Engineering Ethics Case Study of 1986 Space Shuttle Challenger Disaster

Term Paper Moral & Ethics for Engineers
Space Shuttle Challenger KXEX 2165
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UNIVERSITY OF MALAYA
DEPARTMENT OF MECHANICAL ENGINEERING
SESSION 2012/2013
KXEX 2165
MORAL AND ENGINEERING PROFESION ETHICS
TERM PAPER
AN IN-DEPTH ANALYSIS OF ENGINEERING
ETHICS CASE STUDY:
SPACE SHUTTLE CHALLENGER DISASTER
Lee Chia Chun KEM100017
Fahmin KEM

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1.0 ExecutiveSummary
On January 28, 1986, seven astronauts were killed when the space shuttle they were
piloting, the Challenger, exploded at just over a minute into the flight. The failure of the
solid rocket booster O-rings to seal 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 of the joints that the O-
ring sealed lack of proper communication between different levels of NASA management
and environmental factors. The objective of term paper is to discuss and analyze the
accident by providing justification based on the moral values and standard reference.
Firstly, Chapter 2, Introduction explains the topic of the term paper, which is Space
Shuttle Challenge. Inside, it consists of organizations involved and the background story
narrated according to the timeline. Only significant events are shown in the timeline and
can be summarized in pre-, during and post-accident.
Next, Chapter 3, Methodology provides an overview of how the research was made using
the four simple steps. The problem statements are provided with as well.
Moving on is the Chapter 4, Analysis encompasses situational analysis in the four key
areas, namely mechanical aspect (section 4.1), communication breakdown (section 4.2),
environmental pressure (section 4.3) and flaw in the decision-making aspect (section 4.4).
In section 4.1, factual clarity is provided and factual issues are being brought forward to
address the moral issues in mechanical aspect. In section 4.2, conceptual issues are used
to justify the right and wrong of the decision in the selected situations. Kantianism and
Utilitarianism were deployed in explaining the circumstances. In section 4.3, a mix of
conceptual issues, moral issues and factual clarity are being used. In section 4.4, factual
issues are brought up as well.
Under the Chapter 5.0, Moral Solutions, there are total of five proposed moral solutions.
First method is whistle-blowing method, following by ethical codes as an engineer,
proposal on physical meeting, proposal on applying Delphi method in a critical
discussion and finally is the voting system using simple two-third majority rule.
Chapter 6.0, Other Opinions showcases the importance of valuing an engineer’s
expertise, the importance of accuracy of data and the responsibility of an engineer.
Finally, Chapter 7.0 is the conclusion whereas Chapter 8.0 is the reference of the term
paper, expressed in MLA formatting and style.

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2.0 Introduction
The space shuttle Challenger incident is described in a more in-depth manner, in three
essential parts, namely pre-, during and post-accident. Specific and significant part of the
history is highlighted and arranged according to the timeline to show relevancy. The
parties involved in this incident are shown in section 2.1 to ease readers’ understanding.
2.1 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 of Morton
Thiokol
Bob Lund - Engineering Vice President
Robert Ebeling - Engineer who worked under Morton Thiokol
Roger Boisjoly - Engineer who worked under Morton Thiokol
Joe Kilminster - Engineer in a management position
Jerald Mason - Senior executive who encouraged Lund to reassess his
decision not to launch
2.2 Background
Pre-Accident
1973 From the beginning of the design and development phase of the Solid
Rocket Motor (SRM) project, Marshall had trouble with Morton-
Thiokol and the joints. Several Center engineers worried that the joint
and seal designs were deficient and Center managers fretted about the
contractor’s quality systems. But after improvements, reviews, and
many successful tests, senior project managers and engineers decided
that the design was successful and the joints were safe to fly.
Early
September
1977
Hydroburst test was carried out on the field joints. The company’s final
report of the test concluded that failure occurred in the joint seals. The
leakage was caused by the clevis spreading and not providing the
required O-ring squeeze due to joint rotation that had caused the O-ring
to lose compression. Thiokol denied that the tests revealed design
flaws. The test subjected the same hardware with the same O-rings to

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20 cycles of pressure and release; only in the final cycles did the rings
leak. Consequently, Thiokol engineers believed that with each cycle,
the O-ring was pushed into the gap then released, then pushed in
farther, and so on until the rubber condensed, cut, and failed. Rather
interpreting the tests as indications of bad design, Thiokol engineers
argued that the joint had withstood many cycles without failure and so
test results showed the soundness of the joint. They believed that
potential leaks on flight motors could be avoided through careful
assembly of the joints and by inserting dozens of shims, which were U-
shaped clips, between the outer clevis and the tang. The shims would
maintain the centricity of the case and the compression of the O-rings;
this would prevent any “gathering” or bunching of the O-ring that could
cause a leak.
Late
September
1977
Some engineers in Marshall’s laboratories disagreed with the contractor
and believed the joint design was flawed. Glenn Eudy, the Center’s
chief engineer for the SRM, expressed his doubts to Alex McCool,
director of the Structures and Propulsion Lab, and argued that refined
assembly methods alone could not fix the problem. He requested that
the director of Science and Engineering review the problem.
October
1977
Center engineer Leon Ray argued that shims allowed for error during
assembly, therefore unacceptable. He advised that the best option for a
long-term fix was a “redesign of the tang” to prevent joint opening.
Early
January
1978
Ray and his boss, John Q. Miller, chief of the Structure and Propulsion
Lab’s solid rocket motor branch, believed that the joint issue required
the “most urgent attention” in order to “prevent hot gas leaks and
resulting catastrophic failure.” Alarmed that Thiokol was trying to
lower requirements for the joint, they saw “no valid reason for not
designing to accepted standards.” Miller and Ray recommended
“redesign of clevis joints on all oncoming hardware at the earliest
possible effectivity to preclude unacceptable, high risk, O-ring
compression values.
Late
January
1978
Not only did Thiokol reject the analysis of the Marshall rocket
engineers, but so did Center managers. Marshall management accepted
the existing design, complemented by shims, mainly because of the
continued successes of static motor firings. Furthermore, McCool
further endorsed the decision during the firing and post-test
examination revealed neither discolorations nor other evidence of
leakage. Robert Lindstrom, Shuttle Projects Office manager at Marshall
approved the analysis report that no problems which require immediate
attention of NASA.
October A Thiokol report indicated that all case joints were intact and showed

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1978 no evidence of pressure leaking. The report acknowledged that the
relative movement of the sealing surfaces is much more than indicated
but this evidence of joint rotation was not presented as anything
ominous.
November
1978
Thiokol’s SRB (Solid Rocket Booster) project manager wrote George
B. Hardy, Marshall’s project manager, that the static firings “confirmed
the capability of the O-rings to prevent leakage under the worst
hardware conditions.
Through
the
Summer
1978
Results from Structural Test Article–1 (STA–1) were less optimistic.
Hydroburst tests on STA–1 again revealed the dangers of joint rotation.
Thiokol’s report concluded that the relative movement between the
clevis and the tang at the interior of the case joints was greater
than expected. This resulted in some oil (pressurizing fluid) bypassing
the O-ring seals at the case joints. The engineers decided that the O-
rings unseated as the joint opened. Nevertheless, company engineers
dismissed the leaks, arguing that test pressure was higher than flight
pressure and “the amount of oil loss on any one occasion or totally was
very small and motor case pressurization was never lost or affected by
this phenomenon.” As on the tests from the previous year, they
concluded that the repressurization cycles had caused the failures rather
than a faulty design. They acknowledged that imprecise calibration
devices prevented accurate measures of the joint opening, but denied
that the joint opened so wide as to be unsafe. STA–1 data led Miller
and Ray to call Thiokol’s design completely unacceptable.
January
1979
The company engineers wrote another memo to Eudy and Hardy,
explaining that joint rotation prevented the design from meeting
contractual requirements. The contract specified that seals operate
through compression, but the opening of the joint caused the primary
O-ring to seal through extrusion. As a sealing mechanism, extrusion
used ignition pressure to push the O-ring across the groove of the inner
flange of the clevis until it distorted and filled the gap between clevis
and tang. This, they said, “violates industry and Government O-ring
application practices.” In addition, Miller and Ray for the first time
questioned whether the secondary O-ring provided redundancy.
Although the contract required verification of all seals, tests had proven
the secondary O-ring design to have been unsatisfactory because the
opening of the joint completely disengaged the O-ring from its sealing
surface.
February
1979
Ray sought advice from two seal manufacturers. One manufacturer said
that the design required the O-ring to seal a gap larger than that covered
by their experience. The Parker Seal Company, the contractor for the
SRB O-rings, believed that the O-ring was being asked to perform

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beyond its intended design and that a different type of seal should be
considered. However, Ray and Miller failed to convince Thiokol and
Marshall to change their commitment to the existing design.
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February
1979 and
1980
Thiokol’s summary of the development motor firings concluded that
after each test all case joints were intact and showed no evidence of
pressure leaking and measurements revealed no stresses that indicate
design problems or that compromise the structural integrity of the case.
Three qualification motors fired successfully and had no leaks.
May –
September
1980
The Center and contractor presented their data and conclusions to
NASA’s Space Shuttle Verification Propulsion Committee on the
motor. The committee fretted over O-ring leaks, assembly problems,
and joint rotation. Although the O-ring leak check put the secondary O-
ring in position to seal, it pushed the primary O-ring in the wrong
direction.
During the Accident
28 January
1986
The Space Shuttle Challenger, mission 51–L, rose into the cold blue sky
over the Cape. Within 73 seconds after liftoff, however, the external
tank ruptured, its liquid fuel exploded, and Challenger broke apart.
Seven astronauts were killed.
Post-Accident
May 1986 A presidential commission led by former Secretary
of State William P. Rogers and a NASA team investigated the accident.

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State the
Problem
Get the
Facts
Defend
Viewpoints
Give
Recommendation
3.0 Methodology
Our approach used in attempting the case follows the steps shown in the diagramme
above.
Explanation to each of the step is as below:
1. State the Problems
We clearly defined the exact nature of the ethical problems or dilemma found in the
case of space shuttle “Challenger” disaster so that we could anticipate the kind of
solution that is required. There are four main problem areas identifiable as
mechanical aspect, communication breakdown aspect, environmental pressures
(media, government and public) and flaw decision-making process. As for this
Challenger incident, the moral dilemma faced by the engineers is choosing between
loyalty and duty ethics in carrying out their duty throughout the launch of
Challenger.
2. Get the Facts
To arrive at an informed, sound decision, we read between the lines found in the
history of the space shuttle “Challenger” disaster. We made clear any interpretations
of factual and conceptual matters or the values that underlie conflicting moral
viewpoints. Throughout our attempt of gathering facts, we relied on Wikipedia and
the investigation reports issued by Rogers Commission as the main sources, as well
as the journey authored independently by Malcolm McConnell, Thomas F. Gieryn
and Anne E. Figert and findings from National Aeronautics and Space
Administration.
3. Defend Viewpoints
On this stage, we critically assessed the strengths and weaknesses of competing
moral viewpoints by identifying what we believed to be the most compelling reason
for the course of action. Then, we justified the course of action. The moral dilemma

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is highlighted, that is should an engineer comply with the instruction from
management as opposed to the engineering decision? The dilemma is attempted to be
solved using the moral standard and values proposed in the lecture slides. Moral
values such as loyalty, moral duty of an engineer, honesty, utilitarianism or cost
benefit analysis, Kantianism or duty ethics are incorporated in the analysis to re-
define the best, possible solutions that could have been taken.
4. Give Recommendation
In the section 5.0 and 6.0, we strive to come up with logical, moral and ethical
solutions to the problems faced by all of the parties in this space shuttle Challenger
incident.
On a summary, our research method largely relies on internet searches, electronic
journals and lecture slides.
4.0 Analysis
The space shuttle Challenger disaster presents several issues that are relevant to
engineers. These issues raise many questions that may not have definite answers, but can
serve as a percept to the engineers when faced with a similar situation in the future.
The situational analysis is stemmed from the four problem areas: mechanical aspect,
communication breakdown aspect, environmental pressures and flaw decision-
making process.
4.1 Situational Analysis on Mechanical Aspect
There are a total of four mechanical aspects of the Challenger problems, blow holes, O-
ring erosion, joint rotation, and the response of O-rings during low temperature. The
condition of the primary seal is essential to the successful operation of the rocket booster.
Engineers had to make sure that the seal was not damaged, so they increased the pressure
of the leak test to above the pressure that the putty could withstand. This was supposed to
make sure the O-ring was correctly covering the gap without the help of the putty. Blow
holes were tiny tunnel-like holes that were left in the zinc chromate putty of the rocket
booster insulation. The putty was supposed to protect the O-rings from the hot exhaust.
The holes were a result of pressurized test known as the leak check port. The leak test left
engineers worried; they did not think that the pressure was high enough to identify any
problems with the seals. The high pressure of this test was too much for the putty; it blew
holes through the putty before it was able to seal the opening. These holes allowed
focused exhaust gasses to reach the primary O-ring during launch. Engineers knew that
the blow holes were a concern, but they continued to do the high pressure test. They

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thought that the holes were less of a threat than if the primary O-ring was faulty or flawed
in any way.
The blow holes led to the erosion of the primary O-ring. The gasses and extreme
temperature that were allowed to pass through the holes were causing the O-ring to break
down. Engineers knew that this was a threat. They had inspected the joints with the putty
and O-rings after each use and found that the primary O-ring erosion was about 12%.
After the pressure increased during the leak test, the erosion rate increased to 88%. Now
not only was the primary O-ring greatly damaged, the secondary O-ring was also
beginning to erode due to the high temperature of the gasses. Managers decided that this
erosion was acceptable and continued to perform the leak test.
O-ring resilience is the ability of the O-ring to go back to its natural size after it has been
stretched. As the O-ring gets colder it becomes stiffer. On the day of the launch the
outside temperature was 36o C, fifteen degrees colder than the next coldest launch. The
cold temperature caused the O-rings to be unable to expand and contract quickly. The
slow reaction time of the O-rings made it impossible for them to fill the gap caused by
joint rotation. The O-rings had been previously tested and found to be five times more
responsive in seventy-five degree weather than in thirty-degree weather. The cold
weather could have been a huge factor in the improper functioning of the O-rings.
Above all four factors combined together to cause devastating event.
Engineer is a profession to act at the best interest of public welfare. Failing to fulfill this
duty brings a heavy sense of guilty. By applying the utilitarian rules, let us perform a
simple cost-benefit analysis on the basis of assuming and hoping the faulty mechanical
parts did not turn worst:
- (Minus) Destruction of spacecraft
- (Minus) Valuable lives of seven astronauts
- (Minus) Public accuse
- (Minus) NASA’s and its affiliates’ reputation tarnished
- (Minus) Affected country’s reputation
+ (Plus) Lower launching budget
+ (Plus) Fulfill the launching schedule
Tally: -5 + (+2) = -3, therefore, undesirable outcomes
As we all also know that part of responsible engineering practices are the exercise of
preventive ethics and the practice of sound ethical decision making to avoid more serious
problems later. The Thiokol engineers and NASA were aware of the problems, however,
NASA did not strongly express the flaws found in the mechanical parts, and instead, they
accepted them as a norm.

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Fraud and dishonesty should not be hindering the practice of a profession as an engineer,
as a whole, the functionality of an engineering firm, such as Thiokol. However, the action
of regulating the information purposefully to avoid the real truths to be told is beyond the
moral judgment and the firm should have been pursued legally. As Thiokol and NASA
have entered into a contract which must have required Thiokol to deliver quality, safety
services or products within a stipulated time prior to the award of contract to Thiokol,
therefore, NASA could sue Thiokol for breaching the contract and causing the loss of
lives. The eventual outcome of intentionally misrepresenting data indirectly by Thiokol is
to bear a huge amount of financial losses.
After that, the redesign efforts were carried out by Thiokol. 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
“Marshall had failed to discuss O-ring resiliency at the August briefing, and evidently
told Thiokol to delete from the conclusion a sentence that said “data obtained on
resiliency of the O-rings indicate that lower temperatures aggravate this [sealing]
problem.” Center managers continued to deny that temperature was a factor because
erosion had occurred at cool and warm temperatures.” Adapted from “Power to Explore: A
History of Marshall Space Flight Center,1960-1990”by Andrew J. Dunar & Stephen P. Waring

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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. (Power to Explore, History of
MSFC,1990)
Every manager throughout the organizations is responsible for systematically identifying
risks, hazards, or unsafe situation or practice, and then for taking steps to assure adequate
safety of the space shuttle. Arguing from moral perspective, the manager should make a
decision based on facts and figures given by the engineers, re-examine the engineering
processes of arriving at such facts and then verify the statement.
4.2 Situational Analysis on Communication Breakdown
The engineers had their doubts about the O-rings working properly. They knew that there
had been problems with the O-rings in the past. The O-rings were tested and examined
after each use, and they had found erosion problems. NASA’s management was warned
of this possible problem but did nothing. The engineers were not certain that the O-rings
were going to work correctly and efficiently enough to have a successful launch.
Managers did not see this as a major problem. Again, this is a breach of code of National
Society of Professional Engineers (NSPE). The managers were more concern on not
delaying the launch any longer and were also feeling a lot of pressure to launch as soon
as possible. So when the engineers voiced their concerns to the managers did not realize
how important and critical the situation was. The managers may not have completely
understood what the engineers were saying. Management and engineers used different
terminology, causing them to be unable to properly understand each other. This caused
the managers to muffle the opinions of the engineers. This memo is an example of the
loss of communication and valuable information. It should have been given to the top
management but the managers decided to not pass it up the ladder. The memo is from
Leon Ray in the Solid Motor Branch to the Distribution Department. Mr. Ray reported
the concerns that two companies have about the O-rings. The top management and the
people with the power to stop the launch never saw this memo.

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“Although the O-rings were not seen as a major area of concern for the
managers, they were ultimately the most important part of the entire shuttle. If
communication problems had been overcome, the Challenger would probably
have made a successful launch and the mission would have been a victory.”
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. 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]
After several delays, the Challenger launch was scheduled for January 28, 1986, at
9.38am EST. At about 1pm, 27th, a meeting was held to review the effect the low
temperatures might have on the SRM. Engineers were concerned about the cold weather
that could greatly reduce the resilience of O-rings. A teleconference among Thiokol,
Marshall and Kennedy personnel was set for 5.45pm EST to discuss the situation. At the
teleconference made no official recommendation about delaying the launch. At this
point, the engineers were facing dilemma of whether to remain loyal to firm at the
expense of engineering failures and loss of lives or perform their ethical duty as engineer.
At this point, we analyze the situation by adopting Kantianism. Kant’s theory
requires that everyone should be treated as a free person equal to everyone else.
[Categorical Imperative (1st Formulation)]. Question here is “Can NASA in a dire

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straits compromise the fatal effects of cold weather on the O-rings with the intention
of keeping launching schedule on track?” To articulate it into a statement, by all means
NASA can compromise the fatal effects of cold weather having on the O-rings in order to
keep the launching schedule on track, even if it is at the expense of human life.
Reversing the statement, it becomes “Human life is ready to be sacrificed as long as
NASA can keep the launching schedule on track, disregarding to the effect of cold
weather have on the O-rings.” This is neither true nor moral, because people (astronauts)
have fundamental rights that engineers/firms have duties to protect. (John Locke)
Pursuing this matter further by applying Categorical Imperative (2nd Formulation of
Kantianism), NASA and Thiokol should treat the astronauts and themselves as ends in
themselves, and never put the astronauts as a mean to an end. In reality, the moment
NASA and Thiokol were still keeping the launching schedule active despite knowing the
fact that cold weather effect on the O-rings, was a clear indicator of immorality in them
as they have reduced the poor astronauts as mere means to their ends, treating them
as mere objects to gratify their needs. Universalization of the statement also indicates a
person or an organization could compromise the negative consequences of a bad decision
as long as the end goal is achieved.
The decision taken by NASA and Thiokol engineers to continue the launch was wrong.
Kantianism allows no exception to moral laws.
4.3 Environmental Pressure
A conceptual issue to explain the Challenger accident is that the NASA managers were
anxious to launch the Challenger for several reasons. Firstly, political pressure to provide
a reliable, reusable space vehicle with rapid turnaround time and deployment seriously
hindered the ability for effective systems integration and development. (Jeff Forrest)
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.
In short, NASA wanted to launch the Challenger without any delays.
Ends : Space shuttle Challenger to be launched on January 28, 1986
Means : Seven astronauts to be sacrificed

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Secondly, it was not feasible to construct any complete management support systems
(MSS) that could consider all of the factors associated with such a diverse group of
variables.
Thirdly, additional uncertainty and low NASA employee morale was created because the
Shuttle was declared "operational" even before the "developmental" stage had been
completed. Also, Congress expected the Shuttle program to be financially self-
supportive. This forced NASA to operate as a pseudo commercial business
Fourthly, an additional factual clarity shows that the primary reason for the slow progress
was Thiokol’s incentive-award fee contract. After 51-L, congressional investigators
found that the contract offered Thiokol no incentives to spend money to fix problems as
if not expecting any mission failure. Based on this information, a sociologist concluded
that, the incentive fee, rewarding cost savings and timely delivery, could total as much as
14% of the value of the contract; the award fee, rewarding the contractor’s safety record,
could total a maximum of 1%. No provisions existed for performance penalties or flight
anomaly penalties. Absent a major mission failure, which entailed a large penalty after
the fact, the fee system reinforced speed and economy rather than caution. In Malaysia,
the Contract Act 1950 would not facilitate the establishment of this contract as it has not
taken safety into consideration, which is most needed in the profession as an
engineer/engineering firm.
Since the launching of space shuttle is decided by the management, they will concern the
health of the company and the space program as a whole. Given the political climate at
the time of the launch, if problems and delays continued, ultimately Thiokol might have
lost NASA contracts, NASA budgets might have been severely reduced, and the wide
media coverage on the launch cancellation would hurt the reputation of NASA and its
affiliates. Clearly, this scenario could have led to the loss of many jobs at Thiokol and
NASA.
4.4 Situational Analysis on Flaw Decision-Making Process
The decision making model used by NASA was called Group Decision Support System
(GDSS). The parties that were involved were NASA and the subcontractor Thiokol, who
was directly responsible for the development of the SRB "O" rings. GDSS is a class of
electronic meeting systems, a collaboration technology designed to support meetings and
group work. It consisted of same-time/different-place conference rooms equipped with a
connected and distributed computer interface.
On the eve of the launch of Challenger, both parties were already aware that the seals on
the SRB needed upgrading but did not feel that it was critical. Though the information

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provided by the GDSS showed that the "O" rings would perform under the predicted
temperatures, Thiokol engineers questioned their own testing and data that were
programmed into the GDSS. Soon, they realized the flawed information about the O-ring
was fed into the GDSS, therefore providing permissible forecast of the launch.
To add on, Thiokol was aware of the "O" ring problem at least several months before the
Challenger launch. However, the goal was to stay on schedule. NASA was made aware
of the problem but it was downplayed as a low risk situation due to environmental
factors. The situation at that point of time was Thiokol and NASA wanted to launch
the rocket, only the Thiokol engineers have huge concerns over the launch under
such cold weather. On the other hand, the computer which was fed with the wrong
input about the O-ring, made a false impression for the launch. So, the NASA took
the convenient reason, which is to believe in the supercomputer, while actually NASA
wanted it to be launched by hook or by crook. If only NASA had been aware of the
significance of the "O" ring situation, they probably would have given more credence to
the advice of the Thiokol engineers' recommendations. Due to the presence of conflict of
decision between the Thiokol engineers and the rest who eagerly wanted to launch space
craft, an offline virtual meeting was called forth that was attended by Thiokol Senior
Vice President, Jerry Mason who took charge of the discussion. It soon became clear that
he was not persuaded by the argument against the launching while Roger Boisjoly and
Arnie Thompson were firm on their recommendation to scrub the launch on the basis that
the effect of unexpected cold weather would greatly erode the O-ring and caused
catastrophic consequences. But because the members of the Shuttle team wanted it to be
launched so badly, any decision to delay the launch would be fell onto the deaf ears. All
members of the GDSS felt that they should live up to the "norms" of the group; they soon
changed their presentation of objections once threatened with the possibility of being
expelled from the program. Thiokol became highly susceptible to "groupthink" as it
was so afraid of losing potential future revenue should they disagree with NASA. In fact,
all parties were also afraid of public and political response to another launch cancellation.
Therefore, each party began to rationalize that past success equaled future success.
Seeing things were not positive anymore, some individuals departed from the group
norms. The apparent democratic way of voting on whether or not to continue the launch
was only participated by the four managers who choose to believe the launch as a
management decision, but not engineering decision anymore. Roger Boisjoly and Arnie
Thompson were excluded from the voting procedures. They have no right to stop the
launch from continuing. Conflict management was avoided by NASA's domination of the
entire meeting. NASA, at times, became very assertive and intimidating. Considering
NASA's attitude, no group member or individual was willing to be held accountable for
any comment or decision. Ultimately, the Thiokol gave a green light to NASA to launch
the space shuttle Challenger.
The rest of the story after 73-second into the launch was history. Takziah.

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In short, NASA was operating in a phase of semi-uncontrolled decision making while
trying to serve the military, industry and international research organizations with a space
vehicle that had been declared operational before completion of the developmental stage.
5.0 MoralSolutions
Appropriate responses or solutions should be proposed in addressing the problems. We
do know that some problems were not apparent at the first glance, these errors were only
surface when you look back at the accident itself after everything has happened. In order
to develop a fair ethical dimension, we should ask ourselves, “What did they know at that
time?”, “What could they do with the knowledge or observation on mind at that
moment?” Otherwise, we would be committing the infamous retrospective fallacy.
Firstly, instead of leaving disappointedly, the Thiokol engineers should have committed
whistle-blowing by appealing to the appropriate authorities such as the White House.
This is because an engineer could do so when the public welfare (as in, the seven
astronauts’ lives) was in jeopardy. The engineers should not feel that this very action
would be regarded as not loyal, but rather to see it as permissible and obligatory because
for the following reasons:
 Actual or potential harm is serious
 Harm is documented (e.g. the memo and hydro test indicated the need to improve
O-ring)
 Concerns have been reported to superiors (NASA was aware of the situation)
 Do not get satisfaction, explore all other organizational channels to the top (e.g.
Roger Boisjoly was very against to the launch of the Challenger)
The whistleblowing act is indeed reasonable because it may help prevent or remedy the
harm, thus saving the seven astronauts from being sacrificed unnecessarily.
Secondly, the Thiokol engineers should be clear of their ethical codes as an engineer as
outlined in NSPE. They must not treat the O-ring problem with a laissez-faire attitude,
failing to provide certainty of the expected outcomes of the O-ring under the cold
weather. At the end of the meeting NASA, very reluctantly, suggested that they would
still cancel the launch if Thiokol insisted. Because no response from Thiokol was made.
Engineers have the right to say “No” to critical circumstances because they are the
profession who has the better understanding of the real situation.
Thirdly, the meeting place should be the same for NASA crew members and Thiokol
engineers to ensure effective meeting. Considering that a speaker phone and CPU modem
was used in GDSS, it was easy for NASA to downplay the personal opinions of the
Thiokol engineers.

17
Fourthly, in a discussion, the ideas, suggestions and objections were solicited but not
anonymously. Some members might have fear to voice out to their bosses. Some
individuals choose to depart from the group norms as they did not want to involve in the
“dirty” works. On this instance, the Delphi method could incorporated into the
brainstorming or trouble-shooting session. Through this way, the members could voice
out while maintaining anonymity of their identity.
Fifthly, a voting process on the basis of simple two-third majority should be adopted in
the situation and is to be participated by all working crews of the space shuttle
programme.
6.0 Other Opinions
(a) Value and Evaluate Engineers’ Expertise
It is important that the managers should not ignore their own engineering experiences, or
the expertise of their subordinate engineers. Often a manager, even if one has engineering
experience, is not as up-to-date on current engineering practices as are those actual
practicing engineers. One should keep this in mind when making any sort of decision that
involves an understanding of technical matters.
(b) Clarity and Certainty of Engineering Data are Pivotal to Important
Decision
Another issue is the fact that managers encouraged launching despite the fact that there
was insufficient low-temperature data for which the O-ring would perform. Since there
was not enough data available to make a sound 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 stop the program until the problem was solved.
(c) Engineers Bear the Responsibility to Safeguard the Public Welfare

18
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 endeavours. 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. Although single-minded pursuits of a goal is
delightfully romantic and even a real inspiration, 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. Every engineer needs to find the fine line between unselfish
loyalty to the welfare of mankind and the selfish loyalty to the firm he or she is working
in, then work along the boundary and commit necessary evil based on justice and
personal moral standard references.
7.0 Conclusion
Despite the Space Shuttle Challenger was regarded as an accident, scientists and
engineers knew about the root cause even way much earlier before the launch of
Challenge. Safety is always first, next only is operational goal. Engineers have the rights
to safeguard the lives and welfare of human beings by all means.
“Hold paramount the safety, health and welfare of the public…” NSPE
There were many causes to the explosion of the Challenger. NASA’s employees, the
engineers and the management, were unable to communicate and understand each other
clearly. Another problem area of communication was between NASA and Morton-
Thiokol, the maker of the O-rings. In the end there was a communication barrier that was
unable to be overcome. There were also technical problems with the O-rings. The O-rings
were not responsive enough in cold weather, and could not work properly.
The Challenger disaster taught NASA and the world, that communication is the single
most important part of any operation. A clear, honest communication is the key to
determine the success and safety of the launch in the future. Authority should make a
decision based on sound engineering facts and figures. An ethical decision-making
process must be introduced into the organizational framework to promote public
welfare, humanity rights and moral obligation.

19
8.0 Reference
i. Malcolm McConnell, Challenger: A Major Malfunction, A True Story of Politics,
Greed, and the Wrong Stuff (Garden City, New York: Doubleday, 1987); Joseph
Trento, Prescription for Disaster (New York: Crown, 1987).
ii. Thomas F. Gieryn and Anne E. Figert, “Ingredients for a Theory of Science in Society:
O-Rings, Ice Water, C-Clamp, Richard Feynman, and the Press” in Susan E. Cozzens
and Thomas F. Gieryn, eds., Theories of Science in Society (Bloomington: University
of Indiana Press, 1990)
iii. National Aeronautics and Space Administration (30 March 2011) Retrieved 10th May
2013 from http://history.nasa.gov/sts51l.html
iv. 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
v. Feynman (March, 1996), Feynman's Appendix to the Rogers Commission Report on
the Space Shuttle Challenger Accident Retrieved 11th May 2013 from
http://www.ralentz.com/old/space/feynman-report.html
vi. Mark Rossow (2012), Engineering Ethics Case Study: The Challenger Disaster (pg 14
– 15), New York: Continuing Education and Development, Inc.
vii. Wikipedia (2013), Group Decision Support System Retrieved 10th May 2013 from
http://en.wikipedia.org/wiki/Group_decision_support_systems
viii. Jeff Forrest (1995), The Space Shuttle Challenger Disaster: A failure in decision
support system and human factors management Retrieved 10th May 2013 from
http://dssresources.com/cases/spaceshuttlechallenger/
ix. Lecture slides, Chapter 1 – 6, by Mr. Baharuddin retrieved from Spectrum
End of Assignment

Engineering Ethics Case Study of 1986 Space Shuttle Challenger Disaster

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Engineering Ethics Case Study of 1986 Space Shuttle Challenger Disaster