Diane Vaughan

This is an excellent, thorough account of the Challenger disaster that turns on its head the idea of amoral calculating middle managers and production pressures being the sole cause of the disaster. The truth is much more complicated than that, and Vaughan dissects it carefully. She also presents the theory of the normalization of deviance: that as things happen that are outside the norm, they are rationalized until all these deviances *become* the norm and an accident happens. The first show more four chapters, which are about the technical failures, were tough slogging for me but still very fascinating. I'll have to buy a copy to read this again -- especially now that Adam Higginbotham has written a book about Challenger as well (Challenger: A True Story of Heroism and Disaster on the Edge of Space). I can't wait to compare the two accounts. show less

The Challenger Space Shuttle disaster has become a favoured model for management gurus who talk glibly about amoral decision making, internal communication failures and the normalisation of aberrance. Which is fine, and Vaughan does the same here, except that she's not glib. As she puts it, complexity - not simplicity - is the path to truth. And she doesn't spare the reader the complexity. She pulls the reports of the official enquiries apart to reveal the workings of the final engineering show more meetings that made the 'go'/'no go' decision, backed up with interviews with the participants. In the end her relating of that discussion is so persuasive (and at variance with the generally understood account) that you feel that you had just spent a couple of hours sitting in the same room as those engineers. Except, and that was a major part of the problem, it wasn't one room but three at remote locations connected by a primitive telephone hook-up.

One of the best things about Vaughan's book is her use of a Rashomon technique, telling the story first from the perspective of the official investigation, and then - much later - from the perspective that she has developed and shared with the reader. The contrast is quite shocking, and that is part of her story. It's not just the defects in the system, but how we investigate and 'understand' them. The official reports identified what the faults were, but fell far short in understanding how they arose and persisted in arguably one of the most safety conscious and technically qualified organisations in the world. She quotes a senior NASA engineer observing that after all of this the solid fuel rockets (the cause of the disaster) won't be a problem, but 'something else will get us'. And of course it did, with the foam shedding problem leading to the destruction of the Space Shuttle Columbia.

In the end this is a tour de force in both telling the story of the disaster, and telling the story of how disastrous decisions are made. The technical detail is unrelenting, but the human stories are gripping. It should be mandatory reading for anyone in the sciences or business. Although it stands alone perfectly well, it is even more extraordinary when read alongside Mike Mullane's 'Riding Rockets'. Mullane was a Shuttle pilot, and his observations about NASA's culture, and the astronauts' shared responsibility for the fateful launch decision makes powerful reading. show less

If you're like me, you probably thought of the Challenger disaster in terms like this: "why didn't those stupid managers just listen to the engineers... they never would have had a problem!" Most of the framing around the decision to launch paints the managers as these bad guys who didn't listen to or didn't believe or didn't pass on the information from engineers who were worried about a cold weather launch.

Diane Vaughan paints a compelling picture that the decision to launch was in fact show more much more complicated than that. The culture of the managers and engineers contributed to a fundamental misunderstanding of the SRB joint and a continuation of launching even with deviant joint behavior (blow-by and erosion).

I felt that the book was repetitive at times. However, sometimes (but not all the time) I was glad for the repetition as it really made some connections a lot more clear to me, and reminded me of points that I may not have remembered from earlier in the book.

The expanded version contains information about the Columbia disaster in the preface. I sort of wished there had been an afterward with more Columbia details as well. It's sad that so many people died due to the normalization of deviance in regards to both the SRB joint behavior and foam shedding from the ET. Astronauts know that they have inherently risky jobs, but they trust everybody at NASA and all of the contractors and subcontractors to be on top of their game.

The only thing I really disliked about this book was in the publishing itself. It looked like a photocopy of a mimeograph that had then been scanned and uploaded into Microsoft Paint and then printed out in book form. It was seriously difficult to read at times. One would think that in 2016, when the new version of this book was published, it would be possible to print a 500+ page book without cutting off the ends of all of the words in the margins. show less

Institutions Create and Condone Risk

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 show more 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. show less