The Space Shuttle Challenger Disaster

A
failure in decision support system and human factors management

by Jeff Forrest

Metropolitan State
College

INTRODUCTION

This
article discusses the environmental and human decision making factors that were
associated with the launching of the Space Shuttle Challenger on January 28,
1986. Shortly after launch, the Shuttle exploded destroying the vehicle and all
crew members. The cause and contributing factors that lead to the Challenger
tragedy are explored in detail. Focus is placed on NASA's use of a group
decision support system (GDSS) meeting to make the decision to launch.

Examples
are included that show how contributing factors such as multiple priorities and
demands influenced NASA from operating in a responsible and ethical manner. Proof that NASA used a flawed database in its GDSS and how it
mismanaged the GDSS meeting is also offered. Finally, the inability of
each GDSS member to vote anonymously on the decision to launch is discussed as
a critical factor that, had it been allowed, probably would have prevented the
Challenger tragedy.

THE SHUTTLE 51-L MISSION

Environmental Factors- Societal Impacts

The
Space Shuttle Challenger 51-L was the 25th mission in NASA's STS program. On
Jan. 28, 1986, STS 51-L exploded shortly after liftoff, destroying the vehicle
and all of its seven crew members.

The
STS 51-L mission was to deploy the second Tracking and Data Relay Satellite and
the Spartan Halley's Comet observer. Paramount
to this mission was crew member S. Christa McAuliffe - the first Space Shuttle
passenger/observer participating in the NASA Teacher in Space Program (cf.
[1]). Ms. McAuliffe would have conducted live educational broadcasts from the
Shuttle and transmitted them to classrooms throughout the world.

The loss of life and the unique position that symbolized Christa
McAuliffe as the first civilian working as a teacher in space had a profound
impact on society and its attitude toward NASA and the U.S. Space programs.

As
this article will explore, the tragic decision to launch STS 51-L was based on
long term contributing factors and the use of a flawed group decision support
system that was further aggravated by its related mismanagement. The outcome of
this action created costs to society in terms of life, resources and public
mistrust. NASA subsequently experienced years of setback for its related
scientific research and operations.

BACKGROUND

Human Factors - Contributing to a Tragedy

Although
the destruction of the Shuttle Challenger was caused by the hardware failure of
a solid rocket booster (SRB) "O" ring, the human decision to launch
was, in itself, flawed. The resolution to launch was based upon faulty group
decision support information and further aggravated by the related
mismanagement of that information. However, as in most transportation
accidents, there are usually other contributing factors that help to create an
environment leading to mistakes and failures. Therefore, a brief review of the
contributing factors leading to the Challenger destruction is in order.

Environmental Factors - Demands on the Space Shuttle

The
process of "selling" the American public and its political system the
need for a reusable space transportation system began in the late 1960's.
Conceptually, the Space Shuttle was introduced during the crest of the
successful Apollo mission. Unlike the Apollo mission, the Space Shuttle was
approved as a method for operating in space, without a firm definition of what
its operational goals would be ([2] pg. 3). Here is the first contributing
factor. The Shuttle was developed as a utility without a firm application.
Therefore, support for such a project, both politically and economically, was
not very strong. To gain political support it was sold as a project with a
"quick payoff" (cf., [2]). Additional support was gained by offering
the Shuttle program to the military as a means to increase national security
and to industry as a tool to open new commercial opportunity. Scientists argued
to the American people that the Shuttle would be an "American Voyage"
([2] pg. 10) with great scientific gain. Globally, the Shuttle was sold as a
partnership with the European Space Agency (ESA) and as a means to improve
national and social relations by combining peoples of different nationalities,
races and sexes who would serve as crew members.

The
process used to develop economic, political and social support for the shuttle
introduced the second contributing factor called heterogeneous engineering.
That is, the Shuttle engineering and management decisions were made to meet the
needs of organizational, political, and economic factors as opposed to a single
entity mission profile with specific goals ([2] pg. 9). Once functional, the
Shuttle became exposed to operational demands from a multitude of users. The
Shuttle now had to live up to NASA's promises. Coordinating the needs of
political, commercial, military, international and scientific communities
placed immense pressures on the Shuttle management team. First, political
pressure to provide a reliable, reusable space vehicle with rapid turn around
time and deployment seriously hindered the ability for effective systems
integration and development. Secondly, it was not feasible to construct any
complete management support systems (MSS) that could consider all of the factors
associated with such a diverse group of environmental variables. Third,
additional uncertainty and low NASA employee moral was created when the Reagan
Administration pushed for the Shuttle to be declared "operational"
before the "developmental" stage had been completed [2].

After
spending billions of dollars to go to the moon, Congress expected the Shuttle
program to be financially self-supportive ([2] pg. 15). This forced NASA to
operate as a pseudo commercial business. Therefore, the environment within NASA
preceding the Challenger launch was one of conflict, stress, and short cuts
[2].

NASA

Decision Support System (DSS) - Environmental Effects

The
probability for disaster was growing higher as increasing demands were being
placed on NASA just prior to the Challenger launch [2]. A false sense of
security was felt by NASA officials, with twenty-four successful Shuttle
missions to their credit. Just prior to the STS 51-L launch, NASA was an
organization filled with internal strife and territorial battles([3],
pg. 412). Mangers operated in an environment of "overload and
turbulence" [3]. In short, NASA was characterized as having a "disease " ([3] pg.414) of decay and destruction.

As
incredible as it may seem, it would appear that NASA had no formal DSS program
initialized for the Shuttle operations before the Challenger launch. Evidence
is strong that decisions were made primarily by "satisficing"
and conscious "muddling through." Specific characteristics of
decision making at the time consisted of short cuts, compromise and operational
heuristics ("operational heuristics; to cannibalize existing parts"
as defined by Jarman and Kouzmin
[3] pg. 414). In short, NASA was operating in a phase of semi-uncontrolled
decision making while trying to serve the military, industry and international
research organizations with a space vehicle that had been declared operational
before completion of the developmental stage [4].

NASA
used decision making by default as its primary DSS. Its organizational boundary
was highly political and open for manipulation by any entity that could exert
political power. Upon declaring the Shuttle "operational," the Reagan
Administration removed the motivation of NASA employees to manage and left them
with the impression that decision making would be made by directive from
political sources.

The
declaration of "operational" status was the critical turning point
for NASA and its management of Shuttle operations. Complacency began to grow
among employees and safety considerations were traded for time spent on keeping
the Shuttle on schedule and "the client of the day" satisfied. This
was the environment just before the launch of STS 51-L.

THE DECISION TO LAUNCH

Group Decision Support System (GDSS) - Situational
Analysis

A
group support system did exist between NASA and related developers of the
Shuttle. Focus in this discussion will be placed on Thiokol - the subcontractor
directly responsible for the development of the SRB "O" rings. The
GDSS system between NASA and Thiokol consisted of same-time/different-place
conference rooms equipped with a connected and distributed computer interface.
Speaker phones with audio only were also available.

On
the evening of January 27, 1986, Thiokol was providing information to NASA
regarding concerns for the next day's planned launch of STS 51-l. Thiokol
engineers were very concerned that the abnormally cold temperatures would
affect the "O" rings to nonperformance standards. The mission had
already been canceled due to weather, and, as far as NASA was concerned,
another cancellation due to weather was unthinkable ([4] pg. 23). Both parties
were already aware that the seals on the SRB needed upgrading but did not feel
that it was critical. Though the information provided by the GDSS (with an
associated expert system) showed that the "O" rings would perform
under the predicted temperatures, Thiokol engineers questioned their own
testing and data that were programmed into the GDSS. Thus on the eve of the
Challenger launch, NASA was being informed that their GDSS had a flawed data
base.

At
this point, NASA requested a definitive recommendation from Thiokol on whether
to launch. Thiokol representatives recommended not to launch
until the outside air temperature reached 53º F. The forecast for Florida did not show temperatures
reaching this baseline for several days. NASA responded with pressure on
Thiokol to change their decision. NASA's level III manager, Mr. Lawrence Mulloy, responded to Thiokol's decision by asking, "My
God, Thiokol, when do you want me to launch, next April?" ([4] pg. 24).

After
this comment the Thiokol representatives requested five minutes to go off-line
from the GDSS. During this period the Thiokol management requested the chief
engineer to "take off his engineering hat and put on his management
cap," suggesting that organizational goals be placed ahead of safety
considerations [4]. Thiokol reentered the GDSS and recommended that NASA
launch. NASA asked if there were any other objections from any other GDSS
member, and there was not.

Group Support System - Critical Analysis

There
is little doubt that the environment from which NASA and its affiliated
developers operated provided an opportunity for significant human error.
Nevertheless, NASA and Thiokol had a "golden" opportunity to avoid
disaster during their GDSS meeting before the STS 51-L launch. The following
factors are offered as potential explanations for what created the flawed GDSS
and the associated mismanagement of its information:

First,
Thiokol was aware of the "O" ring problem at least several months
before the Challenger launch. However, the goal was to stay on schedule. NASA
was made aware of the problem but it was "down-played" as a low risk
situation. Here is the first element of flawed information that was input into the
GDSS. If NASA had been aware of the significance of the "O" ring
situation, they probably would have given more credence to the advice of the
Thiokol engineers' recommendations. However, the data transmitted during the
GDSS meeting from Thiokol did say that it would be safe to launch for the
forecasted temperatures. NASA was frustrated over the conflicting advice from
the same source.

Second,
the decision to delay a Shuttle launch had developed into an
"unwanted" decision by the members of the Shuttle team [5]. In other
words, suggestions made by any group member that would ultimately support a
scheduled launch were met with positive support by the group. Any suggestion
that would lead to a delay was rejected by the group.

Third,
all members of the GDSS felt that they should live up to the "norms"
of the group. Although the Thiokol engineers were firm on their recommendation
to scrub the launch, they soon changed their presentation of objections once
threatened with the possibility of being expelled from the program (as
suggested by a NASA administrator who was "appalled" at a company
that would make such a recommendation based on the data available) [5].

Fourth,
Thiokol became highly susceptible to "groupthink" when they requested
a break from the GDSS. At this point they became insulated, conducted private
conversations under high stress and were afraid of losing potential future
revenue should they disagree with NASA. All these factors are considered prime
to the formulation of "groupthink" [5].

Fifth,
all parties were afraid of public and political response to another launch
cancellation (there had already been six cancellations that year). Each party
began to rationalize that past success equaled future success [5].

Finally,
the GDSS was seriously flawed. As already mentioned, the data
base contained erroneous information regarding the "O" rings.
Ideas, suggestions and objections were solicited but not anonymously.
Individuals who departed from the group norms were signaled out as unwelcome
members. An agenda was never defined and NASA was therefore surprised by the
Thiokol presentation. Conflict management was avoided by NASA's domination of
the entire meeting. NASA, at times, became very assertive and intimidating.
Considering NASA's attitude, no group member or individual was willing to be
held accountable for any comment or decision [5].

The
setting for such an important GDSS meeting was also ineffective. Considering
that a speaker phone and CPU modem was used, it was easy for NASA to down-play
the personal opinions of the Thiokol engineers. If the meeting could have been
held at the same place for all members, the outcome might have been different.
At the end of the meeting NASA, very reluctantly, suggested that they would
still cancel the launch if Thiokol insisted. No response from Thiokol was made
and the NASA officials could not see the expression of
"self-censorship" that was being communicated on the face of each
Thiokol engineer [5].

Perhaps
the most significant flaw in the GDSS was when Thiokol requested a private five
minute meeting with its own members. Up to this point Thiokol had stayed with
its recommendation to cancel the launch. Once disconnected, Thiokol became an
isolated member and the GDSS failed altogether. Once reconnected, Thiokol had
changed its position and offered the go ahead to launch without any objection.

CONCLUSIONS

The Critical Human Factor - Need for Voting Tool

Many
conclusions may be drawn as to the primary cause and contributing factors
associated with the Challenger tragedy. It is the opinion of this author that
regarding the GDSS and decision to launch the ability of each member to have
voted anonymously was the key factor that would have maintained the integrity of
the GDSS and the quality of the decision.

It
has been shown that just after Thiokol's presentation to NASA, most of the GDSS
group members were very concerned with the "O" ring situation and
believed that the opinions expressed by Thiokol engineers were cause for
serious consideration of launch cancellation [5]. However, only selected senior
officials were allowed to vote their "opinion", which they did
verbally and at the request of NASA. From the research conducted on this paper,
the author believes that had a universal anonymous vote been conducted of the
total GDSS membership, a decision to cancel the launch would have been made.

The
factors which lead to the Challenger incident can be traced back to the
inception of the shuttle program. NASA and Thiokol failed to maintain a quality
assurance program through MSS, as was initiated on the Apollo program, due to
multiple source demands and political pressures. The GDSS used for the launch
decision contained inaccurate data. Engineering members of the GDSS did not
believe in the testing procedures used to generate the data components in the
GDSS. And, the entire meeting was mismanaged.

The
decision to launch the Challenger Shuttle and its subsequent destruction had a
major affect on society and the management of our space program. Challenger's
unique mission and the death of Christa McAuliffe opened the door for
discussion and research on how managers use DSS to make decisions that will
affect public trust.

AFTERMATH

Ethics and MSS/DSS - Human Factors Management

A
complete discussion of ethical decision making is beyond the scope of this
article. However, the question of how NASA and Thiokol managed ethical
considerations is central to the decision to launch the Challenger Shuttle and,
therefore, deserves a brief overview.

The
first area of ethical concern is the area of information accuracy. The fact
that both NASA's and Thiokol's managers had little regard to the concerns of
Thiokol's engineers is very distressing. All members of the group made a
decision knowing that the decision was based on flawed information. A second
concern is that the decision made put safety last and operational goals first.
Only one member of the GDSS expressed serious concern for the potential loss of
life [5]. Additionally, open and free communication before and during the GDSS
meeting was discouraged through such group dynamics as mind guarding, direct
pressure and self-censorship [5]. Individuals who know of a situation that,
unless acted upon with integrity might cause social harm, have a responsibility
to contact any authority that will manage and control that situation in the
best interest of the public ([4] "Whistleblowing,
pg. 34).

Human
factors analysis and management science have begun to define the incorporation
of MSS/DSS as a socially responsive way of conducting business ([6] pg. 826).
This is especially true for government agencies and large public projects like
the Shuttle program. It could be argued that GDSS technology had not evolved to
the level of effectiveness that was needed to support the Challenger project.
The success of the DSS used in the prior Apollo mission shows that this was not
the case. In the Challenger program social and ethical decision making was
discarded for the sake of cost, schedule and outside environmental demands.

REFERENCES

[1]
NASA Spacelink Challenger Press Release,
http://history.nasa.gov/sts51lpresskit.pdf

[2]
Launius, Roger D., "Toward an Understanding of
the Space Shuttle: A Historiographical Essay". Air
Power History, Winter 1992, vil.
39, no. 4.

[3]
Jarman A. and Kouzmin, A.,
"Decision pathways from crisis. A contingency-theory
simulation heuristic for the Challenger Shuttle disaster", Contemporary
Crises, December 01, 1990, vol. 14, no. 4.

[4]
Kramer, Ronald C. and Jaska, James A., "The
Space Shuttle Disaster: Ethical Issues in Organizational Decision Making",
Western Michigan University,
April 1987, 39 pgs.

[5]
Groupthink videorecording written by and produced by
Kirby Timmons; produced by Melanie Mihal, Carlsbad,
Calif., CRM Films, c 1991 25min.

[6]
Turban, Efraim, Decision Support and Expert
Systems, Macmillan Publishing Company, N.Y., N.Y.
1993.

Editor's Note

The
NASA history site on the Challenger STS 51-L Accident at
http://history.nasa.gov/sts51l.html links to many
resources including Jeff Forrest's analysis. Reader's are especially encouraged
to read and review the Report of the Presidential Commission on the Space
Shuttle Challenger Accident (commonly called the Rogers Commission Report),
June 1986 and the Implementations of the Recommendations, June 1987. The GDSS
was an audio teleconference. The slides had been faxed to the NASA meeting
site. Mr. Mulloy of NASA testified that Mr. Kilminster of Thiokol requested the 5 minute off-net caucus
that ultimately lasted approximately 30 minutes. The opinions in this analysis
are those of the author and not necessarily those of the Editor or of
DSSResources.com.

Some Questions for
Further Analysis and Discussion

What is a group decision
support system?

Did NASA and Thiokol use a
GDSS?

Did the group decision
support system fail or was the problem with the participants?

What do you think was the
cause of the decision-making failure in this situation?

Could improved GDSS
technology have avoided this tragedy? If so what was needed? Video, anonymous
voting?

Web links

www.aerospaceweb.org/question/investigations/q0122.shtml

history.nasa.gov/sts51l.html

Please cite as:

Forrest,
J., "The Space Shuttle Challenger Disaster: A failure in decision support
system and human factors management", originally prepared November 26,
1996, published October 7, 2005 at URL DSSResources.COM.

Jeff
Forrest is an Associate Professor and Chair of the Aviation & Aerospace
Science Department at Metropolitan State College (MSCD) in Denver, Colorado.
He is also pursuing a Doctoral Degree in Information Science in The School of
Computer and Information Sciences at Nova
Southeastern University.
Contact him by email at [email-masked] .

Jeff
Forrest provided permission to publish this case analysis at DSSResources.COM
on August 28, 2005. This article was posted at DSSResources.COM on Friday,
October 7, 2005.

This
case analysis was posted at DSSResources.com to honor the memory of Francis R. Scobee, Space Shuttle Challenger Commander, Michael J.
Smith, Pilot, Judith A. Resnik, Mission Specialist 1,
Ellison S. Onizuka, Mission Specialist 2, Ronald E.
McNair, Mission Specialist 3, Gregory B. Jarvis, Payload Specialist 1, and
Sharon Christa McAuliffe, Payload Specialist 2. May their lives and subsequent
tragic deaths remind us of the limitations of both people and technologies.

I.
Space Shuttle Challenger Crew

back row, left to right:
Ellison Onizuka, Christa McAuliffe, Greg Jarvis, Judy
Resnik. front row, left to
right: Michael Smith, Dick Scobee, Ronald McNair.

II.
Rest in peace.

This
case analysis is provided for informational purposes only. DSSResources.COM
makes no warranties, express or implied, about the accuracy of the conclusions.