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Challenger Disaster INTERACTION of HUMAN FACTORS (PEOPLE (Engineers…
Challenger Disaster
INTERACTION of HUMAN FACTORS
MANAGEMENT
Job design
Task Design
Team work problems
poor communication
between approximately 70 different systems involved in Launch readiness preparations of Challenger Space Shuttle
Upper middle and lower management, MT & Marshal of space flight
team decisions not supported
launch readiness authorised against team recommendation
Engineers refusal to sign Launch doc
recommendation by MT engineers for joint redesign not supported
Workload
Time pressure
Pressure to meet deadlines
Known O-Ring Faulty design
pressure to find a solution in a limited time frame with a limited budget
BANDAID FIX
5 delays
launch pad required for subsequent mission on the 29th Jan
Supervision
Lack of clear direction
Concerned with deadlines and cost
Procedures and Policy Disregarded
Testing Certification
quality control
Materials
Required to be tested and certified to a space worthy standard
SRB 'CRITICALLY 1' no back up
O-ring composition unknown.
SRB testing in cold weather conditions inconclusive
The joint test and certification programs were inadequate
NASA chose to continue to fly with a flawed design and to follow a measured, 27-month, corrective program
no oversight of materials used in subcontrators to meet safe worthy standards
Government Publishing Office 1986
Communication issues
Sawariagi 2005
Information Transfer
Communication
Lack of communication between Morton Thiokol and NASA regarding major issues surrounding SRB joint and O-ring issues
MT and NASA management failed to recognise or accept the severity of the O-ring situation
Disconnect between engineers and Management
MT and NASA engineers refused to sign Authority to launch DOC
Lack of communication between NASA, Motorn Thiokol and engineers with the required parameters for O-Ring testing
Lack of communication between NASA upper and lower management
Lack of direction and oversight by NASA management with contracting companies
Policies and Procedures lack weight and are broken by management if impacts schedule or budget
between approximately 70 different systems involved in Launch readiness preparations of Challenger Space Shuttle
Government publishing office 1986
Handerovers
Morton Thiokol provided NASA with a substandard product with known issues that had not been sufficiently tested
a known substandard product allowed was signed off and installed to challenger rocker booster
Once erosion was detected on O-ring after first flight with SRB joint why was extensive testing not conducted to determine the cause and an alternative solution put forward years before challenger accident
Inadequate especially there was potential to impact schedule or budget
Instructions
Lack of instructions and NASA oversight in the development of SRB joint design
Product used in the manufacturing of O-Ring not tested or controlled
manufacturer of O-Ring used insufficient product
Lack of clear instructions surrounding required testing for O-ring
Bea 2006
Inspections
No regulatory body
Reliant on NASA to conduct own inspections
Organisational Systems factors
Resourcing
budget
Cost cutting
quality control standards over looked
Manufacturing
Outsourcing
Morton Thiokol awarded contract in 1974 to build SRB
Oring composition unknown as manufacturing was out sourced
No Certification or approval required for the company(s) responsible for manufacturing the O-rings
Government Publishing Office 1986
1981 Engineers discovered erosion on the O-rings
1982 NASA deemed SRB Joint Criticality 1 'No backup"
1 more item...
1979 Space Shuttle orbiter manufacturer Rockwell a contract to convert test flight vehicle to Challenger, a space-rated orbiter.
National Aeronautics and Space Administration 2013
contract incentives promoted adequately meeting cost and schedule requirements before quality and safety.
Government Publishing Office 1986
According to NASA time did permit Joint redesign
Schedule placed above safety despite NASA policy
Putty and additional O-Ring added to Joint (Bandaid fix)
Choose to fly with a flawed design implemented a 27 month corrective program for SRB joint
Joint issues known since 1981
Government Funded
Wages not competitive with private sector, Budget cuts
loss of significant number of technical/scientific personnel due salary inadequacies between the government and private sector
Staffing reductions for years prior to accident
Expectations and Pressure to achieve meet Schedule deadlines
Gries & Blessing 2006
Organisation of work
Policy's and Procedures disregarded by Management
No evident Safety Management System
No regulatory body
Incentives for meeting deadlines not ensuring safety and quality
Engineers reported issues with joint 1981
Reporting safety issues with zero resolution
Lack of oversight by management
between approximately 70 different systems involved in Launch readiness preparations of Challenger Space Shuttle
Out sourcing
Policies
Safety standards
The Shuttle Safety, Reliability and Quality Assurance Program failed as engineers concerned with O-ring performance disregarded on multiple occasions
O-rings "Critical 1" no back up in 1982
MT proposes new field joint NASA refuses and opts for a 27 month corrective program
extra O-ring & putty added "bandaid fix"
Continued to fly after numerous incidents involving SRB erosion of previous missions
1 more item...
Joint installed with known issues
Adopeted a 27month corrective program
inadequate testing of SRB joint in cold-weather operations
O-ring composition and putty unknown
1977 Marshall Management aware of SRB joint sealing capabilities
Reported to MT using internal channels and did not involve NASA
Direct breach of NASA regulations
28th Jan MT & NAsA engineers refused to sign the Authority to Launch Doc overruled by MT MSC NASA management
Director of Marshall ShuttleProjects Office did not relay information to Associate Administrator of Safe Flight
Breach of Policy
Government Publishing Office 1986
Berkes 2016
STS Program manager violated NASA operational requirements
Launch Readiness approval despite failing NASA requirements
Leadership
Space race
Desire to beat the Russians
Reputation for impeccable safety standards
Government pressure to Launch first civilian into space
Unattainable Launch schedule
24 flights per year Launch Schedule
company culture to meet deadlines above all else
Government Publishing Office 1986
Budget cuts
Management Decisions
Decision to launch despite known safety concerns
Colder temperatures than all previous launches
MT and NASA engineers refused to sign authority to launch DOC
Concerns regarding faulty O-Rings in Joint
Previous missions indicate O ring issues
Low level management ignored recommendations to terminate launch sequence due ice on launch pad
launch initiators worried ice would damage Shuttle during lift off
5 previous launch cancellations due to weather and mechanical issues
Pressure to meet deadline
Launch pad was required for subsequent mission on the 29th which was to obtain photographs and data of Halley's comet
If achieved the word beat the Russian's , who were expected to launch a few days after
Raval 2014
Decision to adopt 27 month corrective program
Decision to Launch
Decision to continue to fly after numerous incidents surging SRB joint and critically 1 status
Government Publishing Office 1986
WORKPLACES
Equipment Design
Controls
Once launch sequence initiated cannot terminate ignition of the rocker booster
No Emergency evacuation system for Orbiter after SRB Launch initiation
Warning systems
No indication system to determine if O-Rings sealed prior to launch commencement
No pressure test
Astronauts unaware of issue
no systems in place to abort mission
Pärttö & Saariluoma 2012
Interface feed back
Work environment
Temperature
Cold temperature than all other launches
Ice on launch pad and rocket
SRB joint that failed was on the side of the rocket not in sun
temperature affected Oring sealing ability
Workplace Factors
Site design
Hazardous conditions
No anti Icing procedure
Ice was able to accumulate prior to initiating launch sequence
Weather
temperature
Colder than all other previous launches
Ice on launch pad and Space Shuttle
launch should not occur until ice was cleared from the platform leading to the pad escape system
Government Publishing Office 1986
winds
high level crosswinds reported
Aluminum oxides from the burned solid propellant sealed the joint temporarily, preventing a disaster on the launch pad
Challenger passed through severe High level crosswind and Max Q point which is thought to have dislodged the temporary seal on the SRB joint
Had the aluminum oxide kept the seal intact for few extra seconds the shuttle may have made it to space without causality
Raval 2014
Systems not resistant to failure
no recovery opportunities once launch sequence initiated
PEOPLE
Challenger Shuttle Crew
Expectations
Reliant upon NASA's impeccable safety standards
Complete Mission safely
Knowledge
Potentially unaware of issues with SRB Joint and it's risk to launch safety
No Evacuation option during launch once SRB ignited
Goals
To achieve mission goals and return to Earth safely
Launch the first Civilian successfully into space
Stress
Launch Schedule
previous delays due to technical issues
Away from family and loved ones
Morton Thiokol
Knowledge
Joint design was faulty
Bandaid fix inconclusive testing on performance
SRB Joint O-ring considered Criticatly 1
aware of temperature concerns with O-ring sealing capabilities
aware that O-ring performance had not been tested in cold weather such as was expected on launch day
Launch date was the coldest temperature conditions of any shuttle launch
aware of engineering concerns with O-ring performance in cold weather due to previous missions
Stress
budget
cost cutting
schedule
NASA
preasure to meet Launch schedule
previous launch Cancelations
faulty SRB Joint design
Competency
Thiokol management discounted technical concerns and engineering judgment in their recommendation to launch
Grossly incompetent
Out source O-ring manufacturing and unaware of composition
Government Publishing Office 1986
Engineers
Competency
Propasal for redesign of SRB Joint
Were not provided time or budget to redesign the SRB Aft Joint
Nelson, G 2010
Stress
Time pressure
No time allocated for Joint redesign
Bandaid fix required
Pressure to meet strict deadlines
Cost and Schedule before Safety and Quality
aware of potential SRB failure and ramifications
Knowledge
SRB joint design faulty
Concerns raised with Morton Thiokol Management and NASA Management
Concerns ignored on numerous occasions
Testing was not conducted on O-ring in cold weather operations
Attempted to raise concerns about O-ring's temperature performance issues in cold weather opperations
Refused to sign the Authority to Launch Document
NASA and MT Management ignored engineers concerns
extra O-ring added and putty in an attempt to sea O-ring and prevent blow-evident on previous missions
Chao 2004
Expectations
Companys culture of schedule before all else
NASA's Reputation for impeccable safety standards
Fatigue
May or may not have been a factor
Pressure to meet deadlines
Launch Director
Stress
Presure to Launch
Previous delays
Not wanting to make the call not to launch
Knowledge
Knew Ice was an potential issue should have questioned the STS Manager recommendations
Competency
Did not ensure safety was paramount when evaluating launch readiness.
Government Publishing Office 1986
The Director of Marshall’s Shuttle Projects Office
Competency
Did not relay information from teleconference with MT management and engineers regarding Oring performance in cold weather , to the Associate Administrator for Space Flight
violated NASA’s Flight Readiness Review policy directive
Knowledge
Marshall managers discounted Thiokol engineers concerns on SRB joints performance in cold weather operation and O-rings inability to seal.
Thiokol management discounted technical concerns and engineering judgment in their recommendation to launch
Stress
previous delays
Launch pad required next day for a subsequent mission
Pressure to maintain launch schedule
Government Publishing Office 1986
Expectations
STS Program Manager
Knowledge
Recommended not to launch due to Ice on Launch Pad potentially damaging shuttle during Liftoff
Competency
Launch should have been delayed until ice removed from the Launchpad
Confirmed launch readiness given despite ice hazard
Stress
meet launch deadlines
Launch pad required following day
Schedule above safety culture
HUMAN FACTORS INVESTIGATION TOOL RECOMMENDATIONS
MORT (MANAGEMENT OVERSIGHT AND RISK TREE)
Organisational factors
ICAM (INCIDENT CAUSE ANALYSIS METHOD)
holistic approach encompass the latent and active failures contributing to the accident
SOL (SAFETY THROUGH ORGANISATIONAL LEARNING)
a number of organisational issues are detailed this would be used to encompass those lines of inquiry
HIERARCHICAL TASK ANALYSIS
Determine potential active failures to do with the task
Physical factors
PRISMA (PREVENTION & RECOVERY INFORMATION SYSTEM MONITORING ANALYSIS)
SCAT (SYSTEMATIC CAUSE ANALYSIS TECHNIQUE)
Environmental Factors
Public Pressure
National expectations
Public Pressure to beat the Russians (SPACE RACE)
View NASA as a world Leader in SPACE Travel
Teacher in space program
possibility of civilian space travel
Government
Texas A&M University 2006
Budget cuts
Supported the teacher in space mission
Political Pressure to meet deadlines
Launch Pad required for a subsequent mission to gather from Halley's commet before Russian competitors on the 29th January
Regulators
No government regulatory body
Ware 2016
NASA able to disregard policies to meet schedule deadlines
LATENT FAILURE
LATENT FAILURE