Risky Technology, Culture, and Deviance at NASA, Enlarged Edition
Author: Diane Vaughan
Publisher: University of Chicago Press
Category: Technology & Engineering
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. Diane Vaughan recreates the steps leading up to that fateful decision, contradicting conventional interpretations to prove that what occurred at NASA was not skullduggery or misconduct but a disastrous mistake. 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. In a new preface, Vaughan reveals the ramifications for this book and for her when a similar decision-making process brought down NASA's Space Shuttle Columbia in 2003.
On February 1, 2003, the unthinkable happened. The space shuttle Columbia disintegrated 37 miles above Texas, seven brave astronauts were killed and America's space program, always an eyeblink from disaster, suffered its second catastrophic in-flight failure. Unlike the Challenger disaster 17 years earlier, Columbia's destruction left the nation one failure away from the potential abandonment of human space exploration. Media coverage in the immediate aftermath focused on the possible cause of the disaster, and on the nation's grief. But the full human story, and the shocking details of NASA's crucial mistakes, have never been told -- until now. Based on dozens of exclusive interviews, never-before-published documents and recordings of key meetings obtained by the authors, Comm Check takes the reader inside the conference rooms and offices where NASA's best and brightest managed the nation's multi-billion-dollar shuttle program -- and where they failed to recognize the signs of an impending disaster. It is the story of a space program pushed to the brink of failure by relentless political pressure, shrinking budgets and flawed decision making. The independent investigation into the disaster uncovered why Columbia broke apart in the sky above Texas. Comm Check brings that story to life with the human drama behind the tragedy. Michael Cabbage and William Harwood, two of America's most respected space journalists, are veterans of all but a handful of NASA's 113 shuttle missions. Tapping a network of sources and bringing a combined three decades of experience to bear, the authors provide a rare glimpse into NASA's inner circles, chronicling the agency's most devastating failure and the challenges that face NASA as it struggles to return America to space.
Diane Vaughan reconstructs the Ohio Revco case, an example of Medicaid provider fraud in which a large drugstore chain initiated a computer-generated double billing scheme that cost the state and federal government half a million dollars in Medicaid funds, funds that the company believed were rightfully theirs. Her analysis of this incident—why the crime was committed, how it was detected, and how the case was built—provides a fascinating inside look at computer crime. Vaughan concludes that organizational misconduct could be decreased by less regulation and more sensitive bureaucratic response.
From Hunting Broken Components to Understanding Complex Systems
Author: Sidney Dekker
Publisher: CRC Press
Category: Technology & Engineering
What does the collapse of sub-prime lending have in common with a broken jackscrew in an airliner’s tailplane? Or the oil spill disaster in the Gulf of Mexico with the burn-up of Space Shuttle Columbia? These were systems that drifted into failure. While pursuing success in a dynamic, complex environment with limited resources and multiple goal conflicts, a succession of small, everyday decisions eventually produced breakdowns on a massive scale. We have trouble grasping the complexity and normality that gives rise to such large events. We hunt for broken parts, fixable properties, people we can hold accountable. Our analyses of complex system breakdowns remain depressingly linear, depressingly componential - imprisoned in the space of ideas once defined by Newton and Descartes. The growth of complexity in society has outpaced our understanding of how complex systems work and fail. Our technologies have gotten ahead of our theories. We are able to build things - deep-sea oil rigs, jackscrews, collateralized debt obligations - whose properties we understand in isolation. But in competitive, regulated societies, their connections proliferate, their interactions and interdependencies multiply, their complexities mushroom. This book explores complexity theory and systems thinking to understand better how complex systems drift into failure. It studies sensitive dependence on initial conditions, unruly technology, tipping points, diversity - and finds that failure emerges opportunistically, non-randomly, from the very webs of relationships that breed success and that are supposed to protect organizations from disaster. It develops a vocabulary that allows us to harness complexity and find new ways of managing drift.
Disastrous High-Tech Decision Making: From Disasters to Safety offers new insights for scholars studying management, decision making, cognition in the wild, and safety in the context of imperatives to continue operations. This book takes you inside the deliberations and action that have produced high-tech disasters in safetycritical enterprises. From primary data and analyses never before considered in scholarly assessments of the Challenger disaster, Frederick F. Lighthall, Professor Emeritus at The University of Chicago, applies the insights of macroergonomics, social psychology, naturalistic decision making, and legal argumentation to this expanded set of documents and data. He argues that the Challenger case represents a prototype of decision making that arises whenever a possibly threatening change in operating conditions becomes evident. In this situation, inevitable in boundarypushing enterprises, four generic decision-making pitfalls await engineers and managers who must decide whether continuing to operate is safe or dangerous. These four decision-making vulnerabilities are also evident, Lighthall argues, in the decision situations of other high-tech disasters both similar (the Columbia shuttle) and dissimilar (Deepwater Horizon oil spill disaster). In Part I of the book Lighthall traces decision participants’ chart-by-chart deliberations and argument about whether proceeding with the Challenger’s launch would be dangerous. Part II analyzes from contrasting perspectives the dynamics revealed in the narrative. Lighthall’s analysis ends by examining the demanding changes in outlook, knowledge disciplines, and learning processes required for safety to compete with the production imperatives of high-tech enterprises operating in unforgiving environments. This book is a must read both for students of management and of engineering who may find themselves working in these high-tech settings, and for managers and engineers who now work in these settings.
Just after 9:00 a.m. on February 1, 2003, the space shuttle Columbia broke apart and was lost over Texas. This tragic event led, as the Challenger accident had 17 years earlier, to an intensive government investigation of the technological and organizational causes of the accident. The investigation found chilling similarities between the two accidents, leading the Columbia Accident Investigation Board to conclude that NASA failed to learn from its earlier tragedy. Despite the frequency with which organizations are encouraged to adopt learning practices, organizational learning—especially in public organizations—is not well understood and deserves to be studied in more detail. This book fills that gap with a thorough examination of NASA’s loss of the two shuttles. After offering an account of the processes that constitute organizational learning, Julianne G. Mahler focuses on what NASA did to address problems revealed by Challenger and its uneven efforts to institutionalize its own findings. She also suggests factors overlooked by both accident commissions and proposes broadly applicable hypotheses about learning in public organizations.
high technology and organizational change in the U.S. space program
Author: Howard E. McCurdy
Publisher: Johns Hopkins Univ Pr
Category: Business & Economics
The National Aeronautics and Space Administration began its space flight program in October of 1958 by launching the 84-pound Pioneer I space probe. Scarcely a decade later, in July of 1969, NASA amazed the world by landing the first humans on the Moon. In the two decades that followed, however, the agency appeared to lose both its vigor and its creativity. Inside NASA explores how an agency praised for its planetary probes and expeditions to the Moon became noted for the explosion of the space shuttle Challenger and a series of other malfunctions. Using archival evidence as well as in-depth interviews with space agency officials, Howard McCurdy investigates the relationship between the performance of the U.S. space program and NASA's organizational culture. He begins by identifying the beliefs, norms, and practices that guided NASA's early successes. Originally, the agency was dominated by the strong technical culture rooted in the research-and-development organizations from which NASA was formed. To launch the expeditions to the Moon, McCurdy explains, this technical culture was linked to an organizational structure borrowed from the Air Force Ballistic Missile Program. Over time, however, changes imposed to accomplish the lunar expedition - as well as the normal aging process and increased bureaucracy in the government as a whole-altered NASA's original culture and eroded its technical strength. McCurdy observes that NASA's early success depended on a number of related characteristics: extensive testing, in-house technical capability, hands-on experience, exceptional people, stoic acceptance of risk and failure, and a frontier mentality. He concludes that, given the conditions ofmodern government, the performance of high-technology agencies like NASA inherently tends to decline. Inside NASA offers a revealing study of both organizational culture and bureaucratic aging.
The Accidental Shootdown of U.S. Black Hawks over Northern Iraq
Author: Scott A. Snook
Publisher: Princeton University Press
Category: Social Science
On April 14, 1994, two U.S. Air Force F-15 fighters accidentally shot down two U.S. Army Black Hawk Helicopters over Northern Iraq, killing all twenty-six peacekeepers onboard. In response to this disaster the complete array of military and civilian investigative and judicial procedures ran their course. After almost two years of investigation with virtually unlimited resources, no culprit emerged, no bad guy showed himself, no smoking gun was found. This book attempts to make sense of this tragedy--a tragedy that on its surface makes no sense at all. With almost twenty years in uniform and a Ph.D. in organizational behavior, Lieutenant Colonel Snook writes from a unique perspective. A victim of friendly fire himself, he develops individual, group, organizational, and cross-level accounts of the accident and applies a rigorous analysis based on behavioral science theory to account for critical links in the causal chain of events. By explaining separate pieces of the puzzle, and analyzing each at a different level, the author removes much of the mystery surrounding the shootdown. Based on a grounded theory analysis, Snook offers a dynamic, cross-level mechanism he calls "practical drift"--the slow, steady uncoupling of practice from written procedure--to complete his explanation. His conclusion is disturbing. This accident happened because, or perhaps in spite of everyone behaving just the way we would expect them to behave, just the way theory would predict. The shootdown was a normal accident in a highly reliable organization.
On January 28, 1986, the space shuttle Challenger launched from the Kennedy Space Center in Florida. Seventy-three seconds after launch, the fiery breach of a solid motor joint caused a rupture of the propellant tanks, and a stunned nation watched as flames engulfed the craft, killing all seven crew members on board. It was Hugh Harris, “the voice of launch control,” whom audiences across the country heard counting down to lift-off on that fateful day. With over fifty years of experience with NASA’s missions, Harris presents the story of the Challenger tragedy as only an insider can. With by-the-second accounts of the spacecraft’s launch and a comprehensive overview of the ensuing investigation, Harris gives readers a behind-the-scenes look at the devastating accident that grounded the shuttle fleet for over two years. This book tells the whole story of the Challenger’s tragic legacy.
A “must-read” (Booklist) from Harvard Business School Professor and Codirector of the Harvard Kennedy School’s Center for Public Leadership: A guide to making better decisions, noticing important information in the world around you, and improving leadership skills. Imagine your advantage in negotiations, decision-making, and leadership if you could teach yourself to see and evaluate information that others overlook. The Power of Noticing provides the blueprint for accomplishing precisely that. Max Bazerman, an expert in the field of applied behavioral psychology, draws on three decades of research and his experience instructing Harvard Business School MBAs and corporate executives to teach you how to notice and act on information that may not be immediately obvious. Drawing on a wealth of real-world examples and using many of the same case studies and thought experiments designed in his executive MBA classes, Bazerman challenges you to explore your cognitive blind spots, identify any salient details you are programmed to miss, and then take steps to ensure it won’t happen again. His book provides a step-by-step guide to breaking bad habits and spotting the hidden details that will change your decision-making and leadership skills for the better, teaching you to pay attention to what didn’t happen, acknowledge self-interest, invent the third choice, and realize that what you see is not all there is. While many bestselling business books have explained how susceptible to manipulation our irrational cognitive blind spots make us, Bazerman helps you avoid the habits that lead to poor decisions and ineffective leadership in the first place. With The Power of Noticing at your side, you can learn how to notice what others miss, make wiser decisions, and lead more successfully.
The History and Legacy of NASA's Most Notorious Tragedy
Author: Charles River Charles River Editors
*Includes pictures *Profiles the origins of the mission and what went wrong *Includes online resources and a bibliography for further reading *Includes a table of contents In the decades after the Apollo program, American space shuttles flew over 130 missions and successfully completed over 98% of them, but unfortunately, the two most famous missions were the ones that ended tragically aboard the Challenger and Columbia. The Space Shuttle Challenger was the most heavily used space shuttle in the three years it was operational, carrying the first minority astronaut and woman astronaut into space. Challenger was also the first space shuttle to complete a landing at night. On the morning of January 28, 1986, the Space Shuttle Challenger launched for the 10th time, beginning mission STS-51-L. Space shuttles had already successfully completed 24 missions, and no American spacecraft had ever failed to reach orbit during an official mission. On this mission, the Challenger was carrying a satellite for the Tracking and Data Relay Satellites system, which was to be deployed in orbit. The crew included Ronald McNair, who had already been the second African-American in space, and Ellison Onizuka, who had already been the first Asian-American astronaut in space. But the highlight of the mission was to be the "NASA Teacher in Space Project," in which a civilian teacher would give teaching lessons to his or her class while onboard the space shuttle. The winner of the competition was Christa McAuliffe, a high school teacher in Concord, New Hampshire, who wrote a winning essay and had to undergo a year of astronaut training before that fateful day. It was a beautiful morning, and many spectators came to the Kennedy Space Center to watch the launch, including McAuliffe's parents and her students. Several news networks were carrying live broadcasts of the launch, including live shots of McAuliffe's parents as they watched the Challenger liftoff. Mission Control's transmissions to the Challenger were being blared over loudspeakers to give spectators a play-by-play of the shuttle's ascent. Ascent seemed to be going normally during the first minute, but about 75 seconds into the ascent, a plastic O-ring used to seal a joint in one of the solid rocket boosters failed, causing a breach of hot gas. That gas spread to the other rocket booster and the external fuel tank, causing an explosion. When the spectators saw the explosion, many of them started cheering, unaware of what was really happening. But Mission Control quickly announced that there had been some sort of problem, and the crowd became confused and then panicky as the space shuttle, fuel tank and rocket boosters all broke apart and flew in opposite directions. Some cameras fixed on the falling debris as it fell to the ocean, while others stayed focused on McAuliffe's parents. The entire crew was killed in the explosion, and investigations concluded that they may have survived until crashing into the ocean. After the Challenger disaster, the space shuttles were grounded for about two years, and a commission issued findings that would be used in an effort to prevent similar tragedies. The Space Shuttle Challenger Disaster: The History and Legacy of NASA's Most Notorious Tragedy chronicles the disaster from the origins of its mission to what went so terribly wrong. Along with pictures of important people, places, and events, you will learn about the Challenger like never before.
the history of the National Space Transportation System : the first 100 missions
Author: Dennis R. Jenkins
Publisher: Specialty Pr Pub & Wholesalers
Provides schematic diagrams and photographs of various components of the space shuttle system, and chronicles the development of reusable spacecraft from the designs of Nazi rocket scientists to versions currently under discussion.
ORGANIZATIONAL COMMUNICATION: APPROACHES AND PROCESSES presents organizational communication from both a communication and managerial perspective. Professor Miller's clear writing style and consistent use of examples and case studies result in a text that you'll find easy to understand. Important Notice: Media content referenced within the product description or the product text may not be available in the ebook version.