ABSTRACT NASAs 25th Space shuttle mission, after being postponed 5 times, was scheduled to be launched on 28th January

1986. The challenger space shuttle burst into flames after 73 seconds of its launch from Pad 39B at Kennedy Space Center. The disaster killed all seven astronauts the shuttle was carrying. President Ronald Regan appointed a presidential committee to investigate the challenger accident. The presidential commission reported that the explosion was caused by the right solid booster which in turn was the result of O-ring failure connecting the segments of solid rocket booster (SRB). These SRB were made by a company named Morton Thinkol. Engineers at this company had already foreseen this catastrophe and tried to warn NASA about the impending danger. The managers at NASA as well as Morton Thinkol were not ready to for another rescheduling of the launch. The O-ring charring was previously known by engineers as well as managers but the managers did not consider it seriously as previous launches had successfully taken place. The engineers opposed the launch as they knew O-rings failure probability increased at lower temperatures, but could not provide hard evidence for this fact and thus could not stop the launch. Roger Boisjoly, a Morton Thinkol engineer who had tried his best to convince NASA and his top management about the criticality of the issue, submitted all the evidence to the Presidential committee against the wishes of his company and colleagues. He was branded a whistle blower and isolated by the company. This report details these issues and discusses about the ethics of NASA who wanted the launch without correcting the sealant problem so as to please the politicians and retain funding. As well as that of Morton Thinkol management who did not want to risk their contract by exposing a flaw.

INTRODUCTION Twenty six years ago, on 28th January 1986 occurred one of the most tragic event in the history of United States space program (Brian, 2011). Mission 51-L which had the space shuttle Challenger on its 10th flight to space exploded 73 seconds after its launch. Thus ending the mission and also resulting in the death of all seven astronauts abroad (Mahal, 1995). The deceased astronauts were mission commander Francis R Scobee, pilot Commander Michael J Smith, Dr Judith A Resnik, Dr Ronal McNair, Lieut. Col. Ellison S Onizuka, Gregory B Jarvis and Christa McAuliffe (Broad, 1986). Broad (1986) also reported that flaming debris were falling on the Atlantic ocean, even after an hour of the ariel explosion. The event was witnessed by thousands of people including the students of Mrs McAuliffe who was a high school teacher. The people watched in wonder as the launch took place and then horror as the ship burst into flames. This report focusses on the disaster, its causes and its aftermath like Morton Thinkol Engineer Roger Boisjolys whistle blowing. The report also mentions some suggestions by the author, if given a chance, on how he would have handled a similar situation. THE MISSION The challenger mission planned had the following objectives (nasa.gov). Day 1: To ready the TDRS-B satellite and deploy its inertial upper stage booster. Day 2: To do the initial recordings for Teacher in Space programme, to begin the Comet Halley Active Monitoring Program and to place challenger at the 152 mile orbital altitude from where the Spartan was to be deployed. Day 3: Prepare satellite Spartan for launch and after launch separate the shuttle from the satellite by 90 miles. Day 4: To continue the fluid dynamics experiments conducted by Gregory B. Jarvis and to hold a live telecast Mrs McAuliffe. Day 5: To stow back the satellite Spartan to challengers payload bay. Day 6: Prepare for re-entry into Earth. Day 7: The shuttle was schedule to land back in Kennedy space center. The website (nasa.gov) sates furthermore that, initially the launch was scheduled on 22nd January 1986, which was shifted to 23rd, then to, 24th, 25th, 26th and 27th of January due to various delays like faults with fixtures and adverse weather conditions. And finally after much pressure from the top management the launch was to take place at 9:37 am EST, on 28th January 1986. Even then the launch was again delayed by another two hours when a hardware for fire detection failed. After all these hurdles the shuttle was launched at 11:38 EST from Pad 39B in Kennedy Space Center, but about a minute past its launch the obiter
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challenger began to break apart and eventually exploded in mid-air killing all of its crew members (Brian, 2011). AFTERMATH Investigations Following this catastrophe NASA as ever kept a very secretive approach and did not divulge much details of the explosion. Though newspapers like New York Times published speculative reports stating it was a leak in the fuel chamber that lead to the destruction, NASA engineers were already focussing its investigation into the booster damage (cbsnews, 1986). Two commissions investigated the challenger disaster they were the Presidential commission also known as the Rogers commission and the Congressional committee which reviewed the findings of Rogers commission report (Dombrowoski, 1991).

Figure 1: Diagram of Space Shuttle Challenger and solid rocket booster, showing location of the O-ring (Available from: http://www.ahrtp.com/RSSJSfeeds/Shuttles_Challenger_Columbia_Tragedies.html ) The two committees concluded the cause of this accident to be due to an O-ring failure on the solid fuel booster. These O-rings are those mechanical sealants which are used to prevent unwanted leakage of fluid between different fuel compartments on the boosters (Brian, 2011). An O-ring had failed and the fuel volatility surrounding it resulted in an eruption of fire at several locations causing more damages to the shuttle. Several more fires were started and explosions took place which eventually caused the space craft to shift from its set path. When travelling at velocities greater than that of sound, it is imperative for a space craft to fly at the
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correct angle in order to be competent to handle all the aerodynamic forces it is subjected to. And in the case of Challenger the appropriate angle was lost due to those above mentioned causes which ultimately led to the catastrophic break apart (Brian, 2011).

Figure 2: Events before explosion (Availabble from from http://nige.wordpress.com/2011/02/15/) Factors Aside from the technical factors which directly resulted in the accident several other major deductions, which led to this unfortunate event, were made by the two investigating bodies. They are as follows. James Oberg (2003), described the cause of catastrophe as a combination of true mistakes and mere coincidences that made the mistake far worse. Some of the factors that led to the explosion of space shuttle Challenger are described below: 1. Environmental factors: Challenger was the first shuttle to be launched from a new pad in Florida. In a previous mission, the coldest temperature the O-rings experienced was 54F. The predicted ambient temperature on January 28, 1986 was 26F. Morton Thiokols engineers knew that the O-rings had experienced erosion at very low temperatures (Ethics.tamu, 2000). On the morning of the launch cold breeze blew
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across the cryogenic tank which was located across the solid rocket boosters. When the shuttle was launched, the section backup was not warmed enough because of the cool air. The O-rings could not expand fast enough to maintain the seal of the field joints on the right hand of solid rocket boosters. A small flame appeared at the vicinity of joints which became a continuous plume after few seconds. (Allday, 2002)

Figure 3: Graph showing relation of O-ring failure to temperature. (Available from:

http://motherboard.vice.com/2012/1/27/was-space-shuttle-challenger-a-casualty-of-bad-datavisualization)

2. Decision making factors/ failure of foresight: According to James Oberg (2003), the tragedy was a result of a string of bad human decisions and choices. The engineers did not consider the erosion of the O-rings in cold temperature when the design for the Challenger shuttle was constructed. While testing when these events occurred, it was concluded that the shuttle could tolerate the erosion of the O-rings. Rather than eliminating these risks, the engineers accepted the risks and decided to fly the shuttle while ignoring the unsafe conditions. This first decision was a critical turning point for the O-rings of the shuttle (Westgrad, 2009). The operational and management decisions which should have been made considering the mission profile and goals were actually made under organizational and political pressures. The decision to launch the shuttle was made by the top level managers and executives who were under the pressure from the powerful politicians who demanded to launch the mission. Peoples perceptions play an important role in resolving the ethical status of these decisions. The NASA managers decided to gamble by launching the shuttle under unsafe conditions regardless of ethical consideration (Rossow, 2012). The bad decisions made by NASA to launch the faulty space shuttle were one of the causes of the catastrophe (Ethics.tamu, 2000). 3. Budgetary pressures: (Westgard, 2009) NASA had promised the politicians that they will launch missions routinely and economically. But they could not meet up with these schedules because of several
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delays and difficulties. NASA decided to cut its safety programs under funding pressure.

Figure 4: NASA Budget history from year 1958 to 2008 (Available from http://www.monstertechblog.com/2011/05/02/slashgear-101spaceflight/) 4. Organizational and management cultures: One of the contributing factors to the disaster of Challenger is the organizational and management cultures in NASA. Garett (2011) and Levy, et al., (2010) emphasizes the differentiation between the top level and mid-level managers and executives knowledge and the engineers knowledge. These differences are the keys to unlock the organizational problems in NASA. The organization is basically run by the top level managers and executives rather than technical engineers and experts. In NASA, the engineers knowledge was considered to be below than that of the managers. The managers ignored small flaws like O-ring erosions and it was considered as routine operation. The management culture was such that the goal was to launch as many shuttles as possible. To repair the problems of the O-rings would delay the launch. Hence, it was decided to fix such kind of minor flaws only after the launch schedule were met. The managers in NASA considered scarce resources as a major flaw and decided to launch the shuttle without fixing the problem associated with the O-rings. This disaster is considered as an example of an ethical violation by irresponsible management in NASA. (Westgard, 2009)

Figure 5: Shuttle missions per year Whistle blowing Valeques (1982) states that An employee blows the whistle on a company when, knowing the company is engaged in serious unethical activity and having made reasonable but unsuccessful efforts to the company to desist by working from within, the employee chooses to disclose the information to the public. Roger Boisjoly and fellow engineers Allan McDonald and Arnie Thompson were branded as whistle blowers because of the testimonies, against their company Morton Thinkol, in front of the Presidential commission. They believed that the management had ignored their warnings on the effect of low temperature on O-ring failure. Boisjoly presented is evidence to the commission without consulting his employer and did not heed their warnings that his statements were affecting the companys reputation negatively. Though Boisjoly and his colleagues undertook an ethical course of action, they were shunned by others in the company and ignored them. Boisjoly was never again included in any of the major roles in joint redesign work and eventually he took an extended sick leave from the company (Rossow, 2012). He got awarded the American Association for the Advancement of Science Award for Scientific Freedom and Responsibility for the efforts he took to avert the challenger disaster (Online Ethics, 1987) RECOMMENDATIONS The Author if given an opportunity to deal with a similar situation recommends the following steps to be taken so as to tackle any unforeseen accidents. 1. Changing the organizational structure: If the engineers had been successful in getting their point across to the senior managers, the mission would have been postponed to a different date. The engineers would have gotten time to dismantle the solid rocket
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boosters and replace the damaged O-rings. This procedure would have been a costly affair but not so much as the cost of the lives of the crew members and the shuttle. The organizational structure needs to be changed. The needs and requests of the engineers should be taken care of and the upper management should respect and explore the decisions and intuitions of the engineers. According to Joseph Lorenzo Hall (2003), during the pre-launch process the hierarchy system should be flattened. The management system in the space industry should be effective so as to make the best possible decisions concerning the success of the launch and the safety of the crew members. Proper ethical conduct should be maintained in the workplace. 2. Improving the relationship between the different parties involved: The relationship between the NASA and the contractors was mainly product and delivery oriented (Hall, 2003). This system should be changed and there should be better interface between them. The different parties involved in a shuttle launch such as NASA, contractors and the researchers should try to work together to develop or improve their product and also to detect errors and make necessary corrections. Simultaneous engineering and joint testing can also be done by the different entities. 3. Determining the root cause: Necessary action should be taken if a system shows any kind of faults or defects. The engineers should try to find the root cause of the problem. According to the seriousness of the situation, they should take appropriate action to avoid or eliminate it. It is also important to consider the different variables like temperature, humidity, wind and pressure that come into play while launching a shuttle into space. Various tests should be conducted to determine the target problems response to these variables in different scenarios. Consulting personal advisors is also a very good idea. 4. Modification and extensive testing: According the flaws or new demands, modification in the system is required. It is important to understand the technological weaknesses and imperfections and steps should be taken to fix them which might require extensive testing. In space industry, latest and improved systems with modern hardware and programming techniques are to be used. Finally, it goes without saying that it is really essential to gather and provide as many data as possible to make the best decision towards the success as well as the safety of the mission.

CONCLUSION The Challenger disaster raised many issues about the organisational culture in NASA. This article throws light on the steps that led to the Challenger disaster. According to the code of ethics, the safety and well being of the crew members should be the main priority of the managers and engineers at NASA. The management structure and safety culture in NASA needs to be changed.

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Broad, W. (1986) The Shuttle Explodes. New York Times, [online] 29th January. Available at: http://www.nytimes.com/learning/general/onthisday/big/0128.html [Accessed: 17th March 2012]. Dombrowski, P. (1991) Lessons From the Challenger Investigations. IEEE Transactions on Professional Communication, 34 (4), p.211-219. Drombowski, P. (1995) Can Ethics be Technologized? Lessons from Challenger, Philosophy, Rhetoric. IEEE Transactions on Professional Communication, 38 (3), p.146-150. Ethics.tamu.edu (2000) Engineering Ethics: The space shuttle challenger disaster . [online] Available at: http://ethics.tamu.edu/ethics/shuttle/shuttle1.htm [Accessed: 20th Mar 2012].
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Mahal, D. (1995). The Space Shuttle Challenger Accident. Available: http://www.mahal.org/articles/space/1995/12/the-space-shuttle-challenger-accident/page/1. Last accessed 15th March 2012. Rossow, M. (2012). 'Engineering Ethics Case Study: The Challenger Disaster', lecture notes distributed in the topic Course No: LE3-001. CED Engineering, New York.

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