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

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.

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.

Having been priviledged to work at NASA's Kennedy Space Center for 17 years this exceptionally well researched work brought back much. This book is not simply a rehash of media coverage. I recommend it to anyone who works DoD or NASA or similar programs. It rings true with the culture, brilliant and not so, that is and was NASA. I left three months before the launch of STS 51L and until now had no real insight into the why that one looks for to explain exceptional grief. All I knew when I left was that things were much different than they were in the Apollo era. And I got chills reading of how the other issue that night before launch was ice impinging on the Shuttle.

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.