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Space Shuttle Challenger

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98 views16 pages

Space Shuttle Challenger

Uploaded by

tricksterthoth
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Space Shuttle Challenger

On Jan 28, 1986, at 11.38 am EST,


the space shuttle challenger was
launched from Cape Canaveral,
Florida.

The mission ended 73 seconds later


when the Challenger exploded.

All 7 crew members were killed.


Space Shuttle Challenger (2)

Cause of the explosion?


Hot propellant gases flew past the
aft joint of the right solid rocket
booster, burning through two
rubber O-rings.
Cause of the accident?
“The decision to launch the
Challenger was flawed”
“The fundamental problem was
poor technical decision-making”
Challenger O-Rings
Space Shuttle Challenger
Challenger MPEG

QuickTime™ and a
decompressor
are needed to see this picture.
Discussion Questions

How were decision routines used to reduce complexity


and uncertainty?
How was information seeking and use influenced by
organizational roles, rules and routines?

Did organizational politics play a part in the decision


making process?
To what extent was the case a failure of organizational
sensemaking?

To what extent was the case a failure of organizational


knowledge creation and use?
Discussion Question (1a)

How were decision routines used to reduce complexity


and uncertainty?

Shuttle Launch Decision Routine


1. Signals of potential danger
2. Official act acknowledging escalated risk
3. Review of evidence
4. Official act indicating the normalization of deviance:
accepting the risk
5. Shuttle launch.
Discussion Question (1b)

How were decision routines used to reduce complexity


and uncertainty?
Routines normalized potentially dangerous signals as
“normal acceptable risk” in highly innovative projects.

“Since the risk of O-ring erosion was accepted and


indeed expected, it was no longer considered an
anomaly to be resolved before the next flight. ...
I concluded that we’re taking a risk every time.
We all signed up for that risk. ... We’d be taking
essentially the same risk on Jan. 28 that we have been
ever since we first saw O-ring erosion.”

(Mulloy, SRB manager, Marshall SFC)


Discussion Question (2)
How was information seeking and use influenced by
organizational roles, rules and routines?
Division of Roles
“Well, it’s time to make a management decision. ...
It's time to take off your engineering hat and put on your management
hat." (Jerry Mason, SVP Thiokol)

Engineers’ role: technical design


Managers’ role: bureaucratic accountability
Information Reduction
Four levels of Flight Readiness Reviews
Level IV FRR documentation 1/2 inch
Level I FRR documentation 10 pages
Level II and I administrators no time to read
Discussion Question (3)

Did organizational politics play a part in the decision


making process?

Dependencies
• Thiokol as contractor to NASA
• NASA depends on federal government funding
• Political accountability: to provide “routine space
travel”
• Reagan seeking re-election
Discussion Question (4a)

To what extent was the case a failure of organizational


sensemaking?

Bracketing
Isolating data and information to help sensemaking --
did it help?
Flight Data Presented Prior to Launch
Data From All Past Flights
Data From All Past Flights (2)

Tufte 1997. Visual Explanations, p. 45


Discussion Question (4b)
To what extent was the case a failure of organizational
sensemaking?

Action-driven sensemaking
Strong preference to launch on Jan 28, 1986
“My God, Thiokol, when do you want me to launch, next April?”
(Mulloy, SRB Mgr, Marshall)

Belief-driven sensemaking
What shared belief about NASA was the basis of
sensemaking?
“Can-do” image, “frontiers of flight” mentality:
NASA can accomplish any challenge that is put to it.

What shared belief about the shuttle was the basis of


sensemaking?
Discussion Question (5)

To what extent was the case a failure of organizational


knowledge creation and use?
Engineers could not convert tacit knowledge into
explicit knowledge
“It was away from goodness in the current database”
(Boisjoly, Thiokol engineer)
“Thiokol created a rule, using the experience database:
do not launch unless O-ring temperature is >53 deg. F”
(Vaughan)

O-ring knowledge gap recognized as early as 1977, but


the gap remained unfilled
Discussion

Decision to launch shuttle:

Beliefs about NASA


Beliefs about O-rings
Inability to share knowledge
Inability to fill critical knowledge gap
Decision culture
Organizational culture

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