Facts of the case
The fatal accident occurred on January 28, 2008, 73 seconds after the mission began and was caused by a technical failure (Vaughan, 1990). The O-rings sealing failed because of the prevailing cold conditions and as a result, there was a gas leak that produced flames that in turn reached the highly combustible Hydrogen fuel tank leading to an explosion.
Causes
According to Perrow (1984) cited in Vaughan, it was expected that the technical system should fail. In fact, they were bound to fail sooner or later by design. Turner (1978) on the other hand believed that the failure of the technical system was caused by the accumulation of small ‘red flag’ events that had been overlooked over time. The O-ring problem for instance had been known since 1970 since more than half of the missions had experienced the problem. The problem was well known that it was one possible factor that could cause an accident.
Though the immediate cause of failure was identified as technical, further analysis has shown that it was an organizational technical failure; that is failure within the organization to identify, measure and correct problems due to the organization structure leading to technical failure. Thus, the O-ring failures that led to the space shuttle disaster were caused by the following organizational failure
The problem was caused by poor communication, inadequate information handling, faulty decision making, failure to comply with regulations and confusion of priorities given to cost and time deadline over safety.
Dependent regulatory bodies also depended more on NASA yet they were supposed to regulate it. This is due to its size complexity and sensitivity to the nature of projects it was carrying out.
Recommendations
A stronger oversight body is needed: The ASAP should be strengthened to oversee the safety standards are met since the government provides funding for the program. If safety standards are not met they should be able to withdraw funding. Thus, the regulator must be able to threaten and impose meaningful sanctions
Staffing and Resources for the regulatory bodies: The three bodies that were concerned with regulating NASA were understaffed and poorly resourced. There is a need to employ more staff to be able to adequately monitor NASA’s work. SRQ&A had a staff of 500 compared to the 22,000 staff of NASA (Vaughan, 1990). The SSCCP had only twenty non-full-time staff that were needed to work full time.
Top management position for Quality and Regulatory body: The need for the position of the quality regulator to be given a more senior position to advise the administration and to guide organization policy and strategy. There is also a need for a fully-fledged department with enough staff to monitor the work of NASA and its contractors. This will make it easier to access vital information easily and to take action against them which is a limitation that external regulators could not overcome.
Reducing informational dependency by ensuring that both the regulator and regulated understand that they have a common and mutual destiny. The government relied on NASA to fulfill its goal of showing US supremacy in international competition for scientific advances and military supremacy.
NASA on the other hand depends on the government for funding needed for continued operations. NASA needs to appreciate that its output is the input for regulators and must therefore provide all information.
Concerns about the danger of the O-ring had been raised and a call to cancel the shuttle launch was made, this was canceled by a middle-level supervisor. Thus, there is a need for a clear mechanism in which any danger detected is escalated to top management who are the only ones with the authority to allow for the launch under such circumstances after extensive consultation with all quality stakeholders i.e. contractors internal and external regulators and government.
More cross-functional teams should be involved in project developments evaluation and reporting: Future development should involve parties from the government, contractors, NASA, internal and external regulators. This ensures that the information they have access to is equally accessible among all teams and thereby enhances problem-solving exercises. Finally, there should be a clear mechanism for reporting which should be established for identifying and informing all parties on potential problems.
References
Vaughan, D. 1990. Autonomy, Interdependence, and Social Control: NASA and the Space Shuttle Challenger. Administrative Science Quarterly, 35(2): pp 225-257.
Turner, B.1976. The Organizational and Interorganizational development of Disaster. New York: Prentice Hall.