Challenger Launch Decision
JOE KILMINSTER’S ACCOUNTABILITY IN THE CHALLENGER DISASTER
On January 28, 1986, the Challenger, one of the reusable space shuttle by the National Aeronautics and Space Administration or NASA, was launched off at the John F. Kennedy Space Center in Cape Canaveral, Florida but exploded 72 seconds after liftoff. The launch was approved and ordered by the management of the Morton Thiokol, Inc., an aerospace company, that manufactures solid propellant rocket motors for big clients, including the NASA, and per NASA’s urging despite the objection of Morton Thiokol’s engineers that the 30-degree F. temperature was inclement to the shuttle’s boosters. The launch was a publicized event as NASA’s 25th mission and had a selected teacher, Christa McAulifee and six astronauts on board. All these passengers perished (Jennings 1996).
The launch was repeatedly postponed because the engineers of Thiokol notes the failure of an O. ring assembly in the rockets they used in tests conducted the previous year at the Marshall Space Flight Center in Utah. But because of political and economic motivations, the management of Thiokol yielded to the pressure from NASA and gave the go-signal to launch. Joe Kilminster, an engineer, and the Vice President or Space Booster Programs at Thiokol, was one of four management signatories who approved the launch and the author of the written recommendation that it was all right for the shuttle to fly (Jennings). Thiokol’s contract with the NASA provided that shuttles with boosters, like the Challenger, would function properly only within the range of 40 to 90 F. Its engineers also formalized their objection to such launch the day before the disaster.
What was the cause of the failure? Who were aware of the imminence of the failure? What steps were taken to prevent it, if any? Who is Joe Kilminster and how far was his accountability for the misfortune?
To answer these and related questions, the incident, the individuals involved and applicable laws should be understood, investigated and related. The damage was not limited to the explosion of the shuttle itself but extended to the death of the seven persons on board. Could and should the incident have been prevented? Was it within the power of Joe Kilminster to do so?
This study will recount the incident and go through the detailed background to identify the mechanical defect or defects that made the Challenger unfit for launch on January 28, 1986. It will review the organization setup of Morton Thiokol, the communications and the events that occurred previous to the explosion. In the process, the study will determine how far Joe Kilminster should be held accountable for the incident, based on his managerial capabilities and in accordance with the professional ethics for engineers to which he swore as a member of the profession.
The study will discuss the details from the organization level of the Morton Thiokol, the supervisory level, then the pre-conditional or immediate level, and the individual act of Joe Kilminster and those with whom he shared authority. The study is deemed quite significant in that it teaches a lesson that a technical problem should be handled by technical experts and that management should heed technical recommendations.
II. REVIEW OF LITERATURE
Jennings, MM. Summary of the Challenger Episode. Case studies in Business Ethics, second edition. West Publishing, 1996
This work provides ample background and information on the Challenger catastrophe, the people behind it, the events and the technical failure that led to the catastrophe. It zeroes in on the O. rings as the technical source, booster rockets manufactured by Morton Thiokol, Inc. For NASA specifically for the widely publicized January 28, 1986 launching event for which it held a nationwide search for a teacher to fly in it as NASA’s 25th space mission. The author, Jennings, writes that the launch was repeatedly delayed because of the booster problem, but NASA still called to ask if the shuttle could be flown even in a 30-degree F. Thiokol’s contract specified that the lowest temperature for the boosters was 40F. Thiokol engineers Allan McDonald and Rogers Boisjoly formally opposed the launch due to this technical problem.
Jennings relates that a presidential commission later, however, came up to say that management reversed its decision and, instead, gave the go-signal for the launch. One of the managers who reversed the former decision was Joe Kilminster, an engineer. He was Thiokol’s Vice President for Space Booster Programs. On his journal, Boisjoly wrote down his disagreement to, and disappointment over, some of Kilminster’s statements in the summary the latter made in approving the launch. Boisjoly also expressed apprehensions of a catastrophe, which, indeed happened only 72 seconds from liftoff of the shuttle.
After the incident, blame was placed squarely on Thiokol but Thiokol CEO disowned responsibility in that he never agreed to the launch under temperatures lower than those specified in its contract with NASA. He insisted that the matter should have been referred to its headquarters and he would not have given clearance. Since Boisjoly and McDonald testified, they had been isolated and later demoted or transferred to “special projects.” Later on, Boisjoly separated from Thiokol and now runs his own consulting firm and frequently speaks on business ethics before professional organizations and firms.
Jennings also recounts that, in 1989, the Morton partner of Thiokol separated but Thiokol remained under contract with NASA and redesigned the shuttle rocket motor to correct the defect. The author points out that no one was fired or prosecuted because of the Challenger accident. The only response was the creation of the Government Accountability Project in Washington DC, which provides legal assistance and materials to help advocates working on government projects.
Stubley, Gordon. Engineer and Integrity. The Objectivist Center, 1998
This work delves more into the details of the faulty O-ring seal that led to the Challenger explosion and which the author links with the carbon monoxide poisoning incident in the Taggart Tunnel disaster. Stubley writes that there was no reason to expect the O-rings to work. Right before the launch, the predicted temperature was 26 F. And 18 F. overnight. The situation was discussed at a teleconference among senior NASA administrators and four Thiokol executives, namely, senior vice president of aerospace division Jerald Mason, vice president and GM for space division Calvin Wiggins, Joe Kilminster, and vice president for engineering Robert K. Lund. After the engineering team presented evidence opposing a launch, Lund and Kilminster recommended its postponement until warmer air temperatures.
NASA administrators, however, were stunned and turned off by the recommendation, because they were then under severe pressure to prove the viability of their space shuttle program. Joe Kilminster sensed this pressure and asked to go off-line for five minutes. Apparently, there was a phone call during those five minutes, because when it ended, Mason announced that there had to be a management decision to overturn the engineers’ recommendation. Mason told Lund to take off his engineering hat and put on his management hat. The result was the disaster.
Vaughan, Diane. The Challenger Launch Decision. Paperback. University of Chicago Press, February 1996
The author, professor Diane Vaughan exposes the failures of investigation methods into two recent and prominent air crashes occurring in two organizations with solid reputation for high sensitivity to safety. She begins her own investigation from the NASA, the world’s most reputable in the field of risk assessment and operational safety until its fiasco on January 28, 1986. The givens were the findings of a presidential commission, the NASA itself, and a special subcommittee of the House of Representatives concluded that the accident was caused by a combination of production pressures and wrong managerial decision and viewed as a technical failure to which both the NASA and Thiokol contributed.
Vaughan uses her scholarly expertise in organizational ethics and misconduct in acquiring new data directly from the primary sources in determining and understanding the basis of the decision to launch. She interviewed the participants in the original “stream of decisions” and, in evaluating their actions and decisions in the chronological and cultural order, she came upon what she described as an “incremental descent into poor judgment.” She determines that it was not the managers’ amorally violating the rules that led to the accident but their conformity that did (p 138). She also says that this finding eluded investigators because they did not ask the right questions but simply made conventional conclusions, which, in turn, led to erroneous interpretations.
Vaughan offers insights into decision-making mechanisms in investigating organizational or managerial influences. In the Challenger disaster’s case, she points to NASA managers’ uncritical acceptance of deviance from established expectations and limits and the consequent normalization of deviations inclined or compelled them to approve the launch. She comes to realize that these limitations also lacked scientific basis in that they were derived from irrelevant and un-tested applications data. She also discovered that many aspects of the behavior of the solid rocket booster joint used for the Challenger were either unknown or un-recognized before the fatal launch.
Vaughan shares insights with investigators who hope to improve the results of their investigations in the search for preventive measures. They should approach the primary sources of decision in discovering what really happened and what institutional forces were considered. They should seek out direct links among actions and decisions made by primary sources and how these were influenced or programmed by operational, technical, financial and other managerial influences within and without. From there, the “decision stream” can be constructed in a chronological order around the time of the accident or event and against which the organization’s world view can be drawn.
She also suggests that investigators go through incomplete or erroneous system definitions, the existing knowledge of system operation and system performance and their roles in decision-making. They should choose a method that will enable them to discover, find and ask the right questions of those who made and influenced the decisions.
Most importantly, Vaughan’s discussion of causation deserves notice by those in charge of air safety investigation. She writes that all causal explanations have significant implications for control, whereby explanations for organizational failure that trace back to individual decision makers make quick remedies possible. These remedies include firing, transferring or retiring the erring person or persons; fixing the technological defect or error; implement control decisions; and proceed (p 392).
National Society of Professional Engineers. Code of Ethics for Engineers.
This Code of Ethics states that engineering is an important and learned profession and that engineers are to exhibit the highest standards of honesty and integrity. Because the profession has a direct impact on the lives of people, engineers are sworn to practice honesty, impartiality, fairness and equity and to be dedicated to the protection of public health, safety and welfare. Engineers must observe and adhere to the highest principles of ethical conduct, whereby they must hold the safety, health and welfare of the public of paramount importance; perform services only within their areas of competence; issue public statements objectively and truthfully; act as faithful agents or trustees for each employer or client; avoid deceptive acts; and behave honorably, responsibly, ethically and lawfully so as to enhance the honor, reputation and usefulness of the profession.
Department of Philosophy and Department of Mechanical Engineering. The Space Shuttle Challenger Disaster. Texas A & M. University
This was written by an anonymous contributor, who also volunteered details on the mechanical failure of the Challenger, a list of those involved in the launch decision and their probable motivations to the decision.
The unknown contributor points to the mechanical cause as the failure of the solid rocket booster or srb, in turn, due to technical defects, such as faulty design, insufficiently low temperature testing of the O-ring material, the sealing of the O-rings, and miscommunication among and between managerial levels at the NASA and Thiokol.
The contributor lists names and dates involved in the accident. McDonald was director of the Solid Rocket Motors Project and he had Roger Boisjoly and Robert Ebeling as engineers working under him; Bob Lund was Thiokol engineering vice president, Joe Kilminster as Thiokol’s vice president for space booster programs; and Jerald Mason as vice president and general manager for space division. The unknown author traces that NASA awarded the contract to Morton Thiokol in 1974; accepted Thiokol’s booster design in 1976; Morton Thiokol discovered the joint rotation problem in 1977 and the O-ring erosion problem after the second shuttle flight; Thiokol called attention to the worst O-ring accident in a shuttle flight on January 24, 1985 and ordered new steel billets for a new field joint design; Thiokol informed the first level management of NASA on the srb problem; a teleconference was held in the evening of January 27, 1986 to discuss and justify a launch despite the cold temperature; and, the following day, the Challenger was flown but exploded 72 seconds after lifting.
In addition, the contributor offers speculations on the influences and motivations behind the sudden change of decision to launch the Challenger.
III. FINDINGS, CONCLUSIONS AND RECOMMENDATIONS
NASA managers were adequately and promptly informed about the un-suitability of the approved design of shuttle rocket boosters when used under temperatures below 40 F. per the contract signed with Morton-Thiokol. Thiokol engineers, true to their oath, formally recommended postponements of the launch until the weather improved. Chronological records show this and bear them out.
But NASA authorities were also subject to severe economic and political pressures, as well as schedule backlogs, at that time (Department of Philosophy and Department of Mechanical Engineering). Competition with the European Space Agency compelled NASA to embark in this ambitious flight to prove cost effectiveness and as a commercial potential. It tried to justify budget requests by launching a number of missions that year. It did not want any more delays so that it could collect data a few day before another Russian project could be sent. It can also be inferred that NASA wanted to time the Challenger with then President Regan’s State of the Union address, which focused on education and honored the first teacher in space, Christa McAuliffe.
Knowing the technical problem with the boosters as early as in 1977, Thiokol initiated redesign efforts in 1985 and informed NASA leaders about the move. Thiokol ordered new steel billets for a new design, but these were not ready in January 1986 when the accident occurred, as it took several months to manufacture (Department of Philosophy and Mechanical Engineering).
The critical element was the teleconference between the engineers and managers at the John F. Kennedy Space Center in Alabama and Thiokol in Utah to explore the performance of the boosters in that cold weather. Lund endorsed his engineers’ recommendation not to launch the shuttle but Mulloy first tried to challenge the position and arguments of the engineers, then bypassed Lund by asking Joe Kilminster, a middle manager, for his comments instead. Kilminster had extensive engineering background and was duly informed of the risks of a launch in that temperature. He was also subject to the decisions made by Lund, his superior, and to the ethical standards of his profession.
Instead of upholding his superior’s decision, his fellow professionals’ technical findings and recommendations and observing is profession’s code of ethics, Joe Kilminster subjected himself to the pressure of NASA and asked for a five-minute recess during which he could find rationalization for a decision to proceed with the launch. During that brief intermission, Kilminster joined Mason in “taking off his engineer’s hat and in putting on a manager’s hat (Department of Philosophy and Department of Mechanical Engineering).”
Conclusively, Kilminster became accountable for writing out a new recommendation to proceed with the launch and got back to the teleconference and stated that, while the low temperature was a safety concern, their people said that the original data were inconclusive and that their engineering assessment was recommended. The truth was that the engineers were excluded from the decision made to proceed with the launch.
Kilminster becomes immediately and morally accountable and culpable for the disaster by ignoring what he himself as an expert engineer knew and what his subordinate professionals strongly recommended on the basis of technical knowledge. He also violates the professional code of ethics for engineers, which obligates him to put the welfare of the public above all personal considerations and to conduct himself honorably, responsibly, ethically and lawfully so as to enhance the honor, reputation and usefulness of his profession (National Society of Professional Engineers). Kilminster yielded to Mason and NASA officials’ pressure despite the firmness of his boss, Lund, and their engineers. And despite the firm position of Lund, Kilminster asked for a time-out off the teleconference to look for rationalizations to reverse their decision not to launch.
In the least, Kilminster is/was guilty of insubordination and un-professionalism. At most, he knowingly and directly risked the lives of seven persons inside the Challenger.
Benner, L. (1996). The Challenger Launch Decision by Diane Vaughan. Book Review, International Society of Air Safety Investigators: ISASI Forum. http://www.ipri.org/Reviews/Vaughan.html
Jennings, MM. (1996). Summary of the “Challenger” Episode. Case Studies in Business Ethics, second edition. West Publishing. http://www.calbaptist.edu/dskubik/nasa.htm
Stubley, G. (1998). Engineers and Integrity. The Objectivist Center. http://www.ios.org/tex/gstubley_engineers-integrity.asp
Vaughan, D. (1996). The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA.. Paperback. University of Chicago Press.
1997). Targets for Fire-Fighting: Lessons from the Challenger Tragedy. Association of Wildland Fire: Wildfire
Engineering Ethics. Department of Philosophy and Department of Mechanical Engineering. http://www.connix.com/~harry/shuttle1.htm
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