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ENGINEERING ETHICS
The Space Shuttle Challenger Disaster
Department of Philosophy and Department of Mechanical
Engineering
Texas A&M University
NSF Grant Number
DIR-9012252
Instructor's Guide
Introduction To The Case
On January 28, 1986, seven astronauts were killed when the
space shuttle they were piloting, the Challenger,
exploded just over a minute into the flight. The failure of the
solid rocket booster O-rings to seat properly
allowed hot combustion gases to leak from the side of the
booster and burn through the external fuel tank. The
failure of the O-ring was attributed to several factors, including
faulty design of the solid rocket boosters,
insufficient low- temperature testing of the O-ring material and
the joints that the O-ring sealed, and lack of
proper communication between different levels of NASA
management.
Instructor Guidelines
Prior to class discussion, ask the students to read the student
handout outside of class. In class the details of the
case can be reviewed with the aide of the overheads. Reserve
about half of the class period for an open
discussion of the issues. The issues covered in the student
handout include the importance of an engineer's
responsibility to public welfare, the need for this responsibility
to hold precedence over any other responsibilities
the engineer might have and the responsibilities of a
manager/engineer. A final point is the fact that no matter how
far removed from the public an engineer may think she is, all of
her actions have potential impact. Essay #6,
"Loyalty and Professional Rights" appended at the end of the
case listings in this report will be found relevant for
instructors preparing to lead class discussion on this case. In
addition, essays #1 through #4 appended at the end
of the cases in this report will have relevant background
information for the instructor preparing to lead
classroom discussion. Their titles are, respectively: "Ethics and
Professionalism in Engineering: Why the Interest in
Engineering Ethics?;" "Basic Concepts and Methods in Ethics,"
"Moral Concepts and Theories," and
"Engineering Design: Literature on Social Responsibility
Versus Legal Liability."
Questions for Class Discussion
1. What could NASA management have done differently?
2. What, if anything, could their subordinates have done
differently?
3. What should Roger Boisjoly have done differently (if
anything)? In answering this question, keep in mind
that at his age, the prospect of finding a new job if he was fired
was slim. He also had a family to support.
4. What do you (the students) see as your future engineering
professional responsibilities in relation to both
being loyal to management and protecting the public welfare?
The Challenger Disaster Overheads
1. Organizations/People Involved
2. Key Dates
3. Space Shuttle Solid Rocket Boosters (SRB) Joints
4. Detail of SRB Field Joints
5. Ballooning Effect of Motor Casing
6. Key Issues
ORGANIZATIONS/PEOPLE INVOLVED
Marshall Space Flight Center - in charge of booster rocket
development
Larry Mulloy - challenged the engineers' decision not to launch
Morton Thiokol - Contracted by NASA to build the Solid
Rocket Booster
Alan McDonald - Director of the Solid Rocket Motors Project
Bob Lund - Engineering Vice President
Robert Ebeling - Engineer who worked under McDonald
Roger Boisjoly - Engineer who worked under McDonald
Joe Kilminster - Engineer in a management position
Jerald Mason - Senior executive who encouraged Lund to
reassess his decision not to launch.
KEY DATES
1974 - Morton-Thiokol awarded contract to build solid rocket
boosters.
1976 - NASA accepts Morton-Thiokol's booster design.
1977 - Morton-Thiokol discovers joint rotation problem.
November 1981 - O-ring erosion
discovered after second shuttle flight.
January 24, 1985 - shuttle flight that exhibited the worst O-ring
blow-by.
July 1985 - Thiokol orders new steel billets for new field joint
design.
August 19, 1985 - NASA Level I management briefed on
booster problem.
January 27, 1986 - night teleconference to discuss effects of
cold temperature on booster
performance.
January 28, 1986 - Challenger explodes 72 seconds after liftoff.
KEY ISSUES
HOW DOES THE IMPLIED SOCIAL CONTRACT OF
PROFESSIONALS APPLY TO
THIS CASE?
WHAT PROFESSIONAL RESPONSIBILITIES WERE
NEGLECTED, IF ANY?
SHOULD NASA HAVE DONE ANYTHING DIFFERENTLY IN
THEIR LAUNCH
DECISION PROCEDURE?
Student Handout - Synopsis
On January 28, 1986, seven astronauts were killed when the
space shuttle they were piloting, the Challenger,
exploded just over a minute into flight. The failure of the solid
rocket booster O-rings to seat properly allowed
hot combustion gases to leak from the side of the booster and
burn through the external fuel tank. The failure of
the O-ring was attributed to several factors, including faulty
design of the solid rocket boosters, insufficient low
temperature testing of the O-ring material and the joints that the
O-ring sealed, and lack of communication
between different levels of NASA management.
Organization and People Involved
Marshall Space Flight Center - in charge of booster rocket
development
Larry Mulloy - challenged the engineers' decision not to launch
Morton Thiokol - Contracted by NASA to build the Solid
Rocket Booster
Alan McDonald - Director of the Solid Rocket Motors Project
Bob Lund - Engineering Vice President
Robert Ebeling - Engineer who worked under McDonald
Roger Boisjoly - Engineer who worked under McDonald
Joe Kilminster - Engineer in a management position
Jerald Mason - Senior Executive who encouraged Lund to
reassess his decision not to launch.
Key Dates
1974 - Morton-Thiokol awarded contract to build solid rocket
boosters.
1976 - NASA accepts Morton-Thiokol's booster design.
1977 - Morton-Thiokol discovers joint rotation problem.
November 1981 - O-ring erosion
discovered after second shuttle flight. January 24, 1985 - shuttle
flight that exhibited the worst O-
ring blow-by. July 1985 - Thiokol orders new steel billets for
new field joint design.
August 19, 1985 - NASA Level I management briefed on
booster problem.
January 27, 1986 - night teleconference to discuss effects of
cold temperature on booster
performance.
January 28, 1986 - Challenger explodes 72 seconds after liftoff.
Background
NASA managers were anxious to launch the Challenger for
several reasons, including economic considerations,
political pressures, and scheduling backlogs. Unforeseen
competition from the European Space Agency put
NASA in a position where it would have to fly the shuttle
dependably on a very ambitious schedule in order to
prove the Space Transportation System's cost effectiveness and
potential for commercialization. This prompted
NASA to schedule a record number of missions in 1986 to make
a case for its budget requests. The shuttle
mission just prior to the Challenger had been delayed a record
number of times due to inclement weather and
mechanical factors. NASA wanted to launch the Challenger
without any delays so the launch pad could be
refurbished in time for the next mission, which would be
carrying a probe that would examine Halley's Comet. If
launched on time, this probe would have collected data a few
days before a similar Russian probe would be
launched. There was probably also pressure to launch
Challenger so it could be in space when President
Reagan gave his State of the Union address. Reagan's main
topic was to be education, and he was expected to
mention the shuttle and the first teacher in space, Christa
McAuliffe. The shuttle solid rocket boosters (or SRBs),
are key elements in the operation of the shuttle. Without the
boosters, the shuttle cannot produce enough thrust
to overcome the earth's gravitational pull and achieve orbit.
There is an SRB attached to each side of the external
fuel tank. Each booster is 149 feet long and 12 feet in diameter.
Before ignition, each booster weighs 2 million
pounds. Solid rockets in general produce much more thrust per
pound than their liquid fuel counterparts. The
drawback is that once the solid rocket fuel has been ignited, it
cannot be turned off or even controlled. So it was
extremely important that the shuttle SRBs were properly
designed. Morton Thiokol was awarded the contract to
design and build the SRBs in 1974. Thiokol's design is a scaled-
up version of a Titan missile which had been
used successfully for years. NASA accepted the design in 1976.
The booster is comprised of seven hollow
metal cylinders. The solid rocket fuel is cast into the cylinders
at the Thiokol plant in Utah, and the cylinders are
assembled into pairs for transport to Kennedy Space Center in
Florida. At KSC, the four booster segments are
assembled into a completed booster rocket. The joints where the
segments are joined together at KSC are
known as field joints (See Figure 1). These field joints consist
of a tang and clevis joint. The tang and clevis are
held together by 177 clevis pins. Each joint is sealed by two O
rings, the bottom ring known as the primary O-
ring, and the top known as the secondary O-ring. (The Titan
booster had only one O-ring. The second ring was
added as a measure of redundancy since the boosters would be
lifting humans into orbit. Except for the
increased scale of the rocket's diameter, this was the only major
difference between the shuttle booster and the
Titan booster.) The purpose of the O-rings is to prevent hot
combustion gasses from escaping from the inside of
the motor. To provide a barrier between the rubber O-rings and
the combustion gasses, a heat resistant putty is
applied to the inner section of the joint prior to assembly. The
gap between the tang and the clevis determines the
amount of compression on the O-ring. To minimize the gap and
increase the squeeze on the O-ring, shims are
inserted between the tang and the outside leg of the clevis.
Launch Delays
The first delay of the Challenger mission was because of a
weather front expected to move into the area,
bringing rain and cold temperatures. Usually a mission wasn't
postponed until inclement weather actually entered
the area, but the Vice President was expected to be present for
the launch and NASA officials wanted to avoid
the necessity of the Vice President's having to make an
unnecessary trip to Florida; so they postponed the launch
early. The Vice President was a key spokesperson for the
President on the space program, and NASA coveted
his good will. The weather front stalled, and the launch window
had perfect weather conditions; but the launch
had already been postponed to keep the Vice President from
unnecessarily traveling to the launch site. The
second launch delay was caused by a defective micro switch in
the hatch locking mechanism and by problems in
removing the hatch handle. By the time these problems had been
sorted out, winds had become too high. The
weather front had started moving again, and appeared to be
bringing record-setting low temperatures to the
Florida area. NASA wanted to check with all of its contractors
to determine if there would be any problems with
launching in the cold temperatures. Alan McDonald, director of
the Solid Rocket Motor Project at Morton-
Thiokol, was convinced that there were cold weather problems
with the solid rocket motors and contacted two
of the engineers working on the project, Robert Ebeling and
Roger Boisjoly. Thiokol knew there was a problem
with the boosters as early as 1977, and had initiated a redesign
effort in 1985. NASA Level I management had
been briefed on the problem on August 19, 1985. Almost half of
the shuttle flights had experienced O-ring
erosion in the booster field joints. Ebeling and Boisjoly had
complained to Thiokol that management was not
supporting the redesign task force.
Engineering Design
The size of the gap is controlled by several factors, including
the dimensional tolerances of the metal cylinders
and their corresponding tang or clevis, the ambient temperature,
the diameter of the O-ring, the thickness of the
shims, the loads on the segment, and quality control during
assembly. When the booster is ignited, the putty is
displaced, compressing the air between the putty and the
primary O-ring. The air pressure forces the O-ring into
the gap between the tang and clevis. Pressure loads are also
applied to the walls of the cylinder, causing the
cylinder to balloon slightly. This ballooning of the cylinder
walls caused the gap between the tang and clevis gap
to open. This effect has come to be known as joint rotation.
Morton-Thiokol discovered this joint rotation as
part of its testing program in 1977. Thiokol discussed the
problem with NASA and started analyzing and testing
to determine how to increase the O-ring compression, thereby
decreasing the effect of joint rotation. Three
design changes were implemented:
1. Dimensional tolerances of the metal joint were tightened.
2. The O-ring diameter was increased, and its dimensional
tolerances were tightened.
3. The use of the shims mentioned above was introduced.
Further testing by Thiokol revealed that the
second seal, in some cases, might not seal at all. Additional
changes in the shim thickness and O-ring
diameter were made to correct the problem.
A new problem was discovered during November 1981, after the
flight of the second shuttle mission.
Examination of the booster field joints revealed that the O-rings
were eroding during flight. The joints were still
sealing effectively, but the O-ring material was being eaten
away by hot gasses that escaped past the putty.
Thiokol studied different types of putty and its application to
study their effects on reducing O-ring erosion. The
shuttle flight 51-C of January 24, 1985, was launched during
some of the coldest weather in Florida history.
Upon examination of the booster joints, engineers at Thiokol
noticed black soot and grease on the outside of the
booster casing, caused by actual gas blow-by. This prompted
Thiokol to study the effects of O-ring resiliency at
low temperatures. They conducted laboratory tests of O-ring
compression and resiliency between 50lF and
100lF. In July 1985, Morton Thiokol ordered new steel billets
which would be used for a redesigned case field
joint. At the time of the accident, these new billets were not
ready for Thiokol, because they take many months
to manufacture.
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.1 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.
The Launch
During the night, temperatures dropped to as low as 8°F, much
lower than had been anticipated. In order to
keep the water pipes in the launch platform from freezing,
safety showers and fire hoses had been turned on.
Some of this water had accumulated, and ice had formed all
over the platform. There was some concern that the
ice would fall off of the platform during launch and might
damage the heat resistant tiles on the shuttle. The ice
inspection team thought the situation was of great concern, but
the launch director decided to go ahead with the
countdown. Note that safety limitations on low temperature
launching had to be waived and authorized by key
personnel several times during the final countdown. These key
personnel were not aware of the teleconference
about the solid rocket boosters that had taken place the night
before. At launch, the impact of ignition broke
loose a shower of ice from the launch platform. Some of the ice
struck the left-hand booster, and some ice was
actually sucked into the booster nozzle itself by an aspiration
effect. Although there was no evidence of any ice
damage to the Orbiter itself, NASA analysis of the ice problem
was wrong. The booster ignition transient started
six hundredths of a second after the igniter fired. The aft field
joint on the right-hand booster was the coldest spot
on the booster: about 28°F. The booster's segmented steel
casing ballooned and the joint rotated, expanding
inward as it had on all other shuttle flights. The primary O-ring
was too cold to seat properly, the cold-stiffened
heat resistant putty that protected the rubber O-rings from the
fuel collapsed, and gases at over 5000°F burned
past both O-rings across seventy degrees of arc. Eight
hundredths of a second after ignition, the shuttle lifted off.
Engineering cameras focused on the right-hand booster showed
about nine smoke puffs coming from the booster
aft field joint. Before the shuttle cleared the tower, oxides from
the burnt propellant temporarily sealed the field
joint before flames could escape. Fifty-nine seconds into the
flight, Challenger experienced the most violent
wind shear ever encountered on a shuttle mission. The glassy
oxides that sealed the field joint were shattered by
the stresses of the wind shear, and within seconds flames from
the field joint burned through the external fuel
tank. Hundreds of tons of propellant ignited, tearing apart the
shuttle. One hundred seconds into the flight, the
last bit of telemetry data was transmitted from the Challenger.
Issues For Discussion
The Challenger disaster has several issues which are relevant to
engineers. These issues raise many questions
which may not have any definite answers, but can serve to
heighten the awareness of engineers when faced with
a similar situation. One of the most important issues deals with
engineers who are placed in management
positions. It is important that these managers not ignore their
own engineering experience, or the expertise of their
subordinate engineers. Often a manager, even if she has
engineering experience, is not as up to date on current
engineering practices as are the actual practicing engineers. She
should keep this in mind when making any sort
of decision that involves an understanding of technical matters.
Another issue is the fact that managers
encouraged launching due to the fact that there was insufficient
low temperature data. Since there was not
enough data available to make an informed decision, this was
not, in their opinion, grounds for stopping a launch.
This was a reversal in the thinking that went on in the early
years of the space program, which discouraged
launching until all the facts were known about a particular
problem. This same reasoning can be traced back to
an earlier phase in the shuttle program, when upper-level NASA
management was alerted to problems in the
booster design, yet did not halt the program until the problem
was solved. To better understand the responsibility
of the engineer, some key elements of the professional
responsibilities of an engineer should be examined. This
will be done from two perspectives: the implicit social contract
between engineers and society, and the guidance
of the codes of ethics of professional societies. As engineers
test designs for ever-increasing speeds, loads,
capacities and the like, they must always be aware of their
obligation to society to protect the public welfare.
After all, the public has provided engineers, through the tax
base, with the means for obtaining an education and,
through legislation, the means to license and regulate
themselves. In return, engineers have a responsibility to
protect the safety and well-being of the public in all of their
professional efforts. This is part of the implicit social
contract all engineers have agreed to when they accepted
admission to an engineering college. The first canon in
the ASME Code of Ethics urges engineers to "hold paramount
the safety, health and welfare of the public in the
performance of their professional duties." Every major
engineering code of ethics reminds engineers of the
importance of their responsibility to keep the safety and well
being of the public at the top of their list of priorities.
Although company loyalty is important, it must not be allowed
to override the engineer's obligation to the public.
Marcia Baron, in an excellent monograph on loyalty, states: "It
is a sad fact about loyalty that it invites...single-
mindedness. Single-minded pursuit of a goal is sometimes
delightfully romantic, even a real inspiration. But it is
hardly something to advocate to engineers, whose impact on the
safety of the public is so very significant.
Irresponsibility, whether caused by selfishness or by
magnificently unselfish loyalty, can have most unfortunate
consequences."
Annotated Bibliography and Suggested References
Feynman, Richard Phillips, What Do You Care What Other
People Think,: Further Adventures of a Curious
Character, Bantam Doubleday Dell Pub, ISBN 0553347845, Dec
1992. Reference added by request of
Sharath Bulusu, as being pertinent and excellent reading - 8-25-
00.
Lewis, Richard S., Challenger: the final voyage, Columbia
University Press, New York, 1988.
McConnell, Malcolm, Challenger: a major malfunction,
Doubleday, Garden City, N.Y., 1987.
Trento, Joseph J., Prescription for disaster, Crown, New York,
c1987.
United States. Congress. House. Committee on Science and
Technology, Investigation of the Challenger
accident : hearings before the Committee on Science and
Technology, U.S. House of Representatives,
Ninety-ninth Congress, second session .... U.S.
G.P.O.,Washington, 1986.
United States. Congress. House. Committee on Science and
Technology, Investigation of the Challenger
accident : report of the Committee on Science and Technology,
House of Representatives, Ninety-ninth
Congress, second session. U.S. G.P.O., Washington, 1986.
United States. Congress. House. Committee on Science, Space,
and Technology, NASA's response to the
committee's investigation of the " Challenger" accident :
hearing before the Committee on Science,
Space, and Technology, U.S. House of Representatives, One
hundredth Congress, first session, February
26, 1987. U.S. G.P.O., Washington, 1987.
United States. Congress. Senate. Committee on Commerce,
Science, and Transportation. Subcommittee on
Science, Technology, and Space, Space shuttle accident :
hearings before the Subcommittee on Science,
Technology, and Space of the Committee on Commerce,
Science, and Transportation, United States
Senate, Ninety-ninth Congress, second session, on space shuttle
accident and the Rogers Commission
report, February 18, June 10, and 17, 1986. U.S. G.P.O.,
Washington, 1986.
Notes
1. "Challenger: A Major Malfunction." (see above) p. 194.
2. Baron, Marcia. The Moral Status of Loyalty. Illinois Institute
of Technology: Center for the Study of Ethics
in the Professions, 1984, p. 9. One of a series of monographs on
applied ethics that deal specifically with the
engineering profession. Provides arguments both for and against
loyalty. 28 pages with notes and an annotated
bibliography.
Engineering Ethics Case Study:
The Challenger Disaster
Course No: LE3-001
Credit: 3 PDH
Mark Rossow, PhD, PE, Retired
Continuing Education and Development, Inc.
9 Greyridge Farm Court
Stony Point, NY 10980
P: (877) 322-5800
F: (877) 322-4774
[email protected]om
Engineering Ethics Case Study: The
Challenger Disaster
Mark P. Rossow, P.E., Ph.D.
2
© 2012 Mark P. Rossow
All rights reserved. No part of this work may be reproduced in
any manner without the written
permission of the author.
3
Preface
On January 28, 1986, the Space Shuttle Challenger burst into
flame shortly after liftoff. All
passengers aboard the vehicle were killed. A presidential
commission was formed to investigate
the cause of the accident and found that the O-ring seals had
failed, and, furthermore, that the
seals had been recognized as a potential hazard for several years
prior to the disaster. The
commission’s report, Report to the President by the Presidential
Commission on the Space
Shuttle Challenger Accident, stated that because managers and
engineers had known in advance
of the O-ring danger, the accident was principally caused by a
lack of communication between
engineers and management and by poor management practices.
This became the standard
interpretation of the cause of the Challenger disaster and
routinely appears in popular articles and
books about engineering, management, and ethical issues.
But the interpretation ignores much of the history of how NASA
and the contractor’s engineers
had actually recognized and dealt with the O-ring problems in
advance of the disaster. When
this history is considered in more detail, the conclusions of the
Report to the President become
far less convincing. Two excellent publications that give a
much more complete account of
events leading up to the disaster are The Challenger Launch
Decision by Diane Vaughan, and
Power To Explore -- History of Marshall Space Flight Center
1960-1990 by Andrew Dunar and
Stephen Waring. As Dunar and Waring put it—I would apply
their remarks to Vaughan’s work
as well— “Allowing Marshall engineers and managers to tell
their story, based on pre-accident
documents and on post-accident testimony and interviews, leads
to a more realistic account of
the events leading up to the accident than that found in the
previous studies.” I would strongly
encourage anyone with the time and interest to read both of
these publications, which are
outstanding works of scholarship. For those persons lacking the
time—the Vaughan book is
over 550 pages—I have written the present condensed
description of the Challenger incident. I
have drawn the material for Sections 1-8 and 10 from multiple
sources but primarily from
Vaughan, the Report to the President, and Dunnar and Waring.
Of course, any errors introduced
during the process of fitting their descriptions and ideas into my
narrative are mine and not the
fault of these authors. Sections 9, 11, and 12 are original
contributions of my own. All figures
have been taken from Report to the President.
Mark Rossow
4
Introduction
Course Content
This course provides instruction in engineering ethics through a
case study of the Space Shuttle
Challenger disaster. The course begins by presenting the
minimum technical details needed to
understand the physical cause of the Shuttle failure. The
disaster itself is chronicled through
NASA photographs. Next the decision-making process—
especially the discussions occurring
during the teleconference held on the evening before the
launch—is described. Direct quotations
from engineers interviewed after the disaster are frequently
used to illustrate the ambiguities of
the data and the pressures that the decision-makers faced in the
period preceding the launch. The
course culminates in an extended treatment of six ethical issues
raised by Challenger.
Purpose of Case Studies
Principles of engineering ethics are easy to formulate but
sometimes hard to apply. Suppose, for
example, that an engineering team has made design choice X,
rather than Y, and X leads to a bad
consequence—someone was injured. To determine if the
engineers acted ethically, we have to
answer the question of whether they chose X rather than Y
because 1) X appeared to be the
better technical choice, or 2) X promoted some other end (for
example, financial) in the
organization. Abstract ethics principles alone cannot answer
this question; we must delve into
the technical details surrounding the decision. The purpose of
case studies in general is to
provide us with the context—the technical details—of an
engineering decision in which an
ethical principle may have been violated.
Case Study of Challenger Disaster
On January 28, 1986, the NASA space Shuttle Challenger burst
into a ball of flame 73 seconds
after take-off, leading to the death of the seven people on board.
Some months later, a
commission appointed by the President to investigate the causes
of the disaster determined that
the cause of the disaster was the failure of a seal in one of the
solid rocket boosters (Report to the
President 1986, vol. 1, p. 40). Furthermore, Morton Thiokol, the
contractor responsible for the
seal design, had initiated a teleconference with NASA on the
evening before the launch and had,
at the beginning of the teleconference, recommended against
launching because of concerns
about the performance of the seal. This recommendation was
reversed during the teleconference,
with fatal consequences.
To understand the decisions that led to the Challenger disaster,
you must first understand what
the technical problems were. Accordingly, this course begins
by presenting the minimum
technical details you will need to understand the physical cause
of the seal failure. After laying
this groundwork, we examine what occurred in the
teleconference. You will probably find, as
you learn more and more about the Challenger project, that
issues that had appeared simple
initially are actually far more complex; pinpointing
responsibility and assigning blame are not
nearly as easy as many popular accounts have made them. The
purpose of the present course is
1) to consider some of the issues and show by example how
difficult it can be to distinguish
unethical behavior from technical mistakes (with severe
consequences), and 2) to equip you to
think critically and act appropriately when confronted with
ethical decisions in your own
professional work.
5
The course is divided into the following topics:
1. Two Common Errors of Interpretation
2. Configuration of Shuttle
3. Function of O-rings
4. History of Problems with Joint Seals
5. Teleconference
6. Accident
7. Ethical issue: Did NASA take extra risks because of pressure
to maintain Congressional
funding?
8. Ethical issue: Did Thiokol take extra risks because of fear of
losing its contract with
NASA?
9. Ethical issue: Was the Principle of Informed Consent
violated?
10. Ethical issue: What role did whistle blowing have in the
Challenger story?
11. Ethical issue: Who had the right to Thiokol documents
relating to the Challenger
disaster?
12. Ethical issue: Why are some engineering disasters
considered ethical issues and others
are not?
13. Summary
1. Two Common Errors of Interpretation
Persons studying the history of an engineering disaster must be
alert to the danger of committing
one of the following common errors: 1) the myth of perfect
engineering practice, and 2) the
retrospective fallacy.
The Myth of Perfect Engineering Practice
The sociologist, Diane Vaughan, who has written one of the
most thorough books on Challenger,
has pointed out that the mere act of investigating an accident
can cause us to view, as ominous,
facts and events that we otherwise would consider normal:
“When technical systems fail, …
outside investigators consistently find an engineering world
characterized by ambiguity,
disagreement, deviation from design specifications and
operating standards, and ad hoc rule
making. This messy situation, when revealed to the public,
automatically becomes an
explanation for the failure, for after all, the engineers and
managers did not follow the rules. …
[On the other hand,] the engineering process behind a
‘nonaccident’ is never publicly examined.
If nonaccidents were investigated, the public would discover
that the messy interior of
engineering practice, which after an accident investigation
looks like ‘an accident waiting to
happen,’ is nothing more or less than ‘normal technology.”
(Vaughan 1996, p. 200) Thus as you
read the description of the Challenger disaster on the pages to
follow, keep in mind that just
because some of the engineering practices described are not
neat and tidy processes in which
consensus is always achieved and decisions are always based on
undisputed and unambiguous
data, that fact alone may not explain the disaster; such practices
may simply be part of normal
technology—that usually results in a nonaccident.
The Retrospective Fallacy
Engineering projects sometimes fail. If the failure involves
enough money or injuries to
innocent people, then investigators may be brought in to
determine the causes of the failure and
6
identify wrongdoers. The investigators then weave a story
explaining how decision-makers
failed to assess risks properly, failed to heed warning signs,
used out-of-date information,
ignored quality-control, took large risks for personal gain, etc.
But there is a danger here: the
story is constructed by selectively focusing on those events that
are known to be important in
retrospect, that is, after the failure has occurred and observers
look back at them. At the time
that the engineers were working on the project, these events
may not have stood out from dozens
or even hundreds of other events. “Important” events do not
come labeled “PARTICULARLY
IMPORTANT: PAY ATTENTION”; they may appear important
only in retrospect. To the
extent that we retrospectively identify events as particularly
important—even though they may
not have been thought particularly important by diligent and
competent people working at the
time—we are committing the “retrospective fallacy.” (Vaughan
1996, p. 68-70)
In any discussion of the Challenger disaster, the tendency to
commit the retrospective fallacy
exists, because we all know the horrendous results of the
decisions that were made—and our first
reaction is to say, “How could they have ignored this?” or,
“Why didn’t they study that more
carefully?” But to understand what happened, it is crucial to
put yourself in the place of the
engineers and to focus on what they knew and what they
thought to be important at the time. For
example, NASA classified 745 components on the Shuttle as
“Criticality 1”, meaning failure of
the component would cause the loss of the crew, mission, and
vehicle (NASA’s Response to the
Committee’s Investigation of the “Challenger” Accident 1987).
With the advantage of 20-20
hindsight, we now know that the engineers made a tragic error
in judging the possibility of
failure of a particular one of those 745 components—the seals—
an “acceptable risk.” But at the
time, another issue—problems with the Shuttle main engines—
attracted more concern
(McDonald 2009, pp. 64-65). Similarly, probably most of the
decisions made by the Shuttle
engineers and managers were influenced to some extent by
considerations of cost. As a result,
after the disaster it was a straightforward matter to pick out
specific decisions and claim that the
decision-makers had sacrificed safety for budgetary reasons.
But our 20-20 hindsight was not
available to the people involved in the Challenger project, and
as we read the history we should
continually ask questions such as “What did they know at the
time?,” “Is it reasonable to expect
that they should have seen the significance of this or that fact?,”
and “If I were in their position
and knew only what they knew, what would I have done?” Only
through such questions can we
hope to understand why the Challenger disaster occurred and to
evaluate its ethical dimensions.
2. Configuration of Shuttle.
NASA had enjoyed widespread public support and generous
funding for the Apollo program to
put a man on the moon. But as Apollo neared completion and
concerns about the cost of the
Vietnam War arose, continued congressional appropriations for
NASA were in jeopardy. A new
mission for NASA was needed, and so the Space Shuttle
program was proposed. The idea was
to development an inexpensive (compared to Apollo) system for
placing human beings and
hardware in orbit. The expected users of the system would be
commercial and academic
experimenters, the military, and NASA itself. On January 5,
1972, President Nixon announced
the government’s approval of the Shuttle program.
7
Fig. 1 Configuration of the Shuttle
Because a prime goal was to keep costs down, reusable space
vehicles were to be developed.
After many design proposals and compromises—for example,
the Air Force agreed not to
develop any launch vehicles of its own, provided that the
Shuttle was designed to accommodate
military needs—NASA came up with the piggyback design
shown in Figure 1. The airplane-like
craft (with the tail fin) shown in side view on the right side of
the figure is the “Orbiter.” The
Orbiter contains the flight crew and a 60 feet long and 15 feet
wide payload bay designed to hold
cargo such as communications satellites to be launched into
orbit, an autonomous Spacelab to be
used for experiments in space, or satellites already orbiting that
have been retrieved for repairs.
Before launch, the Orbiter is attached to the large (154 feet long
and 27 1/2 feet in diameter)
External Tank—the middle cylinder with the sharp-pointed end
shown in the figure; the External
8
Tank contains 143,000 gallons of liquid oxygen and 383,000
gallons of liquid hydrogen for the
Orbiter's engines.
The two smaller cylinders on the sides of the External Tank are
the Solid Rocket Boosters
(SRBs). The SRBs play a key role in the Challenger accident
and accordingly will be described
here in some detail.
The SRBs contain solid fuel, rather than the liquid fuel
contained by the External Tank.
The SRBs provide about 80 percent of the total thrust at liftoff;
the remainder of the thrust is
provided by the Orbiter's three main engines. Morton-Thiokol
Inc. held the contract for the
development of the SRBs.
The SRBs fire for about two minutes after liftoff, and then,
their fuel exhausted, are separated
from the External Tank. A key goal of the Shuttle design was
to save costs by re-using the SRBs
and the Orbiter. The conical ends of the SRBs contain
parachutes that are deployed, after the
SRBs have been separated from the External Tank, and allow
the SRBs to descend slowly to the
ocean below. The SRBs are then picked out of the water by
recovery ships and taken to repair
facilities, where preparations are made for the next flight. After
the SRBs are detached, the
Orbiter’s main engines continue firing until it achieves low
earth orbit. Then the External Tank
is jettisoned towards earth where it burns up in the
atmosphere—the External Tank is not re-
used. Once the crew has completed its mission in orbit, the
Orbiter returns to earth where it
glides (No propulsion is used.) to a landing on a conventional
airstrip. The Orbiter can then be
refurbished for its next launch.
More Details about the SRBs
Fig. 2 Solid Rocket Booster with Exploded View Showing
Segments and Joints
9
Figure 2 shows the subassemblies that make up the SRB.
Because the total length of the SRB
was almost 150 feet, it was too large to ship as a single unit by
rail from Thiokol’s
manufacturing facility in Utah to the Kennedy Space Center
launch site in Florida. Furthermore,
shipping the SRB as a single unit would mean that a large
amount of rocket fuel would be
concentrated in a single container—creating the potential for an
enormous explosion. For these
reasons, Thiokol manufactured the SRB from individual
cylindrical segments each
approximately 12 feet in diameter. At Thiokol’s plant in Utah,
individual segments were welded
together to form four “casting” segments, into which propellant
was poured (cast). The welded
joints within a casting segment were called “factory joints.”
The four casting segments were
then shipped individually by rail to Kennedy, where they were
assembled—by stacking, not
welding—to form the solid rocket motor (SRM) of the SRB.
The joints created by the assembly
process at Kennedy were called “field joints.” The sealing
problem that led to the Challenger’s
destruction occurred in the field joint at the right end of the
AFT MID SEGMENT in Figure 2.
Hot combustion gases from the SRM leaked through the joint
and either weakened or burned a
hole in the External Tank, igniting the contents of the Tank and
producing a catastrophic fireball.
3. Function of O-rings
The cutaway view of the SRB in Figure 3 shows the aft field
joint location in the assembled
SRB.
Fig. 3. Location of the Problematic Aft Field Joint
10
Fig. 4. Cross Section of Field Joint
Figure 4 shows how the upper SRM segment in a field joint is
connected to the lower segment by
a pin passing through the “tang” (the tongue on the upper
segment) and the “clevis” (the U-
shaped receptacle cut in the lower segment); 177 such steel pins
are inserted around the
circumference of each joint. When the propellant is burning
and generating hot combustion
gases under the enormous pressure necessary to accelerate the
SRB, the joint must be sealed to
prevent the gases from leaking and possibly damaging exterior
parts of the Shuttle. This sealing
is accomplished by a primary O-ring backed up by a secondary
O-ring (O-rings are widely used
in machine design and, when functioning properly, can seal
pressures in the range of thousands
of psi). An SRM O-ring has been compared to “a huge length of
licorice—same color, same
diameter (only 0.28”)—joined at the ends so it forms a circle
12’ across” (Vaughan 1996, p. 40).
SRM O-rings were made of a rubberlike synthetic material
called Viton. To prevent the hot
combustion gases from contacting and thus degrading the Viton
when the propellant was ignited,
zinc chromate putty was applied in the region shown in Figure 4
prior to assembly of the SRM
segments.
11
Fig. 5. Effect of Compression of the O-ring in Inhibiting
Pressure Actuation
Pressure Actuation of the O-ring Seal
Besides protecting the O-rings from the corrosive effects of the
hot combustion gases, the putty
is intended to be pushed outward from the combustion chamber
during ignition, compress the air
ahead of the primary O-ring, and thus force the O-ring into the
tang-clevis gap, thereby sealing
the gap. This process is referred to as “pressure-actuated
sealing.” Experiments show that
pressure actuation is most effective when the high-pressure air
acts over the largest possible
portion of the high-pressure side of the O-ring. In the leftmost
sketch in Figure 5, for example,
the high-pressure side extends from the “Response Node” at the
top to the point of tangency at
the bottom of the groove. If, however, the O-ring is initially
compressed during assembly, then
the O-ring may deform sufficiently to cause contact with the
left-hand side of the groove, as
shown in the rightmost sketch in Figure 5. In that case, the
high-pressure air acts over only the
surface of the upper left-hand side of the O-ring, and pressure
actuation of the seal is impaired.
This problem is lessened if, upon ignition, the joint gap opens,
and the O-ring is able to spring
back elastically and lose contact with sides of the groove, as in
the middle sketch in Figure 5.
However, when the temperature is low, the O-ring loses much of
its elasticity and as a result may
retain its compressed shape, as in the right-hand sketch of
Figure 5. This retention of the
compressed shape has three unfortunate consequences: 1)
pressure actuation is delayed or
impaired because the high-pressure air cannot get to the lower
left-hand side of the O-ring,
2) pressure actuation is delayed or impaired because the O-ring
does not seal the opened gap, and
the actuation pressure on the O-ring decreases as the fluid is
able to pass by the O-ring, and
3) because of the lack of sealing, compressed air, putty, and
then hot combustion gas may blow
by through the gap, and in the process, damage or even destroy
the O-ring.
In general, pressure actuation was also affected negatively by
several other factors, such as the
behavior of the putty and the increase in gap size caused by re-
use of the SRM. From
consideration of all these factors and from observation of the
explosion, the Presidential
Commission concluded ”that the cause of the Challenger
accident was the failure of the pressure
seal in the aft field joint of the right Solid Rocket Motor
[Italics in the original]. The failure was
due to a faulty design unacceptably sensitive to a number of
factors. These factors were the
12
effects of temperature, physical dimensions, the character of
materials, the effects of reusability,
processing, and the reaction of the joint to dynamic loading.”
(Report to the President 1986, vol.
1, p. 69)
4. History of Problems with Joint Seals
From the very beginning, in 1973, of Thiokol’s contract to
develop the SRM, problems arose
with the joints. The Thiokol design for the SRM was based on
the Air Force’s Titan III, one of
the most reliable solid-fuel rockets produced up to that time.
But Thiokol engineers could not
simply copy the Titan design—the SRM was larger than the
Titan’s motor and had to be
designed for refurbishment and repeated use. One particular
area in which the two motors
differed was the field joints, and Thiokol’s initial design for the
SRM field joints worried
engineers at the Marshall Space Flight Center, who were
responsible for monitoring Thiokol’s
contract. Many modifications and reviews of the design ensued,
and Thiokol and Marshall
finally began various load tests in 1976. Early tests were
successful and gave engineers
confidence. In an important test in 1977, however, the joint
seals surprised the engineers by
exhibiting “joint rotation,” illustrated in Fig. 6. Of particular
concern is the loss of redundancy
in the design because not just the primary but also the
secondary O-ring is rendered ineffective if
the gap opens sufficiently. (It is important to realize the scale
of the events being described: the
gap between the tang and clevis in the unpressurized joint is
tiny: 0.004”, in the pressurized joint
the gap was estimated to lie between 0.042” and 0.06,”—caused
by a joint rotation that occurs in
the first 0.6 seconds of ignition.)
13
Fig. 6 Joint Rotation
Other sealing problems—some but not all related to joint
rotation—such as blow-by, ring
charring, ring erosion, loss of resilience of the O-ring material
at low temperature, and
performance of the putty were observed later in various static
tests and launches. Engineers both
at Thiokol and at the Marshall were aware of these problems.
On July 31, 1985, Roger Boisjoly,
a Thiokol engineer specializing in O-rings, wrote a memo to
Thiokol vice president Robert Lund
with the subject line, "O-ring Erosion/Potential Failure
Criticality", after nozzle joint erosion was
detected in an SRB:
“This letter is written to insure that management is fully aware
of the seriousness of the
current O-ring erosion problem in the SRM joints from an
engineering standpoint. “
"The mistakenly accepted position on the joint problem was to
fly without fear of failure
and to run a series of design evaluations which would ultimately
lead to a solution or at
least a significant reduction of the erosion problem. This
position is now changed as a
result of the [51-B] nozzle joint erosion which eroded a
secondary O-ring with the
primary O-ring never sealing. If the same scenario should occur
in a field joint (and it
could), then it is a jump ball whether as to the success or failure
of the joint because the
secondary O-ring cannot respond to the clevis opening rate and
may not be capable of
pressurization. The result would be a catastrophe of the highest
order-loss of human
life…
14
Boisjoly urged that a team be set up to work on the O-ring
problem, and ended by saying
"It is my honest and very real fear that if we do not take
immediate action to dedicate a
team to solve the problem, with the field joint having the
number one priority, then we
stand in jeopardy of losing a flight along with all the launch pad
facilities." [quoted in
Vaughan 1996, p. 447]
Boisjoly later charged that Thiokol management failed to
provide adequate follow-up and
support to correct the problem described in his memo.
Readers tempted to commit the retrospective fallacy after
reading Boisjoly’s memo should note
that the memo does not mention temperature effects on the seal.
The years of concern about the sealing problems eventually led
to a briefing at NASA
Headquarters in Washington on August 19
th
, 1985, by Marshall and Thiokol, in which they
presented both an engineering evaluation and a redesign plan.
They noted that only 5 of 111
primary O-rings in field joints and 12 of 47 primary O-rings in
nozzle joints had shown erosion
in various tests and flights. Thiokol argued that various
experimental and flight data verified the
safety of the design. They said, however, that the field joint was
the “highest concern” and
presented plans for improving the joints both with short-term
fixes and longer-term fixes that
would take over two years to implement. Data from studies by
Arnie Thompson (Boisjoly’s
boss) of the effect of temperature on ring resiliency were
presented, but imposing a temperature
launch constraint was not mentioned. The review judged that
leak checks and careful assembly
made it “safe to continue flying [the] existing design.”
Nevertheless NASA needed “to continue
at an accelerated pace to eliminate SRM seal erosion.” In the
meantime, the risks were
considered acceptable. [Dunnar and Waring, p. 363].
5. Teleconference
After several delays, the Challenger launch was scheduled for
January 28, 1986, at 9:38 AM
EST. At about 1 PM on the 27
th
, however, NASA personnel became concerned about the
unusually low temperatures—in the low 20’s—predicted for
early morning of the next day. A
Marshall manager asked Thiokol engineers to review the effect
the low temperatures might have
on the SRM. Accordingly, a meeting was held at Thiokol’s
Utah facility. Engineers there stated
their concern that the extreme cold would greatly reduce O-ring
resiliency and ability to seal the
joints. A teleconference among Thiokol, Marshall, and
Kennedy personnel was set for 5:45 PM
EST to discuss the situation.
At the teleconference, Thiokol engineers made no official
recommendation about delaying the
launch. The discussion centered on their concerns about the
effect of the low temperatures on
the O-rings. However, some of the teleconference participants
were unable to hear well, because
of a poor telephone connection, and some key personnel had not
been located in time to be
included in the teleconference, so the teleconference was ended,
and a second one scheduled for
8:15 PM EST. In the interim, Thiokol engineers had time to
organize their data in charts and fax
them to Marshall and Kennedy.
15
A total of thirty-four managers and engineers from Thiokol,
Marshall, and Kennedy took part in
the second teleconference. Thiokol engineers began the
teleconference by discussing the charts
that they had faxed to the other teleconference participants.
The Thiokol position was that
because significant O-ring blow-by and damage had been
observed in the coldest previous
launch—53°F—the O-ring material would lose much of its
resilience and the joint could fail,
were the launch to be conducted at a temperature in the 20’s or
low 30’s. When directly asked
by Larry Mulloy, Manager of the SRB project at Marshall,
Thiokol Vice President Joe
Kilminster …
Code of Ethics for Engineers
4. Engineers shall act for each employer or client as faithful
agents or
trustees.
a. Engineers shall disclose all known or potential conflicts of
interest
that could influence or appear to influence their judgment or the
quality of their services.
b. Engineers shall not accept compensation, financial or
otherwise,
from more than one party for services on the same project, or
for
services pertaining to the same project, unless the circumstances
are
fully disclosed and agreed to by all interested parties.
c. Engineers shall not solicit or accept financial or other
valuable
consideration, directly or indirectly, from outside agents in
connection with the work for which they are responsible.
d. Engineers in public service as members, advisors, or
employees
of a governmental or quasi-governmental body or department
shall
not participate in decisions with respect to services solicited or
provided by them or their organizations in private or public
engineering practice.
e. Engineers shall not solicit or accept a contract from a
governmental
body on which a principal or officer of their organization serves
as
a member.
5. Engineers shall avoid deceptive acts.
a. Engineers shall not falsify their qualifications or permit
misrepresentation of their or their associates’ qualifications.
They
shall not misrepresent or exaggerate their responsibility in or
for the
subject matter of prior assignments. Brochures or other
presentations incident to the solicitation of employment shall
not
misrepresent pertinent facts concerning employers, employees,
associates, joint venturers, or past accomplishments.
b. Engineers shall not offer, give, solicit, or receive, either
directly or
indirectly, any contribution to influence the award of a contract
by
public authority, or which may be reasonably construed by the
public as having the effect or intent of influencing the awarding
of a
contract. They shall not offer any gift or other valuable
consideration in order to secure work. They shall not pay a
commission, percentage, or brokerage fee in order to secure
work,
except to a bona fide employee or bona fide established
commercial
or marketing agencies retained by them.
III. Professional Obligations
1. Engineers shall be guided in all their relations by the highest
standards
of honesty and integrity.
a. Engineers shall acknowledge their errors and shall not distort
or
alter the facts.
b. Engineers shall advise their clients or employers when they
believe
a project will not be successful.
c. Engineers shall not accept outside employment to the
detriment of
their regular work or interest. Before accepting any outside
engineering employment, they will notify their employers.
d. Engineers shall not attempt to attract an engineer from
another
employer by false or misleading pretenses.
e. Engineers shall not promote their own interest at the expense
of the
dignity and integrity of the profession.
2. Engineers shall at all times strive to serve the public interest.
a. Engineers are encouraged to participate in civic affairs;
career
guidance for youths; and work for the advancement of the
safety,
health, and well-being of their community.
b. Engineers shall not complete, sign, or seal plans and/or
specifications that are not in conformity with applicable
engineering
standards. If the client or employer insists on such
unprofessional
conduct, they shall notify the proper authorities and withdraw
from
further service on the project.
c. Engineers are encouraged to extend public knowledge and
appreciation of engineering and its achievements.
d. Engineers are encouraged to adhere to the principles of
sustainable
development1 in order to protect the environment for future
generations.
Preamble
Engineering is an important and learned profession. As
members of this
profession, engineers are expected to exhibit the highest
standards of honesty
and integrity. Engineering has a direct and vital impact on the
quality of life for
all people. Accordingly, the services provided by engineers
require honesty,
impartiality, fairness, and equity, and must be dedicated to the
protection of the
public health, safety, and welfare. Engineers must perform
under a standard of
professional behavior that requires adherence to the highest
principles of ethical
conduct.
I. Fundamental Canons
Engineers, in the fulfillment of their professional duties, shall:
1. Hold paramount the safety, health, and welfare of the public.
2. Perform services only in areas of their competence.
3. Issue public statements only in an objective and truthful
manner.
4. Act for each employer or client as faithful agents or trustees.
5. Avoid deceptive acts.
6. Conduct themselves honorably, responsibly, ethically, and
lawfully so as to enhance the honor, reputation, and usefulness
of the profession.
II. Rules of Practice
1. Engineers shall hold paramount the safety, health, and
welfare
of the public.
a. If engineers’ judgment is overruled under circumstances that
endanger life or property, they shall notify their employer or
client
and such other authority as may be appropriate.
b. Engineers shall approve only those engineering documents
that are
in conformity with applicable standards.
c. Engineers shall not reveal facts, data, or information without
the
prior consent of the client or employer except as authorized or
required by law or this Code.
d. Engineers shall not permit the use of their name or associate
in
business ventures with any person or firm that they believe is
engaged in fraudulent or dishonest enterprise.
e. Engineers shall not aid or abet the unlawful practice of
engineering
by a person or firm.
f. Engineers having knowledge of any alleged violation of this
Code
shall report thereon to appropriate professional bodies and,
when
relevant, also to public authorities, and cooperate with the
proper
authorities in furnishing such information or assistance as may
be
required.
2. Engineers shall perform services only in the areas of their
competence.
a. Engineers shall undertake assignments only when qualified
by
education or experience in the specific technical fields
involved.
b. Engineers shall not affix their signatures to any plans or
documents
dealing with subject matter in which they lack competence, nor
to
any plan or document not prepared under their direction and
control.
c. Engineers may accept assignments and assume responsibility
for
coordination of an entire project and sign and seal the
engineering
documents for the entire project, provided that each technical
segment is signed and sealed only by the qualified engineers
who
prepared the segment.
3. Engineers shall issue public statements only in an objective
and
truthful manner.
a. Engineers shall be objective and truthful in professional
reports,
statements, or testimony. They shall include all relevant and
pertinent information in such reports, statements, or testimony,
which should bear the date indicating when it was current.
b. Engineers may express publicly technical opinions that are
founded
upon knowledge of the facts and competence in the subject
matter.
c. Engineers shall issue no statements, criticisms, or arguments
on
technical matters that are inspired or paid for by interested
parties,
unless they have prefaced their comments by explicitly
identifying
the interested parties on whose behalf they are speaking, and by
revealing the existence of any interest the engineers may have
in the
matters.
9. Engineers shall give credit for engineering work to those to
whom
credit is due, and will recognize the proprietary interests of
others.
a. Engineers shall, whenever possible, name the person or
persons
who may be individually responsible for designs, inventions,
writings, or other accomplishments.
b. Engineers using designs supplied by a client recognize that
the
designs remain the property of the client and may not be
duplicated
by the engineer for others without express permission.
c. Engineers, before undertaking work for others in connection
with
which the engineer may make improvements, plans, designs,
inventions, or other records that may justify copyrights or
patents,
should enter into a positive agreement regarding ownership.
d. Engineers’ designs, data, records, and notes referring
exclusively to
an employer’s work are the employer’s property. The employer
should indemnify the engineer for use of the information for
any
purpose other than the original purpose.
e. Engineers shall continue their professional development
throughout
their careers and should keep current in their specialty fields by
engaging in professional practice, participating in continuing
education courses, reading in the technical literature, and
attending
professional meetings and seminars.
Footnote 1 “Sustainable development” is the challenge of
meeting human
needs for natural resources, industrial products, energy, food,
transportation, shelter, and effective waste management while
conserving and protecting environmental quality and the natural
resource base essential for future development.
As Revised July 2007
“By order of the United States District Court for the District of
Columbia,
former Section 11(c) of the NSPE Code of Ethics prohibiting
competitive
bidding, and all policy statements, opinions, rulings or other
guidelines
interpreting its scope, have been rescinded as unlawfully
interfering with the
legal right of engineers, protected under the antitrust laws, to
provide price
information to prospective clients; accordingly, nothing
contained in the NSPE
Code of Ethics, policy statements, opinions, rulings or other
guidelines prohibits
the submission of price quotations or competitive bids for
engineering services
at any time or in any amount.”
Statement by NSPE Executive Committee
In order to correct misunderstandings which have been indicated
in some
instances since the issuance of the Supreme Court decision and
the entry of the
Final Judgment, it is noted that in its decision of April 25,
1978, the Supreme
Court of the United States declared: “The Sherman Act does not
require
competitive bidding.”
It is further noted that as made clear in the Supreme Court
decision:
1. Engineers and firms may individually refuse to bid for
engineering services.
2. Clients are not required to seek bids for engineering services.
3. Federal, state, and local laws governing procedures to
procure engineering
services are not affected, and remain in full force and effect.
4. State societies and local chapters are free to actively and
aggressively seek
legislation for professional selection and negotiation procedures
by public
agencies.
5. State registration board rules of professional conduct,
including rules
prohibiting competitive bidding for engineering services, are
not affected and
remain in full force and effect. State registration boards with
authority to
adopt rules of professional conduct may adopt rules governing
procedures to
obtain engineering services.
6. As noted by the Supreme Court, “nothing in the judgment
prevents NSPE and
its members from attempting to influence governmental action .
. .”
3. Engineers shall avoid all conduct or practice that deceives the
public.
a. Engineers shall avoid the use of statements containing a
material
misrepresentation of fact or omitting a material fact.
b. Consistent with the foregoing, engineers may advertise for
recruitment of personnel.
c. Consistent with the foregoing, engineers may prepare articles
for
the lay or technical press, but such articles shall not imply
credit to
the author for work performed by others.
4. Engineers shall not disclose, without consent, confidential
information
concerning the business affairs or technical processes of any
present or
former client or employer, or public body on which they serve.
a. Engineers shall not, without the consent of all interested
parties,
promote or arrange for new employment or practice in
connection
with a specific project for which the engineer has gained
particular
and specialized knowledge.
b. Engineers shall not, without the consent of all interested
parties,
participate in or represent an adversary interest in connection
with a
specific project or proceeding in which the engineer has gained
particular specialized knowledge on behalf of a former client or
employer.
5. Engineers shall not be influenced in their professional duties
by
conflicting interests.
a. Engineers shall not accept financial or other considerations,
including free engineering designs, from material or equipment
suppliers for specifying their product.
b. Engineers shall not accept commissions or allowances,
directly or
indirectly, from contractors or other parties dealing with clients
or
employers of the engineer in connection with work for which
the
engineer is responsible.
6. Engineers shall not attempt to obtain employment or
advancement or
professional engagements by untruthfully criticizing other
engineers,
or by other improper or questionable methods.
a. Engineers shall not request, propose, or accept a commission
on a
contingent basis under circumstances in which their judgment
may
be compromised.
b. Engineers in salaried positions shall accept part-time
engineering
work only to the extent consistent with policies of the employer
and
in accordance with ethical considerations.
c. Engineers shall not, without consent, use equipment,
supplies,
laboratory, or office facilities of an employer to carry on
outside
private practice.
7. Engineers shall not attempt to injure, maliciously or falsely,
directly
or indirectly, the professional reputation, prospects, practice, or
employment of other engineers. Engineers who believe others
are
guilty of unethical or illegal practice shall present such
information
to the proper authority for action.
a. Engineers in private practice shall not review the work of
another
engineer for the same client, except with the knowledge of such
engineer, or unless the connection of such engineer with the
work
has been terminated.
b. Engineers in governmental, industrial, or educational employ
are
entitled to review and evaluate the work of other engineers
when so
required by their employment duties.
c. Engineers in sales or industrial employ are entitled to make
engineering comparisons of represented products with products
of
other suppliers.
8. Engineers shall accept personal responsibility for their
professional
activities, provided, however, that engineers may seek
indemnification
for services arising out of their practice for other than gross
negligence, where the engineer’s interests cannot otherwise be
protected.
a. Engineers shall conform with state registration laws in the
practice
of engineering.
b. Engineers shall not use association with a nonengineer, a
corporation, or partnership as a “cloak” for unethical acts.
Note: In regard to the question of application of the Code to
corporations vis-a-vis real persons, business form or type
should not negate nor
influence conformance of individuals to the Code. The Code
deals with professional services, which services must be
performed by real
persons. Real persons in turn establish and implement policies
within business structures. The Code is clearly written to apply
to the Engineer,
and it is incumbent on members of NSPE to endeavor to live up
to its provisions. This applies to all pertinent sections of the
Code.
1420 King Street
Alexandria, Virginia 22314-2794
703/684-2800 • Fax:703/836-4875
www.nspe.org
Publication date as revised: July 2007 • Publication #1102
ENGR 110 – Spring 2020
Assignment #7 – Engineering Ethics – The Challenger Disaster
Write a 500 word or more essay about the Challenger Disaster
engineering ethics case. For information on the subject,
you are only allowed to use the pdf files posted on Moodle
along with this HW assignment.
Additional information you can get from the YouTube video at:
https://www.youtube.com/watch?v=QbtY_Wl-hYI
Your essay should have 6 parts:
Part 1. State the Ethics Case Title.
Part 2. Discuss the historical events (what happened).
Part 3. Discuss why it happened (what caused the accident).
Part 4. Discuss the ethical issues involved in the incident.
Part 5. What was the aftermath.
Part 6. Present/discuss your personal thoughts about this case.
Your essay must clearly separate the topics into Part 1, Part 2,
Part 3, Part 4, etc. Watch out for PLAGIARISM.
Plagiarism will not be tolerated. You will automatically receive
an (F) grade on your assignment if you plagiarize. Your
essay MUST give enough information so the reader can
understand what happened, what caused the collapse, and what
are the ethical issues involved in the incident.
• Your essay must be typed, 12-point letters, Arial font, double
spaced.
• Minimum word length: 500 words.
• All pages must be stapled when they are returned for grading.
• Due date: During regular class time the week of April 6th.
Note: Your work will primarily be graded on quality of content
(clear description of case plus supporting evidence) and
how well the sources are used. Grammar and other mechanical
errors will be judged on how seriously they interfere with
the presentation of your ideas. Ethical use of sources is
especially important. The grading rubric has also been posted so
you can get an idea of how your work will be graded.
ENGR 100 – Spring 2020
Assignment #7
Name:
Student ID:
Date Submitted:
Due Date: Tuesday, April 7, 2020

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ENGINEERING ETHICSThe Space Shuttle Challenger Disaster.docx

  • 1. ENGINEERING ETHICS The Space Shuttle Challenger Disaster Department of Philosophy and Department of Mechanical Engineering Texas A&M University NSF Grant Number DIR-9012252 Instructor's Guide Introduction To The Case On January 28, 1986, seven astronauts were killed when the space shuttle they were piloting, the Challenger, exploded just over a minute into the flight. The failure of the solid rocket booster O-rings to seat properly allowed hot combustion gases to leak from the side of the booster and burn through the external fuel tank. The failure of the O-ring was attributed to several factors, including faulty design of the solid rocket boosters, insufficient low- temperature testing of the O-ring material and the joints that the O-ring sealed, and lack of proper communication between different levels of NASA
  • 2. management. Instructor Guidelines Prior to class discussion, ask the students to read the student handout outside of class. In class the details of the case can be reviewed with the aide of the overheads. Reserve about half of the class period for an open discussion of the issues. The issues covered in the student handout include the importance of an engineer's responsibility to public welfare, the need for this responsibility to hold precedence over any other responsibilities the engineer might have and the responsibilities of a manager/engineer. A final point is the fact that no matter how far removed from the public an engineer may think she is, all of her actions have potential impact. Essay #6, "Loyalty and Professional Rights" appended at the end of the case listings in this report will be found relevant for instructors preparing to lead class discussion on this case. In addition, essays #1 through #4 appended at the end of the cases in this report will have relevant background information for the instructor preparing to lead classroom discussion. Their titles are, respectively: "Ethics and Professionalism in Engineering: Why the Interest in Engineering Ethics?;" "Basic Concepts and Methods in Ethics," "Moral Concepts and Theories," and
  • 3. "Engineering Design: Literature on Social Responsibility Versus Legal Liability." Questions for Class Discussion 1. What could NASA management have done differently? 2. What, if anything, could their subordinates have done differently? 3. What should Roger Boisjoly have done differently (if anything)? In answering this question, keep in mind that at his age, the prospect of finding a new job if he was fired was slim. He also had a family to support. 4. What do you (the students) see as your future engineering professional responsibilities in relation to both being loyal to management and protecting the public welfare? The Challenger Disaster Overheads 1. Organizations/People Involved 2. Key Dates 3. Space Shuttle Solid Rocket Boosters (SRB) Joints 4. Detail of SRB Field Joints 5. Ballooning Effect of Motor Casing 6. Key Issues
  • 4. ORGANIZATIONS/PEOPLE INVOLVED Marshall Space Flight Center - in charge of booster rocket development Larry Mulloy - challenged the engineers' decision not to launch Morton Thiokol - Contracted by NASA to build the Solid Rocket Booster Alan McDonald - Director of the Solid Rocket Motors Project Bob Lund - Engineering Vice President Robert Ebeling - Engineer who worked under McDonald Roger Boisjoly - Engineer who worked under McDonald Joe Kilminster - Engineer in a management position Jerald Mason - Senior executive who encouraged Lund to reassess his decision not to launch. KEY DATES 1974 - Morton-Thiokol awarded contract to build solid rocket boosters. 1976 - NASA accepts Morton-Thiokol's booster design. 1977 - Morton-Thiokol discovers joint rotation problem. November 1981 - O-ring erosion discovered after second shuttle flight. January 24, 1985 - shuttle flight that exhibited the worst O-ring blow-by. July 1985 - Thiokol orders new steel billets for new field joint design.
  • 5. August 19, 1985 - NASA Level I management briefed on booster problem. January 27, 1986 - night teleconference to discuss effects of cold temperature on booster performance. January 28, 1986 - Challenger explodes 72 seconds after liftoff. KEY ISSUES HOW DOES THE IMPLIED SOCIAL CONTRACT OF PROFESSIONALS APPLY TO THIS CASE? WHAT PROFESSIONAL RESPONSIBILITIES WERE NEGLECTED, IF ANY? SHOULD NASA HAVE DONE ANYTHING DIFFERENTLY IN THEIR LAUNCH DECISION PROCEDURE? Student Handout - Synopsis On January 28, 1986, seven astronauts were killed when the space shuttle they were piloting, the Challenger, exploded just over a minute into flight. The failure of the solid rocket booster O-rings to seat properly allowed hot combustion gases to leak from the side of the booster and burn through the external fuel tank. The failure of the O-ring was attributed to several factors, including faulty design of the solid rocket boosters, insufficient low temperature testing of the O-ring material and the joints that the O-ring sealed, and lack of communication
  • 6. between different levels of NASA management. Organization and People Involved Marshall Space Flight Center - in charge of booster rocket development Larry Mulloy - challenged the engineers' decision not to launch Morton Thiokol - Contracted by NASA to build the Solid Rocket Booster Alan McDonald - Director of the Solid Rocket Motors Project Bob Lund - Engineering Vice President Robert Ebeling - Engineer who worked under McDonald Roger Boisjoly - Engineer who worked under McDonald Joe Kilminster - Engineer in a management position Jerald Mason - Senior Executive who encouraged Lund to reassess his decision not to launch. Key Dates 1974 - Morton-Thiokol awarded contract to build solid rocket boosters. 1976 - NASA accepts Morton-Thiokol's booster design. 1977 - Morton-Thiokol discovers joint rotation problem. November 1981 - O-ring erosion discovered after second shuttle flight. January 24, 1985 - shuttle flight that exhibited the worst O- ring blow-by. July 1985 - Thiokol orders new steel billets for new field joint design.
  • 7. August 19, 1985 - NASA Level I management briefed on booster problem. January 27, 1986 - night teleconference to discuss effects of cold temperature on booster performance. January 28, 1986 - Challenger explodes 72 seconds after liftoff. Background NASA managers were anxious to launch the Challenger for several reasons, including economic considerations, political pressures, and scheduling backlogs. Unforeseen competition from the European Space Agency put NASA in a position where it would have to fly the shuttle dependably on a very ambitious schedule in order to prove the Space Transportation System's cost effectiveness and potential for commercialization. This prompted NASA to schedule a record number of missions in 1986 to make a case for its budget requests. The shuttle mission just prior to the Challenger had been delayed a record number of times due to inclement weather and mechanical factors. NASA wanted to launch the Challenger without any delays so the launch pad could be refurbished in time for the next mission, which would be carrying a probe that would examine Halley's Comet. If launched on time, this probe would have collected data a few days before a similar Russian probe would be launched. There was probably also pressure to launch Challenger so it could be in space when President Reagan gave his State of the Union address. Reagan's main
  • 8. topic was to be education, and he was expected to mention the shuttle and the first teacher in space, Christa McAuliffe. The shuttle solid rocket boosters (or SRBs), are key elements in the operation of the shuttle. Without the boosters, the shuttle cannot produce enough thrust to overcome the earth's gravitational pull and achieve orbit. There is an SRB attached to each side of the external fuel tank. Each booster is 149 feet long and 12 feet in diameter. Before ignition, each booster weighs 2 million pounds. Solid rockets in general produce much more thrust per pound than their liquid fuel counterparts. The drawback is that once the solid rocket fuel has been ignited, it cannot be turned off or even controlled. So it was extremely important that the shuttle SRBs were properly designed. Morton Thiokol was awarded the contract to design and build the SRBs in 1974. Thiokol's design is a scaled- up version of a Titan missile which had been used successfully for years. NASA accepted the design in 1976. The booster is comprised of seven hollow metal cylinders. The solid rocket fuel is cast into the cylinders at the Thiokol plant in Utah, and the cylinders are assembled into pairs for transport to Kennedy Space Center in Florida. At KSC, the four booster segments are assembled into a completed booster rocket. The joints where the segments are joined together at KSC are
  • 9. known as field joints (See Figure 1). These field joints consist of a tang and clevis joint. The tang and clevis are held together by 177 clevis pins. Each joint is sealed by two O rings, the bottom ring known as the primary O- ring, and the top known as the secondary O-ring. (The Titan booster had only one O-ring. The second ring was added as a measure of redundancy since the boosters would be lifting humans into orbit. Except for the increased scale of the rocket's diameter, this was the only major difference between the shuttle booster and the Titan booster.) The purpose of the O-rings is to prevent hot combustion gasses from escaping from the inside of the motor. To provide a barrier between the rubber O-rings and the combustion gasses, a heat resistant putty is applied to the inner section of the joint prior to assembly. The gap between the tang and the clevis determines the amount of compression on the O-ring. To minimize the gap and increase the squeeze on the O-ring, shims are inserted between the tang and the outside leg of the clevis. Launch Delays The first delay of the Challenger mission was because of a weather front expected to move into the area, bringing rain and cold temperatures. Usually a mission wasn't postponed until inclement weather actually entered the area, but the Vice President was expected to be present for the launch and NASA officials wanted to avoid
  • 10. the necessity of the Vice President's having to make an unnecessary trip to Florida; so they postponed the launch early. The Vice President was a key spokesperson for the President on the space program, and NASA coveted his good will. The weather front stalled, and the launch window had perfect weather conditions; but the launch had already been postponed to keep the Vice President from unnecessarily traveling to the launch site. The second launch delay was caused by a defective micro switch in the hatch locking mechanism and by problems in removing the hatch handle. By the time these problems had been sorted out, winds had become too high. The weather front had started moving again, and appeared to be bringing record-setting low temperatures to the Florida area. NASA wanted to check with all of its contractors to determine if there would be any problems with launching in the cold temperatures. Alan McDonald, director of the Solid Rocket Motor Project at Morton- Thiokol, was convinced that there were cold weather problems with the solid rocket motors and contacted two of the engineers working on the project, Robert Ebeling and Roger Boisjoly. Thiokol knew there was a problem with the boosters as early as 1977, and had initiated a redesign effort in 1985. NASA Level I management had been briefed on the problem on August 19, 1985. Almost half of the shuttle flights had experienced O-ring
  • 11. erosion in the booster field joints. Ebeling and Boisjoly had complained to Thiokol that management was not supporting the redesign task force. Engineering Design The size of the gap is controlled by several factors, including the dimensional tolerances of the metal cylinders and their corresponding tang or clevis, the ambient temperature, the diameter of the O-ring, the thickness of the shims, the loads on the segment, and quality control during assembly. When the booster is ignited, the putty is displaced, compressing the air between the putty and the primary O-ring. The air pressure forces the O-ring into the gap between the tang and clevis. Pressure loads are also applied to the walls of the cylinder, causing the cylinder to balloon slightly. This ballooning of the cylinder walls caused the gap between the tang and clevis gap to open. This effect has come to be known as joint rotation. Morton-Thiokol discovered this joint rotation as part of its testing program in 1977. Thiokol discussed the problem with NASA and started analyzing and testing to determine how to increase the O-ring compression, thereby decreasing the effect of joint rotation. Three design changes were implemented:
  • 12. 1. Dimensional tolerances of the metal joint were tightened. 2. The O-ring diameter was increased, and its dimensional tolerances were tightened. 3. The use of the shims mentioned above was introduced. Further testing by Thiokol revealed that the second seal, in some cases, might not seal at all. Additional changes in the shim thickness and O-ring diameter were made to correct the problem. A new problem was discovered during November 1981, after the flight of the second shuttle mission. Examination of the booster field joints revealed that the O-rings were eroding during flight. The joints were still sealing effectively, but the O-ring material was being eaten away by hot gasses that escaped past the putty. Thiokol studied different types of putty and its application to study their effects on reducing O-ring erosion. The shuttle flight 51-C of January 24, 1985, was launched during some of the coldest weather in Florida history. Upon examination of the booster joints, engineers at Thiokol noticed black soot and grease on the outside of the booster casing, caused by actual gas blow-by. This prompted Thiokol to study the effects of O-ring resiliency at low temperatures. They conducted laboratory tests of O-ring compression and resiliency between 50lF and 100lF. In July 1985, Morton Thiokol ordered new steel billets which would be used for a redesigned case field
  • 13. joint. At the time of the accident, these new billets were not ready for Thiokol, because they take many months to manufacture. 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.1 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
  • 14. 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
  • 15. 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
  • 16. 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. The Launch During the night, temperatures dropped to as low as 8°F, much lower than had been anticipated. In order to keep the water pipes in the launch platform from freezing, safety showers and fire hoses had been turned on. Some of this water had accumulated, and ice had formed all over the platform. There was some concern that the ice would fall off of the platform during launch and might damage the heat resistant tiles on the shuttle. The ice inspection team thought the situation was of great concern, but the launch director decided to go ahead with the countdown. Note that safety limitations on low temperature launching had to be waived and authorized by key personnel several times during the final countdown. These key personnel were not aware of the teleconference about the solid rocket boosters that had taken place the night before. At launch, the impact of ignition broke loose a shower of ice from the launch platform. Some of the ice struck the left-hand booster, and some ice was
  • 17. actually sucked into the booster nozzle itself by an aspiration effect. Although there was no evidence of any ice damage to the Orbiter itself, NASA analysis of the ice problem was wrong. The booster ignition transient started six hundredths of a second after the igniter fired. The aft field joint on the right-hand booster was the coldest spot on the booster: about 28°F. The booster's segmented steel casing ballooned and the joint rotated, expanding inward as it had on all other shuttle flights. The primary O-ring was too cold to seat properly, the cold-stiffened heat resistant putty that protected the rubber O-rings from the fuel collapsed, and gases at over 5000°F burned past both O-rings across seventy degrees of arc. Eight hundredths of a second after ignition, the shuttle lifted off. Engineering cameras focused on the right-hand booster showed about nine smoke puffs coming from the booster aft field joint. Before the shuttle cleared the tower, oxides from the burnt propellant temporarily sealed the field joint before flames could escape. Fifty-nine seconds into the flight, Challenger experienced the most violent wind shear ever encountered on a shuttle mission. The glassy oxides that sealed the field joint were shattered by the stresses of the wind shear, and within seconds flames from the field joint burned through the external fuel tank. Hundreds of tons of propellant ignited, tearing apart the
  • 18. shuttle. One hundred seconds into the flight, the last bit of telemetry data was transmitted from the Challenger. Issues For Discussion The Challenger disaster has several issues which are relevant to engineers. These issues raise many questions which may not have any definite answers, but can serve to heighten the awareness of engineers when faced with a similar situation. One of the most important issues deals with engineers who are placed in management positions. It is important that these managers not ignore their own engineering experience, or the expertise of their subordinate engineers. Often a manager, even if she has engineering experience, is not as up to date on current engineering practices as are the actual practicing engineers. She should keep this in mind when making any sort of decision that involves an understanding of technical matters. Another issue is the fact that managers encouraged launching due to the fact that there was insufficient low temperature data. Since there was not enough data available to make an informed decision, this was not, in their opinion, grounds for stopping a launch. This was a reversal in the thinking that went on in the early years of the space program, which discouraged
  • 19. launching until all the facts were known about a particular problem. This same reasoning can be traced back to an earlier phase in the shuttle program, when upper-level NASA management was alerted to problems in the booster design, yet did not halt the program until the problem was solved. To better understand the responsibility of the engineer, some key elements of the professional responsibilities of an engineer should be examined. This will be done from two perspectives: the implicit social contract between engineers and society, and the guidance of the codes of ethics of professional societies. As engineers test designs for ever-increasing speeds, loads, capacities and the like, they must always be aware of their obligation to society to protect the public welfare. After all, the public has provided engineers, through the tax base, with the means for obtaining an education and, through legislation, the means to license and regulate themselves. In return, engineers have a responsibility to protect the safety and well-being of the public in all of their professional efforts. This is part of the implicit social contract all engineers have agreed to when they accepted admission to an engineering college. The first canon in the ASME Code of Ethics urges engineers to "hold paramount the safety, health and welfare of the public in the performance of their professional duties." Every major
  • 20. engineering code of ethics reminds engineers of the importance of their responsibility to keep the safety and well being of the public at the top of their list of priorities. Although company loyalty is important, it must not be allowed to override the engineer's obligation to the public. Marcia Baron, in an excellent monograph on loyalty, states: "It is a sad fact about loyalty that it invites...single- mindedness. Single-minded pursuit of a goal is sometimes delightfully romantic, even a real inspiration. But it is hardly something to advocate to engineers, whose impact on the safety of the public is so very significant. Irresponsibility, whether caused by selfishness or by magnificently unselfish loyalty, can have most unfortunate consequences." Annotated Bibliography and Suggested References Feynman, Richard Phillips, What Do You Care What Other People Think,: Further Adventures of a Curious Character, Bantam Doubleday Dell Pub, ISBN 0553347845, Dec 1992. Reference added by request of Sharath Bulusu, as being pertinent and excellent reading - 8-25- 00. Lewis, Richard S., Challenger: the final voyage, Columbia University Press, New York, 1988. McConnell, Malcolm, Challenger: a major malfunction,
  • 21. Doubleday, Garden City, N.Y., 1987. Trento, Joseph J., Prescription for disaster, Crown, New York, c1987. United States. Congress. House. Committee on Science and Technology, Investigation of the Challenger accident : hearings before the Committee on Science and Technology, U.S. House of Representatives, Ninety-ninth Congress, second session .... U.S. G.P.O.,Washington, 1986. United States. Congress. House. Committee on Science and Technology, Investigation of the Challenger accident : report of the Committee on Science and Technology, House of Representatives, Ninety-ninth Congress, second session. U.S. G.P.O., Washington, 1986. United States. Congress. House. Committee on Science, Space, and Technology, NASA's response to the committee's investigation of the " Challenger" accident : hearing before the Committee on Science, Space, and Technology, U.S. House of Representatives, One hundredth Congress, first session, February 26, 1987. U.S. G.P.O., Washington, 1987. United States. Congress. Senate. Committee on Commerce, Science, and Transportation. Subcommittee on
  • 22. Science, Technology, and Space, Space shuttle accident : hearings before the Subcommittee on Science, Technology, and Space of the Committee on Commerce, Science, and Transportation, United States Senate, Ninety-ninth Congress, second session, on space shuttle accident and the Rogers Commission report, February 18, June 10, and 17, 1986. U.S. G.P.O., Washington, 1986. Notes 1. "Challenger: A Major Malfunction." (see above) p. 194. 2. Baron, Marcia. The Moral Status of Loyalty. Illinois Institute of Technology: Center for the Study of Ethics in the Professions, 1984, p. 9. One of a series of monographs on applied ethics that deal specifically with the engineering profession. Provides arguments both for and against loyalty. 28 pages with notes and an annotated bibliography. Engineering Ethics Case Study:
  • 23. The Challenger Disaster Course No: LE3-001 Credit: 3 PDH Mark Rossow, PhD, PE, Retired Continuing Education and Development, Inc. 9 Greyridge Farm Court Stony Point, NY 10980 P: (877) 322-5800 F: (877) 322-4774 [email protected]om Engineering Ethics Case Study: The Challenger Disaster
  • 24. Mark P. Rossow, P.E., Ph.D. 2 © 2012 Mark P. Rossow All rights reserved. No part of this work may be reproduced in any manner without the written permission of the author.
  • 25. 3 Preface On January 28, 1986, the Space Shuttle Challenger burst into flame shortly after liftoff. All passengers aboard the vehicle were killed. A presidential commission was formed to investigate the cause of the accident and found that the O-ring seals had failed, and, furthermore, that the seals had been recognized as a potential hazard for several years prior to the disaster. The commission’s report, Report to the President by the Presidential Commission on the Space Shuttle Challenger Accident, stated that because managers and engineers had known in advance of the O-ring danger, the accident was principally caused by a lack of communication between engineers and management and by poor management practices. This became the standard interpretation of the cause of the Challenger disaster and routinely appears in popular articles and books about engineering, management, and ethical issues.
  • 26. But the interpretation ignores much of the history of how NASA and the contractor’s engineers had actually recognized and dealt with the O-ring problems in advance of the disaster. When this history is considered in more detail, the conclusions of the Report to the President become far less convincing. Two excellent publications that give a much more complete account of events leading up to the disaster are The Challenger Launch Decision by Diane Vaughan, and Power To Explore -- History of Marshall Space Flight Center 1960-1990 by Andrew Dunar and Stephen Waring. As Dunar and Waring put it—I would apply their remarks to Vaughan’s work as well— “Allowing Marshall engineers and managers to tell their story, based on pre-accident documents and on post-accident testimony and interviews, leads to a more realistic account of the events leading up to the accident than that found in the previous studies.” I would strongly encourage anyone with the time and interest to read both of these publications, which are outstanding works of scholarship. For those persons lacking the time—the Vaughan book is over 550 pages—I have written the present condensed
  • 27. description of the Challenger incident. I have drawn the material for Sections 1-8 and 10 from multiple sources but primarily from Vaughan, the Report to the President, and Dunnar and Waring. Of course, any errors introduced during the process of fitting their descriptions and ideas into my narrative are mine and not the fault of these authors. Sections 9, 11, and 12 are original contributions of my own. All figures have been taken from Report to the President. Mark Rossow 4 Introduction Course Content This course provides instruction in engineering ethics through a case study of the Space Shuttle
  • 28. Challenger disaster. The course begins by presenting the minimum technical details needed to understand the physical cause of the Shuttle failure. The disaster itself is chronicled through NASA photographs. Next the decision-making process— especially the discussions occurring during the teleconference held on the evening before the launch—is described. Direct quotations from engineers interviewed after the disaster are frequently used to illustrate the ambiguities of the data and the pressures that the decision-makers faced in the period preceding the launch. The course culminates in an extended treatment of six ethical issues raised by Challenger. Purpose of Case Studies Principles of engineering ethics are easy to formulate but sometimes hard to apply. Suppose, for example, that an engineering team has made design choice X, rather than Y, and X leads to a bad consequence—someone was injured. To determine if the engineers acted ethically, we have to answer the question of whether they chose X rather than Y because 1) X appeared to be the
  • 29. better technical choice, or 2) X promoted some other end (for example, financial) in the organization. Abstract ethics principles alone cannot answer this question; we must delve into the technical details surrounding the decision. The purpose of case studies in general is to provide us with the context—the technical details—of an engineering decision in which an ethical principle may have been violated. Case Study of Challenger Disaster On January 28, 1986, the NASA space Shuttle Challenger burst into a ball of flame 73 seconds after take-off, leading to the death of the seven people on board. Some months later, a commission appointed by the President to investigate the causes of the disaster determined that the cause of the disaster was the failure of a seal in one of the solid rocket boosters (Report to the President 1986, vol. 1, p. 40). Furthermore, Morton Thiokol, the contractor responsible for the seal design, had initiated a teleconference with NASA on the evening before the launch and had, at the beginning of the teleconference, recommended against
  • 30. launching because of concerns about the performance of the seal. This recommendation was reversed during the teleconference, with fatal consequences. To understand the decisions that led to the Challenger disaster, you must first understand what the technical problems were. Accordingly, this course begins by presenting the minimum technical details you will need to understand the physical cause of the seal failure. After laying this groundwork, we examine what occurred in the teleconference. You will probably find, as you learn more and more about the Challenger project, that issues that had appeared simple initially are actually far more complex; pinpointing responsibility and assigning blame are not nearly as easy as many popular accounts have made them. The purpose of the present course is 1) to consider some of the issues and show by example how difficult it can be to distinguish unethical behavior from technical mistakes (with severe consequences), and 2) to equip you to think critically and act appropriately when confronted with
  • 31. ethical decisions in your own professional work. 5 The course is divided into the following topics: 1. Two Common Errors of Interpretation 2. Configuration of Shuttle 3. Function of O-rings 4. History of Problems with Joint Seals 5. Teleconference 6. Accident 7. Ethical issue: Did NASA take extra risks because of pressure to maintain Congressional funding? 8. Ethical issue: Did Thiokol take extra risks because of fear of losing its contract with NASA? 9. Ethical issue: Was the Principle of Informed Consent violated? 10. Ethical issue: What role did whistle blowing have in the Challenger story? 11. Ethical issue: Who had the right to Thiokol documents relating to the Challenger disaster?
  • 32. 12. Ethical issue: Why are some engineering disasters considered ethical issues and others are not? 13. Summary 1. Two Common Errors of Interpretation Persons studying the history of an engineering disaster must be alert to the danger of committing one of the following common errors: 1) the myth of perfect engineering practice, and 2) the retrospective fallacy. The Myth of Perfect Engineering Practice The sociologist, Diane Vaughan, who has written one of the most thorough books on Challenger, has pointed out that the mere act of investigating an accident can cause us to view, as ominous, facts and events that we otherwise would consider normal: “When technical systems fail, … outside investigators consistently find an engineering world characterized by ambiguity, disagreement, deviation from design specifications and operating standards, and ad hoc rule making. This messy situation, when revealed to the public,
  • 33. automatically becomes an explanation for the failure, for after all, the engineers and managers did not follow the rules. … [On the other hand,] the engineering process behind a ‘nonaccident’ is never publicly examined. If nonaccidents were investigated, the public would discover that the messy interior of engineering practice, which after an accident investigation looks like ‘an accident waiting to happen,’ is nothing more or less than ‘normal technology.” (Vaughan 1996, p. 200) Thus as you read the description of the Challenger disaster on the pages to follow, keep in mind that just because some of the engineering practices described are not neat and tidy processes in which consensus is always achieved and decisions are always based on undisputed and unambiguous data, that fact alone may not explain the disaster; such practices may simply be part of normal technology—that usually results in a nonaccident. The Retrospective Fallacy Engineering projects sometimes fail. If the failure involves enough money or injuries to
  • 34. innocent people, then investigators may be brought in to determine the causes of the failure and 6 identify wrongdoers. The investigators then weave a story explaining how decision-makers failed to assess risks properly, failed to heed warning signs, used out-of-date information, ignored quality-control, took large risks for personal gain, etc. But there is a danger here: the story is constructed by selectively focusing on those events that are known to be important in retrospect, that is, after the failure has occurred and observers look back at them. At the time that the engineers were working on the project, these events may not have stood out from dozens or even hundreds of other events. “Important” events do not come labeled “PARTICULARLY IMPORTANT: PAY ATTENTION”; they may appear important only in retrospect. To the extent that we retrospectively identify events as particularly important—even though they may
  • 35. not have been thought particularly important by diligent and competent people working at the time—we are committing the “retrospective fallacy.” (Vaughan 1996, p. 68-70) In any discussion of the Challenger disaster, the tendency to commit the retrospective fallacy exists, because we all know the horrendous results of the decisions that were made—and our first reaction is to say, “How could they have ignored this?” or, “Why didn’t they study that more carefully?” But to understand what happened, it is crucial to put yourself in the place of the engineers and to focus on what they knew and what they thought to be important at the time. For example, NASA classified 745 components on the Shuttle as “Criticality 1”, meaning failure of the component would cause the loss of the crew, mission, and vehicle (NASA’s Response to the Committee’s Investigation of the “Challenger” Accident 1987). With the advantage of 20-20 hindsight, we now know that the engineers made a tragic error in judging the possibility of failure of a particular one of those 745 components—the seals— an “acceptable risk.” But at the
  • 36. time, another issue—problems with the Shuttle main engines— attracted more concern (McDonald 2009, pp. 64-65). Similarly, probably most of the decisions made by the Shuttle engineers and managers were influenced to some extent by considerations of cost. As a result, after the disaster it was a straightforward matter to pick out specific decisions and claim that the decision-makers had sacrificed safety for budgetary reasons. But our 20-20 hindsight was not available to the people involved in the Challenger project, and as we read the history we should continually ask questions such as “What did they know at the time?,” “Is it reasonable to expect that they should have seen the significance of this or that fact?,” and “If I were in their position and knew only what they knew, what would I have done?” Only through such questions can we hope to understand why the Challenger disaster occurred and to evaluate its ethical dimensions. 2. Configuration of Shuttle. NASA had enjoyed widespread public support and generous funding for the Apollo program to
  • 37. put a man on the moon. But as Apollo neared completion and concerns about the cost of the Vietnam War arose, continued congressional appropriations for NASA were in jeopardy. A new mission for NASA was needed, and so the Space Shuttle program was proposed. The idea was to development an inexpensive (compared to Apollo) system for placing human beings and hardware in orbit. The expected users of the system would be commercial and academic experimenters, the military, and NASA itself. On January 5, 1972, President Nixon announced the government’s approval of the Shuttle program. 7 Fig. 1 Configuration of the Shuttle Because a prime goal was to keep costs down, reusable space vehicles were to be developed. After many design proposals and compromises—for example, the Air Force agreed not to
  • 38. develop any launch vehicles of its own, provided that the Shuttle was designed to accommodate military needs—NASA came up with the piggyback design shown in Figure 1. The airplane-like craft (with the tail fin) shown in side view on the right side of the figure is the “Orbiter.” The Orbiter contains the flight crew and a 60 feet long and 15 feet wide payload bay designed to hold cargo such as communications satellites to be launched into orbit, an autonomous Spacelab to be used for experiments in space, or satellites already orbiting that have been retrieved for repairs. Before launch, the Orbiter is attached to the large (154 feet long and 27 1/2 feet in diameter) External Tank—the middle cylinder with the sharp-pointed end shown in the figure; the External 8 Tank contains 143,000 gallons of liquid oxygen and 383,000 gallons of liquid hydrogen for the Orbiter's engines.
  • 39. The two smaller cylinders on the sides of the External Tank are the Solid Rocket Boosters (SRBs). The SRBs play a key role in the Challenger accident and accordingly will be described here in some detail. The SRBs contain solid fuel, rather than the liquid fuel contained by the External Tank. The SRBs provide about 80 percent of the total thrust at liftoff; the remainder of the thrust is provided by the Orbiter's three main engines. Morton-Thiokol Inc. held the contract for the development of the SRBs. The SRBs fire for about two minutes after liftoff, and then, their fuel exhausted, are separated from the External Tank. A key goal of the Shuttle design was to save costs by re-using the SRBs and the Orbiter. The conical ends of the SRBs contain parachutes that are deployed, after the SRBs have been separated from the External Tank, and allow the SRBs to descend slowly to the ocean below. The SRBs are then picked out of the water by recovery ships and taken to repair
  • 40. facilities, where preparations are made for the next flight. After the SRBs are detached, the Orbiter’s main engines continue firing until it achieves low earth orbit. Then the External Tank is jettisoned towards earth where it burns up in the atmosphere—the External Tank is not re- used. Once the crew has completed its mission in orbit, the Orbiter returns to earth where it glides (No propulsion is used.) to a landing on a conventional airstrip. The Orbiter can then be refurbished for its next launch. More Details about the SRBs Fig. 2 Solid Rocket Booster with Exploded View Showing Segments and Joints 9 Figure 2 shows the subassemblies that make up the SRB. Because the total length of the SRB was almost 150 feet, it was too large to ship as a single unit by
  • 41. rail from Thiokol’s manufacturing facility in Utah to the Kennedy Space Center launch site in Florida. Furthermore, shipping the SRB as a single unit would mean that a large amount of rocket fuel would be concentrated in a single container—creating the potential for an enormous explosion. For these reasons, Thiokol manufactured the SRB from individual cylindrical segments each approximately 12 feet in diameter. At Thiokol’s plant in Utah, individual segments were welded together to form four “casting” segments, into which propellant was poured (cast). The welded joints within a casting segment were called “factory joints.” The four casting segments were then shipped individually by rail to Kennedy, where they were assembled—by stacking, not welding—to form the solid rocket motor (SRM) of the SRB. The joints created by the assembly process at Kennedy were called “field joints.” The sealing problem that led to the Challenger’s destruction occurred in the field joint at the right end of the AFT MID SEGMENT in Figure 2. Hot combustion gases from the SRM leaked through the joint
  • 42. and either weakened or burned a hole in the External Tank, igniting the contents of the Tank and producing a catastrophic fireball. 3. Function of O-rings The cutaway view of the SRB in Figure 3 shows the aft field joint location in the assembled SRB. Fig. 3. Location of the Problematic Aft Field Joint 10 Fig. 4. Cross Section of Field Joint Figure 4 shows how the upper SRM segment in a field joint is connected to the lower segment by a pin passing through the “tang” (the tongue on the upper segment) and the “clevis” (the U- shaped receptacle cut in the lower segment); 177 such steel pins are inserted around the
  • 43. circumference of each joint. When the propellant is burning and generating hot combustion gases under the enormous pressure necessary to accelerate the SRB, the joint must be sealed to prevent the gases from leaking and possibly damaging exterior parts of the Shuttle. This sealing is accomplished by a primary O-ring backed up by a secondary O-ring (O-rings are widely used in machine design and, when functioning properly, can seal pressures in the range of thousands of psi). An SRM O-ring has been compared to “a huge length of licorice—same color, same diameter (only 0.28”)—joined at the ends so it forms a circle 12’ across” (Vaughan 1996, p. 40). SRM O-rings were made of a rubberlike synthetic material called Viton. To prevent the hot combustion gases from contacting and thus degrading the Viton when the propellant was ignited, zinc chromate putty was applied in the region shown in Figure 4 prior to assembly of the SRM segments.
  • 44. 11 Fig. 5. Effect of Compression of the O-ring in Inhibiting Pressure Actuation Pressure Actuation of the O-ring Seal Besides protecting the O-rings from the corrosive effects of the hot combustion gases, the putty is intended to be pushed outward from the combustion chamber during ignition, compress the air ahead of the primary O-ring, and thus force the O-ring into the tang-clevis gap, thereby sealing the gap. This process is referred to as “pressure-actuated sealing.” Experiments show that pressure actuation is most effective when the high-pressure air acts over the largest possible portion of the high-pressure side of the O-ring. In the leftmost sketch in Figure 5, for example, the high-pressure side extends from the “Response Node” at the top to the point of tangency at the bottom of the groove. If, however, the O-ring is initially compressed during assembly, then
  • 45. the O-ring may deform sufficiently to cause contact with the left-hand side of the groove, as shown in the rightmost sketch in Figure 5. In that case, the high-pressure air acts over only the surface of the upper left-hand side of the O-ring, and pressure actuation of the seal is impaired. This problem is lessened if, upon ignition, the joint gap opens, and the O-ring is able to spring back elastically and lose contact with sides of the groove, as in the middle sketch in Figure 5. However, when the temperature is low, the O-ring loses much of its elasticity and as a result may retain its compressed shape, as in the right-hand sketch of Figure 5. This retention of the compressed shape has three unfortunate consequences: 1) pressure actuation is delayed or impaired because the high-pressure air cannot get to the lower left-hand side of the O-ring, 2) pressure actuation is delayed or impaired because the O-ring does not seal the opened gap, and the actuation pressure on the O-ring decreases as the fluid is able to pass by the O-ring, and 3) because of the lack of sealing, compressed air, putty, and then hot combustion gas may blow
  • 46. by through the gap, and in the process, damage or even destroy the O-ring. In general, pressure actuation was also affected negatively by several other factors, such as the behavior of the putty and the increase in gap size caused by re- use of the SRM. From consideration of all these factors and from observation of the explosion, the Presidential Commission concluded ”that the cause of the Challenger accident was the failure of the pressure seal in the aft field joint of the right Solid Rocket Motor [Italics in the original]. The failure was due to a faulty design unacceptably sensitive to a number of factors. These factors were the 12 effects of temperature, physical dimensions, the character of materials, the effects of reusability, processing, and the reaction of the joint to dynamic loading.” (Report to the President 1986, vol. 1, p. 69) 4. History of Problems with Joint Seals
  • 47. From the very beginning, in 1973, of Thiokol’s contract to develop the SRM, problems arose with the joints. The Thiokol design for the SRM was based on the Air Force’s Titan III, one of the most reliable solid-fuel rockets produced up to that time. But Thiokol engineers could not simply copy the Titan design—the SRM was larger than the Titan’s motor and had to be designed for refurbishment and repeated use. One particular area in which the two motors differed was the field joints, and Thiokol’s initial design for the SRM field joints worried engineers at the Marshall Space Flight Center, who were responsible for monitoring Thiokol’s contract. Many modifications and reviews of the design ensued, and Thiokol and Marshall finally began various load tests in 1976. Early tests were successful and gave engineers confidence. In an important test in 1977, however, the joint seals surprised the engineers by exhibiting “joint rotation,” illustrated in Fig. 6. Of particular concern is the loss of redundancy in the design because not just the primary but also the secondary O-ring is rendered ineffective if
  • 48. the gap opens sufficiently. (It is important to realize the scale of the events being described: the gap between the tang and clevis in the unpressurized joint is tiny: 0.004”, in the pressurized joint the gap was estimated to lie between 0.042” and 0.06,”—caused by a joint rotation that occurs in the first 0.6 seconds of ignition.) 13 Fig. 6 Joint Rotation Other sealing problems—some but not all related to joint rotation—such as blow-by, ring charring, ring erosion, loss of resilience of the O-ring material at low temperature, and performance of the putty were observed later in various static tests and launches. Engineers both at Thiokol and at the Marshall were aware of these problems. On July 31, 1985, Roger Boisjoly,
  • 49. a Thiokol engineer specializing in O-rings, wrote a memo to Thiokol vice president Robert Lund with the subject line, "O-ring Erosion/Potential Failure Criticality", after nozzle joint erosion was detected in an SRB: “This letter is written to insure that management is fully aware of the seriousness of the current O-ring erosion problem in the SRM joints from an engineering standpoint. “ "The mistakenly accepted position on the joint problem was to fly without fear of failure and to run a series of design evaluations which would ultimately lead to a solution or at least a significant reduction of the erosion problem. This position is now changed as a result of the [51-B] nozzle joint erosion which eroded a secondary O-ring with the primary O-ring never sealing. If the same scenario should occur in a field joint (and it could), then it is a jump ball whether as to the success or failure of the joint because the secondary O-ring cannot respond to the clevis opening rate and may not be capable of
  • 50. pressurization. The result would be a catastrophe of the highest order-loss of human life… 14 Boisjoly urged that a team be set up to work on the O-ring problem, and ended by saying "It is my honest and very real fear that if we do not take immediate action to dedicate a team to solve the problem, with the field joint having the number one priority, then we stand in jeopardy of losing a flight along with all the launch pad facilities." [quoted in Vaughan 1996, p. 447] Boisjoly later charged that Thiokol management failed to provide adequate follow-up and support to correct the problem described in his memo. Readers tempted to commit the retrospective fallacy after reading Boisjoly’s memo should note
  • 51. that the memo does not mention temperature effects on the seal. The years of concern about the sealing problems eventually led to a briefing at NASA Headquarters in Washington on August 19 th , 1985, by Marshall and Thiokol, in which they presented both an engineering evaluation and a redesign plan. They noted that only 5 of 111 primary O-rings in field joints and 12 of 47 primary O-rings in nozzle joints had shown erosion in various tests and flights. Thiokol argued that various experimental and flight data verified the safety of the design. They said, however, that the field joint was the “highest concern” and presented plans for improving the joints both with short-term fixes and longer-term fixes that would take over two years to implement. Data from studies by Arnie Thompson (Boisjoly’s boss) of the effect of temperature on ring resiliency were presented, but imposing a temperature launch constraint was not mentioned. The review judged that leak checks and careful assembly
  • 52. made it “safe to continue flying [the] existing design.” Nevertheless NASA needed “to continue at an accelerated pace to eliminate SRM seal erosion.” In the meantime, the risks were considered acceptable. [Dunnar and Waring, p. 363]. 5. Teleconference After several delays, the Challenger launch was scheduled for January 28, 1986, at 9:38 AM EST. At about 1 PM on the 27 th , however, NASA personnel became concerned about the unusually low temperatures—in the low 20’s—predicted for early morning of the next day. A Marshall manager asked Thiokol engineers to review the effect the low temperatures might have on the SRM. Accordingly, a meeting was held at Thiokol’s Utah facility. Engineers there stated their concern that the extreme cold would greatly reduce O-ring resiliency and ability to seal the joints. A teleconference among Thiokol, Marshall, and Kennedy personnel was set for 5:45 PM EST to discuss the situation.
  • 53. At the teleconference, Thiokol engineers made no official recommendation about delaying the launch. The discussion centered on their concerns about the effect of the low temperatures on the O-rings. However, some of the teleconference participants were unable to hear well, because of a poor telephone connection, and some key personnel had not been located in time to be included in the teleconference, so the teleconference was ended, and a second one scheduled for 8:15 PM EST. In the interim, Thiokol engineers had time to organize their data in charts and fax them to Marshall and Kennedy. 15 A total of thirty-four managers and engineers from Thiokol, Marshall, and Kennedy took part in the second teleconference. Thiokol engineers began the teleconference by discussing the charts that they had faxed to the other teleconference participants. The Thiokol position was that
  • 54. because significant O-ring blow-by and damage had been observed in the coldest previous launch—53°F—the O-ring material would lose much of its resilience and the joint could fail, were the launch to be conducted at a temperature in the 20’s or low 30’s. When directly asked by Larry Mulloy, Manager of the SRB project at Marshall, Thiokol Vice President Joe Kilminster … Code of Ethics for Engineers 4. Engineers shall act for each employer or client as faithful agents or trustees. a. Engineers shall disclose all known or potential conflicts of interest that could influence or appear to influence their judgment or the quality of their services. b. Engineers shall not accept compensation, financial or otherwise, from more than one party for services on the same project, or for services pertaining to the same project, unless the circumstances
  • 55. are fully disclosed and agreed to by all interested parties. c. Engineers shall not solicit or accept financial or other valuable consideration, directly or indirectly, from outside agents in connection with the work for which they are responsible. d. Engineers in public service as members, advisors, or employees of a governmental or quasi-governmental body or department shall not participate in decisions with respect to services solicited or provided by them or their organizations in private or public engineering practice. e. Engineers shall not solicit or accept a contract from a governmental body on which a principal or officer of their organization serves as a member. 5. Engineers shall avoid deceptive acts. a. Engineers shall not falsify their qualifications or permit misrepresentation of their or their associates’ qualifications. They shall not misrepresent or exaggerate their responsibility in or for the subject matter of prior assignments. Brochures or other presentations incident to the solicitation of employment shall not misrepresent pertinent facts concerning employers, employees, associates, joint venturers, or past accomplishments. b. Engineers shall not offer, give, solicit, or receive, either
  • 56. directly or indirectly, any contribution to influence the award of a contract by public authority, or which may be reasonably construed by the public as having the effect or intent of influencing the awarding of a contract. They shall not offer any gift or other valuable consideration in order to secure work. They shall not pay a commission, percentage, or brokerage fee in order to secure work, except to a bona fide employee or bona fide established commercial or marketing agencies retained by them. III. Professional Obligations 1. Engineers shall be guided in all their relations by the highest standards of honesty and integrity. a. Engineers shall acknowledge their errors and shall not distort or alter the facts. b. Engineers shall advise their clients or employers when they believe a project will not be successful. c. Engineers shall not accept outside employment to the detriment of their regular work or interest. Before accepting any outside engineering employment, they will notify their employers. d. Engineers shall not attempt to attract an engineer from another
  • 57. employer by false or misleading pretenses. e. Engineers shall not promote their own interest at the expense of the dignity and integrity of the profession. 2. Engineers shall at all times strive to serve the public interest. a. Engineers are encouraged to participate in civic affairs; career guidance for youths; and work for the advancement of the safety, health, and well-being of their community. b. Engineers shall not complete, sign, or seal plans and/or specifications that are not in conformity with applicable engineering standards. If the client or employer insists on such unprofessional conduct, they shall notify the proper authorities and withdraw from further service on the project. c. Engineers are encouraged to extend public knowledge and appreciation of engineering and its achievements. d. Engineers are encouraged to adhere to the principles of sustainable development1 in order to protect the environment for future generations. Preamble Engineering is an important and learned profession. As members of this profession, engineers are expected to exhibit the highest
  • 58. standards of honesty and integrity. Engineering has a direct and vital impact on the quality of life for all people. Accordingly, the services provided by engineers require honesty, impartiality, fairness, and equity, and must be dedicated to the protection of the public health, safety, and welfare. Engineers must perform under a standard of professional behavior that requires adherence to the highest principles of ethical conduct. I. Fundamental Canons Engineers, in the fulfillment of their professional duties, shall: 1. Hold paramount the safety, health, and welfare of the public. 2. Perform services only in areas of their competence. 3. Issue public statements only in an objective and truthful manner. 4. Act for each employer or client as faithful agents or trustees. 5. Avoid deceptive acts. 6. Conduct themselves honorably, responsibly, ethically, and lawfully so as to enhance the honor, reputation, and usefulness of the profession. II. Rules of Practice 1. Engineers shall hold paramount the safety, health, and welfare of the public. a. If engineers’ judgment is overruled under circumstances that endanger life or property, they shall notify their employer or
  • 59. client and such other authority as may be appropriate. b. Engineers shall approve only those engineering documents that are in conformity with applicable standards. c. Engineers shall not reveal facts, data, or information without the prior consent of the client or employer except as authorized or required by law or this Code. d. Engineers shall not permit the use of their name or associate in business ventures with any person or firm that they believe is engaged in fraudulent or dishonest enterprise. e. Engineers shall not aid or abet the unlawful practice of engineering by a person or firm. f. Engineers having knowledge of any alleged violation of this Code shall report thereon to appropriate professional bodies and, when relevant, also to public authorities, and cooperate with the proper authorities in furnishing such information or assistance as may be required. 2. Engineers shall perform services only in the areas of their competence. a. Engineers shall undertake assignments only when qualified by
  • 60. education or experience in the specific technical fields involved. b. Engineers shall not affix their signatures to any plans or documents dealing with subject matter in which they lack competence, nor to any plan or document not prepared under their direction and control. c. Engineers may accept assignments and assume responsibility for coordination of an entire project and sign and seal the engineering documents for the entire project, provided that each technical segment is signed and sealed only by the qualified engineers who prepared the segment. 3. Engineers shall issue public statements only in an objective and truthful manner. a. Engineers shall be objective and truthful in professional reports, statements, or testimony. They shall include all relevant and pertinent information in such reports, statements, or testimony, which should bear the date indicating when it was current. b. Engineers may express publicly technical opinions that are founded upon knowledge of the facts and competence in the subject matter. c. Engineers shall issue no statements, criticisms, or arguments on
  • 61. technical matters that are inspired or paid for by interested parties, unless they have prefaced their comments by explicitly identifying the interested parties on whose behalf they are speaking, and by revealing the existence of any interest the engineers may have in the matters. 9. Engineers shall give credit for engineering work to those to whom credit is due, and will recognize the proprietary interests of others. a. Engineers shall, whenever possible, name the person or persons who may be individually responsible for designs, inventions, writings, or other accomplishments. b. Engineers using designs supplied by a client recognize that the designs remain the property of the client and may not be duplicated by the engineer for others without express permission. c. Engineers, before undertaking work for others in connection with which the engineer may make improvements, plans, designs, inventions, or other records that may justify copyrights or patents, should enter into a positive agreement regarding ownership.
  • 62. d. Engineers’ designs, data, records, and notes referring exclusively to an employer’s work are the employer’s property. The employer should indemnify the engineer for use of the information for any purpose other than the original purpose. e. Engineers shall continue their professional development throughout their careers and should keep current in their specialty fields by engaging in professional practice, participating in continuing education courses, reading in the technical literature, and attending professional meetings and seminars. Footnote 1 “Sustainable development” is the challenge of meeting human needs for natural resources, industrial products, energy, food, transportation, shelter, and effective waste management while conserving and protecting environmental quality and the natural resource base essential for future development. As Revised July 2007 “By order of the United States District Court for the District of Columbia, former Section 11(c) of the NSPE Code of Ethics prohibiting competitive bidding, and all policy statements, opinions, rulings or other guidelines interpreting its scope, have been rescinded as unlawfully interfering with the
  • 63. legal right of engineers, protected under the antitrust laws, to provide price information to prospective clients; accordingly, nothing contained in the NSPE Code of Ethics, policy statements, opinions, rulings or other guidelines prohibits the submission of price quotations or competitive bids for engineering services at any time or in any amount.” Statement by NSPE Executive Committee In order to correct misunderstandings which have been indicated in some instances since the issuance of the Supreme Court decision and the entry of the Final Judgment, it is noted that in its decision of April 25, 1978, the Supreme Court of the United States declared: “The Sherman Act does not require competitive bidding.” It is further noted that as made clear in the Supreme Court decision: 1. Engineers and firms may individually refuse to bid for engineering services. 2. Clients are not required to seek bids for engineering services. 3. Federal, state, and local laws governing procedures to procure engineering services are not affected, and remain in full force and effect. 4. State societies and local chapters are free to actively and aggressively seek legislation for professional selection and negotiation procedures by public agencies.
  • 64. 5. State registration board rules of professional conduct, including rules prohibiting competitive bidding for engineering services, are not affected and remain in full force and effect. State registration boards with authority to adopt rules of professional conduct may adopt rules governing procedures to obtain engineering services. 6. As noted by the Supreme Court, “nothing in the judgment prevents NSPE and its members from attempting to influence governmental action . . .” 3. Engineers shall avoid all conduct or practice that deceives the public. a. Engineers shall avoid the use of statements containing a material misrepresentation of fact or omitting a material fact. b. Consistent with the foregoing, engineers may advertise for recruitment of personnel. c. Consistent with the foregoing, engineers may prepare articles for the lay or technical press, but such articles shall not imply credit to the author for work performed by others. 4. Engineers shall not disclose, without consent, confidential information concerning the business affairs or technical processes of any
  • 65. present or former client or employer, or public body on which they serve. a. Engineers shall not, without the consent of all interested parties, promote or arrange for new employment or practice in connection with a specific project for which the engineer has gained particular and specialized knowledge. b. Engineers shall not, without the consent of all interested parties, participate in or represent an adversary interest in connection with a specific project or proceeding in which the engineer has gained particular specialized knowledge on behalf of a former client or employer. 5. Engineers shall not be influenced in their professional duties by conflicting interests. a. Engineers shall not accept financial or other considerations, including free engineering designs, from material or equipment suppliers for specifying their product. b. Engineers shall not accept commissions or allowances, directly or indirectly, from contractors or other parties dealing with clients or employers of the engineer in connection with work for which the engineer is responsible. 6. Engineers shall not attempt to obtain employment or
  • 66. advancement or professional engagements by untruthfully criticizing other engineers, or by other improper or questionable methods. a. Engineers shall not request, propose, or accept a commission on a contingent basis under circumstances in which their judgment may be compromised. b. Engineers in salaried positions shall accept part-time engineering work only to the extent consistent with policies of the employer and in accordance with ethical considerations. c. Engineers shall not, without consent, use equipment, supplies, laboratory, or office facilities of an employer to carry on outside private practice. 7. Engineers shall not attempt to injure, maliciously or falsely, directly or indirectly, the professional reputation, prospects, practice, or employment of other engineers. Engineers who believe others are guilty of unethical or illegal practice shall present such information to the proper authority for action. a. Engineers in private practice shall not review the work of another engineer for the same client, except with the knowledge of such engineer, or unless the connection of such engineer with the
  • 67. work has been terminated. b. Engineers in governmental, industrial, or educational employ are entitled to review and evaluate the work of other engineers when so required by their employment duties. c. Engineers in sales or industrial employ are entitled to make engineering comparisons of represented products with products of other suppliers. 8. Engineers shall accept personal responsibility for their professional activities, provided, however, that engineers may seek indemnification for services arising out of their practice for other than gross negligence, where the engineer’s interests cannot otherwise be protected. a. Engineers shall conform with state registration laws in the practice of engineering. b. Engineers shall not use association with a nonengineer, a corporation, or partnership as a “cloak” for unethical acts. Note: In regard to the question of application of the Code to corporations vis-a-vis real persons, business form or type should not negate nor influence conformance of individuals to the Code. The Code deals with professional services, which services must be performed by real persons. Real persons in turn establish and implement policies
  • 68. within business structures. The Code is clearly written to apply to the Engineer, and it is incumbent on members of NSPE to endeavor to live up to its provisions. This applies to all pertinent sections of the Code. 1420 King Street Alexandria, Virginia 22314-2794 703/684-2800 • Fax:703/836-4875 www.nspe.org Publication date as revised: July 2007 • Publication #1102 ENGR 110 – Spring 2020 Assignment #7 – Engineering Ethics – The Challenger Disaster Write a 500 word or more essay about the Challenger Disaster engineering ethics case. For information on the subject, you are only allowed to use the pdf files posted on Moodle along with this HW assignment. Additional information you can get from the YouTube video at: https://www.youtube.com/watch?v=QbtY_Wl-hYI Your essay should have 6 parts: Part 1. State the Ethics Case Title. Part 2. Discuss the historical events (what happened).
  • 69. Part 3. Discuss why it happened (what caused the accident). Part 4. Discuss the ethical issues involved in the incident. Part 5. What was the aftermath. Part 6. Present/discuss your personal thoughts about this case. Your essay must clearly separate the topics into Part 1, Part 2, Part 3, Part 4, etc. Watch out for PLAGIARISM. Plagiarism will not be tolerated. You will automatically receive an (F) grade on your assignment if you plagiarize. Your essay MUST give enough information so the reader can understand what happened, what caused the collapse, and what are the ethical issues involved in the incident. • Your essay must be typed, 12-point letters, Arial font, double spaced. • Minimum word length: 500 words. • All pages must be stapled when they are returned for grading. • Due date: During regular class time the week of April 6th. Note: Your work will primarily be graded on quality of content (clear description of case plus supporting evidence) and how well the sources are used. Grammar and other mechanical errors will be judged on how seriously they interfere with the presentation of your ideas. Ethical use of sources is especially important. The grading rubric has also been posted so you can get an idea of how your work will be graded. ENGR 100 – Spring 2020 Assignment #7
  • 70. Name: Student ID: Date Submitted: Due Date: Tuesday, April 7, 2020