Whistle-blowing Case Study: The Challenger disaster On January 24, 1985, Roger Boisjoly, Senior Scientist at Morton Thiokol Inc. (MTI), watched the launch of Flight 51-C of the space shuttle program and remained to inspect the solid rocket boosters after their recovery from the Atlantic Ocean. These immense boosters are too large to transport, so they are manufactured in cylindrical sections and fastened together with "field joints" before launch. At each joint, the straight terminal ring of one segment (the "tang") slid into a clevis ring (with a Y-shaped cross section) on the mating segment, and this joint was sealed with two O-rings (see Figure 16-1). Boisjoly, then "considered the leading expert in the United States on O-rings and rocket joint seals," was dismayed to find "that both the primary and secondary O-ring seals on a field joint had been compromised by hot combustion gases (i.e., hot gas blow-by had occurred), which had also eroded part of the primary O-ring," although the temperature of the field joint at launch was believed to be a comfortable 53F(12C) (see Figure 162.)19 Segment centerline Unpressurized joint, no rotation Seement centerhine Figure 16-1 Cross section of Challenger booster flange. (From Russell). Boisjoly and Ellen Foster Curtis, "Roger Boisjoly and the Challenger Disaster: A Case Study in Engineering Management, Corporate Loyalty, and Ethics, "Proceedings of the Eighth Annual Meeting, American Society for Engineering Management, St. Louis, MO, October 11-13, 1987, p. 10.) Since rocket motor pressurization following ignition causes some rotation in the field joint, opening the annulus sealed by the O-rings, Boisjoly sponsored a series of subscale laboratory tests in March 1985 of the effect of temperature on O-ring resiliency. In these tests O-rings were squeezed, the pressure removed, and the time for the O-ring to regain shape measured. At 100F(38C) recovery was immediate, at 75F(24C) it took 2.4 seconds, but at 50F(10C) Figure 16-2 Multiple burn-through of Challenger nozzle joint primary O-ring. (From Russell 1. Boisjoly and Ellen Foster Curtis, "Roger Boisjoly and the Challenger Disaster: A Case Study in Engineering Management, Corporate Loyalty, and Ethics," Proceedings of the Eighth Annual Meeting, American Society for Engineering Management, St. Louis, MO. October 1113,1987, p. 8.) the seal had not recovered even after 10 minutes ( 600 seconds). In the ensuing months, Boisjoly emphasized in the strongest terms the need to redesign the field joint. On August 20, 1985, Robert K. Lund, MTI Vice President, Engineering, announced formation of a Seal Erosion Task Team, but little progress was made on solving the problem-despite further blow-by on a flight on October 30, 1985, when the field joint temperature was estimated at a balmy 75F(24C) The stage is now set for the eve of the Challenger tragedy: At 10 a.m. on January 27, 1986, Amie Thompson (MTI Supervisor of Rocket Motor Cases) received a phone call from .

1. Whistle-blowing Case Study: The Challenger disaster On January 24, 1985, Roger Boisjoly,
Senior Scientist at Morton Thiokol Inc. (MTI), watched the launch of Flight 51-C of the space
shuttle program and remained to inspect the solid rocket boosters after their recovery from the
Atlantic Ocean. These immense boosters are too large to transport, so they are manufactured in
cylindrical sections and fastened together with "field joints" before launch. At each joint, the
straight terminal ring of one segment (the "tang") slid into a clevis ring (with a Y-shaped cross
section) on the mating segment, and this joint was sealed with two O-rings (see Figure 16-1).
Boisjoly, then "considered the leading expert in the United States on O-rings and rocket joint
seals," was dismayed to find "that both the primary and secondary O-ring seals on a field joint
had been compromised by hot combustion gases (i.e., hot gas blow-by had occurred), which had
also eroded part of the primary O-ring," although the temperature of the field joint at launch was
believed to be a comfortable 53F(12C) (see Figure 162.)19 Segment centerline Unpressurized
joint, no rotation Seement centerhine Figure 16-1 Cross section of Challenger booster flange.
(From Russell). Boisjoly and Ellen Foster Curtis, "Roger Boisjoly and the Challenger Disaster: A
Case Study in Engineering Management, Corporate Loyalty, and Ethics, "Proceedings of the
Eighth Annual Meeting, American Society for Engineering Management, St. Louis, MO,
October 11-13, 1987, p. 10.) Since rocket motor pressurization following ignition causes some
rotation in the field joint, opening the annulus sealed by the O-rings, Boisjoly sponsored a series
of subscale laboratory tests in March 1985 of the effect of temperature on O-ring resiliency. In
these tests O-rings were squeezed, the pressure removed, and the time for the O-ring to regain
shape measured. At 100F(38C) recovery was immediate, at 75F(24C) it took 2.4 seconds, but at
50F(10C)
Figure 16-2 Multiple burn-through of Challenger nozzle joint primary O-ring. (From Russell 1.
Boisjoly and Ellen Foster Curtis, "Roger Boisjoly and the Challenger Disaster: A Case Study in
Engineering Management, Corporate Loyalty, and Ethics," Proceedings of the Eighth Annual
Meeting, American Society for Engineering Management, St. Louis, MO. October 1113,1987, p.
8.) the seal had not recovered even after 10 minutes ( 600 seconds). In the ensuing months,
Boisjoly emphasized in the strongest terms the need to redesign the field joint. On August 20,
1985, Robert K. Lund, MTI Vice President, Engineering, announced formation of a Seal Erosion
Task Team, but little progress was made on solving the problem-despite further blow-by on a
flight on October 30, 1985, when the field joint temperature was estimated at a balmy 75F(24C)
The stage is now set for the eve of the Challenger tragedy: At 10 a.m. on January 27, 1986, Amie
Thompson (MTI Supervisor of Rocket Motor Cases) received a phone call from Thiokol's
Manager of Project Engincering at MSFC (Marshall Space Flight Center), relaying the concerns
of NASA's Larry Wear, also at MSFC, about the 46F(8C) temperature forecast for the launch of

2. Flight 51-L, the Challenger, scheduled for the nexi day. This phone call precipitated a series of
meetings within Morton Thiokol: at the Manshall Space Flight Center: and at the Kerinedy Space
Center (KSC) that culminated in a three-way telecon, involving three teamis of engineers and
managers, that began at 8:15 p.a. ESI20 Present on the telephone were 14 managers and
engineers at Thiokol's Wasatch (UT) Division Management Information Center, 15 at MFSC,
and 5 at KSC. Boisjoly and Thompson began by detailing the flight and laboratory experience
previously outlined. Lund presented the final chart, recommending against launch unless the O-
ring seal temperature execeded 53F(12C); Joe Kilminster, MTI Vice President, Space Booster
Programs, supported his engineers and would not recommend launch below 53F.
George Hardy, Deputy Director of Science and Engineering at MSFC, was "appalled that
recommendation," but would not recommend to launch if the contractor was against Lawrence
Mulloy, Manager of Booster Projects at KSC, also strenuously objected, saying "M God,
Thiokol, when do you want me to launch? Next April?" Boisjoly continued to obje to a launch,
but finally Kilminster asked for a five-minute caucus of Thiokol people. Jerr Mason, MTI Senior
Vice President of Wasatch Operations, began the caucus by saying tha "a management decision
was necessary" (influenced, very likely, by the fact that MTI was that time negotiating a billion-
dollar follow-on contract with NASA). Thompson and Boisjol re-reviewed their reasons for not
launching, but quit when it was obvious that no one wa listening; Mason then turned to Bob
Lund and, in a memorable statement, asked Lund t "take off his engineering hat and put on his
management hat." At that point Lund, Masor Kilminster, and Calvin Wiggins (MTI Vice
President and General Manager of the Space Fligh Division) held a brief discussion and voted
unanimously to recommend Challenger's launch. The following day, about 73 seconds into
launch, the Challenger exploded in a ball of flam on the television screens of the entire world. In
discussing this "management" decision, Florman concludes as follows: The four so-called
Thiokol "managers" are, in fact, engineers. Mason has a degree in aeronautical engineering;
Lund in mechanical; Wiggins has a degree in chemistry; and Kilmiaster. a master's in mechanical
engineering on top of an undergraduate degree in mathematics. The two NASA "officials,"
Hardy and Mulloy, who urged that Thiokol approve the launch, are also engineers, as are the key
NASA people above them. These men were educated as engineers and had worked as engineers,
eventully moving into positions of executive responsibility. They did not thereupon cease being
engineers, any more than a doctor who becomes director of a hospital stops being a doctor. Were
these engineer-executives under pressure to meet a launching schedule? Of course. But pressure
is inherent in engineering.... Pressure goes with the job like the proverbial heat in the kitchen. It
may help explain, but it cannot excuse, an engineering mistake. 2 Boisjoly's testimony before the
Rogers Commission regarding the foregoing events led to increasing friction with MTI

3. management. "Although given the title of Seal Coordinator for the redesign effort, he was
isolated from NASA and the seal redesign effort. His design information had been changed
without his knowledge and presented without his feedback. .23 As Boisjoly later concluded,
"The research on [whistle-blowing] leads to two conclusions. First, all whistle-blowers attempt
to achieve problem resolution through their organizational chain of command; and, second, they
are all punished by the organization after whistle-blowing outside the organization." 24 He cited
as "timeless" the advice of Adolph J. Ackerman in a June 1967 IEEE article: Engineers have a
responsibility that goes far beyond the building of machines and systems. We cannot leave it to
the technical illiterates, or even to literate and overloaded techaical administrators to decide what
is safe and for the public good. We must tell what we know, first through normal administrative
channels, but when these fail, through whatever avenues we
can find. Many claim that it is disloyal to protest. Sometimes the penalty-disapproval, loss of
status, even vilification, can be severe. 25 Boisjoly understands the last sentence well. His
position at MTI became untenable, and he requested extended sick leave on July 21,1986 , with a
case of post-traumatic stress syndrome. More than two years later, when the redesigned shuttle
put America back in space, it was clear that Boisjoly would never return to work. In a later
analysis of testimony before the Rogers Commission on the correlation between temperature and
O-ring erosion, Lighthall 26 quotes testimony of participants Boisjoly (" couldn't quantify it"),
MTI engineer Jerry Burn ("it is speculation"), NASA's Mulloy "I can't get a correlation"), and
NASA's Hardy ("obviously not conclusive"), then shows by statistical analysis of data available
before the Aight a better than 99.5% probability of just such a correlation. He concludes "that
none of the participants had ever learned, or had long since forgotten, elementary ideas and
methods of statistical analysis and inference," a conclusion of obvious significance for
engineering education.
1.- In the conclusion of the handout on ethics, are listed a few questions on how to gauge ethical
conduct. Imagine you were Boisjoly, and made a recommendation, based on empirical evidence,
to cancel a potential catastrophic space lunch, and your request is denied based on management
factors. How could these questions help you decide your next action? 2. What actions did
Boisjoly take to put safety first? How his actions correlate with the recommendations outline in
the handout on "whistle-blowing"?