Space Shuttle Challenger disaster

Parties

Morton Thiokol

Was the contractor responsible for the construction and maintenance of the
shuttle's Solid Rocket Boosters (SRBs).
Several engineers (most notably Roger Boisjoly) re-expressed their concerns
about the effect of low temperatures on the resilience of the rubber O-rings that
sealed the joints of the SRBs, and recommended a launch postponement.
Thiokol management initially supported its engineers' recommendation to
postpone the launch, but NASA staff opposed a delay.
-

Engineers at the Marshall Space Flight Center

Wrote to the manager of the Solid Rocket Booster project, George Hardy, on
several occasions suggesting that Thiokol's field joint design was unacceptable.
One engineer suggested that joint rotation would render the secondary O-ring
useless, but Hardy did not forward these memos to Thiokol, and the field joints
were accepted for flight in 1980.
-

NASA

Event Sequence

By 1985, Marshall and Thiokol realized that they had a potentially

catastrophic problem on their hands. They began the process of
redesigning the joint

Forecasts for January 28 predicted an unusually cold morning, with

temperatures close to 31 F (1 C), the minimum temperature permitted
for launch. The low temperatures had prompted concerns from Thiokol
engineers.

After the engineers presentation, Bob Lund, the vice president for engineering at
Morton Thiokol, presented his recommendations. He reasoned that since there
had previously been severe O-ring erosion at 53F and the launch would take
place at significantly below this temperature where no data and no experience
were available, NASA should delay the launch until the O-ring temperature could
be at least 53F.

Interestingly, in the original design, it was specified that the booster should
operate properly down to an outside temperature of 31F.
Larry Mulloy, the Solid Rocket Booster Project manager at Marshall and a NASA
employee, correctly pointed out that the data were inconclusive and disagreed
with the Thiokol engineers.
After some discussion, Mulloy asked Joe Kilminster, an engineering manager
working on the project, for his opinion. Kilminster backed up the recommendation
of his fellow engineers. Others from Marshall expressed their disagreement with
the Thiokol engineers recommendation, which prompted Kilminster to ask to
take the discussion off line for a few minutes. Boisjoly and other engineers
reiterated to their management that the original decision not to launch was the
correct one.
A key fact that ultimately swayed the decision was that in the available data,
there seemed to be no correlation between temperature and the degree to which
blow-by gasses had eroded the O-rings in previous launches.
Thus, it could be concluded that there was really no trend in the data indicating
that a launch at the expected temperature would necessarily be unsafe.
Jerald Mason, a senior manager with Thiokol, turned to Lund and said, Take off
your engineering hat and put on your management hat.
NASA did not know of Thiokol's earlier concerns about the effects of the cold on
the O-rings, and did not understand that Rockwell International, the shuttle's
prime contractor, viewed the large amount of ice present on the pad as a
constraint to launch. Due to NASA's opposition, Thiokol management reversed
itself and recommended that the launch proceed as scheduled.

Aberdeen Three
This case involves three civilian managers at the Pilot Plant at the Proving Grounds: Carl
Gepp, manager of the Pilot Plant; William Dee, who headed the chemical weapons
development team;
and Robert Lentz, who was in charge of developing manufacturing processes for the
chemical weapons [ Weisskopf, 1989 ].
Between 1983 and 1986, inspections at the Pilot Plant indicated that there were serious
safety hazards. These hazards included carcinogenic and flammable substances left in
open containers, chemicals that can become lethal when mixed together being stored in
the same room, barrels of toxic chemicals that were leaking, and unlabeled containers of
chemicals.
There was also an external tank used to store sulfuric acid that had leaked 200 gallons of
acid into a local river. This incident triggered state and federal safety investigations that
revealed inadequate chemical retaining dikes and a system for containing and treating
chemical hazards that was corroded and leaking.
In June of 1988, the three engineer/managers were indicted for violation of RCRA, the
Resource Conservation and Recovery Act.

RCRA had been passed by Congress in 1976 and was intended to provide incentives for
the recovery of important resources from wastes, the conservation of resources, and the
control of the disposal of hazardous wastes. RCRA banned the dumping of solid
hazardous wastes and included criminal penalties for violations of hazardous-waste
disposal guidelines.
The three managers claimed that they were not aware that the plants storage practices
were illegal and that they did things according to accepted practices at the Pilot Plant.
Interestingly, since this was a criminal prosecution, the Army could not help defray the
costs of the managers defense, and each of them incurred great costs defending
themselves.
In 1989, the three engineer/managers were tried and convicted of illegally storing,
treating, and disposing of hazardous wastes.
There was no indication that these three were the ones who actually handled chemicals
in an unsafe manner, but as managers of the plant, the three were ultimately responsible
for how the chemicals were stored and for the maintenance of the safety equipment.

The Aberdeen Three

Introduction
This is a case in which the willful disregard of standard chemical safety, storage, and
disposal rules by three chemical professionals resulted in the discharge of hazardous
chemicals into the public environment surrounding the Aberdeen Proving Grounds in
Maryland. They were all chemical engineers who should have been knowledgeable
about the management of the chemicals used and the chemical waste generated. All
three were tried and convicted in 1989 of illegally handling, storing, and disposing of
hazardous wastes in violation of RCRA, the Resource Conservation and Recovery Act.
Chemical professionals have a clear mandate to use their unique position to protect their
community and the environment. From the ACS Professional Employment Guidelines:
Chemical professionals are responsible for working safely and employing all necessary
safety procedures in the course of their professional duties. The employer is responsible
for providing physical facilities that enable the chemical professional to work safely,
comfortably and efficiently. The chemical professional and the employer should work to
reduce risks to the environment. The employer is responsible for providing appropriate
information, physical facilities and equipment that enable the chemical professional to

work safely, comfortably and efficiently. The chemical professional is responsible for
seeking information on the safe handling of chemicals and equipment with which they
work.
The chemical professional should inform the employer and coworkers in writing and/or
verbally, as appropriate, of any immediate or potential safety or health hazards. All
appropriate personnel should be trained in the proper handling of material and
equipment and all pertinent safety procedures to minimize risks.
The chemical professional and the employer should both work to minimize risks to the
environment. The chemical professional and the employer should strive to ensure that
products and processes are safe and that potential hazards to human health or the
environment, including air emissions, water effluents, and discharges to land are
minimized, properly identied and handled in such a way as to protect the environment.
Employers should conduct appropriate environmental studies to ensure the health and
safety of their workers and the surrounding community.
While the magnitude of the chemical release in this incident is probably greater than
want would be normally encountered in an academic setting, it is certainly of a scale that
could be encountered in an industrial setting and therefore has direct applicability to a
wide range of our colleagues, particularly students getting ready to graduate and take
that first job.

Background reading
A case study from Texas A&M used to illustrate the incident. This web site has a good
bibliography at the end for those individuals interested in exploring the responsibility of
engineers and scientists toward the public.
http://ethics.tamu.edu/ethics/aberdeen/aberdee1.htm
(also available through the Online Ethics
Center)http://www.onlineethics.org/CMS/profpractice/ppcases/texindex/aberdeen.aspx

Ethical considerations

Consider the following statement from PEG: The chemical professional should inform
the employer and coworkers in writing and/or verbally, as appropriate, of any immediate
or potential safety or health hazards.
What were the responsibilities of the lab technicians (not the Aberdeen Three) with
respect to reporting the long-standing issues regarding improper storage of chemicals
and chemical waste at the Pilot Plant?
Now consider that these employees may have been in fear of losing their jobs should
they rock the boat by exposing the conditions that they knew were dangerous. What
were their options?
What would you have done if you had been employed in the Pilot Plant in 1984 (before
the acid spill)?
What would you do if you discovered egregious violations of chemical storage
practices in your research environment tomorrow?
Consider the following statement from PEG: The employer is responsible for providing
appropriate information, physical facilities and equipment that enable the chemical
professional to work safely, comfortably and efficiently.
The Pilot Plant facility failed numerous inspections in the years preceding the acid spill.
From the TAMU site:
These problems included
* flammable and cancer-causing substances left in the open
* chemicals that become lethal if mixed were kept in the same room
* drums of toxic substances were leaking. There were chemicals everywhere misplaced, unlabeled or poorly contained. When part of the roof collapsed, smashing

several chemical drums stored below, no one cleaned up or moved the spilled
substance and broken containers for weeks.
What are the ethical responsibilities of the employer (the Aberdeen Proving Ground, in
this case) to the employees in the Pilot Plant?
What do you expect was the fate of the inspection reports that had been submitted
over the years? What does this say about the institutional culture at the Aberdeen
Proving Ground regarding safety?
Source:
http://www.acs.org/content/acs/en/about/governance/committees/ethics/aberdeen.html

Defense and Conviction[edit]

The Aberdeen Three maintained that they had done nothing wrong throughout the trial, arguing
that environmental responsibilities were not a part of their job description. They believed that the
experienced Pilot Plant workers did not need to be told how to handle hazardous materials and
relied on a treatment system to neutralize waste. Also, what the inspectors considered hazardous
waste, the engineers considered to be a precious resource because it took a long time to order
new chemicals. Lastly, the Aberdeen Three claimed federal immunity because they were working
for the Army, a federal entity, so they could only be tried in military courts. However, the court
determined that civilian employees of the Army could not claim immunity. The court rejected their
arguments and the Aberdeen Three were convicted in 1989 of violating the RCRA. The judge
gave them three years probation and 1000 community service hours instead of the maximum 15
years jail time.[2]
Source:
https://en.wikibooks.org/wiki/Professionalism/Gepp,_Dee,_and_Lentz,_and_the_leak_at_Ab
erdeen_Proving_Ground
A3 (genuinely?) did not believe that they were responsible for the acid leak incident (for
expediencys sake?)
5 Nov presentation
Tutorials/assignment
Presentation (Individual) - Dont exceed 5mins per person
Course content
Insight
Hat police hat, investigator and shoe the accused, show empathy
Presentation critique
Q and A
Interim (2 Pages) report 29 Sept 5pm

Approach, elaborate more, check were on the right track

Final report deadline 28 Oct 5pm to tutor (Upload to IVLE 8pm, submit 1 day before
preferably)