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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. 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 skulduggery or misconduct but a disastrous mistake.
Journalists and investigators have historically cited production problems 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 Rocket Boosters as evidence of managerial neglect.
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.
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. This powerful work explains why the Challenger tragedy must be reexamined and offers an unexpected warning about the hidden hazards of living in this technological age.
- Sales Rank: #90106 in Books
- Published on: 1997-04-15
- Released on: 1997-04-15
- Original language: English
- Number of items: 1
- Dimensions: 9.00" h x 1.80" w x 6.00" l, 1.70 pounds
- Binding: Paperback
- 592 pages
From Publishers Weekly
The loss of the Space Shuttle Challenger in 1986 is usually ascribed to NASA's decision to accept a safety risk to meet a launch schedule. Vaughan, a professor of sociology at Boston College, argues instead that the disaster's roots are to be found in the nature of institutional life. Organizations develop cultural beliefs that shape action and outcome, she notes. NASA's institutional history and group dynamics reflected a perception of competition for scarce resources, which fostered a structure that accepted risk-taking and corner-cutting as norms that shaped decision-making. Small, seemingly harmless modifications to technical and procedural standards collectively propelled the space agency toward disaster even though no specific rules were broken. While Vaughan's complex presentation will daunt general readers, her conclusion that the "normalization of deviance" builds error into all human systems is as compelling as it is pessimistic.
Copyright 1996 Reed Business Information, Inc.
From Scientific American
Vaughan gives us a rare view into the working level realities of NASA. . . . the cumulative force of her argument and evidence is compelling.
From Booklist
Had Margaret Mead studied the NASAns instead of the Samoans, this anthropological story of the shuttle catastrophe might have resulted. We see the bureaucratic culture that shaped the behavior of the rocket scientists: they launched Challenger expecting some damage to the now infamous O-rings. How they reached that position of tempting fate infuses Vaughan's account. Making arguable constructions about the engineering mentality and group-think, Vaughan focuses on the fateful teleconference the night before the launch, in which executives of the rocket manufacturer first resisted then caved into NASA's pressure to launch. For exerting that pressure, the space agency's managers were pilloried, but personalizing the blame, Vaughan believes, ignores the acculturated rules they followed--which emanated from the political and funding compromises that created the shuttle design. Though Vaughan's scholastic diction acts as narrative speed bumps, her sociological interpretation helps explain the seemingly inexplicable. This complements the dramatic and popular orientation of No Downlink, by Claus Jensen . Gilbert Taylor
Most helpful customer reviews
26 of 27 people found the following review helpful.
Reliability/Maintenance/Refinery Engineering Application
By Kenneth P. Bloch
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.
3 of 5 people found the following review helpful.
A Hard Read - Worth theEffort
By Dr. David Arelette
A great book - many lessons for business in making decisions based on what you want to see and not what is really in front of you.
The actual cause of the disaster is clear in the first 20 of 500 pages - the booster O ring was safe at perhaps 60F while the booster had been only 8F some two hours before the launch, the ambient temperature was less important as the booster that failed was not in the direct sunlight.
The other 480 pages try to explain why rational people relied on "gut feel" when any non engineer could see that all the available evidence was that the seal would fail - this time or next time but eventually - and sooner rather than later.
Well researched and well converted into low level technical language for non engineers.
Worth reading when you want to be reassured that standing up for what you believe is right in large organisations is a worthy cause.
The only question not asked - would those who made the launch decision traded places with the crew.
9 of 9 people found the following review helpful.
Normalization Of Deviance
By Robert I. Hedges
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.
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