The Space Shuttle Challenger Disaster

A failure in decision support system and human

factors management
by Jeff Forrest
Metropolitan State College

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
jforrest@idcomm.com .

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.
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.
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.
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.