ENDNOTES FOR CHAPTER 8

¶The citations that contain a reference to "CAIB document" with CAB or

¶CTF followed by seven to eleven digits, such as CAB001-0010, refer to a document in the Columbia Accident Investigation Board database maintained by the Department of Justice and archived at the National Archives.

Turner studied 85 different accidents and disasters, noting a common pattern: each had a long incubation period in which hazards and warning signs prior to the accident were either ignored or misinterpreted. He called these "failures of foresight." Barry Turner, Man-made Disasters,

(London: Wykeham, 1978); Barry Turner and Nick Pidgeon, Man-made Disasters, 2nd ed. (Oxford: Butterworth Heinneman,1997).

Changing personnel is a typical response after an organization has some kind of harmful outcome. It has great symbolic value. A change in personnel points to individuals as the cause and removing them gives the

¶false impression that the problems have been solved, leaving unresolved organizational system problems. See Scott Sagan, The Limits of Safety.

¶Princeton: Princeton University Press, 1993.

¶Diane Vaughan, The Challenger Launch Decision: Risky Technology,

¶Culture, and Deviance at NASA (Chicago: University of Chicago Press.

¶1996).⁴⁴ JSC Form 564 (March 24, 2003).

William H. Starbuck and Frances J. Milliken, "Challenger: Fine-tuning the Odds until Something Breaks." Journal of Management Studies 23 (1988), pp. 319-40.

¶Report of the Presidential Commission on the Space Shuttle Challenger

¶Accident, (Washington: Government Printing Office, 1986), Vol. II,

¶Appendix H.

Alex Roland, "The Shuttle: Triumph or Turkey?" Discover, November 1985: pp. 29-49.

¶Report of the Presidential Commission, Vol. I, Ch. 6.⁸⁸ The only actual flight tests conducted of the Orbiter were a series of Printing Office, 1998) for an account of the aftermath of the accident. Approach and Landing Tests where Enterprise (OV-101) was dropped Much of the account in this section is drawn from this source. from its Boeing 747 Shuttle Carrier Aircraft while flying at 25,000 feet. 19 Logsdon, "Return to Flight," p. 348. These tests – with crews aboard – demonstrated the low-speed handling 20 Presidential Commission on the Space Shuttle Challenger Accident capabilities of the Orbiter and allowed an evaluation of the vehicleʼs (Washington: Government Printing Office, June 6, 1986). landing characteristics. See Jenkins, Space Shuttle, pp. 205-212 for more information. 26 Report Volume I August 2003Show full note

¶Turner, Man-made Disasters.⁹⁹ R. J. Gomex et al, "STS-107 Foam Transport Final Report," NSNS- 60506, August 2003. 84 Report Volume I August 2003

¶Vaughan, The Challenger Launch Decision, pp. 243-49, 253-57, 262-64,

¶350-52, 356-72.¹⁰¹⁰ The civil aviation study indicates that the risk to groundlings is significantly 25 Julie Kramer, et al., "Minutes from CAIB / Engineering Meeting to higher in the vicinity of an airport. The average annual risk of fatality Discuss CAIB Action / Request for Information B1-000193," April 24, within 0.2 miles of a busy (top 100) airport is about 1 in a million. 2003. CAIB document CTF042-00930095.

¶Turner, Man-made Disasters.

¶U.S. Congress, House, Investigation of the Challenger Accident,

¶(Washington: Government Printing Office, 1986), pp. 149.¹²¹² Howard E. McCurdy, Inside NASA: High Technology and Organizational 27 Demingʼs management philosophy was not the only new notion that Change in the U.S. Space Program (Baltimore: The Johns Hopkins Goldin attempted to apply to NASA. He was also an advocate of the University Press, 1993), p. 24. "Total Quality Management" approach and other modern management 13 schemes. Trying to adapt to these various management theories was a Garry D. Brewer, "Perfect Places: NASA as an Idealized Institution," in Radford Byerly, Jr., ed., Space Policy Reconsidered (Boulder, CO: source of some stress. Westview Press, 1989), p. 158. Brewer, when he wrote these words, 28 For a discussion of Goldinʼs approach, see Howard McCurdy, Faster, was a professor of organizational behavior at Yale University with no Better, Cheaper: Low-Cost Innovation in the U.S. Space Program prior exposure to NASA. For first-hand discussions of NASAʼs Apollo-era (Baltimore: The Johns Hopkins University Press, 2001). It is worth noting organizational culture, see Christopher Kraft, Flight: My Life in Mission that while the "faster, better, cheaper" approach led to many more Control (New York: E.P. Dutton, 2001); Gene Kranz, Failure is Not an NASA robotic missions being launched after 1992, not all of those Option: Mission Control from Mercury to Apollo 13 (New York: Simon & missions were successful. In particular, there were two embarrassing Schuster, 2000); and Thomas J. Kelly, Moon Lander: How We Developed failures of Mars missions in 1999. the Apollo Lunar Module (Washington: Smithsonian Institution Press, 29 2001). Lambright, Transforming Government, provides an early but 14 comprehensive evaluation of the Goldin record. The quote is from p. Brewer, "Perfect Places," pp. 159-165. 28.Show full note

¶Report of the Presidential Commission, Vol. I, p. 148; Vol. IV, p. 1446.

¶Vaughan, The Challenger Launch Decision, p. 235.

¶Report of the Presidential Commission, Vol. I, pp. 1-3.¹⁵¹⁵ As NASA human space flight personnel began to become closely 30 Goldin is quoted in Bill Harwood, "Pace of Cuts Fuels Concerns About involved with their counterparts in the Russian space program after Shuttle," Space News, December 19-25, 1994, p. 1. 1992, there was grudging acceptance that Russian human space flight 31 personnel were also skilled in their work, although they carried it out McCurdy, Faster, Better, Cheaper. rather differently than did NASA. Report Volume I August 2003 119Show full note

Howard E. McCurdy, "The Decay of NASAʼs Technical Culture," Space Policy (November 1989), pp. 301-10.

¶Report of the Presidential Commission, Vol. I, pp. 164-177. 17

¶Report of the Presidential Commission, Vol. I, Ch. VII and VIII. 18

¶Report of the Presidential Commission, Vol. I, pp. 140. 19

For background on culture in general and engineering culture in particular, see Peter Whalley and Stephen R. Barley, "Technical Work

in the Division of Labor: Stalking the Wily Anomaly," in Stephen R. Barley and Julian Orr (eds.) Between Craft and Science, (Ithaca: Cornell University Press, 1997) pp. 23-53; Gideon Kunda, Engineering Culture:

Control and Commitment in a High-Tech Corporation, (Philadelphia: Temple University Press, 1992); Peter Meiksins and James M. Watson, "Professional Autonomy and Organizational Constraint: The Case of Engineers," Sociological Quarterly 30 (1989), pp. 561-85; Henry Petroski, To Engineer is Human: The Role of Failure in Successful Design (New York: St. Martinʼs, 1985); Edgar Schein. Organization Culture and Leadership, (San Francisco: Jossey-Bass, 1985); John Van Maanen and Stephen R. Barley, "Cultural Organization," in Peter J. Frost, Larry F. Moore, Meryl Ries Louise, Craig C. Lundberg, and Joanne Martin (eds.) Organization Culture, (Beverly Hills: Sage, 1985).

¶Report of the Presidential Commission, Vol. I, pp. 82-111. 21

¶Harry McDonald, Report of the Shuttle Independent Assessment Team. 22

¶Report of the Presidential Commission, Vol. I, pp. 145-148. 23

¶Vaughan, The Challenger Launch Decision, pp. 257-264. 24

U. S. Congress, House, Investigation of the Challenger Accident, (Washington: Government Printing Office, 1986), pp. 70-71.

¶Report of the Presidential Commission, Vol. I, Ch.VII.

Mary Douglas, How Institutions Think (London: Routledge and Kegan Paul, 1987); Michael Burawoy, Manufacturing Consent (Chicago: University of Chicago Press, 1979).

¶Report of the Presidential Commission, Vol. I, pp. 171-173. 28

¶Report of the Presidential Commission, Vol. I, pp. 173-174. 29

¶National Aeronautics and Space Administration, Aerospace Safety

¶Advisory Panel, "National Aeronautics and Space Administration Annual

¶Report: Covering Calendar Year 1984," (Washington: Government

¶Printing Office, 1985). 30

¶Harry McDonald, Report of the Shuttle Independent Assessment Team. 31

¶Richard J. Feynman, "Personal Observations on Reliability of the

¶Shuttle," Report of the Presidential Commission, Appendix F:1. 32

¶Howard E. McCurdy, "The Decay of NASAʼs Technical Culture," Space

¶Policy (November 1989), pp. 301-10; See also Howard E. McCurdy,

¶Inside NASA (Baltimore: Johns Hopkins University Press, 1993). 33

¶Diane Vaughan, "The Trickle-Down Effect: Policy Decisions, Risky Work, and the Challenger Tragedy," California Management Review, 39, 2,

¶Winter 1997.

¶Morton subsequently sold its propulsion division of Alcoa, and the company is now known as ATK Thiokol Propulsion.

¶Report of the Presidential Commission, pp. 82-118. 36

¶For discussions of how frames and cultural beliefs shape perceptions, see, e.g., Lee Clarke, "The Disqualification Heuristic: When Do Organizations

¶Youn and William F. Freudenberg, (Greenwich, CT: JAI, 1993); William

¶Starbuck and Frances Milliken, "Executive Perceptual Filters – What They

¶Notice and How They Make Sense," in The Executive Effect, Donald C. Hambrick, ed. (Greenwich, CT: JAI Press, 1988); Daniel Kahneman,

¶Paul Slovic, and Amos Tversky, eds. Judgment Under Uncertainty:

¶Heuristics and Biases (Cambridge: Cambridge University Press, 1982);

¶Risk." Annual Review of Sociology 14 (1988): 491-519; Stephen J. Pfohl,

¶Predicting Dangerousness (Lexington, MA: Lexington Books, 1978).

¶Report of the Presidential Commission, Vol. IV: 791; Vaughan, The

¶Challenger Launch Decision, p. 178.

¶Report of the Presidential Commission, Vol. I, pp. 91-92; Vol. IV, p. 612.

¶Report of the Presidential Commission, Vol. I, pp. 164-177; Chapter 6, this Report.

¶Report of the Presidential Commission, Vol. I, p. 90.

¶Report of the Presidential Commission, Vol. IV, pp. 791. For details of teleconference and engineering analysis, see Roger M. Boisjoly, "Ethical

¶Decisions: Morton Thiokol and the Space Shuttle Challenger Disaster,"

¶American Society of Mechanical Engineers, (Boston: 1987), pp. 1-13. 42

¶Vaughan, The Challenger Launch Decision, pp. 358-361. 43

¶Report of the Presidential Commission, Vol. I, pp. 88-89, 93. 44

¶Edward Wong, "E-Mail Writer Says He was Hypothesizing, Not

¶Predicting Disaster," New York Times, 11 March 2003, Sec. A-20, Col.¹¹ NASA Agency Contingency Action Plan for Space Flight Operations, January 2003, p. D-2.

¶(excerpts from press conference, Col. 3).

¶Report of the Presidential Commission, Vol. I, pp. 92-95. 46

¶Report of the Presidential Commission, Vol. I, p. 152. 47

¶Weick argues that in a risky situation, people need to learn how to "drop their tools:" learn to recognize when they are in unprecedented situations in which following the rules can be disastrous. See Karl E. Weick, "The

¶Collapse of Sensemaking in Organizations: The Mann Gulch Disaster."

¶Administrative Science Quarterly 38, 1993, pp. 628-652. 48

¶Lee Clarke, Mission Improbable: Using Fantasy Documents to Tame

¶Disaster, (Chicago: University of Chicago Press, 1999); Charles Perrow,

¶Normal Accidents, op. cit.; Scott Sagan, The Limits of Safety, op. cit.;

¶Diane Vaughan, "The Dark Side of Organizations," Annual Review of

¶Sociology, Vol. 25, 1999, pp. 271-305. 49

¶Typically, after a public failure, the responsible organization makes safety the priority. They sink resources into discovering what went wrong and lessons learned are on everyoneʼs minds. A boost in resources goes to safety to build on those lessons in order to prevent another failure.

¶But concentrating on rebuilding, repair, and safety takes energy and resources from other goals. As the crisis ebbs and normal functioning returns, institutional memory grows short. The tendency is then to backslide, as external pressures force a return to operating goals.

¶William R. Freudenberg, "Nothing Recedes Like Success? Risk Analysis and the Organizational Amplification of Risks," Risk: Issues in Health and

¶Safety 3, 1: 1992, pp. 1-35; Richard H. Hall, Organizations: Structures,

¶Processes, and Outcomes, (Prentice-Hall. 1998), pp. 184-204; James G. March, Lee S. Sproull, and Michal Tamuz, "Learning from Samples of

¶One or Fewer," Organization Science, 2, 1: February 1991, pp. 1-13.

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