NASA Case Study Intro

And

Links to Supplementary Material

NASA A case study in expert leadership and organizational culture Space – the final frontier. We are a nation which prides itself on its space exploration program. After all, under president J.F. Kennedy, we put a man on the Moon and returned him safely to Earth. But the space shuttle program has been plagued with disasters. On January 28, 1986, the space shuttle Challenger exploded on launch, costing the lives of all aboard. Investigate the decision-making that led NASA administration to go for launch in spite of technical issues with the space shuttle’s O rings. Roger Boisjoly was an engineer at Morton Thiokol, the company that produced the O rings for NASA’s space shuttles. He and other engineers tried, but failed to stop the launch of the Challenger. He then testified in the investigation into the Challenger disaster. Yet on February 1, 2003, disaster struck again when the space shuttle Columbia disintegrated on reentry. The investigation into the Columbia disaster found problems with NASA’s organizational culture continued after Challenger. As you analyze this case, put yourself in the shoes of Roger Boisjoly. Evaluate how different people weigh in on two contradicting values: the spirit of exploration, and a culture of safety. • http://www.npr.org/templates/story/story.php?storyId=5175151 •http://www.madisoncourier.com/main.asp?SectionID=4&SubSectionID=253&ArticleID=22475&TM=54076.17 • http://www.elmhurst.edu/~bridgeto/eng531web/marlene's%20Annotated%20Bibliography.htm • http://www.guardian.co.uk/g2/story/0,3604,426586,00.html • http://history.nasa.gov/columbia/index.html • http://www.space.com/missionlaunches/caib_report_030826.html

NASA Supplement One

Challenger: Reporting a Disaster's Cold, Hard Facts by Howard Berkes

Breaking News

On Feb. 20, 1986, NPR reporters Howard Berkes and Daniel Zwerdling first reported the effort by Thiokol engineers to postpone the Challenger launch due to cold launchtime temperatures.

A Thiokol Engineer

Howard Berkes interviews former Morton Thiokol engineer Roger Boisjoly in 1987.

Changes at Thiokol

In 1988, Howard Berkes went back to Morton Thiokol to see what lessons were learned from the Challenger explosion, and how the company had changed in response.

Berkes Thiokol Safety Report

Editor's note: NASA and the nation mark a sad occasion this week, the 20th anniversary of the explosion of the Space Shuttle Challenger. On Jan. 28th, 1986, the spacecraft blew apart just 73 seconds after launch.

NPR's Howard Berkes and Daniel Zwerdling were the first to report details of an effort by Thiokol engineers to postpone the Challenger launch due to safety concerns over cold launchtime temperatures. Berkes recounts their hunt for the story.

The images are indelible for those who saw them. Contrails in the sky billowing out like leafy stems from a flower. The face of Grace Corrigan peering skyward, etched in confusion, shaded by a hand. Her daughter Christa McAuliffe, NASA's first "teacher-in-space," was aboard the Space Shuttle Challenger with six other astronauts. She scoured the Florida sky for the spacecraft, but saw only smoke and debris.

All seven astronauts aboard died: Commander Francis Scobee, Pilot Michael Smith, Mission Specialist Ellison Onizuka, Mission Specialist Judith Resnik, Mission Specialist Ronald McNair, Payload Specialist Gregory Jarvis and McAuliffe.

Three weeks later, in a living room in Brigham City, Utah, a proud space program engineer watched the scene again. It played and replayed on television screens, endlessly it seemed. "I should have done more," the engineer told me, shaking his head. "I could have done more."

That engineer and several others were not surprised when Challenger exploded 73 seconds after liftoff on Jan. 28, 1986. They worked for Morton Thiokol (now ATK Thiokol), the Utah-based NASA contractor which produced the solid rocket motors that lifted space shuttles from their launch pads. The rockets were like stacked metal cans stuffed with highly explosive propellant. The forces of liftoff tended to pull the cans apart slightly where they joined. Rubber o-rings lined those joints and kept burning propellant from leaking out.

Some of those Thiokol engineers expected o-ring failures at liftoff. They knew that cold overnight temperatures forecast before launch would stiffen the rubber o-rings. They knew that stiff o-rings didn't provide a secure seal. In fact, there had been evidence of leakage, what the engineers called "blowby," on an earlier shuttle flight. This would be the coldest launch ever.

As I sat with that despondent Thiokol engineer in his home in Utah, my colleague Daniel Zwerdling stood outside a hotel room door in Huntsville, Alabama. Another Thiokol engineer was inside. He first spoke through the door, weeping at times. When the door finally opened, Zwerdling heard a remarkable tale, matching in almost every detail the story that simultaneously unfolded to me in Utah. The engineers had resisted the launch, had recommended against it, citing the "blowby" in an earlier low-temperature launch and studies of the elasticity of the o-rings. The night before liftoff, these two Thiokol engineers, along with several colleagues, tried to convince NASA to postpone liftoff.

"I fought like hell to stop that launch," one of the engineers told Zwerdling. "I'm so torn up inside I can hardly talk about it even now."

Both engineers asked that we not reveal their names in 1986. They feared for their jobs. Neither has released us from that pledge of confidentiality, so they shall remain unnamed.

It wasn't long after the Challenger explosion that word of a pre-launch argument leaked out. A source who asked to remain anonymous told me that Morton Thiokol was "coerced" into approving the launch, after the company's engineers voiced their objections. The source gave me three names. I reached two of the engineers and the wife of a third on the phone. Each confirmed the notion of a coerced launch approval. But none would consent to a detailed interview or on-the-record conversation.

I tried again over the next several weeks, getting a few more details but little substance. Three weeks after the launch, on Feb. 19, I headed to Brigham City, Utah, the town closest to Thiokol's remote plant. Many Thiokol workers lived in Brigham City and the town was taking the disaster

hard. Vandals had scrawled the words "Morton Thiokol Murderers" on a railroad overpass on the road out to the Thiokol plant.

That same day, I huddled on the phone with NPR Science Editor Anne Gudenkauf and Correspondent Daniel Zwerdling. We decided to follow-up on my earlier leads, on new leads found in newspaper stories and in information Zwerdling developed in his own phone conversations with the wives of several Thiokol engineers. We knew that there was a bigger story out there that was still untold.

Zwerdling learned that one of the engineers who opposed the launch was sent to NASA's Marshall Spaceflight Center in Huntsville, Alabama. Zwerdling discovered the name of the hotel where the engineer was staying. He hopped on a plane for Huntsville.

In the meantime, Gudenkauf and I worked through a directory of Thiokol employees. We took the names we already had, and figured that the other engineers involved in the pre-launch meeting would have offices nearby. A list evolved of co-workers with office and phone numbers a few digits different. I matched the list to names in the Brigham City phone directory and began knocking on doors. Other reporters were on the same trail. Some doors had a dozen business cards tucked into them, from reporters all over the world.

This was in an era when NPR reporters did not have cell phones or laptop computers. Zwerdling and I worked independently, phoning in progress reports to editor Gudenkauf in Washington, when we could get to telephones. Neither of us knew it, but doors opened to each of us simultaneously. We heard many of the same details, including exact quotes. We listened to emotionally-charged accounts of a desperate and frustrating attempt to keep Challenger on the launch pad. Fearing for their jobs, neither engineer would permit us to record them, let alone name them.

That night, in a three-way conversation with Gudenkauf, we compared our astonishing notes. There were details no one else had yet revealed. A presidential commission was already investigating the Challenger disaster. But one of the engineers, a key player in the pre-launch debate, had not yet been contacted by the commission.

That engineer told me something that would later become symbolic of NASA's Challenger failures. He described the tense discussion about the cold temperatures forecast for the launch. The Thiokol engineers presented data about earlier low-temperature launches, including evidence of "blowby." To him and his colleagues, the message was clear: it was too cold to launch. At first, the Thiokol managers backed their engineers. They formally recommended that the launch be postponed.

The NASA officials on the line were perplexed. They were trying to establish the Space Shuttle as a regular and reliable means of conducting scientific and commercial missions in space. They had an ambitious launch schedule. Classrooms across the country were ready for the first science class taught from space. And in just a few days, during the State of the Union address, President Ronald Reagan was planning to mention Challenger's launch as a space program achievement.

NASA's Lawrence Mulloy reacted to the resistance this way: "My God, Thiokol. When do you want me to launch? Next April?" That turned the tide of the discussion. The Thiokol managers pressed their engineers to reverse themselves. When that failed, the managers simply overruled them, and submitted their own launch recommendation.

The next morning, two of the engineers told us, they fully expected Challenger to blow up at launch ignition. One of the engineers silently prayed during the countdown. At liftoff, with no explosion, he began to wonder whether he'd been wrong. The relief didn't last. Seventy-three seconds into the flight, as the spacecraft began an expected roll, the forces on the solid rocket motors began to pull one of them apart. The cold and stiff o-rings at one joint didn't flex and seal as designed. Searing hot gasses escaped. In an instant, the sky was filled with smoke and debris. The engineers were filled with grief. And as one later told Zwerdling, "...we all knew exactly what happened."

NASA Supplement Two

Friday, February 18, 2005 Challenger engineer Boisjoly tells story behind disaster at lecture series finale By: Jenny Jones Courier Staff Writer Friday, February 18, 2005 The Challenger disaster was not about an engineering failure and it was not about seven people being killed, according to Roger Boisjoly, aerospace engineer who inspected the shuttle’s O-rings prior to the fateful flight. It was about people who could not handle their professional responsibilities. Boisjoly, who worked for the engineering firm, Morton Thiokol Inc., which was contracted by NASA at the time of the Challenger disaster, spoke Thursday night as the final lecturer in Hanover College’s “Ethical Choices, Individual Voices” series. Boisjoly began his lecture by showing footage of the Challenger explosion and of the control room personnel as they watched the shuttle explode just 73 seconds after launch. “Nine, eight, seven, six ... We have main engine start ... five, four three, two, one ... We have lift off,” a voice said as the Challenger left the launch pad. Audience members were filled with anxiety as they watched footage of Challenger, soaring into the air. “Challenger go with throttle up,” the voice on the video said. A couple seconds later, the Challenger was a giant ball of fire in the sky, and workers in the space shuttle control room looked at one another, stunned. There was “obviously a major malfunction,” the voice on the video said. “Final reports ... vehicle exploded.” Although Boisjoly was just as horrified as the control room personnel and the thousands of Americans who tuned in by television on Jan. 28, 1986, to watch the first flight to carry a teacher into space, he was not surprised that the Challenger exploded. He knew there was almost a 100 percent chance the launch would be disastrous and so did members of Morton Thiokol’s and NASA’s upper management teams. Boisjoly began his career with Morton Thiokol in 1980. At that time, he said, it had already been determined that the shuttles’ O-ring joint design, which was blamed for causing the Challenger disaster, was faulty. But it was Boisjoly’s job to keep the O-ring joints operational. O-rings are rubber rings that seal the joint.

After every launch, Boisjoly said, he and other Morton Thiokol engineers retrieved the shuttles’ rocket fuel cylinders, which contained the O-rings, and prepared them for the next flight. Boisjoly said that when he inspected the cylinders’ O-rings following the launch that took place just before the Challenger, he found that masses of fuel had escaped past the primary seal. The O-rings were not functioning properly, he said. Boisjoly said he determined that the cold weather that had plagued Florida that night caused the seal to fail and allowed gas to reach past the primary seal, destroying the O-rings. The night before the launch, temperatures in Florida dipped below freezing. At the time of the launch, the outside of the fuel cylinders was 67 degrees, but inside it was only 53 degrees. The cold air, mixed with already faulty O-rings, caused the joint to loosen and allowed the gas to reach past the primary seal, Boisjoly said. “It’s my technical opinion that the cold weather that preceded” the launch is what affected the seal, he told his managers. “I estimate that we were within seconds of blowing it out of the sky.” Boisjoly said he and other engineers were instructed to perform tests on the O-rings. Through their tests, Boisjoly said, they found that the rings had trouble sealing at 53 degrees and that if the primary seal was destroyed, the back-up seal had a great chance of failing. It had “close to 100 percent chance of destruction,” he said. After the preliminary tests were performed, Boisjoly said, his managers wanted to keep the information that the rings had trouble sealing at 53 degrees a secret. But when NASA asked Morton Thiokol to make a presentation about the faultiness of the rings, management decided it should tell NASA about the defects, Boisjoly said. When Morton Thiokol told NASA about the defects, Boisjoly said, they asked him and other engineers to form an unofficial task force to study the O-rings further. The task force never met, Boisjoly said. So Boisjoly drafted a letter to his managers, stating how faulty the O-ring joint system was and the affect it could have on flights to come. “It is my honest and very real fear that if we do not take action to dedicate a team to solve the problem with the field joint having the number one priority, then we stand in jeopardy of losing a flight along with all the launch pad facility,” Boisjoly wrote. “The result would be a catastrophe of the highest order — loss of human life.” Boisjoly said his letter never made it past the managers. They put a stamp on the document, deeming it “private,” he said. But Boisjoly wanted his colleagues to know that he had warned management of the risks, so he whited out the private stamp and circulated a copy of his letter to his co-workers. “They’d been put on notice that I’d done this,” he said. After Boisjoly’s colleagues found out about his letter, Morton Thiokol management put Boisjoly and other engineers on an official task team to study the O-rings. The team never met and no tests were performed, Boisjoly said. “We did not accomplish one single test on this joint or this seal, not one,” he said. About a year after Boisjoly initially inspected the O-rings and found that the temperature had an effect on the already faulty joints, it was time for the Challenger launch. The night before the Challenger launch, Florida was to be hit again with record low temperatures, Boisjoly said. Knowing that temperatures in the high teens and low 20s could mean disaster for the flight, Boisjoly and other engineers formed a stop-launch group and met with their chain of command. Boisjoly said that during the meeting, he and his colleagues were able to persuade their superiors to stop the flight. “We had no difficulty convincing all in the chain” not to launch, Boisjoly said. “Everybody knew we were flying on a wing and a prayer.” But when Morton Thiokol told NASA not to launch, NASA’s upper management said they wanted to meet

with the engineering firm’s management and engineers in 45 minutes, Boisjoly said. They wanted Morton Thiokol to prove the launch would fail. “We had 45 minutes to prepare for the most important meeting of our lives,” Boisjoly said. Morton Thiokol engineers and management presented all the proof they could to NASA that the launch would be disastrous, but NASA would not back down, Boisjoly said. NASA accused Morton Thiokol of coming up with criteria the eve of the launch and it accused engineers of messing up the launch schedule, Boisjoly said. In the mist of the pressure, Morton Thiokol managers stepped to the side, ignoring their engineers’ recommendations, and decided to make a “management decision,” Boisjoly said. They gave NASA the OK to launch with no criteria on the weather. At launch time, the temperature was 29 degrees. Boisjoly sat in a room with his fellow co-workers and watched Challenger leave the launch pad. Everything seemed to be going well, and Boisjoly had a sense of relief when the shuttle didn’t explode on the pad as he originally predicted. But seconds later ... disaster. Following the Challenger explosion, NASA and Morton Thiokol tried to deny that they knew about the faulty O-rings and field joints, prior to the disaster. But Boisjoly testified against them. Boisjoly was then black-balled from the engineering business because of his testimony. But he didn’t let that stop him, going on to get his engineering license and starting his own firm. Although his actions cost him a lot, Boisjoly said, “I would do exactly what I did again. I believe that our first responsibility is to others. I could not do anything but what I did.” At the conclusion of the lecture, Hanover College President Russell Nichols commended Boisjoly for making the decisions he made and for taking action. “We admire and appreciate what you’ve done, and we want to thank you for what you’ve done for our country.”

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NASA Supplement Three

Annotated Bibliography Resources on the Challenger Space Disaster

The Challenger spacecraft was launched on January 28, 1986, and exploded 73 seconds after liftoff. Much of the research into what went wrong with the Challenger launch focuses on the lack of communication between NASA, Morton Thiokol, Inc. (MTI) and the Marshall Space Center. An important factor in the communications failure was the relationship between these three organizations. MTI was the contractor responsible for the component that failed during the launch and depended on Marshall for the contract, and Marshall depended on NASA for funding and support.

Almost two years before the fatal launch, MTI became aware that there could be a problem with the O-ring, a sealing component that prevents hot gases from escaping the solid rocket booster and burning a hole in the fuel tank (the physical cause of the Challenger disaster). The engineers at MTI documented this problem and insisted that further testing needed to be done to determine the reliability of the O-ring. Upon further testing they confirmed that the O-ring was not reliable, particularly when temperatures dropped below 53�. Why then was the Challenger given the go

to launch on January 28, 1986 when the temperature at launch time was 36�, well below the safety margin?

This research will examine the causes behind the communication breakdown that led to the fatal launch. The discussion will center on the responsibility of an individual to turn knowledge into accepted facts. There is a difference between writing facts down on paper and having those facts accepted as truths. Writers must be aware that what they write is subject to interpretation and interpretations are subject to corporate culture and pressures from outside sources. Key questions this research will answer are: How is the written word transformed into accepted knowledge? Is a writer responsible for the interpretation or misinterpretation of the facts he presents? What are the ethical implications of accepting or rejecting the written word? How is pressure exerted to conform to corporate culture?

Winsor, Dorothy A. "The Construction of Knowledge in Organizations: Asking the Right Questions about the Challenger" Journal of Business and Technical Communication, v4n2 September 1990: 7-20.

Winsor investigates the difference between "knowing and passing on the information". She claims that knowing something is not enough, if you have the facts, you cannot assume that just writing the facts down will transfer your knowledge to your audience. Audiences vary in their assumptions so evidence that is valid for one group may have no validity for another. The opposing sides in the Challenger disaster both argued facts to support their decision. The managers who gave the go to launch argued that the 24 launches prior to the challenger all returned safely which convinced them that the O-rings functioned properly. They were not proven wrong until the Challenger exploded. The engineers written word failed to transform

facts into knowledge which resulted in the explosion. Winsor’s article examines the reasons facts are not accepted as knowledge.

… "Communication Failures Contributing to the Challenger Accident: An Example for Technical communications" Transactions on Professional Communication, v31n3, September 1988:101-107.

Winsor explores the movement of communications within organizations. After examining the documents relating to the disaster she attributed miscommunication as the leading factor in the disaster. The miscommunication is a result of managers and engineers viewing the same facts from different viewpoints. Shared interpretation of facts is more likely if the sender and receiver share the same corporate role. Reaching the same interpretations is more difficult if the sender and receiver are from different subcultures as is the case in the Challenger disaster. Along with this she states that bad news generally does not travel up the corporate ladder too well. When bad news is sent upward it is less likely to be believed than good news. And lastly, organizations tend not to air "dirty linen" in public. This article looks at the pressures writers face while communicating negative facts upward and how difficult it is to change an accepted viewpoint.

Walzer, Arthur E. and Gross, Alan. "Positivists, postmodernists, Aristotelians, and the Challenger disaster" College English, v56n4 April 1994: 420-433.

Walzer and Gross analyze the Challenger disaster from three different viewpoints – positivists, postmodernist and Aristotelian. They state that since the reliability of the O-ring was questioned on the eve of the launch, the disaster resulted "from a failure of the managers and engineers to reach the best decisions on the eve of the launch". They use the three approaches to look at the different ways that facts are transferred into knowledge and state conclusions that are reached by each approach. The positivists believe that facts are facts and speak for themselves. The engineers had genuine knowledge that the O-ring was unreliable, therefore the disaster resulted from ethical misconduct or a breakdown in communication, e.g. poorly written memos, selective listening, or misdirection of information. The postmodernists agree with Winsor in that facts do not speak for themselves. Facts are subject to interpretation and only count as knowledge when the interpretation has been accepted by the interpretive community. This viewpoint supports the decision made by the managers. The Aristotelian approach is to look for the best reasons for assent or desent and the best reasons for decisions and actions, particularly when there is an absence of consent. The managers and engineers should have first debated the facts presented and if no agreement could be reached on the facts, then the ethical issues should have been debated. The best decision was not reached because only the scientific issues were debated, not the ethical implications. Like Winsor, this article looks at different ways of interpreting facts and the effects of the interpretations.

Moore, Patrick; Louise M. Rosenblatt, "Two comments on ‘Positivists, postmodernists, Aristotelians, and the challenger disaster’" College English, v57n3, March 1995: 349-357.

Moore and Rosenblatt argue that the Aristotelian approach was not an option in the debate on whether or not to launch the Challenger. They claim that the engineers had subordinate roles and knew the hierarchical power of NASA would force them to "fall silent and yield to the decisions

of NASA". This article examines the pressures involved when a hierarchical structure exists. The hierarchical power dominates and controls the interpretation of facts.

Dombrowski, Paul M. "The Lessons of the Challenger Investigations" Transactions on Professional Communications, v34n4, December 1991: 211-215.

Dombrowski agrees with Winsor in that communication is subject to interpretation – he calls it socially contingent. Every communication should consider human action, motives and assumptions rather than only material, objective entities. He sites engineering reports and judgements as being "undone by reconceptualizations which engineers were not party to and were powerless to alter". The abnormalities discovered in the O-rings were eventually accepted as commonplace because the charring happened so often. He states that the lesson for professional communication is this: not the object itself (the charring), but the meaning attached to the object was all important as a condition for continued flight. The technical reports were correct, the people who interpreted the reports used faulty judgements. Writers need to be aware of the human element in conveying facts as knowledge.

… "Can Ethics Be Technologized? Lessons from the Challenger, Philosophy and Rhetoric" Transactions on Professional Communication, v38n3 September 1995: 146-150.

Dombrowski expands upon his first article saying that technical knowledge does not automatically translate to its own ethicality. The human act of conceptualizing and interpreting data is basis for ethical responsibility. He again uses the O-ring charring interpretation to support his theory. The charring went from a major concern to "acceptable erosion", "allowable erosion" and "acceptable risk". The technical data was there but could not be relied upon to tell its own story and could not guide ethical conduct. MTI engineers were very concerned about the O-ring situation, but NASA management was more concerned about postponing a flight that was already behind schedule. The decision to launch was determined not by technical information, but by the prior interpretive framework that management chose to adopt. Dombrowski agrees with Walzer stating that rhetoric is a vital communicative means by which ethics is both revealed and practiced – it would not allow people to forsake their ethical responsibility for a set of rules that could make decisions for them. He further states that ethical responsibility or lack of should have been brought to light by the Rogers commission which investigated the Challenger disaster. Clearly flawed judgement was used in launching the challenger, but the commission refers to "flawed procedures" and difficulties with the "communication system" as the contributing reason for the disaster. This article once again proves that facts do not speak for themselves.

Boisjoly, Russell P. et.al. "Roger Boisjoly and the Challenger Disaster: The Ethical Dimensions" Journal of Business Ethics, v8 1989: 217-230.

Russell Boisjoly was an engineer for MTI. He was considered the O-ring expert at MTI and was also the main opponent to the launch after his research validated that O-ring was unreliable. His conclusions are the same as Winsor’s in that the hierarchical structure and the social culture within the organizations contributed to the fatal decision to launch the Challenger. Boisjoly takes his observations one step further – he feels that management hides behind a groupthink process. In a group decision no one individual has to take responsibility for their actions. Boisjoly had

written memos to enlist support in his crusade to accept the facts he discovered in his empirical observations. Management basically ignored him. Their groupthink decision was already made. At the Roger Commission hearings, the managers stated that they did not understand the reports that reported the problems with the O-rings. Boisjoly feels that ignorance is not an acceptable explanation for allowing the launch to proceed. He contends that systems should be in place to make individuals responsible for their decisions even if the decisions are the result of groupthink. This is especially true for managers who become "instruments of their own ignorance whenever they prevent the free and complete flow of information to themselves, wither directly by their acts, or indirectly through the subtle messages they convey to their subordinates, in their management style or by the organizational climate they help to create". Boisjoly’s article explores the responsibility of making decisions, stressing the importance of each individual to think of themselves apart from a group or organization. Each individual has a responsibility, being part of an organization does not relieve you from the consequences of your decision.

NASA Supplement Four

nside story

'I knew what was about to happen' Fifteen years ago, two senior spacecraft engineers spent six hours pleading with Nasa to delay the launch of Challenger. The next day, the shuttle exploded in the skies, with the loss of its entire crew. Mark Hayhurst pieces together the story of a disaster that should have been averted Special report: space exploration

• Buzz up! • Digg it

• The Guardian, Tuesday 23 January 2001 • larger | smaller • Article history

It is 15 years since the space shuttle Challenger exploded 73 seconds after lifting off from Cape Canaveral, but the signature it left in the Florida skies remains vivid in the mind. It looked like a body writhing in agony. Out of a trunk of white cloud came two unfettered rockets, dementedly skywriting, like a pair of thrashing limbs attached to a decapitated torso. At the same time hundreds of burning fragments started to cascade to the ocean leaving their own smoky entrails.

Rob Navias, a veteran radio reporter was speaking the words most people felt: "Can it ... Can it? Oh my God, can Challenger have exploded? Oh no!" "What on Earth has happened?" he added, intending no irony.

In stark terms the fireball in the sky was the result of half a million gallons of liquid fuel vapourising, but neither the Nasa man nor Navias knew for sure what had happened.

No one knew for sure. But there were two men watching on a TV screen far away in Utah who had a pretty good idea. One was Roger Boisjoly, a senior engineer at Morton-Thiokol, the contractors that built the solid rocket boosters for the space shuttle. The other was his manager, Bob Ebeling.

A few minutes before the launch Boisjoly had been walking past Thiokol's conference room. Ebeling came rushing out and "grabbed my arm and asked me to come in and watch the launch. At first I told Bob, 'no, I don't want to see the launch'. I knew what was about to happen and I just did not want to see the failure".

The previous evening Boisjoly and Ebeling had spent six hours in teleconference with Nasa managers arguing that the Challenger launch should be delayed. The two men had been told that the temperature in Florida was plummeting to below freezing and had been instantly concerned about whether their rockets would perform properly in such conditions.

They appeared to be winning the argument - until their own managers turned against them and gave Nasa the recommendation they appeared to want: to launch.

Boisjoly was persuaded by Ebeling to watch the TV that fateful morning of January 28 1986. He sat on the floor in front of the screen resting his back against the legs of the older man. When the clock reached T minus five seconds the two engineers held hands and braced themselves for an explosion. But to their immense relief Challenger cleared the launch pad. "I turned to Bob and said 'we've just dodged a bullet,' because it was our expectation it would blow up on the pad."

The two men began to relax. But then, at 73 seconds, the heart-stopping plume of white smoke suddenly filled the screen. "There was silence for the longest time," says Boisjoly. "Then I went to my office, sat facing the wall and tried to hold back my emotions."

Boisjoly is telling me this outside Thiokol's test plant beneath the Wasatch mountains in northern Utah. He hasn't been here since leaving the company in July 1986, soon after testifying before the presidential commission into the Challenger disaster. His testimony, much praised by the commissioners, was heavily critical of his managers, and Boisjoly acquired a reputation as a whistleblower.

The company blamed him for releasing documents to the commission which they had not asked for and had no idea existed; his community, for whom he'd once been mayor, blamed him for putting precious jobs in jeopardy.

We're not welcome to go into the plant, but we can walk around the rocket park. It's a fantastic sight. The place bristles with 20 or so rocket motors, including half-remembered names such as the Minuteman, the Peacekeeper, and a Poseidon. The scene-stealer, though, is a decommissioned solid rocket booster hoisted on metal stanchions, 126ft long and dwarfing everything else.

These provide nearly 75% of the thrust to get the shuttle into orbit and clearly, despite the disaster, they are still Thiokol's pride and joy. To commemorate his return, Boisjoly adds an entry to the apparently endless "cools" and "far outs" in the visitors' book. "Roger Boisjoly", it reads, "I worked here and tried to stop the launch of Challenger."

Each booster gets filled with millions of pounds of solid propellant and sent down to Cape Canaveral. No railway can transport an object 126ft long - at least none with a bend in. Thiokol had to build the rockets in sections and ship them to Florida, where they were reassembled on site.

Boisjoly explains what happens when the boosters are ignited. "The steel rim might look tough, but on ignition each section like this reacts to the intense pressure by blowing up like a balloon.

When that happens something has to take up the slack where the joints are, to stop hot gas pouring out of the rocket."

That job was given to two quarter-inch rubber seals called O-rings which had to expand with the metal and seal the gaps. If they failed to keep contact with the metal parts for more than a fifth of a second there would be a leakage. "When solid rocket boosters leak," concludes Boisjoly, "they explode."

"On the day Challenger launched it was very cold," he says, "and when the temperatures dropped these rubber O-rings became harder and less pliable. Hard O-rings move slower and they seal less effectively. There might only be fraction of a second's difference but that is enough to separate success from total disaster."

The tragedy of Challenger is that Boisjoly had been airing doubts about the O-rings for at least six months before the disaster. A year earlier he'd gone to Florida to inspect the spent rockets from a previous mission. He had been amazed at the condition of the joints. The primary seal had failed and allowed hot gas to surge by.

Fortunately the secondary O-ring had trapped the gas. He shows me a photograph he took of the burned joint. All around the seals the normally honey-coloured grease has turned jet black, and parts of the primary O-ring are missing - clear signs that the joint has been scorched. "When I saw that, I almost had a cardiac arrest," says Boisjoly. "I could not believe that we had not blown the shuttle up."

Nasa put the O-rings on the critical list. Thiokol created a task-force to look into the problem, but a shortage of equipment and personnel meant little was accomplished. Boisjoly, a task-force member, sent a memo to Thiokol's vice-president, pleading for a greater sense of urgency in testing the O-rings. "It is my honest and very real fear," he wrote, "that if we do not take immediate action ... we stand in jeopardy of losing a flight, along with all the launch pad facilities. The result would be a catastrophe of the highest order - loss of human life."

That was July 31 1985. On the same day, on the Johnny Carson show, America was being introduced to the most recent recruit to the astronaut elite. Her name was Christa McAuliffe. She wasn't an astronaut really. She was a schoolteacher who had beaten off 11,000 other teachers to win a place on a forthcoming shuttle mission.

Alongside Carson she was impressively unflappable, as if to "the right stuff" born, but she also showed a very un-astronaut ability to see the funny side to what she was about to do. She laughed when her host said that as a kid there were several teachers he would have just lo-o-o-o-ved to have sent into space.

I went to see Christa's mother, Grace Corrigan, who lives in Framingham, Massachusetts. Her husband, Ed, died 10 years ago, retaining a deep anger at Nasa to the end of his life. Grace is a smart, good-looking woman with eyes that dance when she speaks. She has a huge oil painting of Christa in her blue astronaut suit, cradling in her arms a model of Challenger. "Everybody was on a high," she says recalling the moment Christa was first chosen to become the teacher-in-

space. "It was just one of those nice things that happens to nice people. And everywhere she went they just rolled out the red carpet for her. She didn't come on strongly or anything. People just accepted her".

Challenger was meant to launch on January 25, but was twice postponed because of adverse weather reports. Then it was put back yet again, farcically this time. The astronauts were strapped into their seats and preparing for the final countdown when the close-out crew found they couldn't take the handle off the door because one of the screws had a broken thread.

A drill was found but a succession of batteries were flat. Finally, after five hours, a hacksaw was used to sever the bolt and the door was closed. But crosswinds had built to unacceptable levels. The launch was scrubbed again.

Grace followed some of this from her place in the grandstands. The irritation, and the sense that it still might be otherwise, remains strong today. "I mean, after all, this is Nasa, right? They can do all these great things. They can launch, they can put a ship up in orbit. And they can't fix a screw on a handle!"

That afternoon the temperature at the Cape began to plummet. The launch team needed specialist advice. At around 6pm the call was made to Utah to ask whether Morton-Thiokol had any concerns about launching their rockets at a predicted -5C (23F). When the answer was "yes" another call was put in, this time to Nasa's rocket specialists at the Marshall space flight centre in Huntsville, Alabama.

Judson Lovingood at the shuttle projects office received the call, and set about contacting his own engineers. I arranged to meet him in the room that he'd been in that night when the teleconference finally got under way. On the wall are the shields of all the shuttle missions Nasa has flown, including the Challenger flight of January 1986: the only one without a date of re-entry.

He describes in unnerving detail who was there and where everyone sat and his eyes begin to fill - which is ironic, since he's been relating how he was a product of the very special, unsentimental, culture which prevailed here. If an engineer began a sentence starting with "I know" he was listened to with respect. If he began with an "I think", he never got to complete the first sentence. "You don't do engineering by emotion," Lovingood explains. "You can't get up and say, 'Hey, I've got a gut feeling this thing's gonna blow up.' They'll take you to the funny farm."

That night the men at Marshall did listen to Boisjoly and his colleagues from Morton-Thiokol as they explained why the launch shouldn't go ahead in the morning. But they felt that what they were hearing were gut reactions, not engineering rationales. There was data, plenty of it, but it wasn't decisive, says Lovingood.

Thiokol's bottom line was that it didn't want to fly outside its data base - which meant not launching below 12C (53F), the coldest launch temperature to date, and the temperature responsible, according to Boisjoly, for the damaged joints he had inspected a year before. After

nearly five hours a curious impasse had been reached, with Nasa saying it wouldn't launch against a contractor's recommendation, but that the recommendation was baseless.

It was at this point that a Thiokol vice-president asked to go off-line for five minutes. Boisjoly says that "as soon as the button was pressed on the teleconference to sever us and mute us from Nasa, our general manager Jerry Mason, said in a soft voice that we had to make a 'management decision'. My whole being just started to rev up real bad because it was obvious that they were going to change from a 'no launch' to a 'go for launch' decision to accommodate their major customers".

It took 30 minutes, not five, but that is what happened. The engineers, including Boisjoly, were disenfranchised and the four senior managers voted to launch. Boisjoly stood up, grabbed the photograph of the burned O-rings, and planted it on the table in front of the four men. They refused to look at the photo. His boss released the mute button and told Nasa that Thiokol had changed its mind. They were for launch.

Nasa had spent half the evening interrogating Thiokol over its initial recommendation. But this one provoked absolutely no debate. "That was a mistake," says Lovingood. "We should have asked them why they'd changed their minds." Instead Thiokol was simply asked to put its altered position into writing. It took a while to fax the new recommendation through to the Cape, but by midnight Nasa had the "go" it needed to launch Challenger in the morning.

Challenger of course didn't blow up once. It kept blowing up - all day long, all week long even. In a state of shock, Americans wanted to see it again and again, as if the networks' looped tapes could somehow unravel their own anxiety. Eventually the TV stations replaced the image of the stricken craft with more "positive" shots of the astronauts eating breakfast together on the morning of the launch, but as intelligence grew about what had gone wrong - and the sheer avoidability of it - these pictures became in turn like watching a condemned man eating a last meal.

Grace Corrigan accepts risk is an inherent part of spaceflight. It is hubris - and its strange bedfellow, complacency - she warns against. "We'd put Nasa on a pedestal," she says. "We were all children of the first space age and we thought they could do no wrong. Since then we've been forced to grow up."

Boisjoly's disillusionment is greater. Corporate America dislikes a whistleblower and he has struggled to find work as an engineer since he walked away from Thiokol. For several years he was a wreck. "I beat myself up for a long time over what happened on that night. Maybe I hadn't done enough. Maybe I should have gone home and called the New York Times or something. "Well, I don't beat myself up any more. If I couldn't convince the guys on the inside who know all the technical data, how would I have convinced total strangers? They would have called Nasa and the PR people would have said, 'oh come on fellas, there hasn't been a launch since the start of space flight where some engineer hasn't tried to throw a switch and stop it'."

If there is consolation for Boisjoly it is that since 1986, greater powers have been given to engineers working in, and for, Nasa to express dissent and call off flights. Too late to save him, and too late to save Challenger, but a victory of sorts.

• Mark Hayhurst is the producer of Challenger: Go for Launch, showing at 9pm tonight on BBC2.

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G2: The Challenger shuttle explosion This article appeared on p6 of the Comment & features section of the Guardian on Tuesday 23 January 2001. It was published on guardian.co.uk at 03.16 GMT on Tuesday 23 January 2001.

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NASA Supplement Five

Columbia Report Faults NASA Culture, Government Oversight By Brian Berger Space News Writer posted: 03:30 pm ET 26 August 2003

This is an update to a story first posted at 10 a.m. EDT (1400 GMT).

WASHINGTON -- Politics, budgets, schedule pressure and managerial complacency all played roles in causing the Feb. 1 Columbia tragedy, the Columbia Accident Investigation Board (CAIB) said in its final report released today.

The 248-page report, formally released at 10 a.m. EDT (1400 GMT), lays out in detail what has already been said about what went wrong -- both from a physical and organizational point of view -- and lays out what NASA needs to do before it returns any of its three remaining orbiters to the launch pad.

The CAIB was established within the first 24 hours of Columbia's breakup over the western United States. Within three days of the accident, retired U.S. Navy Adm. Harold Gehman had reported for duty as the board's chairman and was leading an expedition to Texas and Louisana to tour Columbia's debris field.

The cause of the accident was not immediately apparent. By the time the board concluded its five-month investigation, their was little, if any, doubt among investigators about the physical cause of the accident: Columbia attempted to re-enter and land the morning of Feb. 1 with a breach in its left wing inflicted some 16 days earlier by a breakaway chunk of foam 81.7 seconds after liftoff.

"In four simple words, the foam did it," said the board's only NASA official, Scott Hubbard, who oversaw the dramatic foam strike tests at Southwest Research Insitute, San Antonio, Texas. Hubbard emphasized the board's confidence in its conclusions about the technical root cause of the accident, pointing out that "we didn't include the words probably, probable or most likely."

As Gehman had promised on many occasions since the investigation got underway nearly seven months ago, the report goes well beyond the root technical cause of the accident and provides an integrated assessment of the cultural, political and budgetary factors at play.

During the weeks leading up to the release of the report, senior NASA managers warned agency personnel that they should brace for a scathing indictment of the NASA culture. On this point, the report delivers. But there is also plenty of blame to go around.

"The past decisions of national leaders -- the White House, Congress, and NASA Headquarters -- set the Columbia accident in motion by creating resource and schedule strains that compromised the principles of a high-risk technology organization," the reports says. "The measure of NASA's success became how much costs were reduced and how efficiently the schedule was met. But the space shuttle is not now, nor has it ever been, an operational vehicle. We cannot explore space on a fixed-cost basis."

NASA's Culture

Investigators said they found NASA's human spaceflight organization to be "in most cases... extremely aggressive in reducing threats to safety. But we also know -- in hindsight -- that detection of the dangers posed by foam was impeded by 'blind spots' in NASA's safety culture."

But, as anticipated, the report also heaps considerable blame on NASA's organizational culture and its role in the accident.

"The organizational causes of this accident are rooted in the space shuttle program's history and culture, including the original compromises that were required to gain approval for the shuttle, subsequent years of resource constraints, fluctuating priorities, schedule pressures, mischaracterization of the shuttle as operational rather than developmental, and lack of agreed national vision for human space flight."

The report goes on to say: "the NASA organizational culture had as much to do with this accident as the foam."

The board also found echoes of the 1986 Challenger disaster during its investigation of the Columbia accident. Time and time again, investigators were struck by similarities and parallels between the two disasters, though 17 years apart.

"For both accidents there were moments when management definitions of risk might have been reversed were it not for the many missing signals -- an absence of trend analysis, imagery data not obtained, concerns not voiced, information overlooked or dropped from briefings," the report says.

Board members also found that lessons NASA learned in the aftermath of the Challenger disaster have to a large degree been forgotten or ignored during the years since.

As board member U.S. Air Force Maj. Gen. John Barry told reporters after release of the report "there is still evidence of a silent safety program with echoes of Challenger."

In talking to reporters and addressing the many television cameras that attended the release of the report, board members also took care to temper their criticism of NASA's organizational culture with praise for the NASA team.

"If the board set out to spend seven months looking at all the good things NASA does, the report would be thicker than this," Gehman said, holding up his inch-thick bound copy of the Columbia accident report.

U.S. Navy Rear Adm. Stephan Turcotte, a board member who spent a lot of time with the space shuttle program's rank and file, concurred, praising the space shuttle workforce for their "hearts and souls."

"These are good people," Turcotte reported. "The people down there working [on the space shuttle program] are working their hearts out."

Missed Signals

A 34-page section of the report, "Decision-Making During the Flight of STS-107," recounts the now familiar tale of missed signals, botched imagery requests and a mission management team largely oblivious to the mortal danger Columbia and her crew were in.

The report details eight separate "missed opportunities" during the 16-day flight, from NASA engineer Rodney Rocha's unanswered e-mail four days into the mission asking Johnson Space Center if the crew had been directed to inspect Columbia's left wing for damage to NASA human space flight chief William Readdy's failure to accept the U.S. Defense Department's offer to obtain spy satellite imagery of the damaged shuttle.

The report excoriates NASA management decisions during Columbia's last flight. "Perhaps most striking is the fact that management . . . displayed no interest in understanding a problem and its implications. Because managers failed to avail themselves to the wide range of expertise and opinion necessary to obtain the best answer to the debris strike question . . . some space shuttle program managers failed to fulfill the implicit contract to do whatever is necessary to ensure the safety of the crew."

Although the report names the key personnel who participated in the debris strike decision, the board does not single anyone out for blame or explicitly call for their ouster.

"It is tempting to conclude that replacing them will solve NASA's problems," the report says. "However, solving NASA's problems are not quite so easily achieved. People's actions are influenced by the organizations in which they work, shaping their choices in directions that even they may not realize."

Political Underpinnings

The report also depicts the broader political scene that helped set the stage for the Columbia accident.

"The causal roots of the accident can also be traced, in part , to the turbulent post-Cold War policy environment in which NASA functioned during most of the years between the destruction of Challenger and the loss of Columbia," the report says. "The end of the Cold War in the late 1980s meant that the most important political underpinning of NASA's Human Space Flight Program -- U.S.-Soviet space competition -- was lost, with no equally strong political objective to replace it."

The loss of the Soviet Union as a competitor in the human space flight arena made it difficult for NASA to obtain budget increases through the 1990s. But rather than adjust its expectations to the new realities, the Board said, NASA continued to push an aggressive agenda that included the development and construction of the international space station.

With no budget increases in sight, NASA's only recourse was to try to do more with less. Enter recent NASA Administrator Daniel Goldin and his "Faster, Better, Cheaper revolution, an era the report characterizes as "one of continuous turmoil, to which the Space Shuttle Program was not immune."

The watchword throughout the agency in the 1990s was efficiency. For the space shuttle program, as well as a host of other NASA efforts, outsourcing and contract consolidation was part of the solution.

"The search for cost reduction led top NASA leaders over the past decade to downsize the Shuttle workforce, outsource various Shuttle Program responsibilities -- including safety oversight -- and consider eventual privatization of the Space Shuttle Program," the report says. Over the past decade, according to the report, the program's purchasing power was reduced 40 percent and "repeatedly raided" to cover mounting space station bills.

Notably abscent from the report is a detailed assessment of the roles that NASA's contractors played in the accident. While the report recounts the rationale behind NASA's decision to consolidate dozens of space shuttle operations contracts into a single contract awarded to the Lockheed Martin-Boeing joint venture United Space Alliance, the board stopped short in giving an opinion on the impact of that outsourcing effort on shuttle safety.

However, the report was not silent on the need for more civil servant oversight of development efforts like the space shuttle program.

One NASA contractor said the report's recommendations are almost certain to influence how NASA structures contracts for human space flight-related services in the future.

Schedule Pressure

The report also calls into question renewed schedule pressure introduced into the space station and space shuttle programs as Sean O'Keefe was preparing to take over as NASA administrator in January 2002.

O'Keefe, who as deputy director of the White House Office of Management and Budget, put NASA on notice in 2001 that it was expected to get the space station program back on track and that a budget bailout was not in the works. Before the end of O'Keefe's first year as NASA administrator, the U.S. space agency had shocked and angered its international partners by cutting key contributions to the space station program in order to eliminate a looming $500 million overrun.

The program also began driving toward a very specific completion date: Feb. 19, 2004.

During its investigation, the Board received several unsolicited comments from NASA personnel regarding pressure to meet that date. Board members at first thought the target date for completing the core space station noteworthy but unrelated to the accident.

But as the investigation continued, the report says, "it became apparent that the complexity and political mandates surrounding the international space station program, as well as shuttle program management's responses to them, resulted in pressure to meet an increasingly ambitious launch schedule."

The Path Ahead

The report also holds up several organizations as embodiments of the right way to manage risk and exemplars of largely accident-free performance.

Those organizations are the U.S. Navy Submarine Flooding Prevention and Recovery (SUBSAFE) program; Naval Nuclear Propulsion programs; and the Aerospace Corporation's Launch Vehicle Verification Process, which supports U.S. Air Force space launch operations.

All these organizations, which the board praises for maintaining impressive safety records in the face of considerable technical risk, have at least one major characteristic in common: "they place a premium on safety and reliability by structuring their programs so that technical and safety engineering organizations own the process of determining, maintaining, and waiving technical requirements with a voice that is equal to yet independent of program managers," the report says.

NASA already has taken the initial steps toward emulating these organizations.

Since the accident, O'Keefe has transferred Kennedy Space Center director Roy Bridges to Langley Research Center in Hampton, Va., where the former astronaut and Air Force general will oversee the establishment of a new safety and engineering center. Bridges said last week he would seek a "generous" testing budget for the center, which is intended to give more clout to NASA's safety watchdogs.

In the end, the board concludes that NASA can resume space shuttle operations provided a number of changes are implemented before the first orbiter is rolled out to the launch pad. The major recommendations -- develop an on orbit inspection and repair capability, toughen the orbiter, prevent the external tank from shedding foam, train more cameras on the shuttle during liftoff and, with the help of U.S. spy satellite agencies, during orbital flight -- had already been publicly released before publication of the final report.

The report also includes 10 new recommendations that NASA must implement before it returns to flight. Most of them, however, merely add specificity to earlier recommendations.

For example, the board goes into greater detail about what kind of camera views NASA should obtain of every launch.

Brand new recommendations include establishing a space shuttle flight schedule that is "consistent with available resources, creating an independent Technical Engineering Authority and independent safety program, maintaining more oversight of final tank foam application processes.

Another recommendation suggested by the board but not previously formally released, is for NASA to redesign a bolt catcher assembly that CAIB-ordered testing revealed to be possibly too weak to do its job. NASA officials announced a few months ago that they were redesigning this part.

Among the most technically challenging of the recommendations, several board members agreed, is the recommendation that NASA develop a capability to inspect and repair while in orbit the reinforced carbon carbon that protects the leading edges of space shuttle wings. Board member Sheila Widnall, a former U.S. Air Force secretary, said the reinforced carbon carbon requirement is the one most likely to slow NASA's return to flight.

The board also puts forward some longer term goals for NASA, including inspecting and recertifying the shuttle's hundreds of miles of wiring as part of the agency's Shuttle Service Life Extension Program, an effort kicked off earlier this year with the goal of keeping the shuttle in good working order through the end of the decade and beyond.

But on the subject when to retire or replace the shuttle, the board is "agnostic," in the words of board member John Logsdon, director of the Space Policy Institute at George Washington University, explaining that NASA could very well conclude that recertifying the shuttle is too difficult or too costly to undertake.

"We believe another vehicle, whether to complement or replace the shuttle, is very, very high priority," Gheman said. "We criticize the U.S. for finding ourselves in the position we are in now where we don't even have a design on the drawing board."

On these longer term recommendations, the report sounds a sobering note: "Based on NASA's history of ignoring external recommendations, or making improvements that atrophy with time, the Board has no confidence that the Space Shuttle can be safely operated for more than a few years based solely on renewed post-accident vigilance."