Challenger Shuttle Disaster

On 28th January 1986, the whole world focused on the Challenger shuttle project, which was an evolution of carrying the first person into space. However, after 73 seconds into the flight, the Challenger was ripped apart above Cape Canaveral in Florida. As a result, the launch of this shuttle exploded and killed seven crew members inside the shuttle. The President initiated a Commission to identify the causes of this shuttle disaster. One technical cause was the O-ring seals in the aft field of the right Solid Rocket Booster (SRB) that has failed due to faulty design of the SRB and insufficient low temperature. The failure of O-ring allowed hot combustion gases to leak from the booster and burn through the external fuel tank, causing the Challenger

damaged. However, after problems searching, the Commission disclosed a lack of proper communications between different levels of NASA management. The poor management also accounted as one of main reasons that caused the shuttle disaster.

CHAPTER 3 Review of the literature
The Challenger shuttle disaster is known as NASA’s unfaithful and negligence over the project. The failures of launching this shuttle lead NASA management to find out the true causes of this shuttle disaster.
Vaughan (1996) explores the impacts of poor human resources management at this shuttle project.

Vaughan (1996) argues that organizational culture and the pressure of shuttle launch at NASA and Morton Thiokol leaded this disaster. It indicates the deviations of the launching of the shuttle were normalized, resulting the managers did not report that important information to their top manager. Also, the managers at Morton Thiokol wanted to compete with their rivals. Thus the engineers remained those faulty designs to launch the shuttle, under the pressure of “change is bad” organizational culture. By analyzing this corporate culture, Vaughan’s explanation suggests different management levels have responsibilities for this accident. The Challenger accident was inevitable due to the culture of “change is bad” was ingrained in the human resources management in

NASA.
Nevertheless, Perrow (1999) focuses on the technology of accidents that caused the Challenger shuttle disaster, showing two types in Normal Accident Theory. The first one is System Accident that caused by complex interactions of multiple independent elements, and tight coupling of components. It represents that one part of the system fails, there is no time to stop connected elements that affected by the failure system. The second theory is Component Failure Accident, which can be described by visible and foreseeable linear interaction between parts, and loose coupling in which the “domino” effect from failed elements can be stopped. These theories demonstrate in the Challenger shuttle project, complex interactions and tight coupling are associated with System Accident, which are more common in this field. They also describe that the difficulties of taking account of those multiple connecting elements.
Moreover, the Challenger shuttle disaster can be considered as both human and technical failure accidents, but Perrow (1999) examines that the managerial negligence of complex interactions, restraining those results of human actions. Based on the system accidents, poor management and the low temperature contribute to the shuttle failures directly although these elements were not connected. The low temperature as an external aspect, which could not be controlled by people, human resources management was a linear interaction that perplexed by poor communications between different management levels and lacking of knowledge. In addition, Rijpma (2003) argues that although accidents are inevitable, there are many projects such as space travel can be seen as high risk projects, but they have proven tracks recorded due to good quality management. It represents that high technology projects have the responsibilities and the ability to prevent from disasters.
Indeed, the O-rings were one of the reasons that caused this disaster. Vaughan (1996) agrees that the high technology shuttle projects are complex and vulnerable to accidents, but the human aspect is the most important factor of this Challenger disaster. Cooperate cultures in NASA stimulated the normalization of deviations. Vaughan (1996) mentions that NASA management suffered from “can do” attitudes, arising from economic pressure caused by government budget cuts. As a result, the Challenger shuttle project forced to continue, which failed to perform led to restriction of funding. Also, Vaughan (1996) observes the space shuttles were used technology and thus might be reasonably expected to contain ambiguities over limitations. For instance, the engineers started to tackle O-ring erosion, which only had one ring. The engineers just added another O-ring instead of designing the whole joint device. This presents the fear of facing changes that lead the O-ring problem affecting the shuttle. The accidents of the Challenger shuttle disaster can be shown in Diagram 1 and Diagram 2.

Diagram 1: The technical flows of the Challenger disaster

Diagram 2: The human management flows of the Challenger disaster

Overall, Vaughan’s theory (1996) reveals that different management levels were to blame for this shuttle disaster. The rejection culture was ingrained at a management that putting people outside their job responsibilities. By contrast analysis of Vaughan (1996) and Perrow (1999), Perrow (1999) argues Vaughan concentrated too much on organizational culture, and understates the power of organization to suppress the engineers’ considerations.
Compared with Vaughan (1996) and Perrow (1999)’s theories, the Ishikawa (1968) diagram also shows the causes of a specific event. The aim of Ishikawa (1968) diagram is using product design and quality defects presentation to identify potential reasons that cause the Challenger shuttle disaster. The possible reasons of this shuttle disaster represented in fishbone format are shown in Diagram 3.

Diagram 3: Causes and Effect diagram of the Challenger shuttle disaster

CHAPTER 4 Discussions
In general, both Vaughan (1996) and Perrow (1999) represent the human and technical causes of the Challenger shuttle disaster, but they do not mention projects’ framework regards to how to avoid accidents. Therefore, Deming (1986) agrees with Vaughan (1996), focusing on the human cause. He believes that firms can achieve high effectiveness and low deviations if they improve the quality management. Deming (1986) argues that although errors in firms cannot be eliminated totally, they could be reduced by applying quality management methods. Deming’s (1986)
14 points for quality management give guidelines for cultural causes of this disaster from a quality perception, and provide methods how the accidents can be avoided. Some 14 points related to the Challenger disaster are shown in Table 1.

Deming’s points Explanations Related to the Challenger
1 Create constancy of purpose The whole project members have common goals. All members in NASA need to work together, such as NASA managers and engineers.
2 Adopt the new philosophy and take on leadership Acceptance of new and good culture/roles, but no defects. Say no to any faults and deviations.
4 Minimize total cost of by improving quality of suppliers. Price is meaningless without quality. Select a better supplier with good quality products.
6 Institute training on the job, and self-improvement Provide training to everyone, and help him or her to understand the project goals well. For example, training for the engineers aims to prevent complex interactions.
8,11 Drive out fear.
Eliminate quotas and substitute leadership The fear is made worse when evaluations are made. The fear of change. The engineers under pressure did not redesign O-rings.
14 The transformation is everybody’s job The importance of the leader. The leader must take action to improve quality. The organizational culture needs to be changed to improve quality management internally.
Deming 1986, Out of the Crisis (p23-24)

Table 1: Deming’s quality management and how they are relevant to the Challenger disaster

From this table, Deming (1986) argues that the expectations for non-faulty system, but this is unable to achieve in the real world. Therefore, those points are aiming to improve the quality of the project through changing organizational culture, training to employees and so on, in order to create a reduced error system. These seven of Deming’s (1986) 14 points are the instructions on faulty reduction that suggest the Challenger disaster can be avoided if those applied to NASA management.
Moreover, after the Challenger shuttle disaster, the Presidential Commission had recommended some solutions to solve and improve the quality, such as hiring experts and the establishment of a department to monitor the quality. Also the organizational culture is an issue that leads the disaster. Employee apprehension causes people in NASA management resist to change the design. Due to the process of NASA management needs to continue improving the quality before the shuttle launches, the Deming circle (PDCA) could be used by NASA for control and continual improvement of processes and products. The PDCA (plan- do-check-act cycle) is shown in Diagram 4. It is an iterative four-step management method to solve problems as well as implement new ideas.

Diagram 4: The plan-do-check-act cycle/Deming circle

Based on these four steps, the following descriptions show PDCA related to NASA management:
• Plan: NASA needs to find out what the problems are and where they exist in the processes.

As possible causes of this shuttle disaster are identified, NASA also needs to come up solutions to solve these issues such as improvement on communication between different management levels.
• Do: Do changes the designed to solve identified problems. In NASA management, “change is bad” culture is a significant issue that causes this disaster. When changes are required, correction rather than redesign (Vaughan 1996) occurred.
• Check: Check any changes achieve the desired goals or not. Moreover, NASA management should continue checking key activities to ensure the quality delivered by the project.
• Act: If the changes work, NASA management needs to implement that change. Also, Act involves people who may benefit from that change.

When the circle is completed and the problem is solved, it allows NASA management to return to Plan step to identify other potential

problems.
In addition, Collins (1999) discusses that the catalytic mechanisms were aimed to achieve “Big, Hairy, Audacious Goals” (BHAG). In his point of view, Collins (1999) reports that the catalytic mechanisms lead to a high performance and a development of a learning culture in Granite Rock. With regards to NASA management, it suggests that the catalytic mechanisms should be used to the end of the project, and the culture management is a core principle. This requires NASA management to choose the appropriate catalytic mechanisms, which could deal with the new cultural establishment. Therefore, NASA managers not only obey corporate culture but also to understand it in order to make a best decision if any accident happens. It also indicates that NASA management could monitor suppliers more closely, which would encourage people to make more efforts in order to improve quality and the culture changes. On the other hand, one limitation of the culture change to improve the quality is that the top management needs to control the project.