Free ebooks ==> www.Ebook777.com www.Ebook777.com Free ebooks ==> www.Ebook777.com THE CHALLENGER LAUNCH DECISION www.Ebook777.com The Challenger~aunch DeCISiOn Risky Technology, Culture, and Deviance at NASA Diane Vaughan The University of Chicago Press Chicago and London Free ebooks ==> www.Ebook777.com Diane V aughan is professor of sociology at Boston College and the author of Controlling Unlawful Organizational Behavior: Social Structure and Corporate Misconduct and Uncoupling: Turning Points in Intimate Relationships The University of Chicago Press, Chicago 60637 The University of Chicago Press, Ltd., London © 1996 by The University of Chicago All rights reserved Published 1996 Printed in the United States of America 13 12 11 10 09 08 07 06 05 04 10 ISBN: 0-226-85175-3 (cloth) ISBN: 0-226-85176-1 (paper) Library of Congress Cataloging-in-Publication Data The Challenger launch decision p cm Challenger (Spacecraft)—Accidents United States National Aeronautics and Space Administration—Management Aerospace industries—United States Organizational behavior— Case studies Decision-making—Case studies TL867.C467 1996 363 12Ј465—dc20 95-39858 CIP ø The paper used in this publication meets the minimum requirements of the American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1992 www.Ebook777.com For Katherine, Zachary, and Sara Vaughan Kristen, Lindsey, and Melissa Mortensen Sophie and Cameron Nicoll Contents List of Figures and Tables Preface ix xi One THE EVE OF THE LAUNCH Two LEARNING CULTURE, REVISING HISTORY Three 33 RISK, WORK GROUP CULTURE, AND THE NORMALIZATION OF DEVIANCE Four 77 THE NORMALIZATION OF DEVIANCE, 1981-1984 119 Five THE NORMALIZATION OF DEVIANCE, Six THE CULTURE OF PRODUCTION Seven STRUCTURAL SECRECY Eight THE EVE OF THE LAUNCH REVISITED Nine CONFORMITY AND TRAGEDY Ten LESSONS LEARNED 1985 153 196 238 278 334 387 vii viii CONTENTS Rppendix R COST/SAFETY TRADE-OFFS? SCRAPPING THE ESCAPE ROCKETS AND THE SRB CONTRACT AWARD DECISION Rppendix H Rppendix C 423 SUPPORTING CHARTS AND DOCUMENTS 432 ON THEORY ELABORATION, ORGANIZATIONS, AND HISTORICAL ETHNOGRAPHY Acknowledgments Notes 469 Bibliography Index 551 533 465 456 Free ebooks ==> www.Ebook777.com figures and Tables All figures are reproductions of documents appearing in Report to the President of the Presidential Commission on the Space Shuttle Accident (Washington, D.C.: Government Printing Office, I986) Figures I Space Shuttle System Solid Rocket Booster Booster Field Joint Flight Readiness Review and Shuttle Program Management Structure Joint Rotation 83 98 STS 41-G Flight Readiness Review Charts 145 Marshall Request for Briefing after STS 51-C STS 51-E Flight Readiness Review Charts STS 51-F Flight Readiness Review Chart 156 158 167 10 August 19, 1985, NASA Headquarters Briefing Chart II January 27, 1986, Teleconference Charts 12 Final ThlOkol Launch Recommendation 326 13 Postaccident Temperature Analysis Br Final Teleconference Participants 177 293 383 432 B2 Relevant Organization Charts: NASA and Morton Thiokol 433 B3 Critical Items List Entry, Solid Rocket Booster, Criticality lR 438 B4 Critical Items List Entry, Solid Rocket Booster, Criticality 440 ix www.Ebook777.com INDEX democracy in, 419; economic constraints as production pressure for, 17, 35; engineering culture in, 209; environment of competition and scarcity in, 34, 73, 74, 198,210,335, 372; escalating concern over O-ring problem, 171-85,445-46; failure to understand joint sealing mechanism, 277,390, 470n.19; 53"F minimum temperature challenged by, 6; first teleconference with Thiokol, 2; 48hour rule for communications hookups, 14; four-tiered launch decision chain, 1,285; House Committee on Science and Technology on, 11, 72; House Committee on Science and Technology oversight of, 470n.18; information dissemination in, 252, 276; information release on disaster, 54-55, 479n.73; in-house investigation of Challenger disaster, 8, 9, 43, 53; learning by doing in, 191; long- and short-term fixes for, 100; management by exception in, 94, 259; management on eve of Challenger launch, 40-42, 47-49; managerial wrongdoing as cause of Challenger disaster, xii, xiii, 8,33-34, 71, 72, 73, 198, 272-73,334, 390; managers as trained engineers, 199; managers not reporting problems to upper-level administrators, xii, 11, 41-42,120,123,150,238,239,389; manned space program of, 19; matrix system, 89, 90, 180, 216, 289, 300, 360, 416; media pressures on, 12; memos as ineffective at, 255; myth managing by administrators, 212; no planned response to a shuttle failure, 54; normalization of deviance at, 62-64,67, 75,272,416-17; observation not counting as data for, 159, 162,221-22,246, 263,361; organizational charts, 433 36; organizational culture of, 42, 50, 59, 79, 198, 209-15; organizational disaster explanation of information release by, 54; organization implicated in disaster, xi-xii, 10-11,34,389; permanent occupancy of space as goal of, 19,26; personnel cuts in, 19, 29; political pressures on, 12-14; Presidential Commission not grasping culture of, 59, 71, 341; problems as the norm at, 223, 243; proceeding with launches despite known flaws, 96, 151; produc- 563 tion pressures institutionalized in decision making of, xiii-xiv, 68, 231 32,335,372; professional accountability in, 211; public image as goal of, 16; redundancy in reporting procedures, 419; risk made incalculable at, 79,421; risk-taking culture of, 50; rule violations attributed to, 41-42, 58-59, 60, 70, 192-94; safety regulation at, 264-72; as seeking a second source of SRMs, 337 38; space centers as competing and cooperating, 214-15; space program as cultural icon, 387-88; SRB certified by despite its flaws, 79, 107, Ill; structural secrecy at, 242-43; as subject to same difficulties as private corporations, 35; as system under stress at time of Challenger launch, 30; top administrators' contribution to disaster, 390, 409; in U.S competition for international supremacy, 17-18; waivers as formal procedure of, 57-58, 133 35 See also Apollo Program; interorganizational relations; launch decision for Challenger mission; Marshall Space Flight Center culture; Space Shuttle Program; and personnel Aldrich, Arnold; Coates, Keith; Cook, Richard C.; Fletcher, James F.; Hardy, George; Lovingood, Jud; Lucas, William; Miller, John Q.; Moore, Jesse; Mulloy, Lawrence; Powers, Ben; Ray, W Leon; Reinartz, Stanley; Smith, Jim; Wear, Larry National Oceanic and Atmospheric Administration, 25 native view, 77-78,96, 120 Nelkin, Dorothy, 34 Nelson, William, 27 nested culture, 198, 236, 396, 410 new institutionalism, xiv, 37, 118, 197-98,236,403, 404-5; theory of practical action and, xiv, 405 news media: criticism of launch delays, 215; manufacture of news by, 393; media pressure behind launch decision, 12; NASA's slow release of information to, 54-55; New York Times on the disaster, 9, 48On.91; retrospective distortion of the launch decision, 68-72; selective use of information on disaster, 72; teleconference recollections affected by, 280 Nixon, Richard, 19, 22, 217 564 INDEX normalization of deviance: cold temperature and, 190; in early development of SRB, 96-111, 114; information in, 238; mistakes caused by, 410; at NASA, 62-64,67, 75, 272; NASA attempts to prevent, 416-17; in organizations and individwls, 75, 409-22; size and complexity not conditions of, 410-11; in Space Shuttle Project 1981-84, 119-52; by SRB work group, 148-52, 170-71, 232-37; in Space Shutt:e Project 1985, 153-95; in SRM joint performance, 65-68, 78, 106, 113, 119, 122, 124-25, 394; uncertainty reduced by, 410 normal science, 401 norms: acceptable risk as normative for NASA, 82; accidents as normal, 200, 415, 528n.79; deviance defined in terms of, 58; incremental expansion of normative boundaries, 409; influencing behavior without specific articulation, 115; normal science as normative, 401; norms, rules, and deviance in the work group, 112-18, 148-52, 190-95; in orga:J.izations, 37; problems as at NASA, 223; proceeding with anomalies as normative in engineering, 223; shuttle work groups conforming to NASA, 114; SRB work group norms institutionalized, 150; waivers as norms for NASA, 58 See also normalization of deviance nozzle joint anomalies: Launch Constraint imposed on joints, 164, 493n.31, 508n.72; leak check pressure for, 165, 489n.67; not discussed at second teleconference, 301, nozzle joints as less vulnerable than field joints, 290, 522n.135; secondary O-rings in, 163, 165; in STS-2, 136; in STS 51-B, 153,163-66,170,190; in STS 51-C, 492n.27; in STS 51-D, 162-63 Nye, David, 387 Ohlin, Lloyd E., 458 Onizuka, Ellison, 1, 283 operator er:or, 392 Orbiter: crew compartment breaks loose and falls into sea, 10; escape rockets omitted irom design of, 22, 42, 50, 423-25; ice on launch pad as concern for Challenger, 7, 328-32; size reduced to cut development costs, 21; in Space Shuttle system, 3; weight reduction of, 21-22,424 organizational misconduct, 405-9; Challenger disaster as example of, 33; competitive pressures and, 34-35, 37-38, 405-9, 458; elaborating a theory of, 456-59; explanations of allowing quick remedies, 392; good people doing dirty work, 36, 406, 408; managers as amoral calculators, 35, 36, 37; organization charateristics and, 34, 250-51,458; regulatory environment and, 34, 264-65; rule violations and, 33, 36-37, 56, 420; three factors in, 34, 458-59 See also managerial wrongdoing organizations: avoiding accidents in, 415-17; culture of, 61, 64; decision making in, 37-38, 67, 116-17, 119, 197,251,402-5, 507n.40; deviance in, 405-9; as embedded in institutional environments, 403; engineers and managers occupying different niches in, 274-75; failures in, 68, 69, 418; garbage can model of management, 38; historical ethnography in analysis of, 459-63; history affecting decisions in, xiv; history and theories of, 403; incrementalism in, xiv; individual behavior understandable only in context of, 114; information flow in, 250; learning by doing in, 191; link between economic constraint and decision making in, 36-38, 46-47, 335; micromacro connection in decision making, 38; new institutionalism and, xiv, 37, 118, 197-98,236,403,404-5; normalization of deviance in, 75, 409-22; norms in, 37; organizational interests given priority over human life, 34-35; problems identified and corrected by, 66-67; public image control by, 52; response to disaster by, 54; risk assessment in, 37, 63, 89; risk taking by, 34-35; routinization in, 410; as "satisficing" rather than optimizing, 116-17, 206; self-regulating, 268; structural secrecy in, 238, 250-64; structure and culture elicited hom documer ts, 61 See also bureaucracies; organizational misconduct original technical culture: in Apollo Program, 209-10; bureaucratic accountability replacing, 357, 385; elites adding political accountability to, 378; of Marshall Space Flight Center, 215-17, 220, 221, 347; in Mulloy's INDEX "April" comment, 348; scientific positivism in, 354; in second teleconference, 349; the SRB work group and, 227-37,396; Thiokol's charts and, 349-56; undermined by bureaucratic accountability in Thiokol's off-line caucus, 363 a-rings: acceptable erosion of, 140; as acceptable risk, Ill, 144, 185-90; in August 19, 1985, meeting, 176-78, 263; burn-through as acceptable risk, 166-67, 170-71; as cause of Challenger disaster, xi, 8, 9, 10; charring and eroding on previous launches, 2, 9; cold-gas tests on, 165; composition of,S; costs of failure of, 48; costs of living with the problem, 234 36; designed and tested for heat tolerance, 160; erosion as expected and accepted, 138, 156, 186,246; erosion at FRR of STS 41-G, 144, 145, 146; erosion in flights following STS 51-B, 186; erosion in 1985 flights, 153; erosion in STS-2, 120-25, 244, 245; erosion in STS-6 and STS 41-B, 136-43; erosion in STS 61C, 285; erosion occurring on some flights but not others, 149; erosion of as self-limiting, 138, 156-58, 188, 490nn 73, 75; erosion of and redundancy related, 164, 170; erosion of distinguished from joint rotation, 131 32, 139; escalating concern over in 1985, 171-85,445-55; extrusion by, 102; Feynman's ice water demonstration with, 39; first evidence of blow-by in, 119; function of, xi, 2, 286; gap size controversy, 97, 100-103, 106, 110-11, 130, 391; history of problems with, xi-xii,9, 10-11,43; increase in erosion as routine signal, 246-47; incremental accumulation of information on, 244; Launch Constraint on waived, 56-58, 153-54, 167-70, 192; licorice compared to, 40; NASA downplays role of, 8, 9, 43, 53, 77; Nerf ball compared to, 39-40; normalization of deviance in development of, 96-111; overcompression of, 391; pattern of decision making regarding, 66; in Presidential Commission hearings, 9; pressure acruation as process of, 486n.77; problem becoming acute, 179; problem history reported at FRR of STS 51-F, 166; problem identified by safety regulators, 269-71; problem officially 565 closed, 154, 172, 182-85, 193-94,226; problem to be worked on even if closed-out, 183-84, 194; Ray visiting manufacturers of, 102 3, 115-16; reviewed in video prior to STS 51-E, 71; rubber ring in Mason jar compared to, 40; Salita model for erosion in, 165, 171, 173, 191,233 34; in shutde and Titan compared, 96-97, 105; in SRM field joints,S; structural secrecy concealing problem with, 67; Thiokol engineers' concerns about, xii; Thiokol on safety requirements of, 177-78; Thiokol's report on in STS 5l-E FRR, 156-60; Thompson's proposed solutions for, 179; as violating industry standards, 101, 102 3; under worston-worst condition, 103-4, 106, 129, 165-66 See also cold temperature's effect on a-rings; a-ring Seal Task Forces; primary a-ring; secondary aring a-ring Seal Task Forces: Boisjoly on need for more people for, 174,225; cold temperature not central to work of, 384; formation of, 153, 171, 173-74; given official status, 179; as inadequately supported, 179-81, 450-53; stopping flights not recommended by, 185; in Thiokol's midday meeting, 287 Paget, Marianne, 387, 421 parachute problem, 234 35, 284 paradigms: defined, 196; overturned by signal too strong to explain away, 264; resistance to change of, 400-402; of SRB work group, 348, 394-95, 401 Parker, Maurice, lOS, 130 Parker Seal Co., 101 patterned informational dependencies, 359 Peoples, Jerry, 289 Perrow, Charles, 34,53,415, 482n.107 Petrone, Rocco, 330 Petroski, Henry, 202, 206 Pfohl, Stephen J., 412-13 Pinto (automobile), 34 35, 408 Policelli, Frederick, 126 political accountability: in Marshall culture, 220-21,347; in Mulloy's "April" comment, 348; in NASA culture, 212-15,372; in second teleconference, 349,372-86,399; and the SRB work group, 227 37,396 566 INDEX political elites See elites politics of blame, 392-93 positivism, scientific See scientific positivism Powell, Walter w., 37, 526n.45 Powers, Ben: on burden of proof not shifting, 343; on continuing to fly despite O-ring problem, 189; on contradictions in Thiokol's data, 352; on Hardy and Lovingood preparing to cancellaunch, 322; on Hardy's feeling appalled at Thiokol recommendation, 312,377; invited to second teleconference, 289; on joint rotation, 97; on launch delays, 95, 228-29; on launch schedule pressures, 230; with McCarty at second teleconference, 300, 361-62; as not speaking at second teleconference, 358; on not voicing his dissent at final decision, 370; on the putty problem, 121) on redundancy, 104; on second-source bidding as not a factor in launch decision, 337; on specialization in FRR, 261; on temperature as not sufficiently emphasized, 178; Thiokol's dislike of, 87; on Thiokol's presentation at second teleconference, 307; on what he might have done to stop the launch,381 Presidential Commission :Rogers Commission), 7-11; on ASAP failures, 268-69; brief of, 7-8; closed session of February 10, 1986,9; on close-out of O-ring problem, 182-83; collaborative oversight as perceived role of, 8, 9; conclusion of, 10-11; on continuing to fly with O-ring flaws as deviant, 185-90; contradictions on NASA decision making by, 49; documentation of O-ring problems, xi-xii; economic strain's link to decision making not addressed by, 46-47; on failure of communication at NASA, 239; historically accepted account of disaster and, xii, 7-11, 70-72; House Committee's role usurped :'y, 388; Launch Constraints misunderstood by, 193; mistakes of fact and interpretation by, 59; on Mulloy's lifting Launch Constraints as deviant, 167-70; on NASA and Thiokol not understanding joint operation, 277, 390, 470n.19; NASA culture not grasped by, 59, 71, 341; on NASA managerial wrongdoing as cause of Challenger disaster, xii, 8, 33-34, 71, 72, 389; on NASA's failure to act on O-ring problem, 171-72,239; on need to get space program going again, 389; not all engineers chosen to testify, 334; on political pressures on NASA, 13; praise for, 70; on production pressure as cause of Challenger disaster, 8, 31-32, 55; report of, 10, 39, 60, 70-72; rule violations attributed to NASA by, 41-42, 58-59, 60, 70, 192-94; on Silent Safety Program at NASA, 264; on SR&QA failures, 267, 271; televised hearings of, 8, 71-72; on Thiokol reversing its engineers' position, 478n.59; turning point in inquiry, See also Armstrong, Neil; Covert, Eugene; Feynman, Richard P.; Hotz, Robert B.; Ride,Sally primary O-ring: belief in adequacy of, 66, 103,105,111, 175-76, 487n.103; blowby and erosion on previous launches, 8; blow-by and erosion in STS 41-D, 143, 144; blow-by in STS 51-C, 3,153, 157,190,246-47,299,364-65;burnthrough in STS 51-B, 163-66, 170-71, 172-73,246-47; erosion in STS-2, 120-21, 124, 128, 244, 245; erosion in STS 41-B, 136-37; erosion in STS 51D, 162; extrusion by, 486n.77; function of, xi; heat reaching in STS-6, 136; as improperly positioned in STS 51-B, 164-65, 170; leak check's effect on, 49On.74; in nozzle joints, 165; in SRM field joints, Problem Summary chart in STS 51-F FRR, 166-67, 494n.44 production of culture: in SRB work group, 74, 78, 119, 154, 195,394-96; as showing how the work group normalized deviance, 66, 114; in structure of culture of production, 197-98; of work group culture at NASA, 110 production pressures: as alleged cause of Challenger disaster, xii, xiii, 8,31-32, 55, 68, 335, 347; at all-time high in NASA on eve of Challenger launch, 30; as built into Shuttle Program, 23; economi:: constraints on NASA as, 17, 35; institutionalized in NASA decision making, xiii-xiv, 68, 231-32, 335, 372; performance pressures at Marshall, 219, 220; in second teleconference, 372-79 See also amoral calculation professional associations, 411 INDEX Program Requirements Control Board, 134, 135, 489n.55 Project Managers, 80; as being lithe long poles," 242; competition among, 218-19; Engineering Change Request approval bypassing, 86, 89-90; in engineering disputes, 87-88; in Flight Readiness Review, 84, 93; as links between engineers and administrators, 215; as "neck of the hour glass," 93, 359; problem resolution as responsibility of, 258; S&E's differences in orientation, 88-89 putty See zinc chromate putty Pye, David, 206 Quinones, John, 12 Quong, Harry, 176, 184 Ranson, Stewart, 213 Rather, Dan, 12 rationality: bounded rationality, 37; Challenger launch decision contradicting rational choice theory, 394, 403; engineers as purveyors of, 200; in organizational decision making, 37-38, 197,403 Ray, W Leon: on blow-by in STS 51-C, 155; on change in Criticality status of SRB joint, 130; on communication channels in NASA, 241; on continuing to fly despite O-ring problem, 189; on deviating from formal industry standards, 115; on ECRs as attention getting, 256; on extrusion by O-rings, 102; on joint rotation, 40, 97, 99-106; on "lying down in the bucket," 349, 356; on managers driven by costs and schedule, 230; memos of, 101, 102, 113,255; on no small mistakes in aerospace, 228; as not present at second teleconference, 289, 421; on 0ring erosion in STS-2, 123; on postdisaster corrections to SRB, 421; Ray/Miller memorandum, 101,225, 508n.53; on redundancy of secondary O-ring, 106, 487n.103; on safety hazards and real safety hazard3, 256; on safety regulators, 270; on S&E winning disputes over risk, 89; on schedule as not a factor in launch decision, 336; on Source Evaluation Board, 97, 428, 479n.67; in SRM joint corrections, 60, 104, lOS, Ill; on SRM redesign, 105, 113, 127; on Thiokol's booster design, 567 97, 100, 430; Thiokol's dislike of, 87; visiting O-ring manufacturers, 102-3, 115-16 Reagan, Ronald: administration's alleged pressure on NASA, 12-14; announcing that a teacher would fly on the shuttle, 27; Challenger flight to give pro education image to, 388; policies making NASA act like a business, 211; Presidential Commission appointed by, 7; speech at fourth orbital test flight, 24, 125, 151 real safety hazards, 252, 257 Redstone Arsenal, 215-16 redundancy: in Criticality categories, 107, 129, 133-34; fail-safe requirement, 129, 133; in NASA reporting procedures, 419; Powers on, 104; in Space Shuttle Program information flow, 251; of TAL sites, 512n.23 See also secondary O-ring as redundant regulation, safety See safety regulation regulatory ineffectiveness, 34, 458 Reinartz, Stanley: Aldrich not informed of Thiokol concerns by, 6, 323, 343-45; in first prelaunch teleconference, 288; on 40'F as legitimate data point, 309; Lucas and Kingsbury informed of Thiokol concerns, 7, 288, 328,329,345; Lucas not awakened to be informed of final launch decision, 328, 345; McDonald protests launch decision to, 371; in NASA launch decision chain, 1,285; not advising Aldrich of second teleconference, 288; poll on feasibility of January 28 launch, 286; requesting further discussion at end of second teleconference, 323, 368-69; requests Hardy's opinion of Thiokol recommendation, 6, 305, 311; in teleconference on booster recovery, 327 residual risk, 79-83, 114, 162, 247 Resnick, Judith, I, 283 Ride, Sally, 353 Riehl, Bill, 289-90, 300-301, 309, 311, 359-60,368 risk: aggregate risk, 82, 95, 162; assessment by technical workers, 399-402; assessment in NASA work groups, 80 84, 400; collective construction of, 272-77; construction of changed in operational stage, 125, 128; construction of formalized for SRBs, 106-10; 568 INDEX risk (continued) construction of repeatedly validated, 148, 163; disqualification heuristic in assessment of, 273-74, 275-77; experts in assessment of, 63; Feynman on NASA playing Russian roulette with safety, 46; flight experience in assessment of, 112; Flight Readiness Review as best conduit of information about, 257; global assessments of, 274-75, 276; information in assessment of, 238; interorganizational negotiation of, 84-96; management risk decisions, 89; managerial assessment of, 37, 63; NASA as risk-taking culture, 50; NASA calculation of in circumstances making it incalculable, 79, 421; in NASA language, 252-53; NASA managers taking calculated risk to launch, 32; as not eliminable in the shuttle, 80; residual risk, 79-83, 114, 162, 247; risk taking in organizations, 34-35, rules increasing through false sense of security, 420; safety regulators contribute to construction of, 270; scientific positivism in resolving disputes over, 89; shifting construction of in 1985, 171-85; social construction of, xiv, 62-64, 143-48, 185-90; SRB work group's construction of as unchanging, 130, 196; SRB work group's construction of at end of 1985, 195; SRB work group's negotiation of, 65-68, 78; in understanding organizational deviance, 407 See also acceptable risk; Acceptable Risk Process; Flight Readiness Review risk rationale, 81 Rockwell International, 7,9,328,329, 330-32,355-56 Rogers, William P., Rogers Commission See Presidential Commission Roland, Alex, 22 Romzek, Barbara S., 21 I, 348 rules: in engineering, 200-201; increasing risk by giving false sense of security, 420; norms, rules, and deviance in the work group, 112-18, 148-52, 190-95; universalistic and particularistic, 114, 201 See also rule violations rule violations: in conventional account of Challenger disaster, 334; incremental expansion of normative boundaries without, 409; Mulloys's reporting practices retrospectively seen as, 152, 169; NASA management following rules on eve of launch, 339; NASA waivers interpreted as, 56-58, 133, 135, 152, 193; New York Times allegations of, 480n.91; official closing of 0ring problem as, 154; D-rings as violating industry standards, 101, 102-3; Presidential Commission attributing to NASA, 41-42, 58-59, 60, 70, 192-94; second teleconference as COiJling to rule-based deCision, 339-47 Russell, Brian: on blow-by in STS 41-D, 144; on Boisjoly's memo warning of catastrophe, 508n.62; charts for seccnd teleconference, 291, 292, 300, 304; in close-out of D-ring problem, 182, 183; on continuing to fly despite D-ring problem, 186, 325; conversation wit:! Boisjoly after second teleconference, 325; disqualification heuristic in, 354; as feeling extra pressure in Challenger launch decision, 338; on Hardy's fee_ing appalled at Thiokol recommendation, 312; hearing no support from Marshall during second teleconference, 362; on increasing leak check pressure, 139; on lifting Launch Cor.straint on joint nozzle, 169; on morning of the launch, 332; on Mulloy's response to Thiokol presentation at second teleconference, 514n.69; on normalization of SRB joint problems, 147; on not voicing his dissent at mal launch decision, 370; preparing final launch recommendation, 326-27; or pressure at second teleconference, 73, 378; proposing full inquiry into D-ri:lg problem, 172; response to Marshall on D-ring performance, 175-76; on schedule as not a factor in launch decision, 336; in second teleconference, 301, 302, 42.1; on second teleconference as similar to Flight Readiness Review, 340; on testifying before Presidential Commission, 281; on Thiokol's mar.agement decision to launch, 367; at Thiokol's midday meeting on cold, 287; on Thiokol's D-ring task force, 174; on Thiokol's presentation at second teleconference, 307; on what he might have done to stop the launch, 381 INDEX safety/cost trade-offs See cost/safety trade-offs safety hazards, 252, 256 safety margin, 120, 176; continuing effort to improve, 173; exceeded in STS 51-B, 163-65; in O-ring erosion, 121-22, 124,353; O-ring erosion in STS 51-C within, 156-58 safety regulation, 264-72; compliance strategy, 266; culture of production in, 271; external regulators, 265-66, 268-69; information dependency of regulators, 269-72; internal regulators, 265-68; Quality Assurance engineers, 267; regulators' autonomy, 264-69, 397, 417; regulators' interdependence, 265-69,398,417; Reliabili:y engineers, 266-67; Safety engineers, 266; safety personnel cuts, 213, 214, 267; structural secrecy in, 397-98 See also accidents Safety, Reliability, and Quality Assurance Program (SR&.QA), 266-67, 269-71,398 Sagan, Scott, 392, 418, 419 Salita, Mark: model for field joint erosion, 165, 171, 173, 191,233-34; on Thiokol's O-ring task force, 174 S&'E See Science and Engineering Directorate Sayer, Larry: on decision being different if they'd had more data, 381; launch decision as acceptable to, 325; on Lund's change of mind on launching, 318,366-67; preparing for second teleconference, 291; on Thiokol's engineering position, 296, 307, 32.4; on Thiokol's off-line caucus, 314 Schell, John, 117,290,300 301,309,351, 359-60 Schwinghamer, Robert, 217, 289, 290, 315,360 Science and Engineering Directorate (S&.£): as the bad news guys, 86, 87; conservative engineering philosophy of, 99; in engineering disagreements with Thiokol, 86-90; as engineering purists, 88; in FRR Level Iv, 92; functions of, 85; memos of, 255; Project Management's different orientation, 88-89; at project reviews, 86; report to Verification and Certification Committee, 107; on SRM redesign, 127 569 scientific management, 204 scientific paradigms See paradigms scientific positivism: in disputes over risk, 89, 91; in engineering, 202, 208; in Flight Readiness Review, 221; in original technical culture, 354; SRB work group's belief in, 233 scientific revolutions, 402 Scobee, Richard, I, 44, 283 Scott, Richard, 197 SEB (Source Evaluation Board), 97, 425-30 secondary O-ring: belief in adequacy of, 66; blow-by in STS 51-C, 3-4, 153, 155, 157, 190,299, 491n.6; erosion in previous launches, 8, 9; function of, xi; hot gases reaching in STS 51-B, 153, 163-66, 178; leak check's effect on, 490n.74; longer tang required by, 97; in nozzle joints, 163, 165; in SRM field joints,S See also secondary O-ring as redundant secondary O-ring as redundant: belief in as institutionalized, 278; belief in as reason for not reporting STS-2 erosion, 123; development of belief in, 196-97; discussed in Thiokol's off-line caucus, 315,316,317,319-20; erosion of primary O-ring and, 129, 132, 137, 164, 169, 170; first challenge to belief in, 244; NASA and Thiokol belief in, 96-97, 110; NASA and Thiokol disagreement on timing in, 101, 106, 108, 129; relation to resiliency as unknown, 339; in SRB work group paradigm, 66, 68, 348, 394; Structural Test Article verifying, 486n.103; technical rationale supporting, 187; Thiokol testing of, 104, Ill, 175-76; under worst-on-worst conditions, 173, 185,312 second prelaunch teleconference, 2-7, 299-314,322.-2.4,347-86; bureaucratic accountability interfering with, 349, 356-72, 399; cold temperature's effect on O-rings discussed, 2.-7, 291-99, 301-11; consensus on sequence of events, 282; decision of as rule-based, 339-47; distractions at, 300; engineering participants underrepresented in televised hearings, 71; events between first teleconference and, 288-99; full disclosure principle in, 369; groupthink in, 404, 525n.41; informa- 570 INDEX second prelaunch teleconference (cont.) tion exchange in undermined by structural secrecy, 349, 357, 398; Kilminster annOl:nces Thiokol's decision to launch, 6, 322, 368; legal advice to participants, 280-81; Lovingood and Smith locating people for, 289; Marshall's harsh criticism of Thiokol's position, 338, 375-76; Marshall's request for Thiokol's recommendation in writing, 41; as microcosm of NASA's cultural imperatives, 398-99; NASA personnel during Thiokol offline caucus, 321-22; NASA's concern for safety exemplified by, 49-50; note taking during, 280, 282; no video transmission as impeding communication, 357,377; as official a::knowledgment of escalated risk, 379; original technical culture interfering with, 349; participa."lts, 432; participants as engineers, 299-300; participants' recollections of, 279-81; political accountability interfering with, 349, 372-86, 399; in Presidential Commission hearings, xii, 8, 9, 10-11; production pressures in, 372-79; as resembling Flight Readiness Review, 340-47, 357, 420-21; scheduling of, 288,372; Thiokol engineers setting a deadline for themselves, 372-73, 384; Thiokol's charts for, 293-99, 349-56, 398-99; Thiokol's off-line ca~cus during, 6, 314-22,363-68,378; Thiokol's preparations for, 290-99; variation in participants' interpretations of, 282; worldview brought by participants, 64, 67-68 secrecy, individual, 239-43 secrecy, structural See structural secrecy self-limiting systems, 120, 176; O-ring erosion considered as, 138, 156-58, 188, 490nn 73, 75 self-regt:lating organizations, 268 Sestile, Gene, 301, 327, 345 Shaprro, Susan, 268 shifting the burden of proof: Mulloy and Hardy deny, 342; seen as deviant, 339, 340; shifting because contractor's position shifted, 343 Short, James F., Jr., 275, 400 signals: cold temperature and erosion as weak signal, 245-46, 262-63; Criticality becoming routine signal, 419; of danger in intimate relationships, 413-15; of danger in SRM performance, 110, 124, 141, 170,395, 397; decision makers' relying on, 251, 507nAO; early O-ring erosion giving mixed signals, 245, 263-64; embedd~d in SRB work group, 243-49; feedbad:, 247-50; FRR reliance on, 262-64; increasing O-ring erosion as routine signal, 246-47, 264; memos as weak signals, 253-57; missing signals in second teleconference, 356-72; missing signals in Thiokol's off-line caucus, 367; mixed signals in Thiokol cham, 351-52; paradigms overturned by signal too strong to explain away, 264; routine signals in Thiokol charts, 350-51; weak signals in Thiokol charts, 353-56 Silviera, Milton, 109 Simmel, Georg, 456 Simon, Herbert A., 116 single-point failures, 129 Smith, Dorothy, 68-69 Smith, J:'m: on anxiety at launches, 96 228; on continuing to fly despite 0ring problem, 190, 234; in FRR Level IV, 92; on launch delays, 249; locating people for second teleconference, 2811; McCarty expressing support of Thiokol position to, 362; on redesign of SRM, 117-18; on relationship of Marshall Space Flight Center and Thiokol, 85; on safety as important because "we know the astronauts," 227; on scheduling of second teleconference, 288; on teleconference participants' fears for therr jobs, 280 Smith, Michael, 1, 44, 283 Smith, R Jeffrey, 16 social location, 272-77, 282, 340, 357, 364,51On.118 social structure and anomie theory (SSAT), 458 Solid Rocket Boosters (SRB): certified as flightworthy, 79, 107, 111; in Challenger disaster, 7, 10, 333; construction of risk formalized for, 106-10; contract awarded to Thiokol, 42,50,425-31; Cook's memo on, 44, Critical Items List for, 438-41; Criti· cality waiver for, 56-58, 120, 13W5, 151-52,224; design based on Titan nI, 96-97, 110, 431, 485n.56; diagram oi, 4; history of decision making about, xiii; ice on launch pad as concern for INDEX Challenger, 7, 328; Launch Constraint on waived, 56-58, 153-54, 167-70, 192; normalization of technical deviations of, xiii; as not tested at 31"F lower limit, 391; parachute problem, 234·-35, 2B4; photographs of flame in aft segment of Challenger's right, 8-9, 53; reusability of, 21,97; right SRB breaks loose during Challenger launch, 10; in Space Shuttle system, 3; in STS-1, 109-10, 112; surface temperature of right SRB on morning of launch, 330; Thiokol design as lowest ranked but cheapest, 42, 427; Thiokol refuSing to acknowledge flaw in, 77; used to reduce Shuttle Program development costs, 21, 423; wind shear's effect on, 391 See also Solid Rocket Motor; SRB work group Solid Rocket Motor (SRM): as acceptable risk, 106, 112, 121, 125, L30, 244, 283; capture feature incorporated in, 126-27, 173, 176, 179, 191; Criticality status changed, 129 32; diagram of, 4; dimensions of joints, 40; factory and field joints in, 4, 5; field joint crosssection,S; history of decision making about the joints, 61-62, 64, 74, 77; hydroburst test of, 9B-lCO; joint failure, 50, 132, 139; joint problem as well-structured after the disaster, 69-70, 149; joint rotation, 40, 97-106, 110-11, 126-27, 128,244, 485n.56; joint rotation distinguished from erosion, 131 32, 139; joints classified as Criticality 1R, 108, 111, 253; joints tinkered with rather than redesigned, 42-43; Mark's call for review of joint problems, 140; Marshall Space Flight Center's oversight of, 85; neither NASA nor Thiokol understanding the joint, 277, 390, 4700.19; normalization of deviance in development of, 96-111, 114; normalization of deviant performance of joints, 65-68, 78, 106, 113, 119,122,124,394; open problems with, 184; Ray's corrections to the joints, 60, 104, 105; redesign considered, 105-6, 113, 117-18, 127, 147-48,232 33,235; risk in negotiated by SRB work group, 65, 78; segmented versus monolithic, 425 31; shimming the joint, 100, 104, Ill; signals of danger in, 110, 124, 141, 170,395,397; SRB work group learning the dynamics 571 of the joints, 119-20, 192; technical deviance of joints redefined as acceptable risk, 61; Thiokol reviews cold's effects on, 7, 286-87; three-factor technical rationale on joints, 61, 66, 120, 138, 140, 141, 156, 161, 176, 186, 350,351, 481n.102 See also nozzle joint anomalies; O-rings; zinc chromate putty Source Evaluation Board ISEB), 97, 425 30 Space Shuttle Crew Safety Panel (SSCSP), 266-67, 269, 417 Space Shuttle Program ISpace Transportation System): Air Force endorsement of, 19,20,26; anomalies expected in, 80; begun in midst of decline of appropriations, 18; blizzard of paperwork in, 251; as business, 24-28; civilians in flight crews, 26-28; commercial goals of, 24 26; competition and scarce resources for, 17-29; competitors of, 25-26; compromise in design of, 20-22; conversion from development to operational stage, 24, 28, 119, 125-28, 150-51, 162; Cook's list of dangerous conditions, 45, 478n.53; cost/safety trade-offs in, 17, 19-24,42-43,47,49-50,117-18, 423 31; Critical Items List, 107-8, 419, 438-41; design as unprecedented, 79, 80; development authOrized, 22; development costs required to be low, 21; deviations as controllable not eliminable in, 223; divided managerial responsibility for, 23; as done on the cheap, 42; early decision making in, 112; economic and safety interests competing in, 47; fixed cost of, 25; fleet reduced from five to four, 2; flight manifest changes, 28-29; flight schedule of, 22, 24 25, 28, 474n.138; as fundamental to manned space program, 19; information flow in, 251; initial orbital tests delayed, 23; launch decisions as continuous feedback loop, 248; launch delay history, 51-52, 215; launch delays occurring at the Cape, 95, 340; launching cost of, 25; launch schedule as important to, 214; launch turnaround time, 25; launch windows, 285-86, 512n.23; management structure and Flight Readiness Review, 83; military links of, 19-20; NASA argues for compromise design, 22-24; NASA's 572 INDEX Space Shuttle Program (continued) failure to redesign, 79, 113; New York Times allegations of rule violations in, 480n.91; 1986 mission schedule, 30-31; normalization of deviance 1981-84, 119-52; normalization of deviance 1985, 153-95; operating costs increased due to low development costs, 23; as paying for itself, 19, 20, 21, 22, 24-25, 212; payload pricing, 24, 473n.lOL; personnel costs in development, 20; preliminary and final launch dates of missions, 285, 483n.16; pressures on as pressure behind launch decision, 16-17; proceeding with launches despite known flaws, 96, 151; production pressures built into program, 23; program milestones of, 151; Program Requirements Control Board, 134, 135, 489n.55; regulatory ineffectiveness in, 34; retrieval missions by, 26; as reusable, 79, 248; risk as not eliminable in, 80; safety personnel cuts, 213, 214, 267; scarce resources for, 19-24; as a space bus, 79, 119, 213; spare parts shortage, 28, 29; in Strategic Defense Initiative, 26; Structural Test Article, 101, 102, 109, 486n.103; technical problems as taken for granted, 128; testing cut, 23-24, 126, 213; unruly technology in, 209; Verification and Certification Committee, 107, lll, ll3-14; weight as consideration, 21-22; widening gap between goals and means, 28-29 See also Acceptable Risk Process; Engineering Change Requests; Flight Readiness Review; Project Managers; Science and Engineering Directorate; Space Shuttle work groups; Space Shuttle system; and individual missions Space Shuttle Safety Assessment Report, 81 Space Shuttle system: diagram of, See also External Tank; Main Engine; Orbiter; Solid Rocket Boosters; Solid Rocket Motor Space Shuttle work groups: culture of production in, 238; engineers and managers in, 80; responsibility for technical work and assessment delegated to, 261; retrospective outsider interpretations differillJ from, 113; risk assessment by, 79, 80-84; turning points in production of culture in, 110 See also Project Managers; SRB work group Speakes, Larry, 14 Speas, Kyle, 322, 377 specialization, 204, 251, 260-62,365, 401,408 Spence, Michael, 507n.40 SR&QA (Safety, Reliability, and Quality Assurance Program I, 266-67, 269-71, 398 SRB See Solid Rocket Boosters SRB work group: aligning its actions with technical culture, 222-37; beliefs and norms of institutionalized, 150; bureaucratic accountability and, 227-37,396; "can do" attitude and, 234, 380; composition of, 65; construction of risk at end of 1985, 195; construction of risk unchanged by signals of danger, 130, 196; continuing to accept risk after STS 51-B burn-through, 185, 186, 188; cost and schedule pressures on, 227-37; cost/safety compromises and, 226-27; culture of production in, 67, 198, 236, 396-97; decision making conforming to NASA rules, 61-62, ll4, 483n.12; in destacking STS-9, 230; dissent in, 66; erosion and joint rotation distinguished, 131-32, 139; feedback on acceptance of risk of, 247-50; five-step decision sequence of, 65, 78, 82, llO, 120, 124, 170,379, 483n.12; as follow· ing all cultural imperatives, 380-81; incrementalism in, ll9, 120, 194-95, 394; key personnel informed of O-ring problem by, 143; as knowing their place in second teleconference, 369; learning the dynamics of the joints, 119-20, 192, 245, 390-91; living with contradictory official constructions, 191; normalizing deviance of SRB joints, 65-{)8, 78, 106, 113, 119, 122, 124-25,170-71,232-37,394; norms, rules, and deviance in, 112-18, 148-52, 190-95; operational phase changing decision making of, 126; original technical culture and, 227-37, 396; paradigm of, 348, 394-95, 401; persistence of work group culture in, 148, 195,234; political accountability and, 227-37, 396; production of culture in, 74, 78, 119, 154, 195,394-96; reassured by flight performance, 192, INDEX 245,396; recommendations to Verification and Certification Committee, 107; redundancy in worldview of, 66, 68, 348; residual risk and decision making in, 79-83; response to bureaucratic authority, 225-26; risk assessment by, 238, 400; risk in SRM negotiated by, 65-68, 78; routinization of problems by, 61; scientific positivism in, 233; in second teleconference, 300; signals of danger to, 243-49; structural secrecy in, 67, 345, 397-98; success as defined by, 224; willingness to delay launches, 228, 238 SRM See Solid Rocket Motor SRM Board, 91 SRM Pre-Board, 91 SSCSP (Space Shuttle Crew Safety Panel), 266-67, 269, 417 STA-1(Structural Test Article), 101, 102, 109,486n.103 Star, Leigh, 401 Starbuck, William H., 69, 253,386 Stein, Scott, 174, 180,231,452-53 Stevenson, Charles, 329, 331 Stinchcombe, Arthur 1., 123,204 Stout, Russell, Jr., 202 structural secrecy, 238-77; as built in to organizational structures, 238, 250-64; defined, 238; in development of meanings in SRB work group, 67, 345,397-98; in Flight Readiness Review, 257, 416; information exchange in second teleconference undermined by, 349, 357, 398; in intimate relationships, 413-15; language in, 252-53; in McDonald's ignorance of higher-level temperature specification, 346; safety regulation interfered with by, 397-98; in Thiokol's off-line caucus, 365; three sources of at NASA, 242-43,272 Structural Test Article (STA-l), 101, 102, 109,486n.103 STS-l Columbia mission (STS-1) STS-2: corrective action taken after, 245; erosion considered idiosyncratic, 140, 149; erosion in O-rings discovered in, 119, 120; erosion not discussed at STS-3 FRR, 123; postflight analysis of erosion, 124, 137; recommendation to fly after, 150; salience of erosion in, 244 STS-3,125 STS-4: boosters not recovered, 128, 573 491n.97; as final development flight, 24, 125, 126 STS-5, 128 STS-6: Criticality status waived prior to, 120, 132-33, 150; erosion discussed at upper-level FRRs, 140; erosion of more than one O-ring in, 136, 149 STS-8,137 STS-9: destacking of, 229-30, 304, 361; leak check pressure increased for, 137, 490n.67; rainwater in joints of, 361, 385 STS 41-B: erosion considered self-limiting, 138, 142, 490n.75; erosion of 0rings in, 136, 137-38; leak check pressure increased for, 137, 142, 490n.67 STS 41-C, 141, 142 STS 41-0, 119, 143, 144 STS 41-G, 143, 144, 145, 146 STS 51-B, 163-71; blow-by reaching secondary O-ring in, 153, 178, 190; FRR reporting on as conforming to procedures, 492n.27; idiosyncratic causes of erosion in, 246-47; NASA and Thiokol actions following, 172-73 STS 51-C: blow-by reaches secondary 0ring, 153, 190,364-65; erosion considered idiosyncratic, 246-47; record low temperature and, 154-63,245-46 STS 51-E (STS 51-D): erosion in O-rings in, 162-63, 490n.75; FRR reporting on as conforming to procedures, 492n.27; Thiokol's presentation at FRR for, 155-59; video of FRR for, 71, 161, 260 STS 51-F, 166-67, 170, 171, 494n.44 STS 51-1 See Challenger mission (STS 51-1) STS 61-C See Columbia mission (STS 61-C) systematic censorship, 250-51; in Flight Readiness Review, 257-64 systematic distortion, 70, 273, 274, 275-77 TAL sites, 285, 330, 512n.23 Taylor, Frederick, 204 technology: competition as integral to technical production, 214; decision making under ignorance with risky, 148-49; developmental versus operational, 125; hazards of technological age, xv; kinks in developmental phase, 111; as prized in American society, 237; risk assessment by technical workers, 399-402; risk assessment of 574 INDEX technology (continued) technical products, 63; technological uncertainty in the shuttle, 79; unruliness of as problem for engineers, 200-204,209,223,421 telecons (teleconferences): as disorderly affairs, 300, 385; as evidence of techni.cal culture in SRB work group, 228; first teleconference on eve of launch, 2, 287-88; House Committee on, 240; as routine at NASA, 86, 91, 305 See also second prelaunch teleconference temperature See cold temperature; cold temperature's effect on a-rings theory elaboration, 456-59; as methodological strategy, xv, 469n.3 thick description, 78, 154, 194,279,334 Thiokol See Morton Thiokol Thompso::l, Arnold: on Boisjoly, 104; charts for second teleconference, 291; on cold temperature and a-ring resiliency, 160; on damaged SRM case, 229; on a-ring problem becoming acute, 179, 256; proposed solutions to a-ring problems, 179, 449; on putty problem, 141; at second teleconierence, 304; on shimming SRM joints, 486n.88; en Thiokol's engineering position, 6, 316-18; at Thiokol's midday meeting on cold, 287; in Thiokol's off-line caucus, 6, 316-18,364-65; on Thiokol's preparation for second teleconference, 298; Thiokol's resiliency results presented by, 173 Tompkins, Phillip, 216 Traficant, James R., Jr., 13 transaction systems, 250 Trapnell, Emily, 188 trial-and-error learning, 191 Thchman, Barbara, 73 Turner, Barry M., 69, 149,410-11 turning points, 9, 110 Tversky, Amos, 400 uncertainty: decision makers relying on signals when faced with, 251; holistic effects on decision making in cases of, 243; as less visible at higher levels of FRR, 276; new designs bringing new, 116; normalization of deviance reducing, 410; about a-ring behavior,308; positivistic science as converting to certainty, 91; preferences taking over in face of, 340; about redundancy of secondary a-rings, 101; in second teleconference, 398; SRB work group deciding in face of technological, 79; in unprecedented joint design, 395; variation in interpreting risk greater under conditions of, 63 United Technologies Center IUTC), 426, 427, 530n.19 Van Allen, James, 31 Vandenberg Air Force Base, 126, 335 Verification and Certification Committee, 107, Ill, 113-14 Von Braun, Wemher, 216-17,354,380 waivers, 56-58, 133-35 Wasatch Division of Thiokol Chemical Corporation, 42 See also Morton Thiokol Wear, Larry: asking Thiokol to review effects of cold, 2, 286; Certificate of Flight Readiness signed by, 92; in closeout of G-ring problem, 182-84; on corr.mitment to a line of action, 249; on cost and schedule pressures, 227; on Engineering Change Requests, 89; on Flight Readiness Reviews as truthful, 241; on high-performance equipment as unforgiving, 228; on in-house standards for decision making, 115; on Ma:shall Center Board FRR, 291-20; on Mulloy's "When you want me to launch?" question, 311; on no one feel· ing the program should be halted, 254; on penalty clause in Thiokol contract, 337; on Presidential Commission not grasping FRR, 341; on production prese sures as institutionalized, 231-32, 374-75; on reporting problems up the hierarchy, 220; on risks of space flight, 95; on second teleconference participants, 299; speculations on result of Thiokol's off-line caucus, 322, SRM Board headed by, 91; on telecons, 86, 91; on Thiokol's data at second teleconference as not new, 351 Weeks, Michael, 172, 176, 177, 495n.90 Wegrich,Bob,289 Weick, KarI,282,357,372 Weingart, Peter, 203 Wiggins, Calvin: at August 19, 1985, meeting, 176; in second telecon:erence, 291, 300, 363; in Thiokol's off-line caucus, 317-20, 378 wind shear, 391 INDEX work group culture: organizational culture compared to, 64-65; work group defined, 64; worldview of, 65 See also Space Shuttle work groups worldview iframe of reference), 62-63; differences in engineers and managers, 199; dominant worldview of a culture, 66; in interpreting information, 75-76, 409; managerial, 275; occupational technique and, 200; of readers of this study, 73; societal cultu!:e affecting, 411; surviving despite persistent challenges, 62-63, 196; in work group culture, 65 See also paradigms Wynne, Brian, 200-201, 223 Young, John W.: management responsibilities of, 261; on NASA compromis- 575 ing flight safety, 44-45; on NASA teleconferences, 305; no accusation of individual wrongdoing by, 55; in STS1,109 Zald, Mayer N., 403, 460 zinc chromate putty: blowholes in, 121, 122, 136; function of, 121, 486n.77; leak check change adding to the blowholes, 137, 138-39, 142, 165; more required than in the Titan, 97; in Presidential Commission hearings, 9; propellant gases penetrate during Challenger launch, 10; in SRM field joints, 5; use as controversial, 141 Zucker, Lynne G., 236 Zussman, Robert, 205, 206 Free ebooks ==> www.Ebook777.com www.Ebook777.com ... when the subject comes up-exactly where they were, what they were doing, and how they felt when they heard about the tragedy The initial shock was perpetuated by the television replays of the Challenger' s... stick to the laun:h schedule No one has forgotten the astronauts, the incident, or the shape of those billowing clouds that recorded the final seconds of the Challenger' s flight Nonetheless, the loss... identified the O-rings as the technical cause of the tragedy Analysis of flight data, films, and the debris of the Challenger retrieved from the ocean floofindicated that the a-rings in the aft