Challenger

A Case study

By:
G.Hariesh-39
V.Chandru-23
S.KarthiKeyan-52
 INTRODUCTION
• On January 28, 1986, the NASA shuttle orbiter
mission STS-51-L and the tenth flight of Space
Shuttle Challenger (OV-99) broke apart 73
seconds into its flight, killing all seven crew
members, which consisted of five NASA
astronauts and two payload specialists
 What is the problem
• In investigating any incident, big or small, the
process of specifying the problem is likely to
elicit multiple responses. At this stage in the
analysis, all potential problems are written
down for later evaluation. In this example, we
will begin by identifying the loss of all seven
crewmembers and the loss of the space
shuttle as the major problems.
 When did it happen?
• In order to measure change, root cause
analysis specifies as precise a time as possible
for a given incident. Here, the Challenger
broke apart two minutes into its tenth
mission, at 11:39:12 AM EST on January 28,
1986.
 Where did it happen?
• Cause Maps related to space disasters
technically describe one incident that occurs
in two locations (with the space shuttle and at
command center), the emphasis remains on
the location that can be controlled: Command
center. In this case, the space shuttle broke
apart just after launch; the Challenger facility
(STS 51-L) at Cape Canaveral is thus captured
as the location for the incident.
 Delays

• Challenger was originally set to launch from KSC in Florida at 14:42 Eastern
Standard Time (EST) on January 22, 1986. Delays in the previous mission,
STS-61-C, caused the launch date to be moved to January 23 and then to
January 24.
• The launch was then rescheduled to January 25 due to bad weather at the
Transoceanic Abort Landing (TAL) site in Dakar, Senegal. NASA decided to
use Casablanca as the TAL site, but because it was not equipped for night
landings, the launch had to be moved to the morning (Florida time).
Predictions of unacceptable weather at KSC on January 26, caused the
launch to be rescheduled for 09:37 EST on January 27.[13]
• The launch was delayed the next day, due to problems with the exterior
access hatch
 Thiokol–NASA conference call

• Forecasts for January 28 predicted an

unusually cold morning, with temperatures
close to −1 °C (30 °F), the minimum
temperature permitted for launch. The Shuttle
was never certified to operate in temperatures
that low. The O-rings, as well as many other
critical components, had no test data to
support any expectation of a successful launch
in such conditions.[17][18]
 ICE
• Ice on the launch tower hours before Challenger launch
• The Thiokol engineers had also argued that the low
overnight temperatures (−8 °C (18 °F) the evening prior
to launch) would almost certainly result in SRB
temperatures below their redline of 4 °C (39 °F). Ice
had accumulated all over the launch pad, raising
concerns that ice could damage the shuttle upon lift-
off. The Kennedy Ice Team inadvertently pointed an
infrared camera at the aft field joint of the right SRB
and found the temperature to be only −13 °C (9 °F
Gas Leakage
7 Passengers
 Questions that have no answer
• 1) Did NASA engineers violate their duty to put public
safety above concerns about maintaining the launch
schedule?
• 2) Did Thiokol engineers violate their duty to put public
safety above concerns about losing a contract with NASA?
• 3) Was the principle of informed consent violated?
• 4) What was the role of whistle blowing and related
possible discriminatory treatment of the whistle blowers?
5) Did a Thiokol engineer violate his duty to treat records—
referring exclusively to his work—as company property?
• 6) What are the characteristics that determine whether or
not the public perceives an engineering decision to involve
an ethical violation?
 Reference
• https://en.wikipedia.org/wiki/Space_Shuttle_
Challenger_disaster#References
• https://www.thinkreliability.com/case_studies
/root-cause-analysis-challenger-explosion/
• https://thegrcbluebook.com/wp-
content/uploads/2013/01/Ethics-Challenger-
Disaster.pdf