Despite extensive ethnographic studies, Vaughan's lack of familiarity with aerospace engineering and engineering organizations results in some very wrong understandings of what risk means in engineering. Her idea of Normalization of Deviance is insightful and useful, but it is a hand that she grossly overplays. And she sees that phenomenon as being more present in engineering judgement than in management, possibly because NASA managers succeeded in buffaloing her during interviews. Her concept of Construction of Risk is a mess. Viewing engineering risk analysis/management only through the lens of post-Kuhnian social constructivism results in incoherent statements like:
"It opens the 'black box' of engineering, following the negotiation of risk and the production of technical knowledge by working engineers making the hands-on risk assessments. At the same time it shows the intersection of the social and the technical in the construction of risk, it gives insight into how scientific paradigms are created, the sources of their obduracy, and the circumstances in which they are—and are not—overturned."
Vaughan never seems to grasp that risk, in engineering, comprises a probability component and a hazard-severity component. In many places where she concludes that deviance has been normalized, she incorrectly judges that engineers and managers had changed their beliefs about the severity of a hazard (erosion and blow-by) rather than that they, rightly or wrongly, concluded (based on evidence) that the probability of the unwanted occurrence was only negligibly changed by newly acquired evidence (i.e. defensible, rational Bayesian belief updates).
She likewise fails to understand what redundancy means, and how it is used, in the design of complex systems with catastrophic failure modes. She views redundancy as a belief – an irrational, unfounded belief – of engineers: “the belief in redundancy was fundamental to their decision not to report.” Again, her wrong understanding of redundancy in design seems to have its basis in poor explanations given to here by NASA in interviews, including some surprisingly ignorant perspectives of NASA management: “You don’t build in redundancy and never expect to use the back-up. If you never use your back-up, you’re wasting money” (George Hardy, NASA).
This book is definitely worth reading, if you’re interested in organizational dysfunction or systems engineering. If your background is engineering, beware of her narrow sociology (Merton-esque) perspective. If your background is sociology or management science, beware of her limited grasp of engineering and risk science.
ISBN-13: 978-0226346823
ISBN-10: 022634682X
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Fantastic analysis but heavy reading.
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Faszinierende Analyse mit breiter Anwendbarkeit
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