# How the Challenger shuttle disaster happened

> A process map exported from forks.world (https://forks.world). Author: Brian. Source: https://forks.world/p/cmv22205m000ri2069ysvbgs7
> It describes who does what, in what order, and with which technology. Read the plain-language sections first; the JSON at the end is the exact, complete data.

## Summary

- 11 steps across 1 layer
- Persona: Rocket engineers, Managers, NASA, Investigation panel
- Technology / systems: The shuttle

## Pain points

Where this process hurts, worst first:

- **Ask the engineers to prove it is NOT safe** (How the Challenger shuttle disaster happened; critical): The burden of proof was reversed
- **Finds the cause, and also a culture that treated small problems as normal** (How the Challenger shuttle disaster happened; critical): Earlier flights had shown damage and nothing was done

## How to read this file

- A process is made of **layers**. The main layer is the top level; any step of kind `subprocess` opens a detail layer with its own lanes and steps.
- **Lanes** are either persona (people/roles) or technology (systems). Each step belongs to one lane; `using` lists tools a person uses for that step.
- Step kinds: `start`, `task`, `decision` (its arrows carry the answer as a label), `subprocess`, `end`.

## How the Challenger shuttle disaster happened

Lanes:
- Rocket engineers: person / role (id `engineers`)
- Managers: person / role (id `managers`)
- NASA: person / role (id `nasa`)
- The shuttle: technology / system (id `shuttle`)
- Investigation panel: person / role (id `panel`)

Steps, in the order they run:

1. **Know that the rubber seals in the rocket joints get stiff in the cold** [start; Rocket engineers; id `c1`]
   - then Forecast calls for the coldest launch ever
2. **Forecast calls for the coldest launch ever** [task; NASA; id `c2`]
   - then Recommend not launching below a safe temperature
3. **Recommend not launching below a safe temperature** [task; Rocket engineers; id `c3`]
   - then Ask the engineers to prove it is NOT safe
4. **Ask the engineers to prove it is NOT safe** [task; Managers; id `c4`] ⚠ PAIN POINT (critical): The burden of proof was reversed
   - then Overrule the engineers and approve the launch
5. **Overrule the engineers and approve the launch** [task; Managers; id `c5`]
   - then Liftoff: a puff of gray smoke from the joint
6. **Liftoff: a puff of gray smoke from the joint** [task; The shuttle; id `c6`]
   - then Hot gas burns through the seal and a flame hits the fuel tank
7. **Hot gas burns through the seal and a flame hits the fuel tank** [task; The shuttle; id `c7`]
   - then The shuttle breaks apart 73 seconds after liftoff
8. **The shuttle breaks apart 73 seconds after liftoff** [task; The shuttle; id `c8`]
   - then A commission investigates and a physicist drops a rubber seal in ice water
9. **A commission investigates and a physicist drops a rubber seal in ice water** [task; Investigation panel; id `c9`]
   - then Finds the cause, and also a culture that treated small problems as normal
10. **Finds the cause, and also a culture that treated small problems as normal** [task; Investigation panel; id `c10`] ⚠ PAIN POINT (critical): Earlier flights had shown damage and nothing was done
   - then Redesigns the joints and changes how safety concerns are heard
11. **Redesigns the joints and changes how safety concerns are heard** [end; NASA; id `c11`]

```mermaid
flowchart LR
  subgraph l_engineers["Rocket engineers"]
    n_c1(["Know that the rubber seals in the rocket joints get stiff in the cold"])
    n_c3["Recommend not launching below a safe temperature"]
  end
  subgraph l_managers["Managers"]
    n_c4["Ask the engineers to prove it is NOT safe"]
    n_c5["Overrule the engineers and approve the launch"]
  end
  subgraph l_nasa["NASA"]
    n_c2["Forecast calls for the coldest launch ever"]
    n_c11(["Redesigns the joints and changes how safety concerns are heard"])
  end
  subgraph l_shuttle["The shuttle"]
    n_c6["Liftoff: a puff of gray smoke from the joint"]
    n_c7["Hot gas burns through the seal and a flame hits the fuel tank"]
    n_c8["The shuttle breaks apart 73 seconds after liftoff"]
  end
  subgraph l_panel["Investigation panel"]
    n_c9["A commission investigates and a physicist drops a rubber seal in ice water"]
    n_c10["Finds the cause, and also a culture that treated small problems as normal"]
  end
  n_c1 --> n_c2
  n_c2 --> n_c3
  n_c3 --> n_c4
  n_c4 --> n_c5
  n_c5 --> n_c6
  n_c6 --> n_c7
  n_c7 --> n_c8
  n_c8 --> n_c9
  n_c9 --> n_c10
  n_c10 --> n_c11
```

## Full data (JSON)

```json
{
  "title": "How the Challenger shuttle disaster happened",
  "maps": {
    "m_root": {
      "id": "m_root",
      "lanes": [
        {
          "id": "engineers",
          "name": "Rocket engineers",
          "type": "person"
        },
        {
          "id": "managers",
          "name": "Managers",
          "type": "person"
        },
        {
          "id": "nasa",
          "name": "NASA",
          "type": "person"
        },
        {
          "id": "shuttle",
          "name": "The shuttle",
          "type": "system"
        },
        {
          "id": "panel",
          "name": "Investigation panel",
          "type": "person"
        }
      ],
      "steps": [
        {
          "id": "c1",
          "kind": "start",
          "lane": "engineers",
          "next": [
            {
              "to": "c2"
            }
          ],
          "uses": [],
          "label": "Know that the rubber seals in the rocket joints get stiff in the cold"
        },
        {
          "id": "c2",
          "kind": "task",
          "lane": "nasa",
          "next": [
            {
              "to": "c3"
            }
          ],
          "uses": [],
          "label": "Forecast calls for the coldest launch ever"
        },
        {
          "id": "c3",
          "kind": "task",
          "lane": "engineers",
          "next": [
            {
              "to": "c4"
            }
          ],
          "uses": [],
          "label": "Recommend not launching below a safe temperature"
        },
        {
          "id": "c4",
          "kind": "task",
          "lane": "managers",
          "next": [
            {
              "to": "c5"
            }
          ],
          "pain": {
            "note": "The burden of proof was reversed",
            "level": 3
          },
          "uses": [],
          "label": "Ask the engineers to prove it is NOT safe"
        },
        {
          "id": "c5",
          "kind": "task",
          "lane": "managers",
          "next": [
            {
              "to": "c6"
            }
          ],
          "uses": [],
          "label": "Overrule the engineers and approve the launch"
        },
        {
          "id": "c6",
          "kind": "task",
          "lane": "shuttle",
          "next": [
            {
              "to": "c7"
            }
          ],
          "uses": [],
          "label": "Liftoff: a puff of gray smoke from the joint"
        },
        {
          "id": "c7",
          "kind": "task",
          "lane": "shuttle",
          "next": [
            {
              "to": "c8"
            }
          ],
          "uses": [],
          "label": "Hot gas burns through the seal and a flame hits the fuel tank"
        },
        {
          "id": "c8",
          "kind": "task",
          "lane": "shuttle",
          "next": [
            {
              "to": "c9"
            }
          ],
          "uses": [],
          "label": "The shuttle breaks apart 73 seconds after liftoff"
        },
        {
          "id": "c9",
          "kind": "task",
          "lane": "panel",
          "next": [
            {
              "to": "c10"
            }
          ],
          "uses": [],
          "label": "A commission investigates and a physicist drops a rubber seal in ice water"
        },
        {
          "id": "c10",
          "kind": "task",
          "lane": "panel",
          "next": [
            {
              "to": "c11"
            }
          ],
          "pain": {
            "note": "Earlier flights had shown damage and nothing was done",
            "level": 3
          },
          "uses": [],
          "label": "Finds the cause, and also a culture that treated small problems as normal"
        },
        {
          "id": "c11",
          "kind": "end",
          "lane": "nasa",
          "next": [],
          "uses": [],
          "label": "Redesigns the joints and changes how safety concerns are heard"
        }
      ],
      "title": "How the Challenger shuttle disaster happened",
      "parent": null
    }
  }
}
```