Ethical And Professional Conduct Report: The Space Shuttle Challenger Disaster

Executive Summary

Today almost all the major organizations and professions have a code of ethics outlined that they follow. The purpose of ethics and code of conduct is to promote ethical behavior by following established compliances. The enforcement of these compliances is generally difficult to enforce and unfortunately due to the lack of understanding of its importance, various earthshattering disasters such as the ones discussed in this report occur. The two case studies discussed here are easily the biggest failures of NASA’s Space program that should have been avoided at all costs. The study of NASA’s Challenger and Columbia Disaster gives us an insight into the challenges in the engineering design processes as well as the work culture of NASA that was directly responsible for these incidents. It also gives us an insight into the work ethic and code of conduct followed at NASA and what were the warning signs that should have been enough to avoid both catastrophes.

Introduction

NASA “National Aeronautics and Space Administration”, was founded on 29th July 1958 whose main purpose was to be a leader for the science and technology related to air and space. Soon after in 1961, the express mission of NASA was to land a man on the moon by the end of the decade which they succeeded on 20th July 1969. NASA completed various missions since its beginning and the two case studies discussed in this report are among many of failed space missions, but the loss of lives makes these two incidents extremely important to understand so that they could be avoided in the future. These two incidents also help us to understand the importance of ethics, protocols, and code of conduct at the workplace. The Space Shuttle programs are one of the most complex fields of engineering ever conceived. Unfortunately, this complexity directly resulted in the unimaginable loss of human life. Seven astronauts lost their lives in the Challenger Disaster of 1986 i. e. “STS-51-L Mission” and another seven astronauts lost their lives in the Columbia disaster of 2003 i. e. “STS-107” Mission.

The Challenger Disaster (1986)

The Last flight of STS-51L was on Jan 28th, 1986 (wikipedia, 2018) with a crew of 7 astronauts which was also known as the ‘challenger’. It was the twenty-fifth shuttle flight which was carrying two satellites. The shuttle shortly exploded after takeoff with a duration of 73 seconds (Mark Rossow, 2012)before the catastrophe happened. Following this catastrophic incident, a commission was established to investigate the incident whose main motive was to find out the cause of this catastrophe as well as to understand the circumstances leading up to the incident and develop recommendations based on those findings so that they can be prevented in the future. The commission was commonly known as the “Rogers Commission” (Mark Rossow, 2012).

Cause Of The Incident

The main cause in the investigation turned out to be the structural failure of the O-rings which was also the concern for the engineering department but since nothing catastrophic had happened in the past, no action was taken to improve the booster rocker design to eliminate the problem (Mark Rossow, 2012). According to the investigation, the O-Rings failed to work as designed/intended due to the cold temperatures at the day of the launch. The O-Rings were not resilient enough to expand back to seal the joints which resulted in the leakage of the fuel tank into the boosters causing an explosion. The reason the shuttle lasted as long was because some of the combustion products temperately sealed the leak at the launch pad and as the shuttle climbed altitude, the wind shear started to tear the gap resulting in the leakage from the fuel tank to the booster rocket causing the ultimate failure resulting in the explosion of the vessel. The following is the timeline of the incident (Mark Rossow, 2012):

Moreover, the chief engineer of the O-Rings, “Roger Boisjoly” tried to warn the vice presidents (Mark Rossow, 2012) about this problem but despite this, the challenger was scheduled to launch. After the investigation, he testified before the Congress on this issue as well. Under tremendous pressure and threats, he even turned down the settlement offer and left the company because of this incident (ScottLPost, 2014).

According to him, the incident could have been avoided by following “engineering ethics”. He was awarded the prize of “Scientific Freedom and Responsibility” (LOVRIN, 2009) by the American Association for the Advancement of Science for his honesty and integrity leading up to the disaster and the aftermath of it as well. Today he gives lectures on various ethical issues that are faced at a workplace (LOVRIN, 2009). The commission for this investigation was also interested to know the reason as to why despite knowing about these problems, why did they move ahead with it. From what the investigators understood was that the managers at NASA were under extreme pressure to maintain the launch schedules. According to their own plans, (LOVRIN, 2009)NASA had planned to launch as much as 50 flights a year where they had managed to launch only 9 flights in 1985 (Mark Rossow, 2012). This directly impacted the manager's decisions at NASA to move ahead with the launch without causing another delay, but this was not the only cause (ScottLPost, 2014). Perhaps the biggest warning sign was the night before the incident which was famously known as the “Teleconference” incident. As the O-Rings were a concern in the engineering departments since their use in 1977 (ScottLPost, 2014), the weather leading up to the launch was a real concern for the engineers. Henceforth a marshal manager asked the engineers to investigate the effects of temperature on the O-Rings ability to seal the joints which resulted in a meeting the evening before the launch. The meeting did not result in any kind of official recommendation that was made for the launch.

As the meeting was scheduled just before the launch, many of the key personnel were not able to attend as well as the connection was not great which lead to a poor communication of the concerns. Consequently, a second meeting was set to discuss the issue. The second meeting consisted of thirty-four managers of different departments and the engineers. According to the engineers in the conference, they observed significant damages and corrosion to the O-Rings in the previous launches when launched around 53°F or 12°C (ScottLPost, 2014)and hence the O-Rings could fail to seal the joints at or around the mentioned temperature but when directly asked they told the managers that the O-Rings would definitely fail if the launch was below 53°F or 12°C. The manager's concern was that they had previously delayed the launch in December when the temperatures were around 41°F but the engineers never raised their concerns at that time also.

Due to the conflicting data presented by the engineers and no real data proving any reason that it was a real concern, they did not peruse the recommendation and moved ahead with the launch. The ultimate decision was taken by the management department and not the engineering department which was also one of the major factors resulting in this disaster, but the engineering department also could not produce any real hard evidence to convince the people concerned with the issue. The report also suggested that the meeting was a standard that was followed all the time at NASA and it was no different than any other launch but the key difference in this teleconference was that never before a contractor had recommended for a delay and not to launch but it was always NASA that made that decision. On the day of the launch, the temperature was 36°F or 2°C (ScottLPost, 2014).

Ethical Issues And Conclusion

When we talk about ethical issues, the answer is never simple. There are various questions surrounding the issue. We will discuss some of the ethical issues relating to this incident. The first concern was whether NASA knowingly took the unnecessary risk due to the pressure of maintaining congressional funding? When the space shuttle program was introduced to Congress, they promised an unrealistic number of flights per year which they were not able to meet. They argued that with time and the number of flights would become a routine and the program will start to pay for itself in the near future. NASA did not realize the challenges and problems it would face due to the fact that the space shuttle program is an extremely complex endeavor and possibly the most complex one the humankind has ever attempted. Consequently, they were not able to fulfill what they promised and hence did not want this project to be delayed further as it was already delayed seven times in the past as no one wanted to be responsible for delaying the mission and costing millions intentionally. Moreover, the space shuttle was designed to launch any time of the year, so the management found it hard to believe that a certain change in temperature could cause such a catastrophe.

The other ethical concern is whether the engineering contractor “Thiokol” knowingly took extra risks to retain their contract with NASA (ScottLPost, 2014). Just before the Challenger disaster, NASA was looking for a secondary supplier to fulfill their needs (ScottLPost, 2014), but it was the result of lobbying by the contractor’s competitors and not because NASA was not happy with the results but according to the commission concluded that “Thiokol” reversed its recommendation to accommodate their biggest supplier NASA. However, according to the people who participated in the teleconference, the second source was not a concern as they already had future orders from NASA and hence was not an immediate concern for them moreover, they were the ones who recommended for a delay. The biggest ethical concern according to me was “Informed Consent” violated (ScottLPost, 2014). In my pursuit of ethical and code of conduct violation for this case study, I found this to be the biggest cause of the disaster. Informed consent is a term used when the concerned person fully understands everything without coercion including the consequences of the action taken thereafter. Typically, it is used in medical practices and experimentations. In this case, I believe this ethical issue was violated.

The people who understood the relevant consequences of the problem did not have any power on the decision of the launch and the people who did, were informed too late due to lack of evidence of understanding on the matter. Taking an example, on the day of the teleconference, the crew was informed of the ice formation on the launching pad but were never informed about the teleconference schedule. This shows that the right people were not informed as for the ones who did not understand its significance and even if they were informed of the teleconference, they were not engineers or scientist who knew the significance of that information. Also, even if the right people were informed on the day or one day before the mission, the engineering department did not have any concrete data to show the importance of it which could have resulted in a delay and further investigation. Moreover, no one wanted to be the reason for the eighth delay of this mission. The incident perfectly demonstrates that the ethical issues sometimes does involve confrontation where in this case the confrontation had to be done from the engineering point of view against the management who is ultimately taking the decisions.

The Columbia Disaster

The Columbia disaster was the second most significant disaster (ScottLPost, 2014) in the history of the NASA’s space shuttle program. The Last flight of STS-107 was on Jan 16h, 2003 with a crew of 7 astronauts which was also known as Space Shuttle Columbia (Marcia S. Smith Specialist in Aerospace and Telecommunications Policy Resources, 2003). It was its 28th flight which makes it the 113th flight of the shuttle program. The space shuttle disintegrated upon re-entry at the end of its mission on 1st Feb 2003 (ScottLPost, 2014). Following the disaster, the investigation board named as “CIAB (The Columbia Accident Investigation Board)” was formed on Feb 12th, 2003.

Cause Of The Incident

According to the investigators, a piece of insulating foam that is used to cover the entire fuel vessel broke off (which was later discovered to be around 24 X 15 inches which weighed around 1 KG) and impacted the left wing of the space shuttle 81 seconds after the space shuttle lift-off from the ground on 16th Jan 2003 (Marcia S. Smith Specialist in Aerospace and Telecommunications Policy Resources, 2003).

The shuttle was successful in reaching the orbit to complete its two-week mission. This incident was not detected until the next day when the video of the launch was reviewed but this was not something that was new and had happened in the past. According to the scientists at NASA, the piece of foam that hit the left wing was relatively slow but was traveling approximately at a speed of 500 m/s (Marcia S. Smith Specialist in Aerospace and Telecommunications Policy Resources, 2003)which created a hole on the left wing at the carbon composite section which was responsible for handling extreme heats upon reentry. Space shuttle Columbia did not make it the landing site and disintegrated at 9: 00 AM EST due to the hole created at lift-off (ScottLPost, 2014). The following is the timeline of the incident (ScottLPost, 2014):

• At 8: 15 the shuttle started deorbiting which lasted for 158 Seconds
• At 8: 44 the shuttle enters earth atmosphere (First abnormal wing data reading)
• At 8: 49 the shuttle rolls to the right
• At 8: 49 the shuttle crosses the CA cost line
• At 8: 54 the first debris was noticed
• At 8: 54 the first abnormal reading at the control center
• At 8: 58 shredding of thermal tile
• At 8: 59 the last communication with Columbia
• At 9: 00 Columbia disintegrated at 9: 00 am EST

According to the investigators, upon re-entry, the hot gases that were as hot as 5000°F breached the carbon composite structure and melted the internal truss structure of the wing which was made from aluminum which resulted in a drag on the left side of the shuttle (Marcia S. Smith Specialist in Aerospace and Telecommunications Policy Resources, 2003). Due to the drag created, the shuttle tilted but the onboard computer tried to keep it straight which caused more stress on the left wing which eventually collapsed resulting in the shuttle to get out of control and started spinning. Due to this uncontrolled spinning at that altitude and speed, the aerodynamic forces broke the Columbia shuttle apart. The Columbia Accident Investigation Board took 5 independent paths of investigation to be unbiased in their investigation (ScottLPost, 2014).

These were:

• Aerodynamic
• Thermodynamic
• Sensor Data Timeline
• Debris Reconstruction
• Imaging and Video footage

All the above paths reached the same conclusion independently that due to the impact of the foam on the wing, a hole was made on the left wing which resulted in the breach of hot airs into the wing and destroying it making the space shuttle unstable and caused it to spin uncontrollably which then disintegrated and broke off into pieces due to aerodynamic pressured caused by the shuttle’s velocity. This conclusion was not well received by the Marshall Spaceflight Centre and therefore CAIB decided to reconstruct the incident as close to the real incident as possible and test what they have discovered (ScottLPost, 2014). The investigators took another shuttle with the same condition and track record as Columbia and tested their conclusion on it. They propelled a piece of identical foam close to the size seen on the footage and matched its velocity at around 500 m/s calculate (Marcia S. Smith Specialist in Aerospace and Telecommunications Policy Resources, 2003). The Foam created a gaping hole at the point of impact of the wing leaving no room for doubt in their investigation.

Warning Signs

To understand the incident in depth, the investigators analyzed the previous 112 shuttle missions where they found that there was quality imaging for only 79 of them. They wanted to study other missions and see what kind of frequency the foam shedding occurred and try to understand what was different in this launch. Investigators found that among 79 of those missions, there was evidence of foam shedding in 65 of them which gives a failure of 82% (Marcia S. Smith Specialist in Aerospace and Telecommunications Policy Resources, 2003). The shuttle program requires for a no-foam shed despite that the engineers were aware of the problem, but they decided to accept this flight risk as nothing significant had happened in the past. Another warning sign was when NASA engineers requested imaging form the DOD (Department of Defense) of the space shuttle to visualize and understand the damage done by the foam impact but they did not go through the right channels.

As the engineers had no concrete proof or data from the past to push for the request, their concerns were not taken seriously enough even though the request was made three times. Another warning sign from the past was in 1999 when the Discovery shuttle landed after servicing the Hubble Telescope when a NASA engineer spotted a fissure (crack) that was extremely deep along the leading edge of the discovery’s wing (Marcia S. Smith Specialist in Aerospace and Telecommunications Policy Resources, 2003). According to him, the crack was so deep that the material behind it was visible, but he was unsure of the reason for such an anomaly (ScottLPost, 2014). It was put by the engineer in their official records, but NASA did nothing to find the source of the problem consequently the same thing happened in March of 2001 when the Discovery went back in space to the international space station.

Ethical Issues And Conclusion

The ethical issues faced in this disaster are like the Challenger disaster. The people who were responsible for making the final decision were not well informed about the past incidents and did not have informed consent to understand the consequence of “what if they were wrong” (LOVRIN, 2009). On the other hand, in this case also the engineering department had a weak point of representation as they failed to make them understand the consequences of the acceptable risks they were taking. Also, the engineering department did not follow the proper chain of command to raise the issue so that the right people are reached and when they were able to reach the people who could help to get the evidence needed, it was denied based on the lack of understanding of its importance and budgetary concerns.

Although one request was granted but was canceled 90 minutes after as the right people who understood its significance were not reached (LOVRIN, 2009). This incident like the challenger was a great failure of foresight and management. The ethical issue in the case of the engineers was to recognize the consequences of not understanding and doing something about the similar problems noted in the discovery shuttle. The ethical issue at NASA’s was that even after knowing about the cracks formed on the discovery shuttle, they never investigated the cause to ensure it does not happen again. The other ethical concern is that the ISS (International Space Station) was dependent on Columbia as they were actively taking the parts of the ISS and hence were on a tight schedule (Marcia S. Smith Specialist in Aerospace and Telecommunications Policy Resources, 2003). Due to the interdependencies of both the programs, NASA cut corners to maintain their schedules. Engineers of today’s generation must be aware of the ethics and code of conduct professionally and should not solely think about their employer and profits after all such cases prove the importance of it. Engineers of today should be committed to provide the best insight for actionable information and always consider its effect on the environment and the quality of life (ScottLPost, 2014). They should always raise their concerns even if their managers do not like it as it could ultimately lead to the cacotopias such as challenger and Columbia. National Society of Professional Engineers (NSPE) (ENGINEERS, 2018)has designed fundamental ethics and code of conduct Canons that needs to be followed by all engineers:

• Health, Safety, and welfare of the public is held paramount
• Should only perform their duties professionally in their areas of expertise
• Always issue public statements in an objective and truthful manner
• Always act as trustees for their employees and clients
• Never use deception of any kind

Comparison Of The Case Studies And Conclusion

As we learn about both the case studies i. e. The Challenger Disaster and The Columbia Disaster, we learn that engineers played a significant ethical role in trying to prevent the disasters but unfortunately failed. It was not only engineers that share the blame as NASA, in other words, but the Managers at NASA were also under tremendous pressure to make as many launches as possible as they wanted their program to pay for itself which directly resulted in them making a decision so that they do not have to delay their launches. The main question concerning this issue is that how it could have happened twice as the similarities between the cases are staggering. From what we learn from the case studies is that nothing really changes politically as well as budgetary after the Challenger disaster. Moving people from one department to another did not really change the culture that NASA had been following.

NASA now has a track record of flying the space shuttles even after knowing about the flaws and did little to change or try to fix it. Both the disasters show us that NASA was following “Normalization of Deviance” which meant that even after knowing the flaws and the potential they had for a disaster, they did nothing to improve upon it since nothing had happened in the past. Although NASA had various safety programs employed they were extremely ineffective and continue to remain that way even after such a catastrophic incident of the challenger. In the Challenger disaster, NASA had the goals such of cost (Pay for itself model), schedule and reputation which did not change after it had happened. Perhaps the biggest problem that NASA had, in my opinion, is the lack of effective communication between the engineers and the management department. Therefore, a clear and precise information along with proper articulation of that information is crucial when considering the ethical implications of any process. These ethical implications must be made very clear from the beginning and given utmost importance before the deployment of any process.