Tragedy 31 years ago provides lessons for the present
Rogers Commission find underestimated design risk
Failure to Communicate also source of problem
The loss of the Shuttle Challenger Crew–Francis R. Scobee; Commander,Michael J. Smith, Pilot; Ronald McNair, Mission Specialist; Ellison Onizuka, Mission Specialist;Judith Resnik, Mission Specialist; Gregory Jarvis, Payload Specialist; and Christa McAuliffe, Payload Specialist, Teacher– on STS-51-L. Out of that horrible tragedy, aerospace and aviation acquired some valuable lessons.
The Presidential Commission on the Space Shuttle Challenger Accident, also known as the Rogers Commission after its chairman, was formed to investigate the disaster. The commission members were Chairman William P. Rogers, Vice Chairman Neil Armstrong, David Acheson, Eugene Covert, Richard Feynman, Robert Hotz, Donald Kutyna, Sally Ride, Robert Rummel, Joseph Sutter, Arthur Walker, Albert Wheelon, and Chuck Yeager.
The Rogers Commission Report found that a failure in the O-rings, sealing a joint on the right solid rocket booster, allowed pressurized hot gases and eventually flame to “blow by” the O-ring. Having escaped that containment protection, the gases and flame were able to contact the adjacent external tank, causing structural failure.
The report determined that the O-rings’ design failed to identify risks, such as low temperatures, which would deteriorate their performance. January 28, 1986 was such a cold day and the O-rings failed.
Basically, the design team, NASA and Morton Thiokol did not adequately assess the risks of the deficient joint design; in fact, they came to assigned the problem as an acceptable flight risk. The report found that managers at Marshall had known about the flawed design since 1977, but never discussed the problem outside their reporting channels with Thiokol—a flagrant violation of NASA regulations. Even when it became more apparent how serious the flaw was, no one at Marshall considered grounding the shuttles until a fix could be implemented. On the contrary, Marshall managers went as far as to issue and waive six launch constraints related to the O-rings. The report also strongly criticized the decision-making process that led to the launch of Challenger, saying that it was seriously flawed.
The inclusive 3600 approach to risk assessment, whether air carrier operational issues or aircraft engineering design, fosters the dialogue which is conducive to comprehensive, proactive solutions. NASA was so dedicated to mission success that risk minimization became an unintended consequence.
The pressures which may have eroded the intensity of internal scrutiny for Challenger may be replicated in the operational or manufacturing context. It might be useful for SMS teams to revisit the findings of the Rogers Commission as a means of reinvigorating your safety culture.
Share this article: