Discuss the inevitability of the Challenger disaster and how it could have been avoided

Flow chart documenting events leading to the Challenger disaster

Introduction

Nature will not be fooled.”¹

73 seconds into the flight, Challenger was ripped apart above Cape Canaveral in Florida². The President initiated a Commission to identify the cause of the disaster, which initially discovered it to be a technical one. The O-ring seals in the aft field joint of the right Solid Rocket Booster (SRB) had failed mainly due to the cold weather, resulting in the shuttle being destroyed. However, after further probing, the Commission revealed that poor management primarily accounted for the incident. The Commission made recommendations for NASA to implement managerial solutions, but the Columbia explosion in 2003 suggests that those measures were insufficient.

This essay will follow the revelations of the Presidential Commission to determine whether the Challenger disaster was avoidable. The first section will outline the relevant theories, including Perrow’s (1999) Normal Accident Theory (NAT), which focuses on the vulnerability of complex technological systems. Vaughan (1996) considers human errors which were made as a result of stifling production pressures. Deming’s (1986) 14 points for management provides a framework for analysing the situation and offers methods of avoiding such a crisis. Jefferson (2002) and Straker (2004) analyse the successes and failures of quality, while Collins’ (1999) discussion of catalytic mechanisms is key in determining the success of particular quality strategies at NASA.

The second part of this essay will examine the theories in detail, arguing that the Challenger disaster and the evaluation of its inevitability can be best explained through quality principles. However, given the apparent failure of quality measurements implemented by order of the Commission, cases such as the NHS and Granite Rock will be examined to identify whether quality would indeed be successful for NASA in handling crises.

It will be concluded that corporate culture was the fundamental reason for Challenger’s demise and that sound application of quality and catalytic mechanisms can help to change this deep-rooted issue and help to prevent future disasters.

Literature Review

The Challenger disaster is famous for NASA’s negligence and dishonesty over the situation, making it is necessary to analyse the disaster from a variety of perspectives to get closer to the true cause of the accident.

Perrow (1999) focuses at the system level of accidents in general, discussing two types in his Normal Accident Theory (NAT), which argues for the inevitability of disasters. System Accidents (SA) are caused by complex interactions of multiple independent elements, and tight coupling of components, where if one fails there is no time to stop interconnected elements being seriously affected. Component Failure Accidents (CFA) are defined by visible and foreseeable linear interactions between parts, and loose coupling in which the “domino” effect from any failed elements can be stopped.

Complex interactions and tight coupling are associated with SAs, which are most common in high technology systems, such as space travel. It is suggested that accidents are likely to occur in such systems, as it is very difficult to keep account of the multiple interacting parts. Perrow does not extensively analyse the human element, although he does imply that the unpredictability of SAs and complex interactions is often caused by limited knowledge of relevant areas.

Examining the Challenger incident in detail, Vaughan (1996) explores the impact of poor Human Resource Management. She argues that the corporate cultures and production pressures at Morton Thiokol and NASA caused the disaster. Vaughan argues that deviance was normalised, resulting from the managers’ “can do” culture at NASA where they did not inform top administration of essential information. The same is true of managers at Morton Thiokol, who did not want to lose their contract to rivals, while the engineers, under the pressure of production and with their “change is bad” attitude, led them to accept faulty designs.

Vaughan’s interpretation of the situation at Morton Thiokol and NASA suggests that the type of thinking at numerous corporate levels meant that an accident was bound to happen. The culture of “acceptable risk” was so ingrained into the system that the Challenger disaster was inevitable.

Perrow (1999) and Vaughan (1996) cover the technical and underlying human causes of the Challenger disaster, but they do not offer a systematic framework with which to clearly understand the situation with regards to how it could have been avoided. Deming (1986) argues that although errors in a company cannot be completely eliminated, they can be greatly reduced by employing quality management methods. He lists 14 points for managers, which can be aptly applied to the Challenger situation, using the information provided by Perrow and Vaughan. The analysis reveals cultural causes of the disaster from a quality perspective, and provides numerous ways it could have been avoided, demonstrating that the accident was not inevitable.

The Commission made quality-based recommendations to NASA, but they were not successful. Indeed, quality management has failed in the past, as discussed by Jefferson (2002), who discusses the NHS and how it was unable to implement quality in the long term. Straker (2004) explains that quality fails due to a performance pressure failure cycle, but argues that it can be very successful if a learning environment is established.

Collins (1999) examines the effectiveness of catalytic mechanisms in companies, such as Granite Rock, which has improved performance by employing selected quality strategies. This suggests that for quality to succeed at NASA, carefully chosen catalytic mechanisms are required, which deal with the unique cultural setting at NASA.

NAT + Culture = QM (4 NASA)?

Although each is the result of component failures, elements in CFAs are clearly related and follow a predictable path where problems can be identified and stopped, while those in SAs are relatively unrelated, with their interactions unforeseeable and unpreventable.

The Challenger disaster can be interpreted as either type of accident (Fig.2).

Challenger can be seen as both a technical and a human CFA, but while the chain of technical events is clear, tight coupling occurs, as once O-ring erosion had begun there was no stopping the immediate subsequent component failures. The links of human activities are also transparent, but Perrow (1999) observes that managerial ignorance complicates interactions, inhibiting comprehension of the consequences of their actions. As an SA, poor management and cold weather are directly linked to the faulty shuttle design even though these elements were not themselves related. This implies that Challenger can be perceived as a combination of a CFA and an SA (Fig.3).


Although cold weather could not have been controlled, management was originally a linear interaction, complicated by a lack of knowledge and poor communication. This suggests that the correction or prevention of poor management was possible, meaning the disaster too was avoidable. In addition, Rijpma (2003) argues that high technology firms have the ability to avoid such an accident, implying that there was more to the Challenger incident than a mere technical anomaly. She mentions that, although accidents are inevitable, according to High Reliability Theory (HRT) there are many firms which are deemed high-risk, but have an excellent proven track record often due to good management.

Indeed, the Commission soon realised that the O-rings were the “tip of the iceberg”, reflecting an underlying and hitherto unrealised cause of the accident; the people. Vaughan (1996) agrees that the high technology system of space travel is very complex and vulnerable to accidents, but she considers the human element the most important contributing factor of the Challenger disaster. Corporate culture encouraged the normalisation of deviance at three levels: NASA management, Morton Thiokol management, and its engineers.

NASA management suffered from the “can do”³ attitude, originating from economic pressure caused by government budget cuts⁴. NASA allied with the AirForce for funding, but this meant they had to fulfil additional military requirements⁵. The result was a compromised design and increased production pressure, where failure to perform led to restrictions in funding. This explains why managers did not fully inform top administration of certain information, such as the teleconference on the eve of the launch, where Thiokol urged the launch be postponed due to the threat of O-ring erosion. It would have prompted further investigation and implied their incompetence at resolving the issue.

NASA claimed that Morton Thiokol was given the Solid Rocket Motor (SRM) contract due their desired “strengths”⁶. These “strengths” revolved mainly around their low cost strategy ($100 million less than their nearest rival⁷), as their Solid Rocket expertise was ranked the worst of the four companies bidding for the contract⁸. Unfortunately, such an optimistic estimate put Thiokol under great production pressure. For example, when a taskforce was initiated to examine the O-rings, NASA began consulting Thiokol’s rivals for solutions. The fear of losing the contract caused Thiokol managers to back down from the issue, even at the final teleconference.

Vaughan examines the engineering culture, describing their attitude to technical problems as “change is bad”⁹. Space shuttles were used technologies and hence might be reasonably expected to contain numerous flaws and ambiguities over their limitations. When changes were required, “correction rather than redesign”¹⁰ occurred. For example, the engineers began to tackle O-ring erosion after the Titan mission, which only had one O-ring. Instead of redesigning the whole joint, they merely added another O-ring to act as a back up. This brought with it new faults, but the fear of facing new evils combined with heavy production pressures meant the O-ring problem was never resolved.

From Vaughan’s analysis it appears that every level was to blame for the disaster. This “denial” culture was ingrained at too many levels for anyone to be able to see the situation outside their individual job role and as a result the accident is deemed as being inevitable. Perrow (1999) argues that Vaughan focuses too much on culture and understates the power of the organisation to suppress the engineers’ concerns. However, this act of oppression typifies the culture to which Vaughan was referring; that of “can do” at whatever cost. In fact Perrow’s NAT, that accidents in complex systems are inevitable, echoes the attitude of those at Morton Thiokol and NASA. Vaughan (1999) inadvertently identifies the flaw in this argument, pointing to the “bad workman blaming his tools” attitude, where people are the cause of accidents, not technologies.

Perrow’s (1999) system level and Vaughan’s (1996) individual level analyses together create a multi-perspective explanation of the Challenger disaster, but they do not assess whether or not it could have been avoided. The assumption appears to be that it was inevitable, which implies that highly technological, poorly managed firms are not in control of their companies. Deming (1986) discusses this issue and, like Vaughan (1996), focuses on the human element to argue his case. He believes that firms can achieve high productivity and low errors and costs if they improve the quality of their business. Deming’s 14 points for management give specific guidelines which, if not adhered to, would likely result in a crisis.

Relevant to Challenger are nine points, some of which are grouped together due to their similarity in this case¹¹ (Table 1.)

Table 1.

relevant to the Challenger disaster

The Rise and Pitfalls of Quality

The Presidential Commission recommended that NASA implement various quality solutions, such as the establishment of an Office of Safety, Reliability and Quality, and hiring knowledgeable astronauts at management level. The Commission also recognised that culture was an issue, ordering the elimination of the tendency for “management isolation”¹⁴, where managers did not provide essential information to authority. However, the Columbia disaster¹⁵ in 2003 suggests that those quality measures were insufficient, calling into question the validity of quality to improve the culture of NASA and that of its contractors.

Jefferson (2002) analyses another government funded firm which applied quality management, the National Health Service (NHS). He reports its failure and attributes it to the NHS culture of “cure, treat and save life”, meaning that treatment need not be a quality experience. This is aggravated by multiple interpretations of “quality” by numerous stakeholders, the majority of which are financially motivated. This means that the NHS, like NASA, is under production pressures. Quantitative evaluations are still made to appease stakeholders such as the government, and quality methods, which are qualitative, are shelved or not supported by top management.

Straker (2004) reports the failure rate of quality strategies to be 80%, but this is less due to the inadequacy of the model than to firms’ misunderstanding of quality management (Fig.4).


The diagram illustrates the failure of quality due to the vicious cycle of performance pressures, combined with dangerous factors such as limited commitment and expertise. Indeed, pressure to produce at the NHS and NASA following quality implementations has occurred and in both cases it has not succeeded.

Rather than using quality as a tool, Jefferson believes that it should be utilised as a concept. Straker (2004) agrees, stating that what is needed is “success through clear understanding rather than success through blind hope”¹⁶. His learning cycle demonstrates this theory (Fig.5).

Straker’s “pressures” have changed to encourage learning, to understand how the approach works, rather than trying to adopt quality methods without adequate understanding and hope they will succeed.

Collins (1999) discusses the case of Granite Rock which successfully implemented quality to become a high performance business. He reports that catalytic mechanisms, defined as “devices that translate lofty aspirations into concrete reality”¹⁷, were used to achieve “Big, Hairy, Audacious Goals”¹⁸ (BHAG). Granite Rock’s BHAG was to have excellent customer service, towards which it worked using two interdependent catalytic mechanisms. The first strategy was the concept of “short pay”, where customers had the power not to pay the full amount if they thought the service was of insufficient quality. The second was performance-related pay where managers’ salaries were based on the company’s profits. These two interlocking strategies meant that managers were strongly encouraged to work hard to provide the excellent service required, in order for them to get paid.

Collins observes that the catalytic mechanisms resulted in the development of a continuous learning culture at Granite Rock, thereby ensuring the long term success of the company’s BHAG. Quality management was also successful, as consistency of purpose and the new philosophy were established, and the intertwined successes of the firm and the individual helped establish pride of workmanship.

With regards to NASA the culture change requirement well qualifies as a BHAG, which suggests that catalytic mechanisms could be used to prosperous ends. Inspiration could be drawn from practices in Toyota¹⁹ where cultural management is a core principle. Examples include, “Principle 9: Grow leaders who thoroughly understand the work, live the philosophy and teach it to others” and “Principle 11: Respect your extended network of partners and suppliers by challenging them and helping them improve”. These are types of quality and catalytic mechanisms, as they encourage managers not just to apply quality but also to understand it. They also are required to get more involved in the supply chain activities which is can encourage managers to work harder to improve quality and change the firm’s culture. Indeed, NASA could monitor its contractors’ movements more closely to ensure quality designs from similarly-minded cultures.

However, these examples of quality improvement by changing the culture can only take place if the program is supported at the top for, as Deming argues in his final point, quality can only be implemented if it has the commitment of top management.

Conclusion

The Challenger disaster is one of the most memorable events in twentieth century Western history, not only due to its dramatic destruction on live global television, but the appalling discovery of the preceding events, which threw doubts over NASA’s integrity.

While O-ring seal erosion of the right SRB was initially to blame, a technical accident explained by Perrow’s (1999) NAT, the Presidential Commission unveiled the truth, that gross human negligence caused the disaster. Vaughan (1996) argues that the “can do/change is bad” culture of NASA’s managers and Morton Thiokol’s managers and engineers resulted in the normalisation of deviance. They accepted flaws in the risky new technologies, believing that nothing could go wrong.

Nine of Deming’s (1986) 14 points reveals that the Challenger incident was avoidable and illustrates the actions that could be taken to prevent a similar crisis from occurring. Many of the Commission’s recommendations to NASA included quality-based improvements, but their failure was marked by the explosion of the Columbia shuttle in 2003.

Jefferson (2002) uses a similarly government funded organisation, the NHS, to demonstrate how quality management can fail, for which the reasons are explained by Straker (2004). However, the latter argues conclusively that quality can be highly successful if a learning organisational culture is created. Collins (1999) remarks upon the success of quality management at Granite Rock due to the implementation of catalytic mechanisms, which implies that NASA could also succeed at attaining their BHAG by employing such methods, such as a culture change program that creates true intrinsic motivation²⁰ to build quality products.

Word count: 3,300

Bibliography

Articles

Collins, J., ‘Turning Goals into Results: The Power of Catalytic Mechanisms’, Harvard Business Review, 1999, p71-82
Rijpma, J., ‘From Deadlock to Dead End: The Normal Accidents-High Reliability Debates Revisited’, Journal of Contingencies & Crisis Management, Vol.1, March 11 2003, p37-45

Books

Deming, W. (1986) Out of the Crisis. Cambridge: Press Syndicate of the University of Cambridge.
Jefferson, H., ‘Quality in the NHS’ in Anthony, J. & Preece, D. (2002). Understanding, Managing and Implementing Quality: Frameworks, Techniques and Cases. London: Routledge.
Kohn (1993). Punished by Rewards. Boston: Houghton Mifflin
Liker, J. (2004). The Toyota Way. New York: McGraw-Hill
Perrow, C. (1999). Normal Accidents: Living with Hight Risk Technologies. Chichester: Princeton University Press.
Vaughan, D. (1996). The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Chigaco: University of Chicago Press
Walton, M. (1989). W. Edwards Deming: The Man and his Mission. London: Mercury Books.

Websites

Straker, D. (2004). ‘Breaking the Fad – Failure Cycle’, in http://www.syque.com/articles/fad_failure/fad_failure_1.htm [Visited March 2006]
The Presidential Commission

http://history.nasa.gov/rogersrep/v1ch4.htm [Visited January 2006]

http://science.ksc.nasa.gov/shuttle/missions/51-l/docs/rogers-commission/Chapter-5.txt [Visited February 2006]

http://science.ksc.nasa.gov/shuttle/missions/51-l/docs/rogers-commission/recommendations.txt [Visited February 2006]
Sites with unidentifiable authors

http://news.bbc.co.uk/onthisday/hi/dates/stories/january/28/newsid_2506000/2506161.stm [Visited January 2006]

http://www.msnbc.msn.com/id/11031097/page/2/ [Visited January 2006]

http://en.wikipedia.org/wiki/Space_Shuttle_Columbia_disaster [Visited March 2006]

1 Richard Feynman, Rogers Commission Report.

2http://news.bbc.co.uk/onthisday/hi/dates/stories/january/28/newsid_2506000/2506161.stm

3 Vaughan, D. (1996). The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA, pg34

4 The capital was apparently being redirected to fund the war effort in Viet Nam. Vaughan (1996), pg17

5 Vaughan (1996), pg20

6 http://www.msnbc.msn.com/id/11031097/page/2/

7 Vaughan (1996), pg42

8 Vaughan (1996), pg42

9 Vaughan (1996), pg116

10 Vaughan (1996), pg106

11 Explanations for some of the points are also derived from Walton (1989). W. Edwards Deming: The Man and his Mission, pp34-36

12 Deming (1986). Out of the Crisis, pg46

13 Deming (1986), pg59

14 http://science.ksc.nasa.gov/shuttle/missions/51-l/docs/rogers-commission/recommendations.txt

15 http://en.wikipedia.org/wiki/Space_Shuttle_Columbia_disaster. The shuttle’s destruction was not due to O-ring erosion, but inadequate foam. However, the “can do”/ “change is bad” culture was the primary cause of the disaster, meaning that things had not changed enough.

16 Straker, D. (2004). ‘Breaking the Fad – Failure Cycle’, in http://www.syque.com/articles/fad_failure/fad_failure_1.htm

17 Collins, ‘Turning Goals into Results: The Power of Catalytic Mechanisms’, Harvard Business Review, 1999, pg72

18 Collins (1999), pg72

19 Liker (2004) The Toyota Way. New York: McGraw-Hill

20 Kohn (1993), Punished by Rewards. Boston: Houghton Mifflin

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