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Book Review

Root Cause Analysis Book -- the Challenger Launch Decision

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The Challenger Launch Decision
Risky technology, culture, and deviance at NASA

by
Diane Vaughan

Jacket Review

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 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 skullduggery or misconduct but a disastrous mistake.

Journalists and investigators have historically cited production pressure 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 Rock Boosters as evidence of managerial neglect.  But, as Vaughan uncovers through her exhaustive research, a piece of the puzzle has always been missing.

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, confronted with signals of danger about shuttle technology, proceeded as if nothing were wrong when repeatedly faced with evidence that something WAS wrong.  They normalized the deviance, so it became acceptable and non-deviant 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.  No one has forgotten the astronauts or the shape of the billowing clouds that recorded the final seconds of the Challenger flight.  Nonetheless, the loss of the Challenger has receded into history.  Normalizing signals of danger contributes to disastrous decisions by individuals and organizations alike.  Thus, the Challenger tragedy must be reexamined, for this powerful work offers an unexpected warning about the hidden hazards of living in this technological age.

Diane Vaughan is associate professor of sociology at Boston College and the author of Controlling Unlawful Organizational Behavior:  Social Structure and Corporate Misconduct and Uncoupling: Turning Points in Intimate Relationships.

Table of Contents
1.  The Eve of the Launch

2.  Learning Culture, Revising History

3.  Risk, Work Group Culture, and the Normalization of Deviance

4.  The Normalization of Deviance (1981-1984)

5.  The Normalization of Deviance (1985)

6.  The Culture of Production

7.  Structural Secrecy

8.  The Eve of the Launch Revisited

9.  Conformity and Tragedy

10.  Lessons Learned

Appendix A:  Cost/Safety Trade-Offs?  Scrapping the Escape Rockets and the SRB Contract Award Decision

Appendix B:  Supporting Charts and Documents

Appendix C:  On Theory Elaboration, Organizations, and Historical Ethnography