Recent orders

NSPE Code of Ethics Case Study (Stacking Hoist)

Introduction The Lakewood Company, a fairly large manufacturing firm, has designed, manufactured and sold hundreds of self-contained storage/retrieval systems which are used for storing heavy parts such as dies, which must intermittently be taken from storage and used elsewhere in the plant. The system consists of two large sets of storage racks, facing each other, with an integral crane that runs between them on 2 bridge crane girders on the top back edges of the storage racks (see Figure 1).

The crane has fork-lift appendages that can slip under a pallet on any of the several levels of the storage racks, retrieve a pallet off the shelf, retract the pallet into the aisle, rotate it parallel to the aisle, and move it to the end of the storage racks. The pallet is subsequently placed at the end of the aisle on the ground for pickup by a wheeled fork lift and transportation to its final destination. The Buchannan company, a large construction vehicle manufacturer, purchased one of these Lakewood “Hi-Stak” units and was using it extensively until one of their employees, West Michaels, had an accident and was seriously injured while operating the crane. (See the appended accident report written by Buchanan.) According to eye witnesses, West had retrieved a 1,460 pound die from the top shelf, and was pulling it to the end of the aisle. The load was well within the crane’s advertised limit of 2,000 pounds. The next thing West knew, as stated in the accident report, he was thrown about 20 feet. His next recollection was awakening in the hospital bed. The accident caused the crane wheels on the back side of the pallet to be pulled free of the lower flange of the A588 steel W6X12 girder on the left side. (See Figures 2 and 3).

NSPE Code of Ethics Case Study (The Ford Pinto)

“The Ford Pinto case is mentioned in most Business Ethics texts as an example of Cost-Benefit analysis, yet in those formats any appreciation of the complexity surrounding the issues of such decisions is overly simplified. As a thorough study, this book provides material that enriches the entire idea of
using a particular case as an avenue of learning about Ethics, Business, Society, Technology, and Government Regulation. Rather than as a mere reference tool for educators and other professionals, this book could be successful in the classroom in a way that no other anthology or collection of short case studies could be.” – Greg Pasquarello, Neumann College
It was the late 60s, when the demand for sub-compacts was rising on the market. Iacocca’s specifications for the design of the car were uncompromising: “The Pinto was not to weigh an ounce over 2,000 pounds and not cost a cent over $2,000.” During design and production, however, crash tests revealed a serious defect in the gas tank. In crashes over 25 miles per hour, the gas tank always ruptured. To correct it would have required changing and strengthening the design. Many studies of reports and documents done by Mother Jones on rear-end collisions involving Pintos reveal that if you ran into that Pinto you were following at over 30 miles per hour, the rear end of the car would buckle like an accordion, right up to the back seat. The tube leading to the gas-tank cap would be ripped away from the tank itself, and gas would immediately begin sloshing onto the road around the car. The buckled gas tank would be jammed up against the differential housing (that big bulge in the middle of your rear axle), which contains four sharp, protruding bolts likely to gash holes in the tank and spill still more gas. Now all you need is a spark from a cigarette, ignition, or scraping metal, and both cars would be engulfed in flames. If you gave that Pinto a really good whack?say, at 40 mph – chances are excellent that its doors would jam and you would have to stand by and watch its trapped passengers burn to death. In pre-production planning, engineers seriously considered using in the Pinto the same kind of gas tank Ford uses in the Capri. The Capri tank rides over the rear axle and differential housing. It has been so successful in over 50 crash tests that Ford used it in its Experimental Safety Vehicle, which withstood rear-end impacts of 60 mph. So why wasn’t the Capri tank used in the Pinto? Or, why wasn’t that plastic baffle placed between the tank and the axle – something that would have saved the life’s hundreds of people. President Semon “Bunky” Knudsen, whom Henry Ford II had hired away from General Motors, and Lee Iacocca, a spunky Young Turk who had risen fast within the company on the enormous success of the Mustang. Iacocca saying was that the Japanese were going to capture the entire American subcompact market unless Ford put out its own alternative to the VW Beetle. Bunky Knudsen said let them have the small-car market, but he lost the battle and later resigned. Iacocca became president and almost immediately began a rush program to produce the Pinto. Lee Iococca wanted that little car in the showrooms of America with the 1971 models. So he ordered his engineering vice president, Bob Alexander, to oversee what was probably the shortest production planning period in modern automotive history. The normal time span from conception to production of a new car model is about 43 months. The Pinto schedule was set at just under 25.
When it was discovered the gas tank was unsafe, did anyone go to Iacocca and tell him? “Hell no,” replied an engineer who worked on the Pinto, a high company official for many years, who, unlike several others at Ford, maintains a necessarily clandestine concern for safety. “That person would have been fired. Safety wasn’t a popular subject around Ford in those days. Whenever a problem was raised that meant a delay on the Pinto, Lee would chomp on his cigar, look out the window and say ‘Read the

NSPE Code of Ethics Case Study (Apollo 1 Mission)

The Apollo 1 mission was scheduled to have been launched on February 21, 1967, with astronauts Virgil Grissom, Edward White, and Roger Chaffee onboard. This would have been the first manned Apollo mission; one in a series of missions designed to get an American to the moon by the end of the 70’s. However, on January 27, 1967, during a preflight test on the launch pad, tragedy struck. A fire swept through the Command Module (CM) which killed all three astronauts. What follows is an account of the events that occured before, during and after the fire. Earlier that day
 The astronauts entered the Apollo 204 spacecraft, which was attached to the Saturn rocket on launchpad 34 at 1:00 p.m.
 Grissom’s spacesuit oxygen loop had a “sour smell”. The crew stopped to take a sample of the suit loop, and after discussion with Grissom decided to continue the test.
 A high oxygen flow indication periodically triggered the master alarm. The matter was discussed with environmental control system personnel, who believed the high flow resulted from movement of the crew. The matter was not really resolved.
 Faulty communications existed between Grissom and the control room for most of the test, even though the crew made adjustments. Later, the difficulty extended to include communications between the operations and checkout building and the blockhouse at complex 34. This failure in communications forced a hold of the countdown at 5:40 p.m.
 At 6:31 the count was about to restart when ground instruments showed an unexplained rise in the oxygen flow into the spacesuits. One of the crew, presumably Grissom, had moved slightly.

The fire
 Four seconds later, an astronaut, probably Chaffee, announced almost casually over the intercom: “Fire, I smell fire.” Two seconds later, Astronaut White’s voice was more insistent: “Fire in the cockpit.” The fire was visible in mission control via the video feed.
 White began preperations to unlatch the hatch, the escape route fromt the module. This involved moving the headrest out of the way, operating the rachet-like equipment to open the latch, and removing the latch.
 The command module ruptured. Flame and thick black clouds of smoke billowed out, filling the launch escape system atop of the spacecraft.
 Some of the men on the launch pad evacuated while others tried to rescue the astronauts. They had dificulties getting close to the module because of the intense heat and dense smoke.
 When the hatch was finally opened, it was determined that all three astronauts were dead. The primary cause of death was carbon monoxide posining, with thermal burns having contributing effects. Firemen arrived within three minutes of the hatch opening, doctors soon thereafter.
Afterwards
 After removal of the bodies, NASA impounded everything at launch complex 34.
 On 3 February, NASA Administrator Webb set up a review board to investigate the matter thoroughly.
 Engineers at the Manned Spacecraft Center duplicated conditions of the Apollo 204 without the crewmen in the capsule.
 The reconstructed events and the investigation on pad 34 showed that the fire started in or near one of the wire bundles to the left and just in front of Grissom’s seat on the left side of the cabin — a spot visible to Chaffee. The fire was probably invisible for about five or six seconds until Chaffee sounded the alarm.
 The exhaustive investigation of the fire and extensive reworking of the CMs postponed any manned launch until NASA officials cleared the CM for manned flight.
 The next manned mission was launched on October 11th 1968. It included the following major improvements: onboard TV camera, S-band radio communications, a fire extinguisher, emergency oxygen masks, less combustible materials in the command module, better wiring, and a new system for minimizing volatility of the atmospheric conditions. It was successful.
Contributing Factors As with most engineering disasters, the determination of the exact cause of the disaster was not easy. The Apollo 1 mission to this day still remains a mystery. The specific initiator of the fire has not yet been determined, and probably never will be. However, after investigation, a number of factors that signifacntly contributed to the disaster were determined. The fire began because of an electical short, it spread quickly because of the volatile atmospheric conditions and the presence of combustible materials inside the module. The hatch design and NASA’s management of the Apollo program may have also been contributing factors.
1. Electrical Components In the Apollo 204 spacecraft, many problems occurred with the electrical wiring. Teflon, has an excellent fire resistance and was therefore chosen as the covering for the wiring in the spacecraft. The specific type used for the craft was easily damaged or penetrated by abrasion. If this wiring experiences penetration by a metal structure (namely spacecraft components) a short is created at the point of conductor contact. Tests performed in highly pressurized atmosphere indicate that sparks blown from an arc can ignite combustible materials that are a short distance away from that arc. Taking this into consideration, it is quite feasible that the many arcs located by investigators on the spacecraft could have been the initiator of the fire.
Electric power distribution malfunctions in the Apollo 204 module were also related to the Environment Coolant System leakage. RS-89 was the coolant the leaked, which is a mixture of 62.5 percent ethylene glycol, 35.7 percent H20, and 1.8 percent stabilizer and corrosion inhibitor. This mixture is not highly combustable, however leakage and spillage of this fliud does present a threat. The water in this fluid evaporates much faster than the ethylene glycol. This results in a salt formation that does not evaporate and which is highly combustable. Furthermore, the residue from RS-89 is electrically conductive, therefore contact with uninsulated wire would result in current exposure to the internal atmosphere. It was proved in laboratory tests that this coolant provides an mechanism to ignite a fire.
2. Spacecraft Atmosphere The high pressure and concentration levels of oxygen gas largely contributed to the dispersion of the fire. During the initial stages of the fire oxygen levels were reported to be at saturated levels which may have prompted the spread of the fire. The initial flow rate increase was probably due to crew movement which normally results in increased leakage to the cabin.
3. Combustible Materials The fire moved rapidly from the point of ignition, traveling along the Raschel net debris traps which were installed in the Command Module (CM) to prevent items from dropping into equipment areas during tests. These nets were made mainly of nylon, and were thus highly combustible. Since these nets ran along large sections of the CM they generated firebrands which scattered, igniting more materials. NASA was aware of this undesirable property, but not anticipating a fire in the test runs, allowed them to be used on the ground but not during space flight.
4. Hatch Design The main exit from the Command Module was through inner and outer hatches. The hatch design for the Apollo 1 spacecraft was not a cause of the disaster, but it had a large impact on the outcome. With this particular design three hatches were installed. The outermost hatch (the Boost Protective Cover (BPC)) covers the Command module during launch. The inner hatch or ablative hatch becomes the outer hatch when the BPC is jettisoned after launch. The inner hatch closes off the Command Module and is the first to be opened by the crew in the case of the emergency.
In the case of the AS 204 testing, the outer BPC was not fully latched because of wiring that was temporarily in place for the tests. The problems maily arose with the inner hatch. As indicated by reports, one of the astronauts attempted to open the inner hatch but was unsucessful. The inner Command Module became highly pressurized as the fire heated up the module, causing the gases to expand. To release the inner hatch it was necessary to open it into the cabin, a task that would have been impossible in the higher cabin pressures. The release valve to allow pressure to be normalized, was not large enough to have any effect in the event of a fire. The crew had also been having problems evacuating in the 90 second benchmark time due to the complicated, multi-step nature of the hatch design.
5. NASA’s Mis-management It was determined by the review board that the organizations responsible for the planning, conduct and safety of the test had failed to identify the situation as hazardous. It was also determined that deficiencies in design, manufacture, installation, rework and quality control existed in the electrical, Environmental Control, and the communication systems. These problems werewstrongly influenced by governmental pressure to minimize cost and time and a lack of communication between NASA and it’s contractors.
Recommendations Space exploration is a considered a highly dangerous job field and because of this safety is considered very important. The Apollo 1 disaster was the first major disaster that NASA encountered. It was reviewed in detail by a board of authorities who investigated the problems that caused it. From the investigation the review board came up with recommendations that would prevent future disasters. The following are some of the main recommendations that were put forth by the review board.
1. Oxygen or any other material that is combustible should be restricted and controlled – That the location and amount of combustible materials should be strictly controlled, both on missions and simulations. – That combustible materials used should be replaced wherever possible with non-flammable materials. – That atmospheric conditions of %100 oxygen are not permissible on tests. – Full-scale flammable mockups should be used to test spacecraft in future.
2. Spacecraft should be designed with saftey as a primary consideration – Electrical wiring and insulation should be appropriate for the application. – In future the time to escape be decreased through other escape routes and a hatch that can easily open under extreme pressure difference. – When the fire broke out in the module, bits and pieces of the conversation between the module and command were heard. At times it left command guessing as to what the astronaut was saying. The review board recommended that a better communication system be set up.

3 Emergency personnel should be availible – It was recommended that all personnel should have proper training and should practice for emergency procedures. – The emergency equipment be reviewed for adequacy in dealing with this incident, and that the launch facilities should be modified to facilitate emergency egress situations. – Inspectors should continually monitor the safety of all test operations and assure that emergency procedures are in place to handle these types of situations.