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by PaulHoule 1562 days ago
Diane Vaughn's The Challenger Launch Decision misattributes responsibility for the disaster to the meeting in which a similar slide was shown.

When the shuttle design was finalized in the late 1970s they knew it had a 2-3% chance of a hull loss per launch. They were still planning to launch it 50 times a year so that would have meant losing a shuttle and crew every year!

The shuttle had hundreds of critical flaws and that 'normalization of deviance' meeting at which slides like this were shown at was a routine part of each shuttle launch. For each of these unacceptable situations they had to convince themselves that, with some mitigation (or not), they could accept it. It was inevitable that something like this was going to happen and then there would be recriminations about the details of that meeting.

Every other crewed space vehicle had an escape system to get the crew away from a failed rocket. The Challenger crew survived the explosion but were killed when the reinforced crew section hit the ocean. Similarly the Colombia astronauts were killed by a thermal protection system that was "unsafe at any speed". When the first few shuttles were launched there was a huge amount of concern about tiles breaking and coming off. Once they'd dodged the bullet a few times they assumed it was alright but it wasn't...

In the literature "normalization of deviance" has turned from a formal process used in managing dangerous technology to incidents such as: surgeon takes a crap and goes to work without washing his hands, forklift operator smokes pot and operates, etc.

1 comments

You can broadly say that both Challenger and Columbia disasters can be attributed to failures in communication. But the Rogers Commission Report (presidential commission for investigating Challenger) doesn't really show quite the same scenario.

At the Flight Readiness Review for the solid rocket boosters before launch the engineers of Morton Thiokol (the solid rocket booster manufacturer) objected to launch because of the detrimental effect of the cold temperatures on the o-rings in the solid rocket boosters. They had never launched in that cold of temperatures before and previous test data had shown erosion of the seals on previous flights. These concerns were not communicated by the Morton Thiokol management or NASA present at that flight readiness review to any of the higher level managers that got final approval on launch.

For Challenger it was a known issue and people specifically said "don't do this".

[0] https://history.nasa.gov/rogersrep/v1ch5.htm

If it hadn’t been one thing it would have been another. The next two missions after STS-51-L were planned to have two shuttles on the pad simultaneously and both of them with thin-skinned liquid fuel upper stages in the cargo bays.

Charles Perron, in the book Normal Accidents warns of the tendency of people to subtract from the safety margin of a successful system in the pursuit of speed, performance, profits, etc.

It does boggle the mind however that with so much documentation for the Shuttle they never thought to specify a minimum launch temperature!