The Space Shuttle Challenger Disaster

A failure in decision support system and human factors management

by Jeff Forrest Metropolitan State College

INTRODUCTION
This article discusses the environmental and human decision making factors that were associated with the launching of the Space Shuttle Challenger on January 28 !"8#$ Shortly after launch the Shuttle e%ploded destroying the vehicle and all crew members$ The cause and contributing factors that lead to the Challenger tragedy are e%plored in detail$ Focus is placed on &'S'(s use of a group decision support system )*+SS, meeting to make the decision to launch$ -%amples are included that show how contributing factors such as multiple priorities and demands influenced &'S' from operating in a responsible and ethical manner$ .roof that &'S' used a flawed database in its *+SS and how it mismanaged the *+SS meeting is also offered$ Finally the inability of each *+SS member to vote anonymously on the decision to launch is discussed as a critical factor that had it been allowed probably would have prevented the Challenger tragedy$

THE SHUTT E !"# $ISSION

En%ironmental &actors# Societal Impacts The Space Shuttle Challenger /!01 was the 2/th mission in &'S'(s STS program$ 2n Jan$ 28 !"8# STS /!01 e%ploded shortly after liftoff destroying the vehicle and all of its seven crew members$ The STS /!01 mission was to deploy the second Tracking and +ata 3elay Satellite and the Spartan 4alley(s Comet observer$ .aramount to this mission was crew member S$ Christa Mc'uliffe 0 the first Space Shuttle passenger5observer participating in the &'S' Teacher in Space .rogram )cf$ 6!7,$ Ms$ Mc'uliffe would have conducted live educational broadcasts from the Shuttle and transmitted them to classrooms throughout the world$ The loss of life and the uni8ue position that symboli9ed Christa Mc'uliffe as the first civilian working as a teacher in space had a profound impact on society and its attitude toward &'S' and the :$S$ Space programs$ 's this article will e%plore the tragic decision to launch STS /!01 was based on long term contributing factors and the use of a flawed group decision support system that was further aggravated by its related mismanagement$ The outcome of this action created costs to society in

terms of life resources and public mistrust$ &'S' subse8uently e%perienced years of setback for its related scientific research and operations$

'AC()ROUND
Human &actors # Contri*uting to a Tragedy 'lthough the destruction of the Shuttle Challenger was caused by the hardware failure of a solid rocket booster )S3;, <2< ring the human decision to launch was in itself flawed$ The resolution to launch was based upon faulty group decision support information and further aggravated by the related mismanagement of that information$ 4owever as in most transportation accidents there are usually other contributing factors that help to create an environment leading to mistakes and failures$ Therefore a brief review of the contributing factors leading to the Challenger destruction is in order$ En%ironmental &actors # Demands on the Space Shuttle The process of <selling< the 'merican public and its political system the need for a reusable space transportation system began in the late !"#=(s$ Conceptually the Space Shuttle was introduced during the crest of the successful 'pollo mission$ :nlike the 'pollo mission the Space Shuttle was approved as a method for operating in space without a firm definition of what its operational goals would be )627 pg$ >,$ 4ere is the first contributing factor$ The Shuttle was developed as a utility without a firm application$ Therefore support for such a pro?ect both politically and economically was not very strong$ To gain political support it was sold as a pro?ect with a <8uick payoff< )cf$ 627,$ 'dditional support was gained by offering the Shuttle program to the military as a means to increase national security and to industry as a tool to open new commercial opportunity$ Scientists argued to the 'merican people that the Shuttle would be an <'merican @oyage< )627 pg$ !=, with great scientific gain$ *lobally the Shuttle was sold as a partnership with the -uropean Space 'gency )-S', and as a means to improve national and social relations by combining peoples of different nationalities races and se%es who would serve as crew members$ The process used to develop economic political and social support for the shuttle introduced the second contributing factor called heterogeneous engineering$ That is the Shuttle engineering and management decisions were made to meet the needs of organi9ational political and economic factors as opposed to a single entity mission profile with specific goals )627 pg$ ",$ 2nce functional the Shuttle became e%posed to operational demands from a multitude of users$ The Shuttle now had to live up to &'S'(s promises$ Coordinating the needs of political commercial military international and scientific communities placed immense pressures on the Shuttle management team$ First political pressure to provide a reliable reusable space vehicle with rapid turn around time and deployment seriously hindered the ability for effective systems integration and development$ Secondly it was not feasible to construct any complete management support systems )MSS, that could consider all of the factors associated with such a diverse group of environmental variables$ Third additional uncertainty and low &'S' employee moral was created when the 3eagan 'dministration pushed for the Shuttle to be declared <operational< before the <developmental< stage had been completed 627$

'fter spending billions of dollars to go to the moon Congress e%pected the Shuttle program to be financially self0supportive )627 pg$ !/,$ This forced &'S' to operate as a pseudo commercial business$ Therefore the environment within &'S' preceding the Challenger launch was one of conflict stress and short cuts 627$

NASA
Decision Support System +DSS, # En%ironmental Effects The probability for disaster was growing higher as increasing demands were being placed on &'S' ?ust prior to the Challenger launch 627$ ' false sense of security was felt by &'S' officials with twenty0four successful Shuttle missions to their credit$ Just prior to the STS /!01 launch &'S' was an organi9ation filled with internal strife and territorial battles)6>7 pg$ A!2,$ Mangers operated in an environment of <overload and turbulence< 6>7$ Bn short &'S' was characteri9ed as having a <disease < )6>7 pg$A!A, of decay and destruction$ 's incredible as it may seem it would appear that &'S' had no formal +SS program initiali9ed for the Shuttle operations before the Challenger launch$ -vidence is strong that decisions were made primarily by <satisficing< and conscious <muddling through$< Specific characteristics of decision making at the time consisted of short cuts compromise and operational heuristics )<operational heuristicsC to cannibali9e e%isting parts< as defined by Jarman and Dou9min 6>7 pg$ A!A,$ Bn short &'S' was operating in a phase of semi0uncontrolled decision making while trying to serve the military industry and international research organi9ations with a space vehicle that had been declared operational before completion of the developmental stage 6A7$ &'S' used decision making by default as its primary +SS$ Bts organi9ational boundary was highly political and open for manipulation by any entity that could e%ert political power$ :pon declaring the Shuttle <operational < the 3eagan 'dministration removed the motivation of &'S' employees to manage and left them with the impression that decision making would be made by directive from political sources$ The declaration of <operational< status was the critical turning point for &'S' and its management of Shuttle operations$ Complacency began to grow among employees and safety considerations were traded for time spent on keeping the Shuttle on schedule and <the client of the day< satisfied$ This was the environment ?ust before the launch of STS /!01$

THE DECISION TO AUNCH

)roup Decision Support System +)DSS, # Situational Analysis ' group support system did e%ist between &'S' and related developers of the Shuttle$ Focus in this discussion will be placed on Thiokol 0 the subcontractor directly responsible for the development of the S3; <2< rings$ The *+SS system between &'S' and Thiokol consisted of same0time5different0place conference rooms e8uipped with a connected and distributed computer interface$ Speaker phones with audio only were also available$

2n the evening of January 2E !"8# Thiokol was providing information to &'S' regarding concerns for the ne%t day(s planned launch of STS /!0l$ Thiokol engineers were very concerned that the abnormally cold temperatures would affect the <2< rings to nonperformance standards$ The mission had already been canceled due to weather and as far as &'S' was concerned another cancellation due to weather was unthinkable )6A7 pg$ 2>,$ ;oth parties were already aware that the seals on the S3; needed upgrading but did not feel that it was critical$ Though the information provided by the *+SS )with an associated e%pert system, showed that the <2< rings would perform under the predicted temperatures Thiokol engineers 8uestioned their own testing and data that were programmed into the *+SS$ Thus on the eve of the Challenger launch &'S' was being informed that their *+SS had a flawed data base$ 't this point &'S' re8uested a definitive recommendation from Thiokol on whether to launch$ Thiokol representatives recommended not to launch until the outside air temperature reached />F F$ The forecast for Florida did not show temperatures reaching this baseline for several days$ &'S' responded with pressure on Thiokol to change their decision$ &'S'(s level BBB manager Mr$ 1awrence Mulloy responded to Thiokol(s decision by asking <My *od Thiokol when do you want me to launch ne%t 'prilG< )6A7 pg$ 2A,$ 'fter this comment the Thiokol representatives re8uested five minutes to go off0line from the *+SS$ +uring this period the Thiokol management re8uested the chief engineer to <take off his engineering hat and put on his management cap < suggesting that organi9ational goals be placed ahead of safety considerations 6A7$ Thiokol reentered the *+SS and recommended that &'S' launch$ &'S' asked if there were any other ob?ections from any other *+SS member and there was not$ )roup Support System # Critical Analysis There is little doubt that the environment from which &'S' and its affiliated developers operated provided an opportunity for significant human error$ &evertheless &'S' and Thiokol had a <golden< opportunity to avoid disaster during their *+SS meeting before the STS /!01 launch$ The following factors are offered as potential e%planations for what created the flawed *+SS and the associated mismanagement of its informationH First Thiokol was aware of the <2< ring problem at least several months before the Challenger launch$ 4owever the goal was to stay on schedule$ &'S' was made aware of the problem but it was <down0played< as a low risk situation$ 4ere is the first element of flawed information that was input into the *+SS$ Bf &'S' had been aware of the significance of the <2< ring situation they probably would have given more credence to the advice of the Thiokol engineers( recommendations$ 4owever the data transmitted during the *+SS meeting from Thiokol did say that it would be safe to launch for the forecasted temperatures$ &'S' was frustrated over the conflicting advice from the same source$ Second the decision to delay a Shuttle launch had developed into an <unwanted< decision by the members of the Shuttle team 6/7$ Bn other words suggestions made by any group member that would ultimately support a scheduled launch were met with positive support by the group$ 'ny suggestion that would lead to a delay was re?ected by the group$

Third all members of the *+SS felt that they should live up to the <norms< of the group$ 'lthough the Thiokol engineers were firm on their recommendation to scrub the launch they soon changed their presentation of ob?ections once threatened with the possibility of being e%pelled from the program )as suggested by a &'S' administrator who was <appalled< at a company that would make such a recommendation based on the data available, 6/7$ Fourth Thiokol became highly susceptible to <groupthink< when they re8uested a break from the *+SS$ 't this point they became insulated conducted private conversations under high stress and were afraid of losing potential future revenue should they disagree with &'S'$ 'll these factors are considered prime to the formulation of <groupthink< 6/7$ Fifth all parties were afraid of public and political response to another launch cancellation )there had already been si% cancellations that year,$ -ach party began to rationali9e that past success e8ualed future success 6/7$ Finally the *+SS was seriously flawed$ 's already mentioned the data base contained erroneous information regarding the <2< rings$ Bdeas suggestions and ob?ections were solicited but not anonymously$ Bndividuals who departed from the group norms were signaled out as unwelcome members$ 'n agenda was never defined and &'S' was therefore surprised by the Thiokol presentation$ Conflict management was avoided by &'S'(s domination of the entire meeting$ &'S' at times became very assertive and intimidating$ Considering &'S'(s attitude no group member or individual was willing to be held accountable for any comment or decision 6/7$ The setting for such an important *+SS meeting was also ineffective$ Considering that a speaker phone and C.: modem was used it was easy for &'S' to down0play the personal opinions of the Thiokol engineers$ Bf the meeting could have been held at the same place for all members the outcome might have been different$ 't the end of the meeting &'S' very reluctantly suggested that they would still cancel the launch if Thiokol insisted$ &o response from Thiokol was made and the &'S' officials could not see the e%pression of <self0censorship< that was being communicated on the face of each Thiokol engineer 6/7$ .erhaps the most significant flaw in the *+SS was when Thiokol re8uested a private five minute meeting with its own members$ :p to this point Thiokol had stayed with its recommendation to cancel the launch$ 2nce disconnected Thiokol became an isolated member and the *+SS failed altogether$ 2nce reconnected Thiokol had changed its position and offered the go ahead to launch without any ob?ection$

CONC USIONS
The Critical Human &actor # Need for -oting Tool Many conclusions may be drawn as to the primary cause and contributing factors associated with the Challenger tragedy$ Bt is the opinion of this author that regarding the *+SS and decision to launch the ability of each member to have voted anonymously was the key factor that would have maintained the integrity of the *+SS and the 8uality of the decision$

Bt has been shown that ?ust after Thiokol(s presentation to &'S' most of the *+SS group members were very concerned with the <2< ring situation and believed that the opinions e%pressed by Thiokol engineers were cause for serious consideration of launch cancellation 6/7$ 4owever only selected senior officials were allowed to vote their <opinion< which they did verbally and at the re8uest of &'S'$ From the research conducted on this paper the author believes that had a universal anonymous vote been conducted of the total *+SS membership a decision to cancel the launch would have been made$ The factors which lead to the Challenger incident can be traced back to the inception of the shuttle program$ &'S' and Thiokol failed to maintain a 8uality assurance program through MSS as was initiated on the 'pollo program due to multiple source demands and political pressures$ The *+SS used for the launch decision contained inaccurate data$ -ngineering members of the *+SS did not believe in the testing procedures used to generate the data components in the *+SS$ 'nd the entire meeting was mismanaged$ The decision to launch the Challenger Shuttle and its subse8uent destruction had a ma?or affect on society and the management of our space program$ Challenger(s uni8ue mission and the death of Christa Mc'uliffe opened the door for discussion and research on how managers use +SS to make decisions that will affect public trust$

A&TER$ATH
Ethics and $SS.DSS # Human &actors $anagement ' complete discussion of ethical decision making is beyond the scope of this article$ 4owever the 8uestion of how &'S' and Thiokol managed ethical considerations is central to the decision to launch the Challenger Shuttle and therefore deserves a brief overview$ The first area of ethical concern is the area of information accuracy$ The fact that both &'S'(s and Thiokol(s managers had little regard to the concerns of Thiokol(s engineers is very distressing$ 'll members of the group made a decision knowing that the decision was based on flawed information$ ' second concern is that the decision made put safety last and operational goals first$ 2nly one member of the *+SS e%pressed serious concern for the potential loss of life 6/7$ 'dditionally open and free communication before and during the *+SS meeting was discouraged through such group dynamics as mind guarding direct pressure and self0censorship 6/7$ Bndividuals who know of a situation that unless acted upon with integrity might cause social harm have a responsibility to contact any authority that will manage and control that situation in the best interest of the public )6A7 <Ihistleblowing pg$ >A,$ 4uman factors analysis and management science have begun to define the incorporation of MSS5+SS as a socially responsive way of conducting business )6#7 pg$ 82#,$ This is especially true for government agencies and large public pro?ects like the Shuttle program$ Bt could be argued that *+SS technology had not evolved to the level of effectiveness that was needed to support the Challenger pro?ect$ The success of the +SS used in the prior 'pollo mission shows that this was not the case$ Bn the Challenger program social and ethical decision making was discarded for the sake of cost schedule and outside environmental demands$

RE&ERENCES
6!7 &'S' Spacelink Challenger .ress 3elease httpH55history$nasa$gov5sts/!lpresskit$pdf 627 1aunius 3oger +$ <Toward an :nderstanding of the Space ShuttleH ' 4istoriographical -ssay<$ Air /o0er History Iinter !""2 vil$ >" no$ A$ 6>7 Jarman '$ and Dou9min '$ <+ecision pathways from crisis$ ' contingency0theory simulation heuristic for the Challenger Shuttle disaster< Contemporary Crises +ecember =! !""= vol$ !A no$ A$ 6A7 Dramer 3onald C$ and Jaska James '$ <The Space Shuttle +isasterH -thical Bssues in 2rgani9ational +ecision Making< Iestern Michigan :niversity 'pril !"8E >" pgs$ 6/7 *roupthink videorecording written by and produced by Dirby TimmonsC produced by Melanie Mihal Carlsbad Calif$ C3M Films c !""! 2/min$ 6#7 Turban -fraim Decision Support and E1pert Systems Macmillan .ublishing Company &$J$ &$J$ !"">$

Editor2s Note
The &'S' history site on the Challenger STS /!01 'ccident at httpH55history$nasa$gov5sts/!l$html links to many resources including Jeff Forrest(s analysis$ 3eader(s are especially encouraged to read and review the 3eport of the .residential Commission on the Space Shuttle Challenger 'ccident )commonly called the 3ogers Commission 3eport, June !"8# and the Bmplementations of the 3ecommendations June !"8E$ The *+SS was an audio teleconference$ The slides had been fa%ed to the &'S' meeting site$ Mr$ Mulloy of &'S' testified that Mr$ Dilminster of Thiokol re8uested the / minute off0net caucus that ultimately lasted appro%imately >= minutes$ The opinions in this analysis are those of the author and not necessarily those of the -ditor or of +SS3esources$com$

Some 3uestions for &urther Analysis and Discussion

!$ Ihat is a group decision support systemG 2$ +id &'S' and Thiokol use a *+SSG >$ +id the group decision support system fail or was the problem with the participantsG A$ Ihat do you think was the cause of the decision0making failure in this situationG /$ Could improved *+SS technology have avoided this tragedyG Bf so what was neededG @ideo anonymous votingG