The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASAUniversity of Chicago Press, 1996 M01 28 - 575 pages When the Space Shuttle Challenger exploded on January 28, 1986, millions of Americans became bound together in a single, historic moment. Many still vividly remember exactly where they were and what they were doing when they heard about the tragedy. In The Challenger Launch Decision, Diane Vaughan recreates the steps leading up to that fateful decision, contradicting conventional interpretations to prove that what occurred at NASA was not skulduggery or misconduct but a disastrous mistake. Journalists and investigators have historically cited production problems and managerial wrong-doing as the reasons behind the disaster. The Presidential Commission uncovered a flawed decision-making process at the space agency as well, citing a well-documented history of problems with the O-ring and a dramatic last-minute protest by engineers over the Solid Rocket Boosters as evidence of managerial neglect. Why did NASA managers, who not only had all the information prior to the launch but also were warned against it, decide to proceed? In retelling how the decision unfolded through the eyes of the managers and the engineers, Vaughan uncovers an incremental descent into poor judgment, supported by a culture of high-risk technology. She reveals how and why NASA insiders, when repeatedly faced with evidence that something was wrong, normalized the deviance so that it became acceptable to them. No safety rules were broken. No single individual was at fault. Instead, the cause of the disaster is a story not of evil but of the banality of organizational life. This powerful work explains why the Challenger tragedy must be reexamined and offers an unexpected warning about the hidden hazards of living in this technological age. |
Contents
THE EVE OF THE LAUNCH | xiii |
LEARNING CULTURE REVISING HISTORY | 29 |
RISK WORK GROUP CULTURE AND THE NORMALIZATION OF DEVIANCE | 73 |
THE NORMALIZATION OF DEVIANCE 198184 | 115 |
THE NORMALIZATION OF DEVIANCE 1985 | 149 |
THE CULTURE OF PRODUCTION | 192 |
STRUCTURAL SECRECY | 234 |
THE EVE OF THE REVISITED | 274 |
LESSONS LEARNED | 383 |
CostSafety Tradeoffs? Scrapping the Escape Rockets and the SRB Contract Award Decision | 419 |
Supporting Charts and Documents | 428 |
On Theory Elaboration Organizations and Historical Ethnography | 452 |
Acknowledgments | 461 |
Notes | 465 |
Bibliography | 529 |
Index | 547 |
Other editions - View all
The Challenger Launch Decision: Risky Technology, Culture, and Deviance at ... Diane Vaughan No preview available - 2016 |
Common terms and phrases
19 March acceptable risk actions administrators Al McDonald Ben Powers blow-by Challenger launch charts construction of risk contractor disaster engi engineering analysis erosion failure field joint Flight Readiness Review Ibid ignition interview transcript Investigation Jack Buchanan January January 28 Launch Constraint launch decision leak check Leon Ray Level Marshall and Thiokol Marshall Space Flight Marshall's McDonald memo mission Morton Thiokol motor Mulloy NASA NASA's National Archives neers nozzle joint O-ring erosion O-ring problem official organization organizational original technical culture participants position Presidential Commission primary O-ring procedures production pressure Project Manager putty recommendation redundancy Report response risk assessment Roger Boisjoly rules safety schedule Science seal secondary O-ring Shuttle Program signals of potential sion Social Solid Rocket Booster Space Shuttle Space Shuttle Challenger Space Shuttle Program SRB joint SRB work group structural secrecy teleconference tests Thiokol engineers tion U.S. Congress worldview