Challenger Disaster Research Articles

Child Protection and Risk-Management: The Death of Victoria Climbie

This paper looks at the concepts of ‘risk’ and ‘safety culture’ within a Social Work context, specifically in relation to child protection. Discussion is made of the systemic and organisational issues that are apparent in many inquiries into child death from abuse, and the authors argue that these issues need to be given a higher profile to ensure avoidable tragedies do not occur as a result of organisational failure. The concept of ‘safety culture’ is described as a tool of best practice used by some organisations in the commercial sector to ensure their risk, for example communication failure, in relation to organisational issues is both understood and controlled. The parallels between an organisational breakdown resulting in a disaster and those relating to the breakdown of childcare services are outlined in relation to two high profile examples, the Challenger Space Shuttle disaster and the tragic death of Victoria Climbie respectively. The authors discuss how the lessons learnt from such disasters and the ways in which high risk commercial organisations give organisational issues such high priority can, and should be, successfully transferred into other sectors, namely Social Work and Child Protection services.

Shuttle diplomacy [NASA's manned space flight programme

The loss of Space Shuttle Columbia means NASA's manned space flight programme is in trouble. The author examines three options. One is to build a new shuttle to replace Columbia. This was the policy followed after the Challenger explosion in 1986 and, undoubtedly, would be the cheaper, faster option. The second is to accelerate the development of the Orbital Space Plane (OSP), a vehicle proposed when space agency heads met to discuss the issue of manned space access. Finally, NASA can do nothing. However, this seems unlikely.

The Shuttle puzzle [Space Suttle Columbia disaster

Will the Columbia catastrophe prove to have been an "accident" in the strict sense of the word? The author discusses the causes of the Challenger disaster and possible causes of the Columbia disaster. The steps that led to the Columbia disaster-paved, like the road to hell, with good intentions and judgments that each in isolation look acceptable-are still being worked out. Only then will we be able to determine whether this event deserves to be called an accident of unforeseeable and unpreventable surprises-or is the grim consequence of incompetent engineering management.

The debiasing effect of counterfactual mind-sets: Increasing the search for disconfirmatory information in group decisions

We hypothesized that the activation of a counterfactual mind-set minimizes decision errors resulting from the failure of groups to seek disconfirming information to test an initial hypothesis. To test this hypothesis, we conducted two experiments examining the decision making processes of groups. The task for both experiments was modeled after the Space Shuttle Challenger disaster, and groups had to actively seek disconfirmatory information to make a correct decision. Prior to beginning the group decision making task, groups were exposed to one of two pre-task scenarios in which the salience of counterfactual thoughts was manipulated. In Experiment 1, groups in the counterfactual prime condition were significantly more likely to make the correct decision than groups in the non-counterfactual prime condition. In Experiment 2, we replicated the effect of counterfactual primes on decision accuracy and demonstrated that groups in the counterfactual prime condition were more likely to seek disconfirmatory information than groups in the non-counterfactual prime condition. We also conducted mediation analyses that clarify the decision making process. Implications for group decision making are discussed.

Fatigue in anesthesia: implications and strategies for patient and provider safety.

HEALTHCARE delivery takes place 24 h a day, 7 days a week, and is colloquially termed a “24/7” operation. Anesthesia providers are required to deliver critical around-the-clock care to a variety of patients. This parallels the situation in many other domains that provide such services, e.g., transportation, law enforcement, communications, fire fighting, technology, manufacturing, and the military. Even “convenience” industries (e.g., gas stations and grocery stores) now provide uninterrupted access. These continuous operational demands present unique physiologic challenges to the humans who are called on to provide safe operations within these systems. Human physiologic design dictates circadian patterns of alertness and performance and includes a vital need for sleep. Human requirements for sleep and a stable circadian clock can be, and often are, in direct opposition to the societal demand for continuous operations. Recently, patient safety has taken center stage in health care. The Institute of Medicine’s report “To Err Is Human: Building a Safer Health System,” revealed that medical errors contribute to many hospital deaths and serious adverse events. The response to this report was widespread and included the Quality Interagency Coordination Task Force’s response to the President of the United States, “Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact.” 2 This report listed more than 100 action items to be undertaken by federal agencies to improve quality and reduce medical errors. One action promised by the Agency for Healthcare Research and Quality was “the development and dissemination of evidence-based, best safety practices to provider organizations.” In addition to the multiple recommendations to improve patient safety, the report from the Agency for Healthcare Research and Quality included a review chapter on sleep, fatigue,# and medical errors.** There is evidence that the issue of fatigue in health care is coming to prominence on a national level. In April 2001, Public Citizen (a consumer and health advocacy group) and a consortium of interested parties petitioned the Occupational Safety and Health Administration to implement new regulations on resident work hours (table 1). The primary intent of the regulations is to provide more humane working conditions, which the petitioners declare will result in a better standard of care for all patients. Also, the Patient and Physician Safety and Protection Act of 2001, which would limit resident physician work hours, was introduced in Congress. Recently, the Accreditation Council on Graduate Medical Education, the accrediting organization for residency training programs in the United States, has approved common program requirements for resident duty and rest hours that will take effect in July 2003.†† This article is accompanied by an Editorial View. Please see: Lydic R: Fact and fantasy about sleep and anesthesiology. ANESTHESIOLOGY 2002; 97:1050–1.

Boisjoly on Ethics

Roger M. Boisjoly was honored as the James T. Pursell, Sr. Distinguished Fellow in Management Ethics at Auburn University in January 2001, the fifteenth anniversary of the Challenger disaster. The interview with him and interviewer commentary include an explanation of the causes of the Challenger disaster, the ethics affecting the situation before and after the disaster, the role of heuristics in making the decision to launch Challenger, career advice for professionals on being ethical, and developing ethical organizational cultures.

The Establishment of Blame in the Aftermath of a Technological Disaster: An Examination of the Apollo 1 and Challenger Disasters

The Establishment of Blame in the Aftermath of a Technological Disaster: An Examination of the Apollo 1 and Challenger Disasters

The establishment of blame in the aftermath of a technological disaster: An examination of the apollo 1 and challenger disasters

The establishment of blame in the aftermath of a technological disaster: An examination of the apollo 1 and challenger disasters

James P. Bagian on Patient Safety Initiatives

James P. Bagian, MD, is director of the Veterans Health Administration (VHA) National Center for Patient Safety (NCPS). With a focus on systems and an emphasis on “prevention not punishment,” NCPS is working to improve patient safety, prevent health care errors, and nurture a culture of safety throughout the 173 VHA medical centers. Previously, Dr. Bagian served as deputy director of the Regional and State Programs Division, Office of Mobile Sources, Environmental Protection Agency. From 1980 to 1995, Dr. Bagian served as a NASA astronaut. He took part in both the planning and provision of emergency medical and rescue support for the first six Space Shuttle flights. In 1986, Dr. Bagian served as an investigator for the Space Shuttle Challenger accident. A veteran of two space flights (STS-29 in 1989 and STS-40 in 1991), Dr. Bagian has logged more than 337 hours in space. Dr. Bagian is currently an adjunct assistant professor of military and emergency medicine at the Uniformed Services University of Health Sciences at F. Edward Herbert School of Medicine and also a clinical assistant professor of preventive medicine and community health at the University of Texas Medical Branch. He is a Colonel in the U.S. Air Force Reserve where he is a pararescue flight surgeon with the 920th Air Rescue Group. He has received the American Medical Association's Nathan S. Davis Award for outstanding public service in the advancement of public health. The NCPS received the 2001 Innovations in American Government Award given by the Institute for Government Innovation at the John F. Kennedy School of Government of Harvard University. The NCPS was the only federal organization to be so identified in 2001.

Goldin Era Ends at NASA, Canada Picks New Space Chief

Dan Goldin, NASA’s longest-serving chief administrator, announced his resignation in mid-October, just days before the results of an investigation into cost overruns of the International Space Station (ISS) were made public. In November, he joined the Council on Competitiveness, a group based in Washington, DC, that promotes American economic and business leadership.Goldin is widely credited with revitalizing enthusiasm for space science exploration both within NASA and among the public (see April 2001, page 25). He was instrumental in getting NASA to consider innovative technological solutions in an agency that was still reeling from the aftereffects of the 1986 Challenger disaster. But he’s probably best known for his mantra “faster, cheaper, better,” which translates into a push to switch from costly spacecraft that took years to develop to smaller, more focused missions that could be launched for under $500 million within 18 months of receiving funding approval. The Lunar Prospector, Deep Space 1, and the 1997 Mars Pathfinder missions are examples.Goldin’s departure comes on the cusp of NASA’s biggest-ever financial crisis. The ISS is projected to be $4.8 billion over budget, the human spaceflight program faces a $1 billion shortfall in its budget for next year, and a $500 million overrun in NASA’s 1999 budget was discovered this fall. In response, this year NASA slashed 40% from the ISS science budget and reduced the space station’s crew from seven to three.Further fixes will follow from the ISS management and cost evaluation task force report, ordered by Goldin this past July to get the ISS back on track without new money. The task force recommends that NASA slash jobs and, to avoid future cost overruns, that the agency adopt strict accounting methods.NASA’s top job is proving hard to fill—by early November, an appointment by President Bush had been imminent for months. It was well known that Goldin didn’t want to leave NASA, but the Bush administration had given him no indication that it wanted him to stay. Courtney Stadd, one of Goldin’s possible successors and NASA’s chief of staff, is temporarily running the day-to-day operations.Meanwhile, north of the border, Marc Garneau has been appointed president of the Canadian Space Agency. Garneau, Canada’s first astronaut, has a bachelor’s degree in engineering physics and a PhD in engineering. The CSA’s annual budget of Can$300 million ($188 million) is just 1.5% of NASA’s. Since 1999 the CSA has emphasized terrestrial applications, such as remote sensing, and closer strategic links among government, academia, and industry. Garneau succeeds Mac Evans, who retired after 35 years at the agency. Garneau CSAPPT|High resolution© 2001 American Institute of Physics.

The Bhopal gas tragedy: could it have happened in a developed country?

Abstract The Bhopal gas tragedy occurred in December 1984 wherein approximately 41 tonnes of deadly MIC was released in the dead of night. It caused the death of over 3000 people and continued life-long misery for over 300,000 with certain genetic defects passed on to the next generation. It happened in a plant operated by a multinational, Union Carbide Corporation, in a developing country, India. The tragedy has changed the chemical process industry (CPI) forever. The results have been new legislation with better enforcement, enhancement in process safety, development of inherently safer plants, harsher court judgements, pro-active media and NGOs, rights-conscious public, and a CPI management willing to invest in safety related equipment and training. These have already resulted in savings of several hundred lives and over a billion dollars in accident damages [Kletz, T. (1998a). Process plants: a handbook of inherently safer designs. London: Taylor & Francis. Sutton, I. Chemical Engineering, 106(5), (1999). 114]. However, thousands did not have to die for the world to realise the disaster potential of CPI. The question that still remains is whether such an accident could have happened in a developed country. The answer is ‘yes’, as a number of major accidents in the developed countries since 1984, such as the Piper Alpha oil platform fire (1988, 167 killed), the Zeebrugge ferry disaster (1987, 167 killed), Phillips petroleum fire and explosion (1989, 23 killed), the Challenger disaster (1986, 7 killed), Esso Australia Longford explosion (1998, 2 killed) have demonstrated. One or more of the following are the primary reasons for such disasters: The indifferent attitude of the management towards safety, the lax enforcement of the existing regulations by the regulatory bodies as well as unusual delays in the judicial systems. Such conditions can happen regardless of the level of development in a country. Hence, the Bhopal gas tragedy could have happened in a developed country too, albeit with a lower probability. This paper is concerned with the possibility and not with the probability value. It also points out that further significant advances in process safety will occur with fundamental research into the causes of accidents and with a move towards inherently safer design.

Alda Plays Feynman in ‘QED’

The scene is Richard Feynman’s office at Caltech on a Saturday in 1986. Phone calls, office visits, and reminiscences weave a brisk, colorful tapestry of Feynman’s life and personality—from the atomic bomb to quarks to picking locks to investigating the Challenger explosion, from playing bongo drums to sketching nudes to Tuva, and from his personal life to the analytical way in which he approached his own cancer. In “QED,” Alan Alda plays Feynman. His portrayal “is uncanny—he’s definitely got the spirit,” says Tom Rutishauser, who used to drum with Feynman and is coaching Alda. In fact, it was Alda’s fascination with Feynman that got things started, says playwright Peter Parnell. The play was inspired by Feynman’s writings and Ralph Leighton’s book Tuva or Bust! “QED” premiered at the Mark Taper Forum in Los Angeles on 23 March, and is scheduled to run through 13 May. For more information, see http://www.Taper-Ahmanson.com. Craig Schwartz PPT|High resolution© 2001 American Institute of Physics.

Confounding the effects of delay and interference on memory distortion: commentary on Schmolck, Buffalo, and Squire.

In a recent article, Schmolck, Buffalo, and Squire (2000) investigated memory distortions in college students’ recollections of how they heard the verdict in the O.J. Simpson murder trial. Students were questioned either 15 months or 32 months after the verdict was rendered. Their responses were compared with their own reports 3 days after the verdict. Responses 15 months after the verdict were more likely than those given after 32 months to be in concordance with participants’ initial reports. Whereas only 11% of 15-month reports contained major distortions, 42.9% of 32-month responses were in error. In addition, Schmolck et al. reported that 77.8% of the major distortions involved incorrectly reporting the source of the news (e.g., television or radio), and that these participants, “described an entirely different situation than the one they had described earlier” (p. 43). Despite their apparently poor memories, 61% of the participants whose responses were characterized as “grossly inaccurate” (p. 43) were highly confident of their accuracy. The breakdown of confidence ratings for these inaccurate participants by delay condition was not reported. The authors concluded that the discrepancy between the 15- and 32-month conditions was due to the difference in the time that had elapsed after the verdict. In drawing this conclusion, they failed to consider a possible confound. Specifically, 16 months after the murder-trial verdict, the month after the 15-month data were collected, the verdict of Simpson’s civil trial was announced. This event, although perhaps not as surprising or emotionally charged as the first verdict, was certainly a memorable event in its own right. Therefore, participants in the 32-month condition were confronted not only with a longer delay, but also with the possibility of interference from their memories of the second verdict. Previous studies that compared immediate and delayed memories of consequential public events included memories of the Challenger Space Shuttle disaster (Bohannon & Symons, 1992; McCloskey, Wible, & Cohen, 1988; Neisser & Harsch, 1992), the resignation of Prime Minister Margaret Thatcher (Conway et al., 1994), and the Loma Prieta earthquake (Neisser et al., 1996). One distinction that has emerged from these studies is that memories approximately 1 year after the event tend to be accurate, whereas those reported after a 3-year delay are more likely to be distorted. However, as these studies differed in various ways, it is still an open question as to whether memory distortion is a function of delay. One of the goals of Schmolck et al. was to determine the effect of delay duration on memories of a single event. However, one cannot be certain that the 32-month participants in this study, unlike participants in earlier studies, were attempting to recall the target event and not the more recent similar event. The remarkably high proportion of errors that involved the report of an “entirely different” (p. 43) event may be a result of the interference of memories of the civil-trial verdict. This confound makes it difficult to tease apart the effects of time and interference. Moreover, the fact that participants in the 15-month condition were more likely to respond “don’t remember” than were those in the 32-month condition (21.4% and 5.7%, respectively) is consistent with the 32-month participants having two memories of verdicts and the 15-month participants having only one. One possible strategy for assessing the relative contributions of memories of the civil-trial verdict to the reports of the 32-month participants would be to classify the responses based on distinctions between the two verdicts. Whereas the criminal-trial verdict was delivered in the morning, when participants would likely be at school, the civil verdict was reported in the evening (interestingly, during President Clinton’s State of the Union Address), when participants would be more likely to be away from school. The fact that the two verdicts were at odds with one another (the criminal verdict was in Simpson’s favor, the civil verdict was not), and that public opinion was split along racial lines (Newport & Saad, 1997), may also allow for the classification of recollections. If the “major distortions” at 32 months are found to have details that are consistent with the events surrounding the civil-trial verdict (e.g., a participant said that the verdict was reported in the evening, or that a mostly Caucasian group of observers cheered), it is likely that the participants were victims of interference. Although Schmolck et al. presented compelling data, care should be taken in interpreting their results. The effects of the confounding factor of a second, similar event on participants in the 32-month condition must be considered. The question of whether flashbulb memories decay over time is still open.

The interface between ethics, decision making and risk assessment in management decision making in matters of life and death: the Challenger launch decision as a case study

As technology advances, and the life and death consequences of its failure become more and more removed from proximate human action, technology management requires greater degrees of ethical awareness and the management of safety becomes a matter of corporate ethical imperative. The corporate ethical imperative includes ethical mandates to take no action which places the lives of others at risk and to inform persons of dangers to their physical safety of which they may otherwise be unaware when one possesses information relevant to the safety of others such that, with the possession of that knowledge, the others can make decisions relevant to protecting their safety, or if others fail to take such action, to take upon oneself the responsibility of taking such action. The ethical duty of primum non nocere implies the corresponding right of the life risking participant to be informed of the kind and degree of risk to which they are to be exposed and the freedom to refuse to take such risk without prejudice. The corporate ethical imperative is to hold human life precious and to uphold that imperative through selectively non-acting, properly informing and acting. The case of the Challenger disaster is utilised as an illustration of decision making which violated these ethical precepts.

Professional Ethics in Engineering: The Challenger and Corporate Culture

Ethics in engineering is an important issue that affects the daily lives of almost everyone in the world. Because engineers and related scientists design, develop, and manufacture the many products that the public-at-large uses or consumes on a daily basis, it is in the best interest of all concerned that engineers be held to high ethical standards. This paper will reflect on the corporate culture issues involved in ethics in engineering, and specifically how corporate culture can affect ethical engineering and how it did in the case of the Challenger disaster.

Pretty Good Technologies and Visible Disasters

On the movie screen and in television commercials, technologies are usu ally portrayed as visions of perfection, their parts seamlessly functioning without a hitch. In real life, however, most technologies are only pretty good or, if excellent, achieve that performance only at great price. Two Florida-based technologies, the space shuttle, symbol of America's techno logical prowess, and the state's voting system, now an icon of technological dysfunction, remind us of the limits of technologies, especially as they are influenced by the American political and economic system. Like the 1986 Challenger explosion in its time, the voting machine fiasco has become an object of intense speculation. How did things go wrong? It might help to consider the differences between space shuttles and voting systems?the first an excellent technology, the second a pretty good one. A pretty good technology works adequately most of the time without major problems or investments, whereas an excellent technology requires significant resources to function properly. (Each shuttle launch demands one to three million person-hours and between four hundred million and eleven hundred million dollars, depending on how you count.) When either technology fails, the results can sometimes be spectacular, truly visi ble disasters.

VTEC: lessons learned from British outbreaks.

Important Escherichia coli O157 outbreaks in England and Scotland since 1982-83 are reviewed. The scientific lessons learned from them are described and their legal consequences outlined. The light shed by them on relationships between law and science is discussed, and questions of blame are analysed in the context of Reason's 'resident pathogen' metaphor and Vaughan's study of the 1986 Challenger Space Shuttle disaster.

Engineering Practice and Engineering Ethics

Diane Vaughan’s analysis of the causes of the Challenger accident suggests ways to apply science and technology studies to the teaching of engineering ethics. By sensitizing future engineers to the ongoing construction of risk during mundane engineering practice, we can better prepare them to address issues of public health, safety, and welfare before they require heroic intervention. Understanding the importance of precedents, incremental change, and fallible engineering judgment in engineering design may help them anticipate potential threats to public safety arising from routine aspects of workplace culture. We suggest modifications of both detailed case studies on engineering disasters and hypothetical, ethical dilemmas employed in engineering ethics classes. Investigating the sociotechnical aspects of engineering practice can improve the initial recognition of ethical problems in real-world settings and provide an understanding of the role of workplace organization and culture in facilitating or impeding remedial action.

Engineering Ethics: Balancing Cost, Schedule, and Risk--Lessons Learned from the Space Shuttle (review)

Reviewed by: Engineering Ethics: Balancing Cost, Schedule, and Risk—Lessons Learned from the Space Shuttle * Michael S. Pritchard (bio) Engineering Ethics: Balancing Cost, Schedule, and Risk—Lessons Learned from the Space Shuttle. By Rosa Lynn B. Pinkus et al. Cambridge and New York: Cambridge University Press, 1997. Pp. xviii+379; figures, appendixes, notes, bibliography, index. $70.00 (hardcover); $27.95 (paper). This book approaches engineering ethics from the perspective of practicing engineers. It does so by documenting the historical development of the main engines of the space shuttle from 1969 to the fateful Challenger explosion of 1986. Although the book might be viewed as presenting historical documentation of the various factors that ultimately resulted in the Challenger disaster, it would be a mistake to see this as its basic aim. Rather, the goal is to demonstrate a methodological approach to the more general subject of engineering ethics. The book advocates an interdisciplinary approach that pays very careful attention to the historical, political, organizational, and technical dimensions of particular engineering contexts that call for ethical reflection and decision making. In arguing for this approach the authors take full advantage of the material available on the development of NASA’s space shuttle program. This enables them to present a detailed account of the role of engineers in a very large, complicated project over a long period of time. In addition to its wealth of historical and technical information, the book presents a series of five case studies based on this information. Only the last of these cases discusses the Challenger disaster. Written as a practical book, Engineering Ethics is intended for engineers, managers, professional ethicists, and students. It focuses on the everyday decisions engineers and managers make as they design, test, and put technologies into operation. The authors characterize engineering as a heuristic skill practiced before “all the facts are in”—estimating risks, balancing budgets and deadlines—rather than an applied science. Just as the authors do not regard engineering simply as the practical application of scientific theory, they do not regard engineering ethics simply as the practical application of philosophical ethics. Here the authors take a lesson from the casuistic approach to medical ethics that begins with cases and brings in abstract moral principles and theories only if careful [End Page 164] analysis of the details of a given case seem to call for this. Thus, taking their cue from Abert Jonsen and Stephen Toulmin’s Abuse of Casuistry (Berkeley: University of California Press, 1988), they embrace the bottom-up rather than top-down approach. This does not mean that they eschew ethical principles. The authors offer three framing principles, each of which they claim is grounded in engineering practice rather than abstract ethical theory. The first is a principle of competence, requiring the application of engineering expertise to the problems at hand. The second is a principle of responsibility, emphasizing the responsibility to communicate knowledge effectively, making best use of information acquired through engineering expertise. The third is what the authors call “Cicero’s Creed II,” which expresses a commitment to reduce risk and failure and to promote public safety. Each of these principles can be applied at both individual and organizational levels. The authors adapt Herbert A. Simon’s theory of organizational behavior to their historical account of the development of the space shuttle main engine. For Simon, organizations have a kind of collective rationality based on their hierarchical structure, with each level being an end relative to those below it and a means relative to levels above it. In evaluating organizational operations, Simon’s key notion is “satisficing” rather than “maximizing” values; feasibility, not optimization, is the appropriate goal in complex organizational hierarchies. This notion is then used to assess how well cost, schedule, and risk trade-offs fared in the development of the space shuttle main engine. The first several chapters develop the authors’ methodological assumptions in great detail. Part 2 of the book (chapters 5–13) presents technical and political background as well as the five case studies. These cases discuss “all up” vs. component testing; cost, risk, and schedule trade-offs; the dissenting voice of engineer A. O. Tischler, who was critical of many of...

Maintaining space shuttle safety within an environment of change

In the 10 years since the Challenger accident, NASA has developed a set of stable and capable processes to prepare the Space Shuttle for safe launch and return. Capitalizing on the extensive experience gained from a string of over 50 successful flights, NASA today is changing the way it does business in an effort to reduce cost. A single Shuttle Flight Operations Contractor (SFOC) has been chosen to operate the Shuttle. The Government role will change from direct “oversight” to “insight” gained through understanding and measuring the contractor’s processes. This paper describes the program management changes underway and the NASA Safety and Mission Assurance (S&MA) organization’s philosophy, role, and methodology for pursuing this new approach. It describes how audit and surveillance will replace direct oversight and how meaningful performance metrics will be implemented.