The Space Shuttle Challenger Disaster

RISK CASE STUDY ASSIGNEMENT 2 August 3, 20111 THE SPACE SHUTTLE CHALLENGER catastrophe pretend focus mean 1. encounter prudence image summarizes hazardiness focusing come, itemization methodologies and processes, de jells e reallyones role definition of jeopardy precaution stick discover. NASA was victimization for the close to start up qualitative adventure judging process. Launch of the hoot was every(prenominal)owed as long as nitty-gritty jeopardy remained acceptable. Quantitive method was applied for peril sagaciousness because if the complex procedures ( equivalent selective breeding gathering) were in quad NASA would be buried with paperwork.NASAs finale was immobile with acceptable gamble. on that point was Risk instruction object in place for NASA because on that point was risk assessment and protocols in place nonwithstanding collectable to unwarranted nature of most of NASA decl atomic number 18 oneselfs waivers became a way of c onducting business. As described in the NASA Handbook, hazards (risks) were study and overseen by the superior Safety Review Board. Each identified risk was classified by an established system, found on both the risks level of of the essence(p)ity on a scale of one to third (C1, C1R, C2, C2R, and C3).However, their review process contended that no single risk or combination of risks would be full to frustrate a immerse, as long as the add up risk remained at an acceptable level. 2. The Risk Management Plan was non followed. Methods use to gather data to assess risk were expensive and labour intensifier and so were the procedures (Flight Readiness Reviews. To keep up with mission manifest memorandum 16 escape cocks per class any) issues had to be unflinching fast (waivers).Once a risk was stated acceptable, it was overlooked during future mission planning sessions. Addition altogethery, they didnt nominate proper procedures for evaluating the reach of unknown ris ks (i. e. the tripe job). Lastly, protocol stated that one risk or one persons concern was non enough to green goddesscel the shew. A no launch recommendation by one party could admit been overruled by the launch director. 3. Differences a. Risk Management Plan is the tabucome of Plan Risk Management emergence and describes how risk counselling is structured and performed.It includes methodology ( snuggle, tools, data source), roles and responsibilities (lead, support), budget (resources, protocol for contingency resource), timing (when and how ofttimes process is performed), risk categories (RBS), definition of risk opportunity and impact (high, medium, low), probability and impact matrix, risk s bedevilholders tolerance. b. shade Assurance Plan describes how quality self-assertion ordain be performed within project to in allow for reduce waste and eliminating processes that do non add value.It is meant to cast up level of efficiency. c. Safety Plan A gumshoe pla n is an organized system of rules and guidelines used to asseverate safe work environment. 4. Pressure to meet schedule sixteen flights a year in 1986 meant that all involved impart take away to face paperwork constraints related to flight readiness assessment. Personnel and contractile organs were working overtime already trying to fill out all necessary paperwork related to line solving, investigations and last flight updates.Waivers were part of NASA protocols to bypass all of this plus they were a way to indicated that risk was acceptable. Number of flight per year was critical to designing risk circumspection plan because of all similarities between flights like temperature launch characterize could become predictable factors to jibe acceptable risk. Risk Identification 5. Risk is uncertain event associated with work, it is a loss multiplied by likelihood that may have impact on the project. There argon three common categories of risks envisionlable knowns, uncontrol lable knowns, and unknowns.Anomaly is a deviation from the standard. Project manager and aggroup define a baseline and decide the difference based on definition of anomaly depictd by fictional character matter experts (engineers). 6. NASA had Flight Readiness Review rough days prior to flight. Risk identification at NASA was conducted by Senior Safety Review Board. In majority of cases risk assessment process was qualitative. If aggregate risk remained acceptable launch should surpass. Hazard were analyzed and subjected to formalized hazard reduction process I in NASA handbook.Quantitative method of risk assessment was not applied because they were expensive and time consuming. Technical experts were not involved enough in any of the discussions. 7. In order to resolve any differences we need to list them and quantify them first which never happened in case of Challenger. Customer is always right and in the long run his finale overrules but contactor must provide as compl eted data as possible based on compendium. Every recognized risk has distinct cargo and whatever of them thru brainstorming can be resolved or even eliminated. 8.Upper management needs to be committed to project of such a wide scale and support it. They should be informed astir(predicate) individual risks and it is up to project manager to provide true study virtually project. It seems that culture of NASA original waiver as a way to determine acceptable risk and considered then as a part of reachicial protocol. 9. Risk associated with any elect method should be classified based on cost (budget), safety and technology (design) and boilersuit impact on the mission. Challenger did not have both solid political support or direction.Cost became the most critical component in conclusion fashioning. change fuel systems were cheaper but also less safe. They pack less research and development but were intentional for reusability. 10. Politically motivated trade-offs argon im possible to control by PM and his/her squad. There is a wedge to for government to deliver promise or a need to see where all funding went. whole PM has is data and measurements based on research, analysis and historical lessons. There should be a limit where safety becomes impossible to trade.This is where government agenda should not applied because risk of losing lives is too high to trade. 11. NASA was nether pressure from government and by the same image pressured contractor (Thiokol). Funding was inconsistent, expectations were very high and there was no clear direction where dummy course of study was going and go awaying manifest was beyond capabilities of force play should he chose to follow all procedures. Risk was metric in every last. 12. Risk Management plan is evolving document as project goes on. different phases should be recorded in Risk Register and 2 separated risk assessments conducted because each phase faces different risks. Identifying risk will serv icing us analyze triple constraint factors. Both risk assessments argon equally important. Risk Quantification 13. Given the complexity of property Shuttle Program it is necessary to address each each technical aspect of the risk. In round cases lesson learned from previous experience with shuttles can be applied to other program given that conditions like weather, resistance to high temperature or fuel type.Certain measurements can be applied to all space shuttle programs. Qualitative risk evaluation could be used at the beginning of the project to sort out level of each risk. Quantitative risk would be possible if there full support from swiftness management (government), budget and methodologies were in place. Both methodologies argon equally valuable in complex project like Challenger. 14. There were 3 separate internal-combustion engine watchfulnesss conducted on the set and drinking glass team indebtedness was to remove any scum. First inspection detain launch due to presence of ice on launch ornament.Second inspection discovered still important presence of ice on launch site and it was determined take off was unsafe. Falling ice could damage heat tiles on the Orbiter. Third inspection still found significant ice presences on the launch pad. 3 major concerns of the ice-on-the-pad issue launch objection due to the weather, ice on the pad was unknown effect on the ignition and junk were considered potency flight safety hazard, freeze vindication plan for launch pad 39B was inadequate. Ice was considered a potential problem. 15.Risk quantification allows preparing better for potential risks. Contractors provide data but it is decision of the customer whether to take some of all data chthonic consideration when making decision. To resolve a matter of dispute, the customer and contractor should collaborate. If there is no agreement customer decides what approach to take. 16. Senior management needs to be presented with information in easy t o visualize form in case of Shuttle short movie presenting what would happen on impact. Only potential problem do it all the way up to higher management not the critical ones.None of the recommendations from Thiokol were passed to top(prenominal) management. There were no established procedures that all risk data cannot be modified by any member of the team without proper access and expertise. 17. It was quantitative system but issuing waivers very often made it null because they by-passed some of the recommendations. Lessons learned were not used by Thiokol paying attentioning temperature at launch which was supposed to be 53 degrees Fahrenheit. Thiokol engineers tried to quantify some of the risks based on historical information regarding blow-bys and temperatures. 18.No, there were no probabilities assign to risk like putty, temperature, rings although there was some historical data available. There were not enough details to develop probabilities and metrics to rely on. En gineers could not determine direct correlation between factors. Risk Response (Handling) 19. Size of the company, available budget, company culture and general resource decide what constitutes acceptable risk. It depends on tolerance of individual company to determine if risk is acceptable. 20. Project manager is always responsible for succeeder and/or bereavement of the project.If there is another personate in the company responsible for handling risk on larger, company scale it should be consulted as well. 21. According to PMBOK there are 4 risk chemical reactions and all of them were used acceptance (consequences were acceptable), avoidance (re-scheduling take off), control (type of aborts and their respective landing sites) and transfer (hiring Thiokol as contractor to transfer risks). 22. There was an abort due to bad weather and ice which was correct response. NASA intractable to launch in spite of C1R which meant 2 components failure (both main and secondary ring booste r are the same type).This is not a correct response to existing risk. This decision was made without any regard for possible consequences of component failure. 23. Subject matter experts and upper management and technical consultants with the knowledge of space technology. Astronauts should be consulted as well since they risk their lives and are in immediate danger. 24. Every project should have risk response mechanism included in risk management plan. All data gathered from SME and specialist in the depicted object should be taken under consideration when developing risk response mechanism.When team cannot agree on it senior management who is ultimately responsible has final saying. 25. Astronauts with technical experience and knowledge should have been consulted. Christa McAuliffe as an example would not digest any matter valuable because her knowledge wasnt in space shuttle design discipline and she did not have any previous experience flying either. They have accepted the r isk already when they agreed to fly no need to re-assure it. Astronauts are all volunteers and understand that safety is space is never 100% guaranteed.In my thought process it is safety staff that should have been included primarily. No safety representative or quality assurance officer was included in any of the decisions (or during the take-off). 26. Waivers were a way of bypassing ordained protocols in order to give schedule. It was a form of acceptance. 27. Waivers were standard operating procedures they are type of active acceptance the wrong thing can be done to solve the problem because its solution was not clearly thought out under pressure in the heat of the importee 8. Yes Schedule pressures made managers less willing to accept possible risks. Despite the fact the temperature was not approving (as required minimum of 50 degrees Fahrenheit), Thiokol & NASA unyielding to go ahead with the launch to meet their want planned schedule. Political pressure affected all responsible parties. 29. The risk response mechanism utilised by managers at Thiokol and NASA was Acceptance. They were richly sensible of the potential risk as yet they decided seat anchor and see what happens. 30.The Engineers did not do everything to convince the management to stop of the launch. After failing to convince the management they decided to take a passive approach of wait and see what happens next while they knew the results will be catastrophic. To make matters worse, Engineer Boisjoly changed his expert maestro opinion after was told put on his management hat. 31. Though NASA claims that its top priority is the safety of the ring and equipment, it did violate its responsibility to ensure safety of the conclave in spite of the evidence that was presented to them by the engineers.They compete Russian roulette with charitable lives. Final findings though confirmed that pressure caused rational men make irrational decisions. 32. YES NASA was completely awar e that the temperature was not roaring for launch (as required minimum of 40 degrees Fahrenheit) however still went ahead with the launch to meet their craved planned schedule. The O-Rings had never been tested below halt temperatures sooner & did not meet the 40 degrees below qualification temperature. Risk Control 33.Documentation is crucial and must to be thorough as part of risk management in order to disclose all potential risks, keep a historical record data , reveal relevant information to the project to ensure project process are in compliant with the companys goals. Depending on the complexity of the projects or programs company is involved beat will differ. Excessive paperwork can be very discouraging to personnel. 34. There was no audit leash to the best of our knowledge. Thiokol had lessons learned regarding erosion, temperatures and blow-bys. 35.Thiokol noticed black lampblack and grease on the outside of the booster casing, caused by actual gas blow-by and h ad ordered new mark billets which would be used for a redesigned case field joint. This vital information should have been disclosed during the hour presentation granted to them which they mostly argued on the ice-cold weather effects. 36. Hard facts speak to upper management better than anything. Presentation and SME opinions quoted within presentation would help to get upper management attention. 37. Again, facts, findings and lesson learned are powerful tools.Once team and upper management is aware that science doesnt covering up decision sole responsibility and pressure is taken off single person and transfer to the whole team. 38. There were 5 different communication and organization failures and 4 of them were directly related to safety program. Lack of problem reporting requirements, inadequate trend analysis, misinterpretation, lack of social function in critical decisions. Safety organization should be better staffed and SUPPORTED. 39. Rockwell was prime contractor to b uild Orbiter. It was believed that Rockwell was not the best choice since it had not been involved in Apollo Program as others.Rockwell issued a concern about possible Orbiter damage due to the ice problem but they never stated they did not want to launch. They never said to NASA launch should be aborted due to unknown nature of the ice. It was never officially recorded that Rockwell objected. By making objection official there is paper trail that can be traced back should situation call for it. 40. Risks levels must be maintained completely at minimal before launching of the spaceship however loss of human life should be avoided at all cost. The overall risk should have been between C2 & C3. 41.It is best to execute a presentation to the higher-ranking Management with adequate evidence of potential risks & the overall impact. In addition, outsource experienced experts who will back you up with their input in order to lucre a favourable decision. 42. The liability should be rigid on the people who made final decision to launch while they fully aware fully of potential risks. Though the Thiokol engineers cried for Help, they were thwarted from beseeching their case and the management went ahead supported NASA transaction with the launch. Both Thiokol management & NASA should share the blame.