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Old 21st Apr 2010, 12:15
  #2179 (permalink)  
STC-8
 
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risk management

Long time 'lurker' - felt compelled to chime in..

Hello to all... I'm not a pilot, aircraft engineer or vulcanologist.

orig. post didn't turn up for some reason so here goes again:

Thoughts go out to stranded travelers and those impacted by the current ash situation.

The dynamics of the debate and the political, business and management pressures on the one hand versus the aircraft engine designers on the other (saying 0 tolerance for ash) is reminiscent to me of events surrounding the Challenger Space Shuttle disaster. I think there are some lessons to be considered there.


Space Shuttle Challenger disaster - Wikipedia, the free encyclopedia

Use as case study

The Challenger accident has frequently been used as a case study in the study of subjects such as engineering safety, the ethics of whistle-blowing, communications, group decision-making, and the dangers of groupthink. It is part of the required readings for engineers seeking a professional license in Canada[52] and other countries. Roger Boisjoly, the engineer who had warned about the effect of cold weather on the O-rings, left his job at Morton Thiokol and became a speaker on workplace ethics.[53] He argues that the caucus called by Morton Thiokol managers, which resulted in a recommendation to launch, "constituted the unethical decision-making forum resulting from intense customer intimidation."[54] For his honesty and integrity leading up to and directly following the shuttle disaster, Roger Boisjoly was awarded the Prize for Scientific Freedom and Responsibility from the American Association for the Advancement of Science. Many colleges and universities have also used the accident in classes on the ethics of engineering.[55][56]
Information designer Edward Tufte has used the Challenger accident as an example of the problems that can occur from the lack of clarity in the presentation of information. He argues that if Morton Thiokol engineers had more clearly presented the data that they had on the relationship between low temperatures and burn-through in the solid rocket booster joints, they might have succeeded in persuading NASA managers to cancel the launch.[57] Tufte has also argued that poor presentation of information may have affected NASA decisions during the last flight of Columbia.

The Presidential Commission on the Space Shuttle Challenger Accident, also known as the Rogers Commission (after its chairman), was formed to investigate the disaster. The commission members were Chairman William P. Rogers, Vice Chairman Neil Armstrong, David Acheson, Eugene Covert, Richard Feynman, Robert Hotz, Donald Kutyna, Sally Ride, Robert Rummel, Joseph Sutter, Arthur Walker, Albert Wheelon, and Chuck Yeager. The commission worked for several months and published a report of its findings. It found that the Challenger accident was caused by a failure in the O-rings sealing a joint on the right solid rocket booster, which allowed pressurized hot gases and eventually flame to "blow by" the O-ring and make contact with the adjacent external tank, causing structural failure. The failure of the O-rings was attributed to a faulty design, whose performance could be too easily compromised by factors including the low temperature on the day of launch.[34]
More broadly, the report also considered the contributing causes of the accident. Most salient was the failure of both NASA and Morton Thiokol to respond adequately to the danger posed by the deficient joint design. However, rather than redesigning the joint, they came to define the problem as an acceptable flight risk. The report found that managers at Marshall had known about the flawed design since 1977, but never discussed the problem outside their reporting channels with Thiokol--a flagrant violation of NASA regulations. Even when it became more apparent how serious the flaw was, no one at Marshall considered grounding the shuttles until a fix could be implemented. On the contrary, Marshall managers went as far as to issue and waive six launch constraints related to the O-rings.[35] The report also strongly criticized the decision making process that led to the launch of Challenger, saying that it was seriously flawed.[36]
...failures in communication... resulted in a decision to launch 51-L based on incomplete and sometimes misleading information, a conflict between engineering data and management judgments, and a NASA management structure that permitted internal flight safety problems to bypass key Shuttle managers.[37] One of the commission's most well-known members was theoretical physicist Richard Feynman. During a televised hearing, he famously demonstrated how the O-rings became less resilient and subject to seal failures at ice-cold temperatures by immersing a sample of the material in a glass of ice water. He was so critical of flaws in NASA's "safety culture" that he threatened to remove his name from the report unless it included his personal observations on the reliability of the shuttle, which appeared as Appendix F.[38] In the appendix, he argued that the estimates of reliability offered by NASA management were wildly unrealistic, differing as much as a thousandfold from the estimates of working engineers. "For a successful technology," he concluded, "reality must take precedence over public relations, for nature cannot be fooled.
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