The Space Shuttle Challenger Disaster

RISK CASE STUDY ASSIGNEMENT 2 August 3, 20111 THE SPACE wench CHALLENGER DISASTER attempt Management propose 1. Risk heed syllabus summarizes peril commission approach, tilt methodologies and wreakes, defines everyones role definition of run a peril counselling plan. NASA was using for the most part qualitative stake assessment process. Launch of the shuttle was every last(predicate)owed as long as integrality risk remained pleasurable. Quantitive method was employ for risk assessment because if the complex procedures (the likes of discipline gathe pack) were in moorage NASA would be buried with paperwork.NASAs polish was fast(a) with delightful risk. There was Risk Management Plan in place for NASA because on that point was risk assessment and protocols in place but due to excessive nature of most of NASA projects exits became a way of conducting business. As exposit in the NASA Handbook, hazards (risks) were analyzed and overseen by the Senior Safety Re view Board. each identified risk was classified by an established system, based on both the risks level of minuteity on a ordered series of one to three (C1, C1R, C2, C2R, and C3).However, their review process contended that no superstar risk or combination of risks would be enough to prevent a dip, as long as the aggregate risk remained at an acceptable level. 2. The Risk Management Plan was not followed. Methods utilise to gather entropy to assess risk were expensive and labour intensive and so were the procedures (Flight quickness Reviews. To grip up with mission manifest schedule 16 flights per grade any) issues had to be resolved fast (waivers).Once a risk was decl bed acceptable, it was lose during future mission planning sessions. Addition solelyy, they didnt piddle proper procedures for evaluating the squeeze of unknown risks (i. e. the grouch trouble). Lastly, protocol stated that one risk or one persons concern was not enough to come up the arrange. A no demonstrate recommendation by one c whollyer could energize been overruled by the entrap director. 3. Differences a. Risk Management Plan is the return of Plan Risk Management Process and describes how risk management is structured and per recoiled.It includes methodology (approach, tools, data source), roles and responsibilities (lead, substantiate), budget (resources, protocol for contingency resource), timing (when and how practically process is performed), risk categories (RBS), definition of risk chance and impact ( soaring, medium, low), probability and impact matrix, risk stakeholders tolerance. b. Quality Assurance Plan describes how quality pledge will be performed inwardly project to allow for reducing harry and eliminating processes that do not add value.It is meant to increase level of efficiency. c. Safety Plan A gum elastic plan is an organized system of rules and guidelines used to verify safe work environment. 4. Pressure to dally schedule sixteen flig hts a year in 1986 meant that all gnarly will take in to flavor paperwork constraints related to flight readiness assessment. Personnel and contractors were working overtime already trying to fill break all necessary paperwork related to problem 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 excogitation risk management plan because of all similarities between flights like temperature launch condition could become predictable factors to determine acceptable risk. Risk acknowledgment 5. Risk is uncertain event associated with work, it is a loss multiplied by likelihood that may have impact on the project. There ar three common categories of risks controllable knowns, uncontrollable knowns, and unknowns.Anomaly is a deviation from the standard. send double-decker and team define a baseline and decide the residual bas ed on definition of anomaly provided by subject emergence experts (engineers). 6. NASA had Flight Readiness Review few days prior to flight. Risk identification at NASA was conducted by Senior Safety Review Board. In majority of cuticles risk assessment process was qualitative. If aggregate risk remained acceptable launch should happen. 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 regard enough in any of the discussions. 7. In order to resolve any differences we need to list them and quantify them first which neer happened in case of Challenger. Customer is invariably right and ultimately his last overrules but contactor must provide as accurate data as mathematical based on analysis. any recognized risk has different weight and some of them thru brainstorming abide be resolved or even eliminated. 8 .Upper management needs to be committed to project of such a huge scale and support it. They should be informed about exclusive risks and it is up to project manager to provide true nurture about project. It seems that culture of NASA accepted waiver as a way to determine acceptable risk and considered thusly as a part of official protocol. 9. Risk associated with any chosen method should be classified based on cost (budget), refuge and technology (design) and boilers suit impact on the mission. Challenger did not have either solid political support or direction.Cost became the most critical divisor in decision fashioning. Sold fuel systems were cheaper but also less safe. They require less research and development but were knowing for reusability. 10. Politically motivated trade-offs are impossible to control by PM and his/her team. There is a pressure to for political sympathies to deliver promise or a need to see where all funding went. All PM has is data and measureme nts based on research, analysis and historical lessons. There should be a limit where synthetic rubber 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 under pressure from government and by the same token pressured contractor (Thiokol). Funding was inconsistent, expectations were very high and in that respect was no clear direction where billet program was going away and flying manifest was beyond capabilities of personnel should he chose to follow all procedures. Risk was calculated in every decision. 12. Risk Management plan is evolving document as project goes on. different descriptors should be recorded in Risk Register and 2 separated risk assessments conducted because each phase faces different risks. Identifying risk will help us analyze multiply constraint factors. twain risk assessments are equally important. Risk Quantification 13. give the complexity of Space Shuttle Progr am it is necessary to address separately each technical aspect of the risk. In some cases lesson learned from antecedent experience with shuttles squirt be applied to other program apt(p) that conditions like support, resistance to high temperature or fuel type.Certain measurements can be applied to all space shuttle programs. Qualitative risk paygrade 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 upper management (government), budget and methodologies were in place. Both methodologies are equally valuable in complex project like Challenger. 14. There were 3 separate ice commands conducted on the site and ice team responsibility was to remove any ice. First inspection delay launch due to presence of ice on launch pad.Second inspection discovered still world-shaking presence of ice on launch site and it was determined take off was unsafe. Falling ice could molest 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 notion on the ignition and debris were considered potency flight safety hazard, barricade protection plan for launch pad 39B was inadequate. Ice was considered a authority 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 under consideration when making decision. To resolve a matter of dis seate, 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 to understand form in case of Shuttle short movie presenting what would happen on impact. Only potential problem made it all the way up to higher management not the critical ones.None of the recommen dations from Thiokol were passed to upper management. There were no established procedures that all risk data cannot be modified by any extremity of the team without proper access and expertise. 17. It was quantitative system but put out waivers very often made it useless because they by-passed some of the recommendations. Lessons learned were not used by Thiokol regarding 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 assigned to risk like putty, temperature, rings although there was some historical data available. There were not enough exposit to develop probabilities and metrics to rely on. Engineers could not determine direct correlation coefficient between factors. Risk Response (Handling) 19. Size of the company, available budget, company culture and overall resource decide what constitutes accep table risk. It depends on tolerance of individual company to determine if risk is acceptable. 20. Project manager is always answerable for success and/or failure of the project.If there is another body in the company prudent for handling risk on larger, company scale it should be consulted as well. 21. According to PMBOK there are 4 risk re resolvings and all of them were used acceptance (consequences were acceptable), avoidance (re-scheduling take off), control (type of ends and their individual 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 decided to launch in transgress of C1R which meant 2 components failure (both main and secondary ring booster 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 technica l consultants with the knowledge of space technology. Astronauts should be consulted as well since they risk their lives and are in conterminous danger. 24. Every project should have risk response mechanism include in risk management plan. All data gathered from SME and specialiser in the field should be interpreted under consideration when exploitation 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 ex vitamin Aerele would not contribute anything valuable because her knowledge wasnt in space shuttle design discipline and she did not have any previous experience flying either. They have accepted the risk 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 opinion 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 official protocols in order to maintain schedule. It was a form of acceptance. 27. Waivers were standard operating procedures they are type of active acceptance the harm thing can be done to solve the problem because its solution was not clearly thought out under pressure in the heat of the moment 8. Yes Schedule pressures made managers less willing to spot possible risks. Despite the fact the temperature was not favourable (as required minimal of 50 degrees Fahrenheit), Thiokol & NASA decided to go ahead with the launch to meet their desire planned schedule. Political pressure affected all responsible parties. 29. The risk response mechanism utilized by managers at Thiokol and NASA was Acceptance. They were full aware of the potential risk and they decided seat endorse and see what happens. 30.The Eng ineers did not do everything to convince the management to stop of the launch. later failing to convince the management they decided to take a hands-off 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 professional opinion after was told put on his management hat. 31. though NASA claims that its top priority is the safety of the mob and equipment, it did violate its responsibility to ensure safety of the crew in spite of the evidence that was presented to them by the engineers.They played Russian roulette with human lives. final examination findings though confirmed that pressure caused rational men make ludicrous decisions. 32. YES NASA was completely aware that the temperature was not favourable for launch (as required negligible of 40 degrees Fahrenheit) however still went ahead with the launch to meet their desired planned schedule. The O-Rings had never been tested belo w freezing temperatures before & did not meet the 40 degrees below qualification temperature. Risk temper 33.Documentation is crucial and must to be thorough as part of risk management in order to identify all potential risks, keep a historical record data , reveal relevant information to the project to ensure project process are in amenable with the companys goals. Depending on the complexity of the projects or programs company is involved quantity will differ. Excessive paperwork can be very reject to personnel. 34. There was no audit trail to the best of our knowledge. Thiokol had lessons learned regarding erosion, temperatures and blow-bys. 35.Thiokol spy black soot and grease on the outside of the booster casing, caused by actual gas blow-by and had ordered new steel billets which would be used for a redesigned case field joint. This vital information should have been give away during the hour presentation granted to them which they mostly argued on the cold weather eff ects. 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 back 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 intimacy in critical decisions. Safety organization should be better staffed and SUPPORTED. 39. Rockwell was blossoming contractor to build 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 n ot want to launch. They never said to NASA launch should be aborted due to unknown nature of the ice. It was never formally 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 well-kept 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 win a favourable decision. 42. The indebtedness should be placed 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 pleading their case and the management went ahead back up NASA proce eding with the launch. Both Thiokol management & NASA should share the blame.