[MUSIC] Welcome to the second video of our fifth week of our course on Unethical Decision Making. In this video, we will illustrate the power of strong situations with a case study. The explosion of Challenger, one of NASA's space shuttles in January, 1986. In this session you will understand how pressure, may lead to disaster. Learn, what happened during and before Challenger flight. And you would see how these events can be interpreted, from the viewpoint of our model of ethical blindness. 1986 was a very bad year for big technologies. On April 26, it came to a meltdown to the nuclear power plant on Chernobyl. Earlier in the same year on January 28th, now thats space ship Challenger broke apart only 73 seconds after lift off, resulting in the death of all seven crew members. We will now look at the Challenger case, in more detail. Initially, the shuttle was supposed to take off on January 22nd. For various reasons the start was then moved, to the 23rd, then to the 24th, then to the 25th and 27th. But it is important to realize that there were, varied delays and that they may have led to some and probably also to some impatience. In the night prior to launch date, from January 27th to 8th, a new problem emerged. The temperatures, dropped tremendously. [SOUND] The forecasted temperature for the morning of the launch, was 31 degrees of Fahrenheit. That is -1 degrees of Celsius. Which was the absolute minimum temperature permitted for launch. Engineers, of Rockville International, the shuttles prime contractor were horrified, when they've seen the amount of ice that had accumulated. The launch was delayed by some more hours. Finally, the shuttle was cleared for launch and took off as it crew of seven astronauts on board, 73 seconds after ignition and 15 kilometers above ground, the spacecraft disintegrated and exploded. What caused this failure? Look at this picture, taken when the shuttle was just about to start. From about, 600 milliseconds after lift off, until three and a half seconds, that smoke, came out of the booster. At this very spot, some 59 seconds after lift off, one could then see this plume here. There were hot gasses that burned a hole in the right solid rocket booster, which then, led to the explosion. What about the smoke, that came out of the booster right after ignition? The booster is not one big piece, it compromises four segments that were assembled together. It is needless to say that these segments needed to be connected such that no gas could leak at the side. To prevent this from happening, these segments had been sealed with so called, O-rings. In fact there were two. The primary O-ring that could do the job alone and a secondary O-ring as a backup. Richard [INAUDIBLE], the famous physicist, Nobel laureate and a member of the Rogers Commission, the commission that analyzed this case, gave a very powerful demonstration of the problem. First, he has shown the rubbers elastic, at room temperature but when he put it into ice water, everyone could see that it loses its pliability and hence, it's ability to seal the segments on the Challenger shuttle. So now we understand why this mission failed. Or at least, it's immediate cause in the world of physics but of course, you cannot blame, the laws of physics or nature for this accident. Why did NASA's flight control center give the command to launch under these conditions? To answer this question, it is important to go back many years. And you know, what we see there? It appears, that the pressure from the hot burning gas that accelerated this huge machinery, was at the end of a very long chain of events. Back to July 20th, 1969, Apollo 11 made it to the moon. This was celebrated as a huge success for another. But where do you go from there? Now, that the mission is accomplished, what do you do with all the equipment, all the know-how, the staff, thousands of jobs? Should you send everybody home and kind of a vacuum situation emerged. Now vacuum is the opposite of pressure and yet it let in response, to the self imposed pressure to come up with a new vision, it was a question of survival the survival of this institution NASA. The new vision was to create a manned orbiting space station and to use it as a transfer point for exploring Mars. This new goal, in turn, required to construct a space transportation system for astronauts, the Space Shuttle Program. With the worsening of the economic situation, just remember the oil crisis in the 1970s and with its biggest achievements now behind NASA's very expensive program, we're losing political support. NASA had to reduce its vision. NASA exploration and orbit station were deemed, too expensive. There was pressure to reduce costs and to find alternative uses for their shuttles fleet. In response, they would use research and they started to cooperate with the defensive department, that was interested in using the shuttles for launching their satellites. Reconstruction then was necessary to enable the shuttle to transport heavy satellites. And here, they had to make compromises. The new design of the shuttle greatly limited its safety. And then there was this growing competition with European Ariane's space program. And competition, leads to pressure. NASA had to prove that its shuttle program was useful, necessary, working and affordable. There was only one way to prove it, increase the number of flights. Ironically, due to the big number of flights, public interest was decreasing. To regain public attention and to forge a new reputation, NASA invented the Teacher in Space program. There was a teacher in the crew, Christa McAuliffe, who should teach her class from space. President Ronald Reagan was expected to give his State of the Union speech with the Challenger being one of the key issues. Taking everything together, 1986 was regarded as the decisive year, for the continuation of the shuttle program. And this is where we started this video, with a report of the situation on January 28th. And you can see, there was already a lot of pressure imposed before on various levels. Society politics, business competition, all that. [SOUND] During the previous launches of a shuttle, there were already some, incidents with the O-rings. Not so weird, but the engineers in charge knew about this problem. And the engineers means the engineers at Morton Thiokol. That was the supplier that produced these solid rocket boosters. In particular, it was Roger Boisjoly, an engineer at Morton Thiokol, who was very concerned and he raised a flag several times. He tried to warn his management. But management was also under pressure. They wanted to have a contract with NASA. They wanted to extend the contract. And the company passed on this pressure to its engineers, in particular Boisjoly. Top management tried to calm him down. Then in September 85, Roger Boisjoly was invited to NASA to make a presentation on the O-ring problem. He was given instruction by his own management at Morton Thiokol, to present it not as urgent and as dangerous. That is an improvement aspect. Seeing the eyes on the ground, Space Flight Center administrator Larry Meloy, [INAUDIBLE] it was clear he wanted to launch, but he did not dare to overrule the experts who had produced the boosters. So it came to a teleconference between NASA and Modern Firecoil, with a group of engineers of Modern, Firecoil participating. Engineers of Modern Firecoil in that conference, recommended NASA not to launch the shuttle, until a safe temperature for the O-rings was reached. NASA did not accept it. I have a patent, said Larry McLoy. Do you want to start me in April? And to understand this reaction, you just, to put yourself in his shoes. So the, machine was fully tanked. This was a serious commitment. It was waiting at the ramp, delayed already several times. And, you should also know that the discussions about the O-ring problems, that was internal. Modern Firecoil made sure that NASA, wou, wouldn't discover it in its full severity. So, Larry Meloy's reaction was understandable. It cannot be that you confront me with this just the day before takeoff. So what did he do? He reacted by demanding, proof of the risk. Which was the complete reversal of the normal procedure. Normally, the engineers had to prove that something was safe. Modern [INAUDIBLE] managers asked to go offline for a few minutes. During this offline discussion, which then at the end, took about 30 minutes, Morton Thiokol's Senior Vice President, Jerry Mason pointed out that the possibility of an O-ring erosion, had always been present in earlier flights. And had been considered an acceptable risk. He underlined, that there was a primary and a secondary O-ring. And that even in the case of the first O-ring eroding, the second one would seal. At that very moment, they were under time pressure. He could not prove that it was not safe. At least he could not convince the others. So basically, Martin Fire Code management, asked the engineers to reconsider their position. And when they refused to change their mind, but they also, could not prove it, the management excluded the engineers from further discussions. So, they conferred about themselves, the managers. And the three managers immediately supported the position of the vice president. While Lund, the superior of the engineers, hesitated. In this situation, Mason said to Lund, it is time to take off your engineering hat and put on your management hat. So basically what Mason said here, he informed the engineers, that the technical decision had to be turned into a management decision. Remember what we said earlier about framing. The frame of an engineer is safety first. This is how they look at the world, at these problems. Safety is above, everything. For manager, manager has a wider frame. He also looks at the business, the money involved. And for him it's a calculated risk that at some point, you may want to take. And also remember what we said about simple heuristics and about one reason decision making. One reason decision making heuristic put one [SOUND] Reason in the foreground. Basically make a decision, based on one reason. And so the question is, which gets priority? In our case here, safety or business opportunity. So, that was the discussion. The engineers would, was, were not able to convince the management. And at some point, the teleconference after 30 minutes was reopened. Mason summarized, Morton Thiokol's position. The data are inconclusive. Some tests, had shown that the first O-ring could, sustain three times more erosion than experienced in the previous, worst case. Furthermore, the second O-ring could serve as a back-up. One of the NASA miniatures asked whether there was any disagreement, or further comment from And that was a very dense situation. Nobody spoke up. Not even the engineers. And if you're in a meeting like this and you do not speak up when you receive this question it means, you agree to launch even Who was, deadly against it. But he could not yield to pressure, that came before from his own management. Morgan Fireco was then asked to fax a copy of the recommendation to NASA and with this approval, NASA okayed the launch and the result, is, known. So, to conclude at first inspection, the Challenger exploded because of the O-rings, didn't seal at this cold temperature. But upon closer inspection, it became clear that various kinds of pressures could be seen, as important contributors. In combination with some bad luck, these pressures led to a situation in which there was not enough margin, to prioritize safety over interests. Thanks for watching. [MUSIC]
