not aware of the potential risk that was
involved with the launch decision. As a result, the unsafe acts layer of defense was discarded,
resulting in a critical flaw in the Swiss Cheese Model—without the provisions to counteract
or override unsafe acts, the model is inadequate for accident prevention. Further investigation
is needed to determine whether another model may be more successful in addressing complex
systems such as the NASA space shuttle launch, in terms of identifying risk factors and
predicting potential accidents. After the accident a commission was appointed by Pres- ident
R. Reagan to find the cause. The commission was headed by former Secretary of State
William Rogers and included some of the most respected names in the scientific and space
communities. The repots states to just 30 minuts before liftoff a commercial jet f;ew above
the launch site as it was hit by headwind of over 300 km per hour it looks like the challenger
must have passed through the same layer of air as it climbed towords space as it entered the
jet stream it would have been hit broadside with a force.

Antinegetive summary of the case:

North america folrida jan -28-1986 80.8 a.m one half hours to liftoff at kennedy space station
final prepration are underway for the most anticipated space mission the key engineer got the
information Meteorological Department a thin layer of air was traveling at 300 km per hour
which also caused a problem to commercial jet which passed on the site of the lunch station.

By gathering this information from Meteorological Department the program was advanced
for 3 hours later hence the challenger mission was successful and all the 7 astronauts returned
safe after completing the mission.
The organization’s hierarchy can assist in identifying their contribution to the safety
constraint violation in terms of their influence to their subordinates. Policies, standards, and
regulations that shape work practices and how activities are performed is key information in
detecting improper task execution. The roles and responsibilities of each staff members
identify the flow of communication channels used and how decisions made and conveyed to
the lower hierarchy. Having this information will build a body of knowledge enabling the
user to recognize limitations in each safety constraint level and where they have been violated
in each hierarchical level.