Safety Indicators

Leading indicators are conditions, events or measures that precede an

incident and that have some value in predicting the arrival of the event,
whether it is an accident, incident, near miss, or undesirable safety issue.
Leading indicators are related with proactive measures that identify hazards
and assess, eliminate, minimize and control risk (Construction Owners
Association of Alberta, 2004). Lagging indicators, in contrast, are measures
of a system that are taken after events, which measure outcomes and
occurrences.

Leading Indicators
The root cause of the accident was the O-ring failure that lead to
escape of gases and ultimately high temperature. To overcome this
difficulty the Solid Rocket Motor Joint can be reengineered to prevent
its failure.
Earlier 2 rings, a primary and a secondary ring was used. The primary
ring would often fail, even in the previous NASA flights. But this issue
was neglected as always the secondary ring would sustain the pressure
and do the job. But in Challengers case the secondary ring could not
hold the pressure of the gases. So to avoid future accidents related to
primary ring, the design should be improved. Also the flight director or
the other concerned designer should not neglect any minor failures for
such a High Reliability Organization. (Report to the President, 1986)
Restructure the NASA Management structure to take important
decisions.
Perform a thorough Failure Mode Effect Analysis of each Space Shuttle
Program before the actual launch of the rocket to access various
possibilities of hazard. And take corrective action and redesigning
steps. (Report to the President, 1986)
 Instead of having the flight director to overlook safety, appoint a
separate committee or an organization that will oversight quality
assurance and safe operations. (Report to the President, 1986)
Strictly avoiding rocket launches in bad weather conditions. The major
reason for O-ring failure was low temperature. The ring could sustain
as low as 510 F but during Challenger flight, it had reduced to below 36 0
F. The drop in temperature was accounted as an important factor that
contributed to the failure of sealing function. ( Report to the President,
1986)
Give NASAs top management freedom from pressure launches and
tight schedules. This will ensure corrective action is taken before the
launch.
Avoid rushing for launch and International Space race.
Make provisions for cabin crew escape via ejector seats, pad abort,
water landing, powered flight separation etc. Also if safety issue is
detected during the first few minutes of the flights launch, abort the
mission and separate the external tank which can be disposed of in the
ocean. The orbiter can be safely flown back to the launch pad. ( Report
to the President, 1986)
Hiring quality people and organizing safety orientation will ensure high
safety performance.
The tire, brakes and nosewheel steering system should be improved to
improve landing safety. (Report to the President, 1986)
Promptly report even small failures such as a leakage, dysfunction of a
sensor etc. as such a small error might magnify to a huge disaster.
Effective problem identification and finding immediate remedies
especially for such a High Reliability Organization will create better
safety culture.
Develop a shared organizational culture of reliability across all
members of NASA, utilizing effective communication at the
organizations interfaces.
Prioritize safety of on board crew members when deciding between an
economic loss and life of on board crew members. This is because life
 is much more important than the success of the mission. Also, losing
the best crew members would always cost more, as more money would
be drained on new members for training, remuneration of deceased
members etc.

Lagging Indicators

Challenger STS-51-L spacecraft exploded 73 seconds after liftoff, on

January 28, 1986.
The biggest blow to this mission was the loss of all the 7 crew
members on board. Their names and mission role are as follows: ( Space
Shuttle Challenger disaster, 2016)
o Francis Richard Scobee, Commander

o Michael J. Smith, Pilot

o Ronald McNair, Mission Specialist

o Ellison Onizuka, Mission Specialist

o Judith Resnik, Mission Specialist

o Gregory Jarvis, Payload Specialist

o Christa McAuliffe, Payload Specialist.

They had an enormous monetary loss of $1 Billion. (Space Shuttle Challenger

disaster, 2016)
NASA had scheduled the mission for 6 days and 34 minutes but actually it
lasted for only 73 seconds. (Space Shuttle Challenger disaster, 2016)
All the design efforts were in vein, also after that the space agency did not
launch any flights for 2 years. A lot of labor and time was utilized in redesign
of the Solid Rocket Fuel joint. Also investigation committee was appointed
(Rogers Commission) to analyze the root causes of the accident and provide
recommendations.
 All the crew members were not believed to be dead immediately after the
explosion because 3 of the 4 Personal Egress Air Packs were found to be
manually activated. Investigators discovered that several electrical system
switches on Pilot Mike Smith's right-hand panel had been moved from their
usual launch positions. These switches were protected with lever locks that
required them to be pulled outward against a spring force before they could
be moved to a new position. Later tests established that neither force of the
explosion nor the impact with the ocean could have moved them, indicating
that Smith made the switch changes, apparently in an unsuccessful attempt
to restore electrical power to the cockpit after the crew cabin detached from
the rest of the orbiter. (Space Shuttle Challenger disaster, 2016)
The disaster led to NASAs stock price go down by almost 10 cents per stock.
(Russell Boisjoly, 1989)
Loss of valuable time and efforts behind the next launch that was done after
2 years of waiting. This was always avoidable if the launch decision was
delayed for a few days.
Whether the crew members remained conscious long after the breakup is
unknown, and it depends on whether the detached crew cabin maintained
pressure integrity. If it did not, the time of useful consciousness at that
altitude wouldnt have been for more than a few seconds. If, on the other
hand, the cabin was not depressurized or only slowly depressurizing, they
may have been conscious for the entire fall until impact. Recovery of the
cabin found that the middeck floor had not suffered buckling or tearing, thus
suggesting that the depressurization may have not happened all at once.
(Space Shuttle Challenger disaster, 2016)
NASA had trained shuttle crew for splashdown events, but the vehicle hit the
ocean surface at roughly 207 mph (333 km/h), with an estimated
deceleration at impact of well over 200 g, which is far beyond the structural
limits of the crew survivability levels. This lead to the loss of all the crew
members. (Space Shuttle Challenger disaster, 2016)
The three shuttle main engines were found intact and attached to the thrust
assembly despite enormous damage from impact with the ocean, marine life,
and immersion in salt water. They had considerable heat damage due to a
LOX-rich shutdown caused by the drop in hydrogen fuel pressure as the
 external tank began to fail. The memory units from Engines 1 and 2 were
recovered, cleaned, and their contents analyzed, which confirmed normal
engine operation until LH2 starvation began starting at T+72 seconds. Loss of
fuel pressure and rising combustion chamber temperatures caused the
computers to shut off the engines. Since there was no evidence of abnormal
SSME behavior until 72 seconds, the engines were ruled out as a contributing
factor in the accident. (Space Shuttle Challenger disaster, 2016)
A deep search to scavenge debris was undertaken which covered an area of
480 nautical miles ,(and took place at depths of up to 370 meters Sonar,
divers, remotely operated submersibles and manned submersibles were all
used during the search operation that was carried out by Department of
Defense. (Space Shuttle Challenger disaster, 2016)
The debris were flying at high speed and crashed at various locations.
Fortunately nobody was injured in the crashes but the marine life may be
disturbed as consistent debris accumulation may pollute the water. Also the
rockets may contain poisonous substances like Lead, Asbestos etc. that might
degrade the marine life.
Inside the twisted debris of the crew cabin were the bodies of the astronauts,
which were nearly unrecognizable after ten weeks of immersion in salt water
and scavenging marine life.

Trends

In 1976, (NASA) unveiled the worlds first reusable manned spacecraft, known
as the space shuttle. Five years later, shuttle flights began when Columbia
traveled into space on a 54-hour mission. Launched by two solid-rocket
boosters and an external tank, the aircraft-like shuttle entered into orbit
around Earth. (Space Shuttle Challenger disaster, 2016)
Challenger, NASAs second space shuttle to enter service, made its first trip
on April 4, 1983, and made a total of nine voyages prior to 1986. That year, it
was scheduled to launch on January 22 carrying a seven-member crew.
(Space Shuttle Challenger disaster, 2016)
Challenger was initially planned to be launched from Kennedy Space Centre
in Florida at 14:42 Eastern Standard Time (EST) on January 22. Delays in the
 previous mission, STS-61-C, caused the launch date to be moved to January
23 and then to January 24. The launch was then rescheduled to January 25
due to bad weather at the Transoceanic Abort Landing (TAL) site in Dakar,
Senegal. NASA decided to use Casablanca as the TAL site, but because it was
not equipped for night landings, the launch had to be moved to the morning
(Florida time). Predictions of unacceptable weather at KSC on January 26,
caused the launch to be rescheduled for 09:37 EST on January 27. (Space
Shuttle Challenger disaster, 2016)
The launch was delayed the next day, due to problems with the exterior
access hatch. First, one of the micro-switch indicators, used to verify that the
hatch was safely locked, malfunctioned. Then, a stripped bolt prevented the
closeout crew from removing a closing fixture from the orbiter's hatch. By the
time repair personnel had sawed the fixture off, crosswinds at the Shuttle
Landing Facility exceeded the limits for a Return to Launch Site (RTLS) abort.
(Space Shuttle Challenger disaster, 2016). While the crew waited for winds to
die down, the launch window had already passed, forcing yet another delay.
Thiokol engineers, the company that manufactured the O-ring warned of the
incessant low temperature and advised them to postpone the launch till the
weather reached at least 53 0 F.
But due to frequent delays in the launch, NASA Management forced the
Thiokol Engineers to change their statement. If NASA had taken their advice
and rescheduled the launch till suitable temperature was reached, this
accident would have never happened.
After the accident, NASA held back from sending astronauts into space for
more than two years as it redesigned a number of the shuttles features.
Flights began again in September 1988 with the successful launching of
Discovery. Since then, the space shuttle has carried out numerous important
missions, including the repair and maintenance of the Hubble Space
Telescope and the construction of the International Space Station. On
February 1, 2003, a second space shuttle disaster rocked the United States
when Columbia disintegrated upon reentry, killing all the crew members.
While missions resumed in July 2005, the space shuttle is was retired in 2011.
(Report to the President: Actions to Implement, 1986)
 From all the line of events that happened, it is very evident that a slight delay
and patience in launching the spacecraft would have saved seven lives,
saved billions of dollars, and delayed missions and cost of opportunity lost.

Summary of the Challenger Episode. (n.d.). Retrieved May 10, 2016, from
http://web1.calbaptist.edu/dskubik/nasa.htm

Report to the President: Actions to Implement the ... - NASA. (n.d.). Retrieved May
10, 2016, from http://history.nasa.gov/rogersrep/actions.pdf

Construction Owners Association of Alberta. Leading Indicators: Best Practices.

http://www.coaa.ab.ca/bp/xii/workshops/Workshop%202%20-%20Leading
%20Indicators%20for%20Safety.pdf, retrieved 18 October 2004.

Space Shuttle Challenger disaster. (n.d.). Retrieved May 10, 2016, from
https://en.wikipedia.org/wiki/Space_Shuttle_Challenger_disaster

Russell Boisjoly, et al. "Roger Boisjoly and the Challenger Disaster: the ethical
dimensions," in the Journal of Business Ethics, Vol. 8:217-230 (1989)