Safety Reliability and Risk Management

QUESTION 1

Challenger Space Shuttle Explosion

This very serious accident occurred twenty-five years ago and came into the books of history as the accident that had changed the world. It occurred on January 28, 1986, in the Atlantic Ocean area off the coast of central Florida. The Space Shuttle Challenger (mission STS-51-L) blasted and broke apart only in one minute and 23 seconds after its launch. This led to the death of seven members of the crew. The fault that led to the crash was the failure of an O-ring seal in the right solid rocket booster. This ultimately caused total disintegration of the spacecraft. Failure of the O-ring therefore caused a break in the SRB joint of the plane. This, in turn, pushed the hot gas under very high pressure outward the spacecraft. The pressurized hot air due to its massive force affected the nearby SRB joint and the external tank of the aircraft. The force of the impingement caused disintegration of the joint. The solid rocket motor, which provided the navigation of the aircraft, began to leak the hot air out.

The damaged SRB separation facilitated entire failure of the external tank functions. It also caused separation of the right side SRB attachment. Since the aircraft has already been in the air moving at a high speed, great aerodynamics forces influenced it particularly hard. These forces swiftly broke the orbiter. Therefore, the airfoil lost its control.

The aircraft was forced to land on the ocean. The crew compartment and many other parts of the astronaut vehicle were found on the ocean bed after a long and rigorous search. All seven crewmembers died, including Francis R. Scobee (the commander), Michael J. Smith, Ronald McNair, Judith Resnik, Greg Jarvis, and Christa McAuliffe.

The outcome of the accident was widespread in the astronaut environment. It led to the formation of the Rogers Commission, a special group that was appointed by then-president, Ronald Reagan, to investigate the accident. The investigation revealed the faults in the organizational structure and decision-making process of the National Aeronautics and Space Administration. In the process of building the spacecraft, it was acknowledged that the O-ring had a problem. Therefore, the construction of SRB, which was developed by Morton Thiokol, was compromised. The body of the Commission received this information in 1977. However, NASA failed to act on this or implement any measures to resolve or correct the situation properly. During the launching, the engineers warned NASA that the morning chilly weather was unsuitable for technical operation of the aircraft. The present NASA officials did not heed to this warning and even did not inform their superiors about it. In the report, the information about the unsuitability of the airfoil to work in low temperature conditions left unnoticed. The aircraft did not receive the approval to operate in those kinds of conditions.

The launch of any vehicle should be preceded by adequate tests to ascertain the suitability and efficiency of the vehicle. Unfortunately, this aircraft did not pass such test. The O-ring, a very important component of the aircraft, was not subjected to critical trials. Therefore, there was no certified test data that the expectations of the launch are attainable. There was later confirmation from Bob Ebeling that the Thiokol design could only operate efficiently up to 40 degrees centigrade. Therefore, there were no expectations that the vehicle would behave in the same way at a temperature of 18 degrees centigrade.

During the powered flight of the space shuttle, the crew could not escape. Even though this measure should be taken into account during the construction of the aircraft, NASA thought the shuttle reliable enough to require an escape system. SR-71 Blackbird ejection seats, which were used for the test missions, were removed in this final mission. The presence of this system would probably save the lives of the seven crewmembers. After the accident, NASA reconsidered their stand on escape systems in space settlers. Initially, there was a thought that this equipment would cost a lot of money due to the high complexity involved and the limited utility for the space journeys.

After the accident, NASA tried to recover the debris from the Atlantic Ocean. The president gave attribute to seven fallen heroes and their families.

To my mind, there are situations when rules need to be bent or broken. However, there are fields where this is relatively inapplicable. NASA should have provided policy that ensures the strict compliance with the management rules. The case of involuntary non-compliance must be acknowledged to all the stakeholders. The technical processes should not endanger a single life for just achieving a certain organizational goal. In case of changing rules, the responsible departments should carefully evaluate the provision of the current management policies to determine where exactly changes are necessary. In addition, the authorities should emphasize that communication is vital during all stages. In such delicate situations, the management system should therefore ensure that the communication system is at its best. This will establish that not only the management provides success but also the people who perform the most fundamental tasks are in safety. At the end of the day, just these people ensure success or failure of an operation.

‘Superdeep’ Powdered Juice

Six months ago, after an advertisement of ‘Superdeep’ powdered glucose on the television, I was so eager to have a test of it. These were 50 g sachets of powdered juice, which could make up to 20 glasses of juice. This proved to be both saving and sweet. This is because you can get an artificial juice for three dollars at the cost of the powder in a quarter. However, after two weeks of regular consumption, I started feeling stomachaches. On visiting the doctor, I learnt that the juice had harmful chemicals that intoxicated consumers. These chemicals, with their high flavoring property, are in large amount in this powder, which ensure maximum returns. This was the reason why the product was so cheap since no safety measures nor many ingredients were involved.

The powder contained Acesulfame Potassium, a sweetener that is even sweeter than table sugar. According to the doctor, continued use of the product could have predisposed me to lung cancer. It can also cause leukemia and chronic respiratory disease. In humans, it can cause low blood sugar attacks.  Recent research suggests that there is a possible linkage of the chemical with breast cancer.

Another additive that made the ingredient list is alginic acid. The doctor stated that this chemical is associated with dull abdominal pains. It may lead to development of complications during pregnancy. It was revealed that it is one of the teratogens that cause congenital birth defects. Apart from this powder, the doctor told me to look out for other artificial juice products, salads, cheese spreads, and jellies since they also contain this additive.

Another ingredient that contributed to the sweetness of the product was aspartame. This chemical causes a range of health problems, depression, including headaches, seizures, rashes, nausea, and dizziness. It is also a contributor of insomnia, blurred vision, hallucinations, and ringing in the ears. He further stated that some investigations prove that it may even cause cancer. The doctor then demonstrated a document written by Dr Janet Hull who studied the allergic effects of aspartame. She found out that consumption of this chemical could trigger or worsen such chronic illnesses: brain tumors, epilepsy, mental retardation, chronic fatigue syndrome, multiple sclerosis, Parkinson’s disease, birth defects, Alzheimer’s, lymphoma, fibromyalgia, and diabetes.

At the end of the consultation, I learnt that I had exposed myself to very dangerous chemicals that could completely alter my health status and my metabolic system.

QUESTION 2

Minimal Cut Sets

  • Disintegration of the O-ring.
  • Failure of NASA to follow instructions and recommendations on the space shuttle design.
  • Breach of communication between the NASA officials at the launch and the superiors.
  • Launch of the space shuttle under low temperature conditions: 18 degrees centigrade.
  • Failure to install an escape system on the space shuttle.

How to Avoid Occurrence of the Top Event

If NASA takes into consideration the recommendations made about the Thiokol design, the necessary adjustments would have been made. Engineers did not pay attention to the fact that the aircraft could not operate under very low temperatures. Therefore, instead of launching the space shuttle under adequate conditions, it was supposed to be launched under 40 degrees centigrade or more. If NASA approves installation of an efficient escape system on the space shuttle, it would have helped to save the lives of seven astronauts.

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