Customer Reviews

The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA

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Penetrating account of the organizational causes of the Challenger disaster. The author shows that the engineering mistake that led to the disaster was not the result of intentional wrongdoing ("amoral calculator" thesis = managers overruling engineers due to economic and/or political pressures) but that quite on the contrary that the NASA and contractor teams played by the rulebook to a fault and that the mistake was "systematic and socially organized". A must read for everybody interested in organizational dynamics or in how to manage risk in the development of technological innovations.
Given the fascinating subject matter and revisionist thesis it's a pity that the writing is very uneven. Most of the "thick description" of the decisions around the booster joint from the early design days to the post-mortem by the Presidential Commission is quite readable. This core of the text, however, is embedded in an unbearably repetitive and plodding overall narrative flow (the account could probably be reduced in length by 50%) which in places degenerates into (sociological?) opaque language. Taking a cue from the author's concept of "structural secrecy" (things are hidden not on purpose but due to organizational compartmentalization), the argument of the book loses a lot of its force due to the undisciplined way of telling it; the author could profit from a strong editor.

I started reading this book to improve my Root Cause Failure Analysis skills after hearing that it covers, in fine detail, a failure that cost the lives of 7 astronauts and destroyed a multi-billion dollar asset. We are first presented with the popular media viewpoint that describes how performance-driven NASA administrators aggressively pursued production, political, and economic goals at the expense of personal safety. How a mechanical flaw formally designated as a potentially catastrophic anomaly by NASA and Thiokol engineers became a normal flight risk on the basis of previous good launches. How a last minute plea from subject matter experts to halt the countdown on an uncommonly cold day in January 1986 was ignored by engineering managers on the decision chain so the launch schedule would not be compromised.

I remember an early feeling of relief in knowing that while similar performance, production, and scheduling pressures exist in my career, the attitudes that were mostly at fault for the Challenger incident are absent from my refinery and violate all 10 of my parent company's business principles starting with #1 (conduct all business lawfully and with integrity).

The author then proceeds to shatter every element of this popular emotional impression by presenting a credible account of the failure based on public record. This is an important point because unlike with Enron's collapse, there is no shredding of pertinent documents behind the Challenger incident. And it is this matter of public record that can benefit anyone having reliability or production engineering responsibilities within a refinery. Here we find evidence that NASA's best friend - a reliable system built to assure the utmost safety in engineering - was to blame for the tragedy. A system that encourages the challenging of engineering data to validate its meaning. A system that prioritizes safety above any other initiative. A system that requires operation within specified safety limits in order to function. A system that requires vendor/customer interaction. A system with multiple departments, requiring effective communication between each.

I soon realized that the book that I was reading was not a book about a tragic point in American history, but a book about managing risks we routinely encounter in a refinery, using the Challenger incident as the case history to relate them to. Like so many case histories in industry, we benefit by understanding what went wrong and taking proactive measures to prevent against it from happening again.

If I owned this refinery and someone came to me saying, "Hey, I'd really like to work here" I would send him or her off with a copy of this book. If that person returned still interested, chances are he or she would get the job.

Who would have thought that the most cognizant explanation of the Challenger accident would be written from an industrial psychology perspective? I've worked for NASA contractors for 24 years and have dealt with all of the types of various reviews and "overhead chart" engineering and management discussions and telecons she studied. I read this book when it first came out and have referred others to it as one of the best texts on management, technical decision making, and quality assurance that I can think of. Years of education led me to think that I was a "professional" but, as Ms Vaughn so eloquently demonstrates, there is no real aerospace engineering profession in the context of the NASA/Industry partnership.

As a sociological explanation of disastrous decision making in high risk applications, this book is without peer, exceeding even Charles Perrow's work by a fair measure. Vaughan, a sociologist, obviously worked very hard at understanding the field joint technology that caused the "Challenger" accident, and even harder at understanding the extremely complex management and decision making processes at NASA and Morton Thiokol.

The book ultimately discards the "amoral calculation" school of thought (which she was preconditioned to believe at the outset of her research by media coverage of the event) and explains how an ever expanding definition of acceptable performance (despite prior joint issues) led to the "normalization of deviance" which allowed the faulty decision to launch to be made. The sociological and cultural analyses are especially enlightening and far surpass the technical material about the actual physical cause of the accident presented.

This is a masterful book, and is impeccably documented. The reference portion of the book in the back is especially useful, in that she reproduces several key original documents pertinent to the investigation which are difficult to obtain elsewhere. My only objection to the book is the extreme use of repetition, which I think needlessly lengthened the book in several areas, and obfuscating sociological terminology like "paradigm obduracy" which not only fails to illuminate the non-sociologists among us, but makes for somewhat tortured prose.

In praise of the book, however, it is a brilliant analysis of how decisions are made in safety-critical programs in large institutions. Chapter ten, "Lessons Learned," is particularly noteworthy in its analysis and recommendations. It's a shame that managerial turnover has ensured that few of the "Challenger" era managers were still at the agency during the "Columbia" accident era. Those who forget history are doomed to repeat it.

This book makes for very weighty and difficult reading. Having said that, I highly recommend it to technical professionals, particularly engineers and managers involved with high-risk technologies. Likewise, it is absolutely imperative reading for safety professionals, consultants, and analysts.

I purchased this book after reading the first chapter in the bookstore. I was very interested in the technical details behind the loss of STS-51L aka the Challenger Disaster. After a brief period of discussion of the specifics of the accident, Vaughn delves incredibly deeply into the culture of NASA and the management culture that in some ways directly led to the loss of the vehicle and her crew.

The amount of info Vaughn is able to bring up is incredible, and she must have done hundreds, if not thousands, of interviews to compile all of her data. I was amazed at how freely some people were with their comments (given the subject matter) and here reconstruction of events in fantastic in it's detail.

This is not a book to be read lightly. It is an in-depth social analysis more than it is a book about the Challenger Disaster. Of note, it was shelved under sociology (and not Science/Technical) at my local bookstore. Many people who live in cultures where high-risk decisions are made(doctors, law enforcement personell, etc) would benefit from this work.

The Space Shuttle Challenger exploded on January 28, 1986. To millions of viewers, it is a moment they will never forget.

Official inquiries into the accident placed the blame with a "frozen, brittle O ring." In this book, Diane Vaughan, a Boston College Professor of Sociology, does not stop there. In what I think is a brilliant piece of research, she traces the threads of the disaster's roots to fabric of NASA's institutional life and culture.

NASA saw itself competing for scarce resources. This fostered a culture that accepted risk-taking and corner-cutting as norms that shaped decision-making. Small, seemingly harmless modifications to technical and procedural standards propelled the space agency toward the disaster. No specific rules were broken, yet well-intentioned people produced great harm.

Vaughan often resorts to an academic writing style, yet there is no confusion about its conclusion.

"The explanation of the Challenger launch is a story of how people who worked together developed patterns that blinded them to the consequences of their actions," wrote Dr. Vaughan.

"It is not only about the development of norms but about the incremental expansion of normative boundaries: how small changes--new behaviors that were slight deviations from the normal course of events- gradually became the norm, providing a basis for accepting additional deviance. Nor rules were violated; there was no intent to do harm. Yet harm was done. Astronauts died."

For project and risk managers, this book offers a rare warning of the hazards of working in structured and institutionalized environments.

It's been a couple of years since I read this book, but the work remains in my mind much as the television images of the explosion itself.

Diane Vaughan is a sociologist and her in-depth research dicusses and goes beyond the technical causes of the disaster. She doesn't stop at the "frozen, brittle O-ring". She reveals the culture of NASA and its contractors' engineers, their assessment of risk and monitoring of deviations from standards.

The story reminds us that there are humans behind the advanced technology used in space exploration. And humans often unknowingly make mistakes. Engineers and technicians often have a different work culture or mind-set than do their managers. So there are bound to be misunderstandings.

The book is very detailed both with technological terms and sociological terms, so reading it can be a bit daunting sometimes - unless you really want to understand what happened on January 28, 1986.

As I read this book I found myself drawing relationships between the events of the Challenger disaster, and some technical projects I have worked on. Fortunately I have never work on a project that has suffered the type of cataclysmic failure that happened to the Challenger, however I have seen the same type of interaction between the "techies" and management. I have heard (almost verbatim) the same conversations that the engineers had in this book when faced with potentially dangerous problems and pressing deadlines. Anybody who works in very complicated disciplines knows that the explosion was not the disaster, but the culmination of a flawed process.

If you manage, or are involved in a technical process I would encourage you to read this book. It is a good case study of how subtly the seeds for a disaster can be planted. Although dry and tedious at times to read it is worth the effort.

"Like organizations in the natural world, it seems that successful organizations evolve appropriate structures and processes for dealing with the challenges of their external environment" (Morgan, 55.) The organizational culture of NASA, similar to the FAA (by whom I was once employed), has its procedures. The Challenger was a casualty of organizational culture because NASA relied so much on risk assessment and expanding the acceptable risk thresholds to satisfy outside pressures. NASA is a government agency, which constrains it. It is essentially a bureaucracy. As Vaughan points out, however, " Clearly, the Challenger incident does not fall into the category of corporate criminality because NASA is not a private enterprise. But consider the following: although it is a government organization rather than a corporate profit seeker, NASA is subject to all the same difficulties. In order to survive in an environment populated by competitors, suppliers, customers and controllers, all organizations must compete for scarce resources-- regardless of their size, wealth, age, experience or previous record" (Vaughan, 35.) Results are expected in return for funding. NASA is an agency that constantly must justify its existence. How can this not influence the entire organizational culture as well as strategic planning? Organizational culture became focused on existence; continuing successful spaceflight missions; good press; satisfying external expectations; not necessarily meeting safety requirements. (It appears after the fact that there was mismanagement and deviant decisionmaking or that NASA as an agency had rules to circumvent their own rules in order to alter or expand the concept of acceptable risk, but this was just a superficial look at NASA's organizational culture.) (Vaughan, 58.) When external forces do not understand fully the organizational culture of a given agency , it can also cause problems. Vaughan's book cites NASA policy-- all of which seemed to be glossed over and misunderstood by those outside of NASA. This is quite similar to the way operations are conducted at the FAA. Risk analysis, safety and the construction of risk are all issues that NASA and the FAA take seriously. In the case of NASA, there are misunderstandings and misconceptions about NASA's internal culture... for example, the misnomer of "launch constraint." (Vaughan, 167.) As well, there are misconceptions of the "normalization of deviance." In technical cultures it is difficult enough for the layman to understand the basic principles of the internal workings let alone the intricacies and rationale behind their decisionmaking and ultimately their construction of acceptable risk. On page 148-9, Vaughan illustrates how even the technical minds at work cannot calculate for everything, "...many decisions about risky technology are most accurately described as `decisionmaking under ignorance' because from a technical standpoint all conditions can never be known." Vaughan also writes, "The following exchange epitomizes that contrast, showing how cultural meanings shaped engineers' definition of the situation..." (188.) In the case of the Challenger, and the incremental glimpses into the problems that the engineers had (Vaughan, 149), "Spaceflight continued because each time an anomaly occurred they believed they understood the cause and the limits of the phenomena they were seeing" (Vaughan, 147.) Two excellent illustrations of the failure of organizational culture as it relates to the Challenger are: "Because their actions conformed to these environmental contingencies the decisions they made were legitimate, acceptable, and not deviant, in their view. In the NASA culture, flying with known flaws was not deviant" (Vaughan, 114.) The second illustration of this failure is, " We are reminded of how repetition, seemingly small choices, and the banality of daily decisions in organizational life-- indeed, in most social life-- can camouflage from the participants a cumulative directionality that too often is discernible only in hindsight" (Vaughan, 119.) This is a perfect complement to Morgan's cautioning that too often organizational metaphor/culture can be blinding to the point that the big picture is ignored. This organizational "cultural immersion" ends up being a hindrance (and often a fatal, tragic one as in the case with the Challenger.)

This is the most comprehensive, thorough and believable analysis of the Challenger shuttle disaster that is available. Diane Vaughn goes far beyond the newspaper accounts or even the capitol hill hearings and really gets to the root causes of this incident found in the management culture of NASA and contractors. I would definitely recommend this to anyone involved in managing risk whether in the aircraft / aerospace industry or any other fundamentally risky industry (refining, chemical manufacturing, construction, etc...)