Challenger 300 Turbulence Death - Prelim Released

[BEEF SUPREME]

STOP!!!!
The post “accident” investigation revealed that this Challenger flight was the 5th or 6th shuttle flight with a fuel leak. The leaks were known LONG before Reagan was President!

In some far left field position, I guess you could state that the TEACHER died because of Reagan pressure but clearly not ALL of the astronauts……. but even this statement would be both over dramatized and an overreach.

Yeah. Gonna have to just disagree with you. The temperature limits for the O-ring seals were well known and violated until this accident. Not sure where you are getting your information on a fuel leak but solid rocket boosters aren't going to leak. They will blow up when the hot gasses escape because of escaping hot gasses bypassing an O-ring that has a temperature limit. The temperature limits for launch are there for a reason:

"A lengthy investigation of the accident conducted by the independent Rogers Commission revealed a plethora of safety issues. Among the commission's findings were a flawed decision-making process for launch, and managers not fully appreciating the dangers of launching a space shuttle in cold weather. The ultimate technical cause was "destruction of the [solid rocket booster] seals that are intended to prevent hot gases from leaking through the joint, during the propellant burn of the rocket motor," the commission wrote."

This kind of behavior led author Diane Vaughn to coin the term "Normalization of Deviance." Below is more information about that:

"In the understanding of safety and risk, Vaughan is perhaps best known for coining the phrase "normalization of deviance",[5] which she has used to explain the sociological causes of the Challenger and Columbia disasters.[6][7][8] Vaughan defines this as a process where a clearly unsafe practice comes to be considered normal if it does not immediately cause a catastrophe: "a long incubation period [before a final disaster] with early warning signs that were either misinterpreted, ignored or missed completely."[9][10]"

So you can type STOP and use four (4) exclamation points and say I'm creating a far left theory but I'll just say "nice red herring". You are entirely missing the point. I'll just go ahead and type the point out clearly: Lots of flight departments and individual pilots are making this mistake on a daily basis. Nothing bad happened last time so we will do it again, even more. That is what NASA did and nearly every flight department that I have flown for.

This behavior needs to be kept in check at an organizational level or there will eventually be a disaster.

 

[SlumTodd_Millionaire]

STOP!!!!
The post “accident” investigation revealed that this Challenger flight was the 5th or 6th shuttle flight with a fuel leak. The leaks were known LONG before Reagan was President!

In some far left field position, I guess you could state that the TEACHER died because of Reagan pressure but clearly not ALL of the astronauts……. but even this statement would be both over dramatized and an overreach.

There was also zero evidence that the White House was exerting any pressure whatsoever on NASA. This was a pure NASA screwup.

 

[SlumTodd_Millionaire]

Yeah. Gonna have to just disagree with you. The temperature limits for the O-ring seals were well known and violated until this accident. Not sure where you are getting your information on a fuel leak but solid rocket boosters aren't going to leak. They will blow up when the hot gasses escape because of escaping hot gasses bypassing an O-ring that has a temperature limit. The temperature limits for launch are there for a reason:

He's obviously referring to the hot gasses leaking, and he's absolutely right. There were numerous cases of this documented BEFORE Reagan, and they kept right on going. One case in particular completely breached the first O-Ring and damaged the second O-Ring. Trying to blame this on Reagan (who I am not a fan of) is one hell of a reach.

 

[BEEF SUPREME]

He's obviously referring to the hot gasses leaking, and he's absolutely right. There were numerous cases of this documented BEFORE Reagan, and they kept right on going. One case in particular completely breached the first O-Ring and damaged the second O-Ring. Trying to blame this on Reagan (who I am not a fan of) is one hell of a reach.

You are also missing the point entirely. I'm not blaming Reagan and I'm super sorry if I created some kind of Republican butt hurt. It's not the point at all. The point is: Processes have to be followed to stop the "Normalization of Deviance" no matter the outside pressures.

 

[FlyingAccountant]

I think the pressure came from within NASA thinking that they were going to lose funding if the shuttle continued to underperform and miss launch dates so there was a pressure there to perform. It didn't help that the original concept of the "shuttle" was quite literally a shuttle that would be going back and forth to space almost weekly and the reality that that would never be the case had started to set in by 1986, so there was a fair bit of apprehension there.

It's worth mentioning that Allan McDonald, an engineer for the company that built the boosters, refused to sign off on the launch and NASA went anyway. He was a hero, in my opinion, and the rest is unfortunately history.

People don't like to acknowledge that the shuttle was deeply flawed from a technical perspective and we're lucky we only lost two of them. Someone did the math on it and determined every launch had a 1 in 50 shot of catastrophic failure.

 

[BEEF SUPREME]

It doesn't matter where the pressure comes from. It matters how the organization separates these kinds of pressures from operational decisions.

I am likely wrong about the outside pressures from the President or social pressures of the media.

The point is that in this Challenger 300 accident the crew likely felt pressure that resulted in a flawed preflight and the subsequent events that led to the death of a passenger.

So lets just say I was wrong about Reagan or any other president. I'm dumb you're right I'm wrong. Weee you win. Now lets think about how outside pressures or organizational pressures can kill people in aviation.

 

[dustoff17]

You are also missing the point entirely. I'm not blaming Reagan and I'm super sorry if I created some kind of Republican butt hurt. It's not the point at all. The point is: Processes have to be followed to stop the "Normalization of Deviance" no matter the outside pressures.

The “normalization of deviance” was a term long before Columbia‘s Destruction. It was coined following the Challenger “accident“ and specifically with regards to the multiple previous launches that revealed O-ring leaks. The “normalization“ in the report was a general statement about the culture but it specifically pointed directly to these leaks as a causation example.

Mine wasn’t a defense of any President or party but rather a rebuttal to a far-reaching statement that has no merit.

I absolutely agree that this C300 crew “normalized” sh….stuff that should have been prioritized. They literally killed the passenger.

 

[form810]

STOP!!!!
The post “accident” investigation revealed that this Challenger flight was the 5th or 6th shuttle flight with a fuel leak. The leaks were known LONG before Reagan was President!

In some far left field position, I guess you could state that the TEACHER died because of Reagan pressure but clearly not ALL of the astronauts……. but even this statement would be both over dramatized and an overreach.

Well, look, it wasn't directly Reagan. In a fashion similar to but distinctly different from how it wasn't "directly" Reagan who scuttled the release of the Iran hostages until after the election. But it sure as hell was the profiteering/power-grabbing ilk at fault. I mean, I get it; I have empathy... Morton Thiokol, knowing full well (whistle blower and all) that their O rings were fubar, was just being 'Murican! and being profitable so the CEO would have to sell only 4 of his 9 houses after the criminal inquiry and the civil suits. If he had to sell 5 of his 9 houses, he might make his wife cry on national television! Pillows, Rockets, Presidents, aircraft owners...the similarity is almost always, "SO MUCH WIN!"... for ME! (replace ME with your favorite scumbag's name.)

 

[dustoff17]

Well then, we should all band together and blame President Nixon!

He’s the one the directed NASA to develop the shuttle program (not named this until later). AND blame whomever the President was when the parts contracts were bid out and selected!
There were two top companies vying for the SRB contract; one in NC (I think but definitely on the east coast) and Morton Thiokol in UT. Morton was awarded the contract because the head of Morton paid off more members of Congress. It wasn’t until Morton had already spent millions of contract money that they notified NASA they would need to change the design (this was “intentional” and an issue raised much later)

The ONLY reason the SRB NEEDS O-rings in the first place is because of the new design. Redesigned because it had to be delivered in sections because the train tunnels and cars that would eventually bring the SRBs to FL weren’t big enough to support the original bid. Morton redesigned the SRB in sections, with a smaller diameter, AND longer than the original plan…thus the necessity for the O-rings. No sections, no O-rings!!!!

The NC company met the original contract requirements and were going to deliver the proposed a single-shelled SRB.

Blame politicians for the Challenger…..

 

[jrh]

Biggest difference is you can’t just book a charter on Netjets. Have to be an owner.

Maybe so. I don't know the details of each operator.

My point was addressing size of the organization versus general trends in safety. It's all corporate.

 

[inigo88]

@BEEF SUPREME is right. The pressure on Challenger did come all the way from the top, from then president Reagan. There was enormous pressure on NASA to meet their schedule commitments and fly the shuttle frequently and reliably to and from orbit as it was sold to politicians and the public. In reality it was a VERY expensive, VERY complex engineering marvel that had many operating limitations that needed to be respected in order to work properly - it was never going to be the reliable quick turnaround vehicle it was sold to be.

The political pressure on the challenger launch schedule commitment and the teacher in space thing was then amplified by many middle managers across government and the private sector trying to squeeze the engineers to meet their milestone and save their own jobs. It’s a tale as old as time (or at least since there have been engineers).

Source: An engineering ethics class case study on Challenger.

 

[inigo88]

Well then, we should all band together and blame President Nixon!

He’s the one the directed NASA to develop the shuttle program (not named this until later). AND blame whomever the President was when the parts contracts were bid out and selected!
There were two top companies vying for the SRB contract; one in NC (I think but definitely on the east coast) and Morton Thiokol in UT. Morton was awarded the contract because the head of Morton paid off more members of Congress. It wasn’t until Morton had already spent millions of contract money that they notified NASA they would need to change the design (this was “intentional” and an issue raised much later)

The ONLY reason the SRB NEEDS O-rings in the first place is because of the new design. Redesigned because it had to be delivered in sections because the train tunnels and cars that would eventually bring the SRBs to FL weren’t big enough to support the original bid. Morton redesigned the SRB in sections, with a smaller diameter, AND longer than the original plan…thus the necessity for the O-rings. No sections, no O-rings!!!!

The NC company met the original contract requirements and were going to deliver the proposed a single-shelled SRB.

Blame politicians for the Challenger…..

I do blame the politicians, although I’m sure the CEO of Morton Thiokol was playing games as well.

I can’t think of a case of a solid rocket fuel grain the size of the space shuttle SRBs that isn’t built in segments. Mixing the fuel grain as a liquid, degassing all the air bubbles and impurities out and then forming it and curing it all at once would be manufacturing insanity. I won’t say it’s impossible but I’d love to see an example if you have one.

The Challenger o-ring issue is a simple Normalization of Deviance problem. It is VERY applicable to aviation and pilot pushing by companies.

The segments were designed as a tang and clevis joint with two o-rings. Each o-ring was sized to take full pressure but it was a safety critical feature (it lets the fire out where it’s not supposed to get out) and therefore a redundant backup was always required. After they started flying SRBs they started noticing that the primary o-ring would deflect away from the tang under pressure leaving only one o-ring doing the job with no redundancy.

They took away the redundant backup because “it seems to work fine as is!” and then started pushing the operating limitations on the remaining good one to meet their schedule / dispatch reliability commitments.

After blowing up a perfectly good space shuttle the fix was trivial, mechanically clamp the deflecting leg of the clevis to keep it from deflecting, and add an extra tertiary o-ring for posterity.

Basically the way I see it is the flight condition they normalized was akin to me saying “hey I know the APU and all your engine driven hydraulic pumps are MELed, but I need you to complete the flight on the RAT so we don’t cancel.”

 

[SlumTodd_Millionaire]

@BEEF SUPREME is right. The pressure on Challenger did come all the way from the top, from then president Reagan.

There is zero evidence to support this. Show your work.

 

[Cherokee_Cruiser]

Look at this "cowboy" behavior that was happening over at Alaska Airlines back in the day.

FAA Proposes $1.6 Million in Civil Penalties Against Alaska Airlines | Federal Aviation Administration

SEATTLE – The U.S. Department of Transportation’s Federal Aviation Administration (FAA) proposes two civil penalties totaling $1.6 million against Alaska Airlines, Inc. of Seattle, Wash., for allegedly operating aircraft that were not in compliance with Federal Aviation Regulations. In the first

www.faa.gov

Pilots were out there flying planes without emergency lights also. How was this considered safe?

Alaska faces FAA safety fine

Federal regulators have proposed a $500,000 fine against Alaska Airlines for flying a jet without required emergency lighting for two months...

www.seattletimes.com

Ok once or twice is honest mistakes, but now it looks like a pattern.

ALASKA AIRLINE AGREES TO PAY $300,000 FINE (Published 1985)

www.nytimes.com

Alaska Airlines agrees to pay $500,000 over 2010 cockpit fire

Alaska Airlines has agreed to pay $500,000 in civil penalty claims after an electrical fire ignited in a Boeing 737-400 cockpit in 2010 while it was parked at a gate in Anchorage, the Justice Department said on Friday.

www.reuters.com

CNN.com - US - FAA proposes almost $1 million fine for Alaska Airlines - December 5, 2000

FAA seeks to fine Alaska Airlines, Horizon Air

Federal officials are seeking $655,125 in fines against Alaska Airlines and its Horizon Air affiliate for alleged safety violations, including failing to inspect a plane for cracks.

news.yahoo.com

Big difference. Those were a long time ago, and none of those have to do with pilots in flight ops. Or their pilot training, checklists, and standardization.

 

[Cherokee_Cruiser]

I mean, he probably didn’t meet the PIC qualifications to work for either until he had been at the airlines for a decade, so he doesn’t really have a leg to stand on.

Huh? Problem with “PIC” requirements is that it ebbs and flows. What was demanded or asked for back then today is a suggestion. Plenty of newbies getting hired straight from right seat RJ. Dumb personal attack. The Corpie world is full of examples of people not even qualified to fly the jets that screw up. Teterboro crash, the FO was rated a 0, as in couldn’t fly any legs. How are you a pilot who literally can’t fly?! And then there was that Corpie that rejected / overran somewhere in the south/Midwest in which it was discovered the PIC didn’t even have a type for that jet. Or something.

 

[Cherokee_Cruiser]

Then there was that one Corpie that took off with the parking brake still on. Didn’t make it, crashed into a building.


The last time a 121 airliner took off with its parking brake on, a ramper was the PIC.

 

[KLB]

Big difference. Those were a long time ago, and none of those have to do with pilots in flight ops. Or their pilot training, checklists, and standardization.

You're averaging a fine about every 5 years over safety issues and you're just dismissing it like your airline is pillar of excellence. Typical....

 

[Cherokee_Cruiser]

You're averaging a fine about every 5 years over safety issues and you're just dismissing it like your airline is pillar of excellence. Typical....

I never said that. And officially, I work for a virtual airline, standard internet disclaimer.

 

[BEEF SUPREME]

I do blame the politicians, although I’m sure the CEO of Morton Thiokol was playing games as well.

I can’t think of a case of a solid rocket fuel grain the size of the space shuttle SRBs that isn’t built in segments. Mixing the fuel grain as a liquid, degassing all the air bubbles and impurities out and then forming it and curing it all at once would be manufacturing insanity. I won’t say it’s impossible but I’d love to see an example if you have one.

The Challenger o-ring issue is a simple Normalization of Deviance problem. It is VERY applicable to aviation and pilot pushing by companies.

The segments were designed as a tang and clevis joint with two o-rings. Each o-ring was sized to take full pressure but it was a safety critical feature (it lets the fire out where it’s not supposed to get out) and therefore a redundant backup was always required. After they started flying SRBs they started noticing that the primary o-ring would deflect away from the tang under pressure leaving only one o-ring doing the job with no redundancy.

View attachment 70814

They took away the redundant backup because “it seems to work fine as is!” and then started pushing the operating limitations on the remaining good one to meet their schedule / dispatch reliability commitments.

After blowing up a perfectly good space shuttle the fix was trivial, mechanically clamp the deflecting leg of the clevis to keep it from deflecting, and add an extra tertiary o-ring for posterity.

View attachment 70816

Basically the way I see it is the flight condition they normalized was akin to me saying “hey I know the APU and all your engine driven hydraulic pumps are MELed, but I need you to complete the flight on the RAT so we don’t cancel.”

I'm smart enough to see the parallels between this accident and any aviation accident where pilot pushing was involved. However I'm not nearly smart enough to spell it out the way you did. Thanks!

 

[SurferLucas]

Then there was that one Corpie that took off with the parking brake still on. Didn’t make it, crashed into a building.


The last time a 121 airliner took off with its parking brake on, a ramper was the PIC.

The Q400’s parking brake wasn’t on, he was dragging the brakes trying to steer it without nose wheel steering on. He did manage to not kill himself on rotation, taking off with no flaps