Analysis of the Smoking Gun Memos
Part I: Introduction
Two tragic incidents, the Challenger Space Shuttle crash of 1986, and the Three Mile Island near meltdown of 1979, have greatly devastated our nation. Both these disasters involved failures of communication among ordinary professional people, working in largely bureaucratic companies. Two memos called the “Smoking Gun Memos,” authored by R. M. Boisjoly, of Morton Thiokol, and D. F. Hallman, of Babcook and Wilcox, will always be associated these two incidents. Unfortunately, neither of these memos were successful in preventing the accidents of the Challenger and the Three Mile Island near meltdown.
R. M. Boisjoly:
R. M. Boisjoly had over a quarter-century’s experience in the aerospace industry in 1985 when he became involved in an improvement effort on the O-ring which connect segments of Morton Thiokol’s Solid Rocket Booster. This was used to bring the Space Shuttle into orbit (OEC, 2006). Morton Thiokol is an aerospace company that manufactures the solid propellant rocket motors used to launch the Challenger (Skubik). Boisjoly authored a memo to R.L. Lund, Vice President of Engineering and four others, in regards to his concerns about the flawed O-ring erosion problem. His warnings were ignored leading to the deaths of six astronauts and one social studies teacher.
D. F. Hallman:
D. F. Hallman was a manager of the Plant Performance Services at Babcock and Wilson. The Babcock and Wilson Company, founded in 1867, manufactures and sells specialty-engineered industrial products, including fossil fuel and nuclear power systems (Gorinson & Kane, 1979). Hallman proposed a memo to B. A. Karrasch, Manager of Plant Integration, to implement changes in the reactor operating ...
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...on they deserve.
Works Cited
Boisjoly, Roger M. “SRM O-Ring Erosion/Potential Failure Criticality.” Memo to R. K. Lund, Vice President of Engineering. 31 July 1985. TS.
Gorinson, Stanley M., and Kevin P. Kane. “The Accidental Three Mile Island: The Role of the Managing Utility and Its Suppliers.” 1979. PDF file.
Hallman, Donald F. “Operator Interruption of High Pressure Injection (HPI).” Memo to B. A. Karrasch, Manager of Plant Integration. 3 Aug. 1978. MS.
Johnson-Sheehan, Richard. Technical Communication Strategies for Today. Glenview: Pearson Education, 2001. Print.
“Roger Boisjoly – The Challenger Disaster.” Online Ethics Center: For Engineering and Science. National Academy of Engineering, 19 May 2006. Web. 27 Mar. 2014.
Skubik, Daniel W. “Summary of the Challenger Episode.” Welcome. California Baptist University, n.d. Web. 26 Mar. 2014.
On March 25, 1947, the Centralia no. 5 mine in Illinois exploded, claiming 111 lives (Martin, 31, 42). The apparent cause was determined to be inadequate mine maintenance by the operator—coal dust had built up on the floor and walls of the mine, creating conditions conducive to a chain reaction of explosions that would kill most of the workers inside of the mine. However, this was not the root cause of the disaster; it was the outcome of a systemic failure within the state government of Illinois. Despite the continuous warnings of a state mining inspector and a chain of notice letters sent from the Illinois Department of Mines and Minerals notifying the mine operator—the Centralia Coal Company—of the dangerous conditions in its mine, the disaster was not averted. The disaster occurred because both the mine operator and the Department itself dismissed the inspector’s warnings. The real, indispensable culprit of the disaster at Centralia no. 5 was political interference within the Department and the failure to conduct independent oversight over it. These failures are near universally applicable to national security organizations and their less...
The Challenger shuttle crash was a crash that touched the hearts of every American due to the televised coverage and the relate ability of the crew. There was concern from the engineers that the unusually cold weather the morning of the launch could have adverse affects on the rubber O-rings that sealed the joints of the shuttles solid rocket boosters. The cold weather on the morning of January 28, 1986 caused the O-rings to tear and leak fuel from the boosters. (Dunbar B, 2005)
Morton-Thiokol Inc. had engineered the space shuttle's solid rocket booster (SRB) based on the Air Force's Titan III design because of its reliability. The SRB's steel case was divided into segments that were joined and sealed by rubber O-rings. Although the Titan's O-rings had occasionally been eroded by hot gases, the erosion was not regarded as significant. A second, redundant O-ring was added to each joint to act as back-up should the primary O-ring failed.
When the Challenger shuttle was set to launch NASA was feeling political pressure to gain congressional support for the space program, to help gain this support the shuttle crew had a high school teacher on board, Christa McAuliffe, and millions of people were excited and tuned into watch. NASA officials were hoping that this new endeavor would help generate funding since the U.S. budget deficit was soaring and they were afraid that their budget could be cut. Technical failure was the reason the shuttle exploding after take-off but this was not the only reason. With pressure mounting, decisions made by NASA and Morton Thiokol Corporation, the contractor who manufactured the piece with the technical failure, put political agendas in front of the technical decisions, which resulted in the tragedy (Bolman & Deal, 2008).
My main objective was to make a risk analysis of the Space Shuttle Challenger Disaster occurred in 1986. My chosen focus area was the risk analysis process of the space shuttle and I was able to understand the risk potential.
On the morning of January 28, 1986, the Space Shuttle Challenger disintegrated in midair as the nation watched in disbelief and sadness. The cause of the Challenger accident was determined to be a system design failure on one of the shuttle’s solid rocket boosters. Solid Rocket Boosters (SRBs) are a pair of large solid strap-on rockets that were utilized by NASA during the first two minutes of the Challenger’s Space Shuttle launch. The pair of SRBs was applied to provide an extra liftoff boost for the Space Shuttle during takeoff. Each SRB were located on each side of the external propellant tank of the spacecraft. Once they began to operate, “the boosters separate from the orbiter/external tank, descend on parachutes, and land in the Atlantic Ocean” (Wilson, 2006). NASA would then send ships into the Atlantic Ocean to retrieve the boosters. The boosters were refurbished so they can be used again. According to NASA officials, “the SRBs were the largest solid-fuel rocket motors ever flown, and the first to be used for primary propulsion on human spaceflight missions” (Wilson, 2006).
On January 28, 1968 the space shuttle Challenger was deployed from Kennedy Space Center in Florida. One minute and thirteen seconds after liftoff the spaceship ignited in mid air and all seven crew members were killed. The cause of the destruction of the challenger was a certain part of rubber that relieves pressure on the side of the actual rocket booster called an O-ring. When a space shuttle as used as the Challenger is about to be used for another mission there should be an even more careful with checking everything before liftoff. The Challenger could have been avoided and there was way too much evidence that shows NASA had some kind of knowledge about the consequences.
Culture at NASA was converted over time to a culture that combines bureaucratic, cost efficiency and schedule efficiency of the flights. This culture of production reinforced the decisions to continue flights rather than delay while a thorough hazard analysis was conducted. Managers were so focused on reaching their schedule targets that the foam insulation problem did not induce them to shift their attention to safety. It appears that at NASA managers overrule engineers when the organization was under budget and time pressure. In my opinion, high-level managers should avoid making important decisions based on beliefs and instead rely on specialist’s opinion.
The Native Americans took over an island and the United States took out the individuals’ who refused to abandon the island.
Wasserman, Harvey. "Three Mile Island: Exposing the Government's Cover Up of Our Most Infamous Nuclear Accident." Alternet.org. AlterNet, 30 Mar. 2009. Web. 02 May 2012. .
The executive order put in place by President Trump banning certain Muslim based countries sparked controversy across the U.S. because the ban seems like a ban based on religion, but it is masked by saying it is only for the countries and not religion. This executive order essentially is just banning Muslim refugees from a certain grouping of countries and those who have dual citizenship with those countries as well. This ban, according to T. Alexander Aleinkoff a professor and a former general counsel member to the Immigration and Naturalization Service, in a quote from the New York Times states, “The ban could conflict with both federal and constitutional law” (Aleinkoff,
Evidence based decision making could of been used to help avoid this disaster if all entities would have taken a conscious effort to research, communicate, and think about the best possible outcome and solutions when making any and all decisions related to the business. Also they needed to place their differences aside and focus on how to improve the overall productivity of the business. In addition, they needed to clearly define protocols and provide the workers adequate and sufficient direction. “Conversely, a premature decision could result in a waste of resources on cost-ineffective or even harmful practices that, once diffused, are hard to eliminate” (Chalkidou, Lord, Fischer, & Littlejohns, 2008, p.1643).
In 1986 when the space shuttle Challenger launched from Kennedy Space Center people watched in awe for a little more than a minute before the shuttle exploded in flight. This was the first of only two major accidents that occurred during over two decades of NASA’s shuttle program. Many would consider the Challenger disaster to be a fluke that could not have been prevented or predicted but, In truth, it was an accident waiting to happen and was a symptom of systemic problems that were occurring at NASA during that era. The 1986 space shuttle Challenger disaster was cause by a number of factors including structural failure of the shuttle, a change in NASA’s work environment from the days of the successful Apollo missions, and additional pressure on the space program, already lacking resources, to push the envelope farther, faster, and cheaper.
The Colgan 3407 crash is one of the most infamous examples to analyze in the aviation industry. This flight just so happened to be littered with potential hazards that, if recognized at the time could have broken a link in the error chain and resulted in a safe arrival. For one, both of the pilots traveled far distances to get to the airport that they were required to fly out of. Traveling long distances is a large cause of fatigue. Along with that, the First Officer also had a slight cold, so her condition was not one in which she should have been flying. Their physical conditions likely hindered their mental agility, but on top of that, they also disregarded routine safety practices such as the sterile cockpit rule. Instead of focusing on their duties, they continued their personal discussion and let it become a distraction to their flying. The conditions in which they were flying that night
...easier to blame the O-rings than to blame people for the disaster. There was a lack of communication and a sense of desperation from the managers to make sure the shuttle launched as they did not want any further delays. The challenger disaster was certainly avoidable, the warning signs were there but the people in charge did not heed them. Thiokol had an opportunity to steer clear of disaster during the meeting with (GDSS) before the launching of challenger. If the pressure to launch in combination with communication breakdowns had not occurred or had been managed better this disaster would not have happened. It seems that leadership was more concerned with public relations instead of being concerned with the problem of the O-ring. So, I believe that bad decision making on launching the Space Shuttle Challenger on the day of January 28 caused by human error.