Case Study: A High-Tech “Near Miss”

Cite as: Lighthall, F. F. 2014, “Case Study: A High-Tech “Near Miss”.

This case presents organizational decision under the pressure of NASA's production schedule.

Unusually cold Florida weather the night before Challenger´s launch (January 27-28, 1986) caused NASA officials at the launch site to let water hoses drip from the top of the towering service structure alongside the shuttle. Their steady dripping created sheets of ice and icicles covering the entire service structure.

The near-miss story unfolds in four parts, tracing recorded conversations between and among engineers and managers as they assess the probability of ice damage to the Orbiter´s undersurface by ice that will be dislodged and fly in swirls when the main engines and boosters are ignited. We hear first-hand assessments by Charles Stevenson, an engineer, reporting severe, threatening ice conditions as he walks gingerly down the service structure. His warning descriptions are followed by launch managers who doubt and challenge his assessments.

We hear conversations among officials of Rockwell International as they assess and agree with Stevenson´s warnings. We also follow previous actions and experiences of Arnold Aldrich, the Houston manager who will decide to proceed with launch or to delay. Just weeks earlier, he had sent a highly critical memo to a long list of NASA subordinates, criticizing deficiencies for the many delays of the immediately preceding launch. His memo revealed his intense commitment to completing each launch on schedule.

Post-accident testimony from all participants together with their real-time conversations show disparities among them in visual access to ice conditions, disparities in estimates of ice trajectories, disparities in views of who had to prove what in order to proceed, and disparities in organizational commitments to on-time versus safe launch. The disparities line up Stevenson and the Rockwell officials on the side of delaying the launch, and the NASA´s launch managers and Aldrich on the side of launching unless “hard data” can prove danger.

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