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Book ReviewReference Frame and MethodologyTeacher in the Space and the O-ring ProblemThe Conventional ExplanationsOrganizational Misconduct: Amoral Calculator at Work?Risk and the Work Group CultureNormalization of DevianceProduction of Culture and the Structural FactorsIn the chapter eight Eve of the Launch Revisited, she repeats the conventional account of the eve of the Challenger launch, juxtaposed against another version that restores the social and complex cultural context in which the launch decision was taken. TLessons LearnedConclusionSamudra Vijay ESD.83 Research Seminar in Engineering Systems 1 Book Review The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA Author: Diane Vaughan Publisher: University of Chicago Press, Chicago and London Publication Year: 1996 Review By: Samudra Vijay In her book The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA, author Diane Vaughan investigates the series of events leading to the ill-fated Challenger launch decision from a new perspective. She rejects the prevalent explanations of the cause of the accident and presents an alternative sociological explanation that explores much deeper root cause of the failure, and warns us of the risks involved in the complex technical systems. She has succeeded in her effort to take the reader beyond the conventional fault finding exercise, deeper into the cause of the accident. Her background and training as a sociologist clearly dictates the framework she uses to examine the tragedy. However, notwithstanding this disciplinary bias, she has been able to allude to some fundamental issues pertaining to the behavior of organizations and how the environmental and cultural context shapes the actions taken by individuals. Reference Frame and Methodology Professor Vaughan is a sociologist, and she uses her disciplinary lens to examine the chronology of events leading to the Challenger accident and attempts to reconstruct the cultural and sociological context of the events and decisions that culminated in the disaster. She uses construction of historical ethnography, as a methodology, to systematically examine the evidence and uncovers a deep cause embedded in the “institutional banalities”, where “deviance” from the norm becomes institutionalized, and “…an incremental descent into poor judgment” finally leads to the decision to launch that resulted in the disaster. In chapter Two of the book, she explains how her training as a researcher in sociology, who looks at the critical interactions between the individuals and the institutions, and her previous work on organizational misconduct shapes her interpretation of the accident. Diane Vaughan claims to unveil a “revisionist history” and a “sociological explanation” of cause of the Challenger accident, as opposed to the commonly accepted “technical failure”, flawed decision making process, and managerial wrongdoing theory.Samudra Vijay ESD.83 Research Seminar in Engineering Systems 2 Many accounts of enquiry into the cause of the accident pose both, a challenge and an opportunity for her. On the one hand, she has made a conscious effort to avoid falling in the trap of accepting the conventional explanation, on the other hand she has extensively used the information dug up by previous enquiries, and supplemented the available information by conducting personal interviews with many of the important players, whose role was not taken into cognizance previously. Teacher in the Space and the O-ring Problem In chapter one The Eve of the Launch, Diane Vaughan first describes the NASA’s space shuttle Challenger’s launch schedule, which was originally scheduled to launch on January 22, 1986, and outlines how inclusion of an elementary school teacher, Christa McAuliffe, made it a special mission. She also discusses the four-tier launch decision team of NASA, and vividly describes the various communications on the eve of launch that took place between NASA and the engineers and managers of Thiokol, the contractor responsible for manufacturing the Solid Rocket Motor (SRM). She described the discussion where Thiokol’s decision to object to the launch of the shuttle, due to abnormally low temperatures and fear of malfunction of the O-ring, which is designed to seal the joints between the SRM case segments of the Solid Rocket Booster (SRB), is reversed by replacing engineering judgment based on technical rationale with “management hat”. Diane Vaughan presents her thesis in following order. First she describes the chronology of the events and delineates the conventional explanation of the accident and findings by the Rogers commission, the House of Representatives committee, and the media. Next, she explains the theoretical framework of her undertaking, and explains the work group culture in the NASA, and how normalization of deviance becomes a part of the culture. Next she discusses factors leading to scarcity of funds and competition, resulting in evolution of a culture of production, where production pressure gets institutionalized. Chapter seven discusses structural secrecy and its impact. In chapter eight, she brings all the pieces of the puzzle together, and presents the eve of the launch events in the light of her theoretical framework, and arguments developed so far. In Chapter nine she explains how conformity to the rules, and the work culture, led to the disaster, and not the violation of any rules, as thought by many of the investigators. She concludes her book with a chapter on lessons learned. The Conventional Explanations In the aftermath of the accident, president Regan appointed Rogers commission to investigate the cause of the accident. Most prominent and a detailed enquiry into the cause of the incident was initiated by the presidential commission (also known as Rogers commission), who attributed the cause of accident to a technical failure of the O-ring - which seals a critical joint of the solid rocket booster (SRB) - and also implicated NASA for its flawed decision makingSamudra Vijay ESD.83 Research Seminar in Engineering Systems 3 process. The presidential commission identified O-ring as technical cause of failure and concluded that the design failure interacted with the temperature and other physical characteristics leading to the failure. Commission also held NASA, as an organization, responsible for contributing to the failure by


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MIT ESD 83 - The Challenger Launch Decision

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