1986 Shuttle Disaster; Lesson in Organizational Knowledge Drift

When an organization’s executive want to make something happen badly enough, two things start to happen in terms of communication inside of the organization.  The first is that the messenger bearing bad news often gets shot.  Bad  news is challenged,questioned, maybe even discredited.  As a result, bearer’s of information that prevent the leadership from doing what they want to do learn quickly that the truth may lead to confrontation with the people who sign pay checks and grant promotions.  In extreme cases they might be intimidated into going along with a decision they know is wrong.   The other thing that happens is people hear what the want to hear.  Good news gets no where near the scrutiny of bad news.  Good news gets accepted at face value, bad news has to be proven.  One of the best examples comes from the shuttle disaster that cost a number of people their lives and could have been avoided.  There are important parallels to what happened then and what is happening now at the IPCC regarding global warming. 

Following is an excerpt from a Texas A&M report of what happens when the administrators want to make something happen so badly that they accept the information that supports their decisions, and demand proof of information that does not. In 1986 NASA was under enormous pressure to launch the Challenger space shuttle on time for reasons that ranged from technical to purely political.  Engineers from Morton Thiokol, the company that designed the booster rocket, believed that their own design had flaws which would result in catastrophic failure should the shuttle be launched in cold weather.  Their opinion was over ruled by management, who decided that they were wrong.  The evidence that they were right in retrospect, seems obvious.  But at the time, they could not prove that they were right, and management chose to “hear” the good new and set the bad news aside: 

The Night Before the Launch

Temperatures for the next launch date were predicted to be in the low 20°s. This prompted Alan McDonald to ask his engineers at Thiokol to prepare a presentation on the effects of cold temperature on booster performance. A teleconference was scheduled the evening before the re-scheduled launch in order to discuss the low temperature performance of the boosters. This teleconference was held between engineers and management from Kennedy Space Center, Marshall Space Flight Center in Alabama, and Morton-Thiokol in Utah. Boisjoly and another engineer, Arnie Thompson, knew this would be another opportunity to express their concerns about the boosters, but they had only a short time to prepare their data for the presentation. Thiokol’s engineers gave an hour-long presentation, presenting a convincing argument that the cold weather would exaggerate the problems of joint rotation and delayed O-ring seating. The lowest temperature experienced by the O-rings in any previous mission was 53°F, the January 24, 1985 flight. With a predicted ambient temperature of 26°F at launch, the O-rings were estimated to be at 29°F. After the technical presentation, Thiokol’s Engineering Vice President Bob Lund presented the conclusions and recommendations. His main conclusion was that 53°F was the only low temperature data Thiokol had for the effects of cold on the operational boosters. The boosters had experienced O-ring erosion at this temperature. Since his engineers had no low temperature data below 53°F, they could not prove that it was unsafe to launch at lower temperatures. He read his recommendations and commented that the predicted temperatures for the morning’s launch was outside the data base and NASA should delay the launch, so the ambient temperature could rise until the O-ring temperature was at least 53°F. This confused NASA managers because the booster design specifications called for booster operation as low as 31°F. (It later came out in the investigation that Thiokol understood that the 31°F limit temperature was for storage of the booster, and that the launch temperature limit was 40°F. Because of this, dynamic tests of the boosters had never been performed below 40°F.) Marshall’s Solid Rocket Booster Project Manager, Larry Mulloy, commented that the data was inconclusive and challenged the engineers’ logic. A heated debate went on for several minutes before Mulloy bypassed Lund and asked Joe Kilminster for his opinion. Kilminster was in management, although he had an extensive engineering background. By bypassing the engineers, Mulloy was calling for a middle-management decision, but Kilminster stood by his engineers. Several other managers at Marshall expressed their doubts about the recommendations, and finally Kilminster asked for a meeting off of the net, so Thiokol could review its data. Boisjoly and Thompson tried to convince their senior managers to stay with their original decision not to launch. A senior executive at Thiokol, Jerald Mason, commented that a management decision was required. The managers seemed to believe the O-rings could be eroded up to one third of their diameter and still seat properly, regardless of the temperature. The data presented to them showed no correlation between temperature and the blow-by gasses which eroded the O-rings in previous missions. According to testimony by Kilminster and Boisjoly, Mason finally turned to Bob Lund and said, “Take off your engineering hat and put on your management hat.” Joe Kilminster wrote out the new recommendation and went back on line with the teleconference. The new recommendation stated that the cold was still a safety concern, but their people had found that the original data was indeed inconclusive and their “engineering assessment” was that launch was recommended, even though the engineers had no part in writing the new recommendation and refused to sign it. Alan McDonald, who was present with NASA management in Florida, was surprised to see the recommendation to launch and appealed to NASA management not to launch. NASA managers decided to approve the boosters for launch despite the fact that the predicted launch temperature was outside of their operational specifications.

In brief, when there is something urgent to be done, pressure to do it renders voices of criticism mute, and even the absence of any data testing a specific issue become reason to decide it doesn’t matter.  So committed has the IPCC become to their vision of the world saved from disaster with themselves as the heroes, that media articles quoting speculation from unqualified researchers becomes “science fact” without scrutiny, while studies showing that there may be no problem to save us from in the first place are challenged, discredited or just simply dismissed.


3 Responses to 1986 Shuttle Disaster; Lesson in Organizational Knowledge Drift

  1. Bonanzapilot says:

    “Too bad the Rogers Commission didn’t pay much attention the vehicle itself, or we might have noticed that foam strikes to the wings were a disaster waiting to happen.”

    -Albert D. “Bud” Wheelon, Rogers Commission Member, Cal Tech Trustee, Fomer President Hughes Airscaft, First Deputy Director for Science and Technology – CIA, Self described “Mayor” of Area 51, Developer of the Corona Satellite System, Decoder of Soviet Missile Telemetry obtained though antennas installed in northern Iran, Dicoverer of the missiles being installed in Cuba 3 months before anyone believed him (the Agency had formed a “Consenus” view that the Soviets would never do such a thing), and, even though I’ll never understand why, my friend.


  2. Bonanzapilot says:

    By the way, an interesting bit of trivia is that the resiliency function for that material is e^-A/T, where A is a rating in the Shore Durometer Scale A. For an exaggerated view, set A to .5 and look what happens to the right of the Y axis. NASA assumed it was a linear function because the mil spec for was for it was -30 to 300 degrees F. But that was for a captured O-Ring, not one installed in a gap of rapidly changing width. They never tested it in the design configuration, just relied on a mil-spec they didn’t understand.

  3. Bonanzapilot says:

    Feb 14, 1986
    DR. WHEELON: Or better yet, can you give us the specification from which you were working?
    MR. BOISJOLY: The specification in question is Mil R 83248A.
    DR. WHEELON: A further question. Did you do any further testing of the O-rings or the O-ring material on your own, independent of the motor?
    MR. KILMINSTER: Not that I can recall.
    DR. WHEELON: So you were just working to the specification of the material as provided in the Mil Spec?
    MR. KILMINSTER: I’m talking in the original qualification program. We subsequently have done testing.
    DR. WHEELON: How subsequently? The last couple of days?

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