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(Event Sequence (1974 Morton Thiokol is awarded contract to build solid…

- - - - Crew Cabin
      - Orbital maneuvering systems
    - - DESIGN FAILURE/PRE-CONDITION Two rubber O-rings
      - Booster-external tank attachment
      - Nozzie and thrust vector control system
      - solid rocket motor
    - - "Gas tank" - liquid hydrogen tank/liquid oxygen tank
      - Liquid oxygen vat valve
      - Forward external tank/ orbit attachment
  - - - The elements of a human-machine system are used together in the intended operational or support environment to perform a given task or achieve a specific production, support or mission required (Cacciabue 2004)
    - - Cacciabue (2004) Systems behave and respond via the automation and follow the rules and principles provided by their designers
  - - - Policies and procedures
      - Cost
      - Accountability
      - Rostering of staff
      - Safety
      - Human- machine interface
        
        Cacciabue (2004) discusses how human-machine system can be defined as a composite at any level of complexity of personal, procedures, materials, tools, equipment, facilities and software
- - - - DESIGN FAILURE-PRE CONDITION In 1985, post flight analysis discovered worst o-ring damage
  - - - Ericson (2015) states that safety concerns during this phase include operator actions, hardware failure, hazardous system designs and safe design changes and system upgrades
  - - - Geocoaching (2015) states that the collect debris of the vessel are currently buried in decommissioned missile silos at Launch Complex 31, Cape Carnaveral memorial at the Kennedy Space Center. :
  - - - Srinvasan & Halada (2012) States that a design flaw is generated when designers fail to create a level of product quality that satisfies the customer
    - - Time did not allow the redesign of the O-rings
    - - O-rings were re-designated as 'Criticality 1"
        
        ACTIVE FAILURE TO ENSURE SYSTEMS WERE FAILSAFE No body at Marshall suggested that the space shuttle be grounded until the safety issue was fixed
  - - - *DESIGN FAILURE TO ENSURE FAILSAFE SYSTEMS WERE INCLUDED Did not cancel shuttle flights until the joints could be redesigned.
    - - FAILURE TO RECOGNISE MISMATCH WITH O-RINGS AND COLD TEMPERATURE Srinvasan & Halada (2012) states that the primary causes of engineering disasters are usually considered to be human factors, design flaws, material failures, extreme conditions and a combination of these reasons
- - - - DESIGN FAILURE Engineer from Morton Thiokol knew there was a problem with the shuttle rocket boosters since 1977. Expressed concerns about shuttle launch in lowest temperatures. Argued that cold weather would exaggerate the problems of joint rotation and delay o-ring seating.
    - - 5 astronauts, 2 payloads including a school teacher
    - - Was 'appalled' when Morton Thiokol engineers argued that Space Shuttle Challenger shouldn't fly in such cold temperatures (Berkes, H 2016)
  - - - ACTIVE FAILURE/ MANAGEMENT POLICY/ PROCEDURE FAILURE Went against all warnings from engineers about concerns regarding low temperatures and o-rings
    - - Supported engineers when recommended the launch be postponed
        
        ACTIVE FAILURE/ MANAGEMENT POLICY/ PROCEDURE FAILURE Management later agreed with NASA that the launch should proceed as scheduled
      - LATENT FAILURE Engineer from Morton Thiokol knew there was a problem with the shuttle rocket boosters since 1977
        
        Ericson (2015) explains that in order to proactively design safety into a product, it is essential that the safety process start at the concept definition phase and continue throughout the life cycle.
    - - Expressed concerns regarding low temperatures and o-rings
    - - call for shuttle flights to stop knowing the joints needed to be re-designed. Issued and waived launch constraints for six consecutive flights (Report of the Presidential Commission on the Space Shuttle Challenger Accident, 1986)
- - - - Economic considerations, political pressures and scheduling backlogs
    - - PRE-CURSER Bad weather caused launch delays for several days
  - - - ACTIVE FAILURE Engineers concerned about shuttle launch in lowest temperatures causing problems of joint rotation and delay in o-rings
    - - An ice team had worked through the night to remove ice from the launch pad, yet engineers still expressed their concern
- - - - Raval (2014) states that in 1984 President Ronald Reagan and announced the "Teacher in Space Project' an initiative was intended to inspire students and to sustain public interest in the over-budgeted shuttle program
    - - ACTIVE FAILURE/ MANAGEMENT POLICY PROCEDURE FAILURE NASA mangers decided to approve the boosters for launch despite the fact that the predicted launch temperature was outside their operational specification
        
        Ericson (2015) explains that a safety system program is a formal approach to eliminate hazards through engineering, design, education, management policy and supervisory control of conditions and practices
  - - - Crew had no indication of a problem before the rapid break-up of the space shuttle system