The NASA Space Shuttle Disaster
The purpose of this paper is to discuss the core organizational problems that led to the crash of the Space Shuttle Challenger in 1986, recommend alternative solutions that could have been used to possibly prevent the crash, and develop a retrospective action plan for the recommended solution. The paper will also discuss how NASA could evaluate the effectiveness of the recommended solution.
The crash of the Challenger was a stark reminder that despite all the technological advances we have witnessed over the past century, the human element can not be ignored. Although the crash of the Challenger was technically due to mechanical failure caused by both miscalculated O-ring tolerances and subnormal Florida temperatures, the crash was actually the unnecessary result of several organizational issues within NASA. In fact, the shuttle program itself was on a collision course long before the Challenger lifted off due to an organizational structure that failed to keep pace with NASA’s unclear and ever-changing mission. This ultimately led to a flaw in NASA’s group decision-making process.
The mission of NASA’s space program had evolved dramatically from the time it was established in 1958 to the Apollo 11 moon landing in 1969 and the Challenger’s crash in 1986. The Agency’s mission was initially scientifically motivated to demonstrate the United States’ technological superiority over the Soviets by putting a man on the moon at all costs. Once the space race was won, however, NASA’s primary mission was transformed to military, commercial and scientific purposes in a number of political compromises. The shuttle program’s budget was substantially reduced and the program was mandated to pay for itself by transforming the shuttle from an R&D oriented space agency to a commercial freight operation. As a result, NASA increasingly had to serve the needs of the private industry to maintain funding. Fourteen years of development and over 30 billion dollars invested produced only 25 flights between 1981 and 1986 whereas financial sponsors were promised 30-60 profit-generating flights annually. As a result, some senior managers were under considerable pressure to keep scheduled flights active by disregarding risk warnings. Conflicts of interest caused by political or economic considerations overruled logical or scientific safety considerations and prevented flight safety concerns from being properly communicated to all decision makers. For example, NASA’s top management either was unaware of the “no-go” recommendation made by engineers and other managers (ie. Kilminster).
According to the article “Surprising but true: Half the decisions in organizations fail”, by Paul Nutt, decision failures can often be traced to managers who impose solutions, limit the search for alternatives and use power to implement their plans. This was clearly the situation at NASA. For example, the management team at the Marshall Center did not accept the Thiokel engineer’s doubts about the O-ring and forced the group to make a yes or no decision on the launch. When the Director of Solid Rocket (MacDonald) strongly argued for a launch delay, Reinhartz and Mulloy at the Marshall Center told him it’s not his decision to make. Finally, Reinhartz stated he would pass on MacDonald’s concerns, but he never did. There clearly existed a conflict of interest between those who were genuinely concerned for the flight’s safety and those who were willing to take a risk because they felt pressured to stay on schedule and deliver results.
NASA had developed a “Japanese” style of management where disagreements bubbled up the hierarchy until someone resolved them. Decisions were being made further and further away from the engineering levels where they were directly impacted. Finally, budget constraints forced many NASA employees to heavy work loads with long hours that increased the likelihood of human error.
1. The quasi ownership / stakeholder structure creates conflicts of interest between political and private industry. Either privatize the space program or maintain it as a fully funded government agency.
2. Develop a clear mission statement to provide a foundation for organization’s values, goals and objectives.
3. Re-establish a clear and concise group decision-making protocol for all non-programmed decisions that require a unique solution and considerable judgement. The protocol should include a formal group decision-making map and communication process. Additionally, senior management should foster an environment where safety is the #1 priority. Employees should be encouraged to do the right things and to communicate their concerns and/or recommendations so that a fully informed decision can be reached.
4. Establish an on-line workflow program (akin to an on-line chat room) that ensures good communication and allows all people to voice their opinions before moving on to the next step. The communication would essentially be an on-line checklist which would give all players the opportunity to voice their opinion before moving on to the next step. As a final back stop, a whistleblower program could be established with reporting to an impartial party.
The criteria used to evaluate the effectiveness of each alternative and recommendation include the following:
1. The solution must be realistically attainable/feasible
2. The solution must be cost-effective
3. The solution must resolve the specified problem
4. Positive and negative ramifications of the decision must also be considered.
Recommended Solution & Action Plan:
The first step should be for senior management to establish a well-defined and formal mission statement for the program. Like any other business, NASA should identify where it stands today and create a well-articulated mission of where it wants to go in the future. Once its mission has been clearly defined, management should meet to discuss, update and develop standard operating procedures for the new organization. An autonomous decision making process should be maintained whereby every core process owner has a vote to cancel the launch or at least publicly state their opinions in a non-threatening environment.
Although resource allocations are a major issue at NASA, human lives are at stake and NASA is a highly technological organization. Overtime work should be managed by hiring additional qualified employees as required. NASA’s decisions should follow a rational rather than political model of decision making in order to ensure the decisions are logical and the analysis is thorough and objective. Although NASA’s concept of group decision making is a good one, they did not execute the methodology. They abandoned the group decision model when they chose to ignore recommendations to cancel the flight due to outside pressures. A new decision protocol should be established for all non-programmed decisions that require a unique solution and considerable judgement. The shuttle program would be unlikely to survive as a fully private business due to its inherently poor economic model which requires continual government funding. As a result, the privatization of the program is not financially viable and should not be considered. Finally, the agency should establish an anonymous reporting system (ie. whistleblower) that is accessible by an objective and non-decision making compliance officer to prevent integrity violations.
The most logical method to evaluate the effectiveness of the recommended actions is to ensure the same tragedy does not occur again by encouraging open and candid communication. The processes in place should be reviewed frequently by leaders from each of the centers and other critical areas to ensure they are working as intended.
The factors that lead to the Challenger tragedy can be traced back to the inception of the shuttle program. A clear, objective, and well-defined decision making process is critical to any business to help ensure all stakeholders have common goals and a voice in the matter. Sadly, it took the crash of the Challenger to awaken the public’s interest, to not take for granted the routine nature of the flights, and reinvigorate the program.
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