Organization at the Limit www.ebook3000.com OATA01 06/14/2005, 10:48 AM OATA01 06/14/2005, 10:48 AM Organization AT THE LIMIT Lessons from the Columbia Disaster EDITED BY WILLIAM H STARBUCK AND MOSHE FARJOUN www.ebook3000.com OATA01 06/14/2005, 10:48 AM © 2005 by Blackwell Publishing Ltd except for editorial material and organization © 2005 by William H Starbuck and Moshe Farjoun BLACKWELL PUBLISHING 350 Main Street, Malden, MA 02148–5020, USA 9600 Garsington Road, Oxford OX4 2DQ, UK 550 Swanston Street, Carlton, Victoria 3053, Australia The right of William H Starbuck and Moshe Farjoun to be identified as the Authors of the Editorial Material in this Work has been asserted in accordance with the UK Copyright, Designs, and Patents Act 1988 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs, and Patents Act 1988, without the prior permission of the publisher First published 2005 by Blackwell Publishing Ltd 2005 Library of Congress Cataloging-in-Publication Data Organization at the limit : lessons from the Columbia disaster / edited by William H Starbuck and Moshe Farjoun p cm Includes bibliographical references and index ISBN-13: 978-1-4051-3108-7 (hardback : alk paper) ISBN-10: 1-4051-3108-X (hardback : alk paper) Columbia (Spacecraft)—Accidents Corporate culture—United States—Case studies Organizational behavior—United States—Case studies United States National Aeronautics and Space Administration I Starbuck, William H., 1934– II Farjoun, Moshe TL867.O74 2005 363.12′4′0973—dc22 2005006597 A catalogue record for this title is available from the British Library Set in 10/121/2pt Rotis Serif by Graphicraft Limited, Hong Kong Printed and bound in the United Kingdom by TJ International, Padstow, Cornwall The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has been manufactured from pulp processed using acid-free and elementary chlorine-free practices Furthermore, the publisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards For further information on Blackwell Publishing, visit our website: www.blackwellpublishing.com OATA01 06/14/2005, 10:48 AM Contents Notes on Contributors Preface Sean O’Keefe Part I viii xvii Introduction Introduction: Organizational Aspects of the Columbia Disaster Moshe Farjoun and William H Starbuck Synopsis: NASA, the CAIB Report, and the Columbia Disaster Moshe Farjoun and William H Starbuck Part II The Context of the Disaster 11 19 History and Policy at the Space Shuttle Program Moshe Farjoun System Effects: On Slippery Slopes, Repeating Negative Patterns, and Learning from Mistake? Diane Vaughan 41 Organizational Learning and Action in the Midst of Safety Drift: Revisiting the Space Shuttle Program’s Recent History Moshe Farjoun 60 The Space Between in Space Transportation: A Relational Analysis of the Failure of STS-107 Karlene H Roberts, Peter M Madsen, and Vinit M Desai 81 21 www.ebook3000.com OATA01 06/14/2005, 10:48 AM Contents vi Part III Influences on Decision-Making 99 The Opacity of Risk: Language and the Culture of Safety in NASA’s Space Shuttle Program William Ocasio 101 Coping with Temporal Uncertainty: When Rigid, Ambitious Deadlines Don’t Make Sense Sally Blount, Mary J Waller, and Sophie Leroy 122 Attention to Production Schedule and Safety as Determinants of Risk-Taking in NASA’s Decision to Launch the Columbia Shuttle Angela Buljan and Zur Shapira 140 Part IV The Imaging Debate 157 Making Sense of Blurred Images: Mindful Organizing in Mission STS-107 Karl E Weick 10 The Price of Progress: Structurally Induced Inaction Scott A Snook and Jeffrey C Connor 178 11 Data Indeterminacy: One NASA, Two Modes Roger Dunbar and Raghu Garud 202 12 The Recovery Window: Organizational Learning Following Ambiguous Threats Amy C Edmondson, Michael A Roberto, Richard M.J Bohmer, Erika M Ferlins, and Laura R Feldman 13 Barriers to the Interpretation and Diffusion of Information about Potential Problems in Organizations: Lessons from the Space Shuttle Columbia Frances J Milliken, Theresa K Lant, and Ebony N Bridwell-Mitchell Part V Beyond Explanation 220 246 267 14 Systems Approaches to Safety: NASA and the Space Shuttle Disasters Nancy Leveson, Joel Cutcher-Gershenfeld, John S Carroll, Betty Barrett, Alexander Brown, Nicolas Dulac, and Karen Marais OATA01 159 269 15 Creating Foresight: Lessons for Enhancing Resilience from Columbia David D Woods 289 16 Making NASA More Effective William H Starbuck and Johnny Stephenson 309 06/14/2005, 10:48 AM Contents vii 17 Observations on the Columbia Accident Henry McDonald 336 Part VI 347 18 Conclusion Lessons from the Columbia Disaster Moshe Farjoun and William H Starbuck 349 Index of Citations 364 Subject Index 370 www.ebook3000.com OATA01 06/14/2005, 10:48 AM Notes on Contributors Betty Barrett is currently a Research Scientist with the Massachusetts Institute of Technology Before going to Massachusetts Institute of Technology she worked on the faculty of Michigan State University’s School of Industrial Relations and Human Resource Management Her research interests include the impact of instability on workers in the aerospace industry, globally dispersed teams, system safety, workplace knowledge creation, and organizational learning She has published work on aerospace workforce and employment, team-based work systems, and alternative dispute resolution, and is co-author of Knowledge-Driven Work (Oxford University Press, 1998) Sally Blount is the Abraham L Gitlow Professor of Management at the Leonard N Stern School of Business, New York University She focuses on the study of managerial cognition and group behavior and is best known for her research in the areas of negotiation, decision-making, and time Her research has been published in a wide variety of psychology and management journals, including Academy of Management Review, Administrative Science Quarterly, Journal of Personality and Social Psychology, Organizational Behavior and Human Decision Processes, Psychological Bulletin, and Research in Organizational Behavior Dr Blount is currently writing a book entitled Time in Organizations Richard M.J Bohmer is a physician and an Assistant Professor of Business Administration at Harvard University His research focuses on the management of clinical processes and the way in which health-care teams learn to improve outcomes, prevent error, and reduce adverse events He has studied catastrophic failures in health care, the adoption of new technologies into medical practice, and more recently the way in which health-care delivery organizations deal with custom and standard operations concurrently He holds a medical degree from the University of Auckland, New Zealand, and an MPH from the Harvard School of Public Health Ebony N Bridwell-Mitchell is a doctoral candidate at New York University’s Stern School of Business in the Department of Management and Organizations Her research focuses on the effects of social assessments and influence processes at OATA01 06/14/2005, 10:49 AM Notes on Contributors ix group, organizational and inter-organizational levels Her most recent project is a four-year NSF-funded study that examines how the social dynamics of the professional community in New York City public schools affect organizational change In addition to training as an organizational scholar, she has a Master’s degree in public policy from the Harvard John F Kennedy School of Government and a BA, summa cum laude, from Cornell University in American policy studies She has over ten years’ experience in educational research, consulting, and practice in organizations such as the US Department of Education, the Peruvian Department of the Interior, the Navajo Nation Tribal (Diné) College, and the New York City Department of Education Alexander Brown is a graduate student in Massachusetts Institute of Technology’s Program in Science, Technology and Society His research examines engineering practice from the 1960s to the 1990s Using accidents/failures and their subsequent investigations as a window into the black box of engineering, he examines the changing cultures of engineering within NASA He is tracking changes in engineering practices from Apollo to Challenger to Columbia Angela Buljan is a Strategic Planning Director at McCann Erickson Croatia and a pre-doctoral researcher at the University of Zagreb She plans to start her Ph.D program in Management and Organization at the University of Zagreb, where she received a B.S degree in psychology and a Master’s degree in marketing Her research interests include managerial risk-taking, organizational decision-making, and consumer decision-making In 2004 she was a guest researcher at Management and Organizations Department at the Stern School of Business, New York University, where she participated in research projects on risk-taking under the supervision of Zur Shapira One of these is presented in this book John S Carroll is Professor of Behavioral and Policy Sciences at the Massachusetts Institute of Technology Sloan School of Management and the Engineering Systems Division He is co-director of the MIT Lean Aerospace Initiative He taught previously at Carnegie-Mellon University, Loyola University of Chicago, and the University of Chicago He received a B.S (physics) from MIT and a Ph.D (social psychology) from Harvard His research has focused on individual and group decision-making, the relationship between cognition and behavior in organizational contexts, and the processes that link individual, group, and organizational learning Current projects examine organizational safety issues in high-hazard industries such as nuclear power, aerospace, and health care, including self-analysis and organizational learning, safety culture, leadership, communication, and systems thinking He is also part of a research team working collaboratively with the Society for Organizational Learning Sustainability Consortium, a cross-industry group of companies developing sustainable business practices Jeffrey C Connor is a Lecturer in Organizational Behavior at the Harvard Medical School He has previously been on the faculty of the Graduate School of Education at Harvard University where he co-taught the Organizational Diagnosis seminar He is an independent contractor for senior leadership development in the intelligence www.ebook3000.com OATA01 06/14/2005, 10:49 AM x Notes on Contributors community of the US government and consults with professional service organizations and businesses on executive leadership development and organizational change He received a Master’s degree in psychology from Boston College, and a Ph.D in administration, policy, and research from Brandeis University Joel Cutcher-Gershenfeld is a senior research scientist in the Massachusetts Institute of Technology’s Sloan School of Management and Executive Director of its Engineering Systems Learning Center He is co-author of Valuable Disconnects in Organizational Learning Systems (Oxford University Press, 2005), Lean Enterprise Value (Palgrave, 2002), Knowledge-Driven Work (Oxford University Press, 1998), Strategic Negotiations (Harvard Business School Press, 1994), and of three additional co-authored or co-edited books, as well as over 60 articles on large-scale systems change, new work systems, labor–management relations, negotiations, conflict resolution, organizational learning, public policy, and economic development He holds a Ph.D in industrial relations from MIT and a B.S in industrial and labor relations from Cornell University Vinit M Desai is a doctoral student and researcher in organizational behavior and industrial relations at the Walter A Haas School of Business, University of California at Berkeley His research interests include learning, decision-making, and the study of organizations in which error can have catastrophic consequences He works with colleagues to examine organizations that operate with hazardous technologies yet experience extremely low error rates, and his work spans various industries, including space exploration, health care, telecommunications, naval aviation, and natural gas He has worked in the private and public sectors Nicolas Dulac is a doctoral student in the department of Aeronautics and Astronautics at the Massachusetts Institute of Technology His current research interests span system engineering, system safety, visualization of complex systems, hazard analysis in socio-technical systems, safety culture, and dynamic risk analysis He holds an M.S degree in aeronautics and astronautics from MIT, and a B.S degree in mechanical engineering from McGill University Roger Dunbar is a Professor of Management at the Stern School of Business, New York University He is interested in how understandings develop in support of particular perspectives in organizations, and how this basis for stability makes it difficult for change to occur His research explores this theme in different contexts One example is the dialog that took place in the Journal of Management Inquiry, (1996) around two papers: “A Frame for Deframing in Strategic Analysis,” and “Run, Rabbit, Run! But Can You Survive?” with Raghu Garud and Sumita Raghuram He is currently a senior editor of Organization Studies Amy C Edmondson is Professor of Business Administration, Harvard Business School, and investigates team and organizational learning in health care and other industries Her research examines leadership, psychological safety, speaking up, and experimentation in settings ranging from hospitals to corporate boardrooms Recent publications include “Framing for Learning: Lessons in Successful Technology Implementation” (California Management Review, 2003) and “The Local and Variegated OATA01 10 06/14/2005, 10:49 AM 374 Subject Index data availability diffusion process, 255–6 interpretation process, 252–3 systems approaches to safety, 280, 281–3, 284 data evaluation, drift toward failure, 294 data indeterminacy, 202–18 organizing modes, 204–8; NASA, 208–18 Daugherty, Robert, 193 deadlines, 124, 125, 131–5, 144, 345–6 see also International Space Station (ISS) programs, Node goal; schedule pressures debate, structured, 261–3 Debris Assessment Team (DAT) attention allocation, 151 Columbia’s recovery window, 23, 225, 229–30, 231–2, 234 data indeterminacy, 211, 213–15 drift toward failure, 294–6 formal designation, 171–2, 191, 196, 197, 213, 229, 250 mindfulness, 161, 164, 167, 171–2 organizational learning lens, 250, 254, 255 structurally induced inaction, 191, 192–3, 194–5, 197 decentralization BST strategy, 54 CAIB recommendations, 51 during Goldin’s tenure, 30, 31 fragmented analysis and, 225, 230 relational analysis, 91–2 systems approaches to safety, 284 decision-making attention allocation, 105, 141, 144, 145–53, 154, 155 basic engineering judgments, 299 CAIB report, 13–17, 49–50 constructive conflict, 261–3 cross-checks, 299, 300, 302 data pre-eminence in, 256 generic vulnerabilities, 289–301 in high-risk situations, 140–4; see also data indeterminacy; recovery window; structurally induced inaction information cues, 249 language–culture interplay, 101–20, 340–1; analytical method, 105–6; OATZ02 374 Columbia accident, 112–15, 119–20; Columbia debris assessment, 117–18; in NASA headquarters, 106–9; STS-112 foam debris, 116–17; theoretical framework, 103–5; within space shuttle program, 109–20 mindful, 159–76; anticipation, 166, 173–4; characteristics of, 160, 165; compounded abstraction concept, 162–6; coordination, 163; migrating decisions to experts, 166, 174–5; preoccupation with failure, 166–8; reluctance to simplify, 166, 168–70; resilience, 166, 173–4; sensitivity to operations, 166, 170–3 practical lessons of safety drift, 78 Presidential Commission recommendations, 46–7, 55 resilience engineering, 290, 301–5 revising risk assessments for, 300–1 sacrifice decisions, 303 safety information systems, 280–1 structured debate, 261–3 system effects, 42–4, 45, 46–7, 48–50, 52, 54–5 temporal uncertainty, 122–3, 127–36 under pressure, 131–5, 144–53, 154–5 demographic cliff, 278, 283 Department of Defense (DOD) birth of shuttle program, 24, 313, 317 imagery requests to, 13, 16; attention allocation, 151, 152; Columbia’s recovery window, 232; data indeterminacy, 214, 215; mindful decision-making, 161; organizational learning lens, 254, 255, 256–7; structurally induced inaction, 192, 193, 198 interorganizational network, 316–17 dependence, relational analysis, 85–95 design of the shuttle, see space shuttle design development–operations balance, see R&D–operations balance deviance normalization, see normalization of deviance Devil’s Advocacy, 262 Dialectical Inquiry, 262 Diaz Team, 323, 325 06/14/2005, 11:14 AM Subject Index 375 differentiation, 180–2 structurally induced inaction, 182–4, 198–9; Boston Children’s Hospital, 185–7; Columbia imagery decision, 191–8; friendly fire shootdown, 188–90 diffuse responsibility, 183, 187, 190, 196–8 diffusion of information, 248, 249, 253–9, 254, 259–63, 345 disaster incubation model (DIM), 83–4 Discovery, STS-95 mission, 338 dissent safety communication, 278–9 team climate, 230–1, 234, 240, 242 distancing through differencing, 298, 342 distributed knowledge, 203–4 organizing modes and, 204–8; NASA, 208–18 distributed learning, 318 distributed problem-solving, 294–6 Dittemore, Ron, 41, 152, 217, 226, 250, 254 diversity of NASA, 310–11, 344–5 division of labor, 180–2 between NASA and contractors, 318 see also specialization downsizing, see workforce reduction drift toward failure, 289–90 charting, 291–6 general patterns, 296–301 hindsight bias, 291 problem-solving process, 294–6, 299–300 resilience engineering, 290, 301–5 see also safety drift Dryden Flight Research Center, 323 economic pressures, see resource pressures electrical wiring problem, 338–9, 342–3 employment at NASA demographic cliff, 278, 283 employees’ satisfaction, 330, 331 history of, 312–13 Interagency Personnel Act, 337 interorganizational network, 316, 318 performance measurement, 331 personnel selection, 331 see also workforce reductions Engelauf, Phil, imagery request, 16, 254 engineering discipline, system safety as, 269–72 see also systems approaches to safety engineer–manager tension attention allocation, 149, 152, 153 CAIB report, 13–16, 16 Columbia’s recovery window, 230–1, 232, 233–4 data indeterminacy, 214–15, 216 facilitating learning, 260, 261–3 improving NASA’s effectiveness, 324–5 information diffusion, 256–7, 258–9 information interpretation, 250–1, 251, 252–3 mindfulness, 161, 162, 164, 169, 172, 173–4, 175 ombudsmen, 324–5 organizational culture, 233–4 safety communication, 278–9 structurally induced inaction, 191–8 entrainment, 124–6, 127 Erminger, Mark, 16 escalation of commitment, 129–30 experimental–operational balance, see R&D–operations balance experimentation, exploratory, 239–40 experts, migrating decisions to, 166, 174–5 exploratory organizing mode, 204–7 NASA, 208–18 see also R&D–operations balance exploratory threat response, 235–43, 235 action orientation, 237 benefits, 241–2 costs, 240–1 dissent, 240, 242 experimentation, 239–40 mindset, 237–9 team problem-solving, 236–7, 241–2 threat exaggeration, 236, 240, 241 External Tank Office, 116 F-15 fighters, friendly fire, 179, 188–90 failure drift toward, see drift toward failure exploratory organizing mode, 206 improving NASA’s effectiveness, 329–30 preoccupation with, 166–8 prevention, 222–3; see also recovery window Failure Modes Effects Analysis, 47 www.ebook3000.com OATZ02 375 06/14/2005, 11:14 AM 376 Subject Index faster, better, cheaper (FBC) strategy, 30–2, 35 organizing modes, 209 safety drift, 65–6, 67–8, 69, 73 system effects, 48 system safety, 275 vocabulary of organizing, 106–9 February 19, 2004 deadline, see International Space Station (ISS) programs, Node goal federal funding, see resource pressures Federally Funded Research and Development Centers (FFRDCs), 310, 322–3 feedback, upward transfer, 248 see also information diffusion Feynman, Richard, 239–40, 282 fighter planes, friendly fire, 179, 188–90 financial pressures, see resource pressures Fletcher, James, 313 Flight Readiness Review (FRR), 43–4, 47 cognitive biases, 226 partial response graph, 211 relational analysis, 90, 91 vocabulary of organizing, 105, 109–10, 113 foam debris ambiguous threat response, 220–1, 224–35, 343; exploratory alternative, 236–43; organizing modes, 210–18 CAIB conclusions, 13–16, 15–16, 17, 340–2 cognitive biases, 226–7, 282–3 decision-making processes: attention allocation, 150–3, 155; mindfulness, 161–5, 166–76; structurally induced inaction, 191–8, 345 drift toward failure, 291–6, 298, 299 language–culture interplay, 101–2; vocabulary of safety, 102, 104, 105, 113–15, 116–18, 119–20, 340–1 McDonald’s observations, 339, 340–2, 343, 345 organizational learning lens, 246–7; diffusion process, 253–9, 345; interpretation process, 249–53 original design requirements, 162 partial response graph, 211 relational analysis, 89–90 shifting status of, 291–4 systems approaches to safety, 282 OATZ02 376 foresight, creating, 289–305 escaping hindsight bias, 290–4 general patterns in accidents, 296–301 problem-solving process, 294–6, 299–300 resilience engineering, 290, 301–5 friendly fire shootdown, 179, 188–90 Frosch, Robert, 26 funding pressures, see resource pressures Garn, Jake, 313 Gehman, Harold, 12 General Accounting Office (GAO), 313 see also Index of Citations General Dynamics, 317–18 Genovese, Kitty, 182–3, 199 Glenn Research Center, 311, 312, 318, 323 Goddard Space Flight Center, 323, 330 Goldin, Dan history of shuttle program, 29–34, 37, 65–9, 72–5 McDonald’s observations, 337–8, 339, 340 organizing modes, 209 system effects and, 48 vocabulary of organizing, 106–9 group knowledge, 281–3 group-level factors, ambiguous threat response, 229–31, 234–5, 236–7, 240, 241–2 Hale, Wayne, imagery request, 16 decision-making processes, 152, 191, 192 organizational learning lens, 254, 255, 256–7 Hallock, James, 240 Ham, Linda, imagery request, 16 ambiguous threat response: organizing modes, 211, 214, 215; recovery window, 226, 229, 230–1, 232, 239 attention allocation, 151–3, 155 improving NASA’s effectiveness, 324 mindfulness, 167, 170, 171, 175 organizational learning lens, 250, 252–3, 254, 255, 256–7 relational analysis and, 90 structurally induced inaction, 192, 195–6, 198 “having the bubble,” 170–1 helicopter shootdown, 179, 188–90 06/14/2005, 11:14 AM Subject Index 377 hierarchy attention allocation, 153 Columbia’s recovery window, 229 improving NASA’s effectiveness, 324, 331 mindfulness, 161, 175 organizational learning lens, 248, 257, 258, 259 structurally induced inaction, 187, 190, 194 system effects, 49, 50 system safety, 274–5 high-reliability organizations (HROs), 82–3 attention allocation, 142, 154–5 coordination neglect, 84–5 disaster incubation model, 83–4 McDonald’s observations, 340 mindfulness, 160, 162, 166–75 redundancy, 86 social properties, 223; see also recovery window structurally induced inaction, 179–80 High Reliability Theory (HRT), 160, 176 see also high-reliability organizations hindsight bias, 289, 290–6 historical legacy of NASA, 311–13 “History as Cause” thesis, 50 hospitals, 178, 185–7, 241 Hubble telescope, 28, 29, 30, 52 human space flight program, 11–12, 13 Augustine Committee report, 28–9 CAIB conclusions, 16–17 CAIB recommendations, 17–18, 37 during Goldin’s tenure, 31, 107–8 knowledge transfer, 74, 78 system safety and, 283–4 see also International Space Station (ISS) program; space shuttle program imagery of foam debris damage ambiguous threat response, 224–35; exploratory alternative, 236–43; organizing modes, 210–18 attention allocation, 151–2, 155 CAIB report, 13–15, 16 mindfulness, 161–5, 166–76 organizational learning lens, 246–7; diffusion process, 253–9, 254, 259–63; interpretation process, 249–53, 259–63 partial response graph, 211 structurally induced inaction, 179, 191–8 vocabulary of organizing and, 117–18, 120 “in-family anomaly” Columbia’s recovery window, 227 data indeterminacy, 212–13, 214 mindful processing, 168–9 vocabulary of safety, 113, 114–15, 116, 117, 340–1 “in-flight anomaly” data indeterminacy, 210, 212 decision-making processes, 151, 152–3, 170, 171 drift toward failure, 291–4 vocabulary of safety, 116, 117 independence relational analysis, 85–95 safety function, 275–6, 304–5, 344 Independent Technical Authority (ITA), 51, 53, 92, 94–5, 323, 327–8, 343, 344 indeterminacy of data, 202–18 information diffusion, 248, 249, 253–9, 254, 259–63, 345 information interpretation, 248, 249–53, 259–63 information systems, safety, 280–1 information valence, 257 informational independence, 93, 94–5 institutional environment, 43, 47, 48, 49–50, 51, 52, 56 insulating foam, see foam debris integration, achieving, 180–2, 194, 196–7, 199 Interagency Personnel Act (1970), 337 Intercenter Photo Working Group (IPWG) ambiguous threat response, 224–5 organizational learning lens, 250, 254, 255, 258–9 structurally induced inaction, 191, 192, 210–12, 214 interfaces, organizational, 81–95 international cooperation, 314, 315 International Space Station (ISS) programs, 11 decision-making processes and, 148 historical analysis, 21, 23; shuttle–station linkage, 24, 25, 28, 29, 34, 35, 36, 37, 148; after Challenger disaster, 27, 28, 29, 148; during Goldin’s tenure, 29, 30, www.ebook3000.com OATZ02 377 06/14/2005, 11:14 AM 378 Subject Index International Space Station (cont’d) 31–2, 33–4, 69; during O’Keefe’s tenure, 34–5, 69, 70; key observations, 35, 36, 37; safety drift and, 69 interorganizational network, 317 Node goal (February 19, 2004): attention to safety, 148–53; CAIB report, 13; Columbia’s recovery window, 228–9; historical context, 34, 69; McDonald’s observations, 345–6; mindful processing, 171; organizing modes, 216–17; partial response graph, 211; relational analysis, 90; temporal uncertainty, 130–6 system effects and, 52 interorganizational network, 316–19 interorganizational redundancy, 86, 87 interpretation process, organizational learning, 248, 249–53, 259–63 IPAs, 337 Iraq, helicopter shootdown, 179, 188–90 ISS Management and Cost Evaluation Task Force, 34 Jet Propulsion Laboratory (JPL), 66, 310, 323 see also Mars programs Johnson Space Center, 11 autonomy, 310 contractor support, 12 employee satisfaction, 330 interorganizational network, 316 McDonald’s observations, 340, 343–4 safety architecture, 91 Space Shuttle Program Office, 11–12 Kennedy, Jim, 278 Kennedy, John F., 283 Kennedy Space Center, 11 contractor support, 12 improving NASA’s effectiveness, 325, 330 interorganizational network, 316 NASA’s diversity, 310 relational analysis, 90–1 SIAT recommendations, 339 system safety, 278 knowing, forms of, 163, 164, 165–76 knowledge, systems approaches to safety, 281–3 OATZ02 378 knowledge distribution, 203–18 NASA, 208–18 organizing modes, 204–8 knowledge transfer, 74, 78 Kranz, Gene, 223–4, 230, 240 labor, division of, 180–2 between NASA and contractors, 318 see also specialization Langley Research Center, 310, 311, 318, 323, 344–5 language–culture interplay, 101–20, 340–1 analytical method, 105–6 Columbia accident, 112–15, 119–20 Columbia debris assessment, 117–18 in NASA headquarters, 106–9 STS-112 foam debris, 116–17 theoretical framework, 103–5 within space shuttle program, 109–20 leaders, cultural change, 53, 55 leadership to improve NASA’s effectiveness, 321 McDonald’s observations, 344 recovery window, 223–4; encouraging dissent, 240; team problem-solving, 237; threat exaggeration, 236, 240 resilience engineering, 304 safety drift and, 75, 77 systems approaches to safety, 279–80, 281 leading edge structure, see RCC panels learning, distributed, 318 learning, organizational, 246–63 CAIB, 17, 61 constructive conflict, 261–3 data indeterminacy, 218 decision-making processes, 141, 154–5 exploratory response mode, 241 facilitating, 259–63 improving NASA’s effectiveness, 322, 325, 326, 329–30, 332 McDonald’s observations, 343 organizing modes, 218 process model, 248, 249; diffusion, 248, 249, 253–9, 254, 259–63; interpretation, 248, 249–53, 259–63 resistance to external recommendations, 36–8 safety drift and, 60–1; analysis of events, 72–7; historical narrative, 65–70, 71; 06/14/2005, 11:14 AM Subject Index 379 practical implications, 77–8; theoretical framework, 62–5, 65; theoretical implications, 77 system effects, 54–7 theoretical framework, 247–9 vocabulary of safety and, 115 see also foresight, creating; recovery window learning orientation, ambiguous threat response, 221–2 Apollo 13, 223–4 exploratory, 236–43 team climate, 230–1 Lederer, Jerome, 270 linguistic categories, 104–5 linguistic relativism, 103 Lockheed Martin interorganizational network, 316, 317–18 joint venture with Boeing, see United Space Alliance Madera, Pam, 234 management style, change, 279–80 manned space flight, see human space flight program Mark, Hans, 324, 328 Mars programs history of space shuttle program and, 31, 32, 33, 37; safety drift, 60–1, 66, 67–8, 69, 70, 74, 76–7 McDonald’s observations, 344 safety information systems, 280–1 safety oversight, 277 safety/production tradeoffs, 301 system effects and, 52 Marshall Space Flight Center, 11 autonomy, 310 contractor support, 12 improving NASA’s effectiveness, 323, 330 NASA’s diversity, 310 political environment, 313 Mason, Jerald, 153 matrix organization, safety function, 274–5 McCormack, Don, 152, 193, 232, 254, 255, 258–9 McDonnell-Douglas, 316, 318 McKnight, William, 205 mechanistic tendencies, NASA, 325–6, 332 Mercury program, 92–3 Millstone Nuclear Power Plant, 279 mindfulness, 142, 159–76 anticipation, 166, 173–4 characteristics of, 160, 165 compounded abstraction concept, 162–6 coordination, 163 migrating decisions to experts, 166, 174–5 preoccupation with failure, 166–8 reluctance to simplify, 166, 168–70 resilience, 166, 173–4 sensitivity to operations, 166, 170–3 mindset drift toward failure, 291–4 openness, 237–9 Mir, 31–2 Mission Management Team (MMT) ambiguous threat response: organizing modes, 211, 212, 213, 214, 215; recovery window, 227, 231, 232, 234 anomaly analysis process, 296 attention allocation, 152–3 CAIB recommendations, 51 mindfulness, 161, 164, 165, 167, 171, 172, 174, 175 organizational learning lens, 252, 254, 255–6, 258, 259 structurally induced inaction, 191, 192, 193, 194, 195–6 vocabulary of organizing, 102, 105, 109–10, 117–18, 120 Mission Operations Directorate (MOD), 192, 193 Morton Thiokol, 153, 154, 281, 313 Moss, Frank, 313 motivation, systems approaches to safety, 272–3, 283 motivational momentum, 124–5, 126–7 motivational pressure, 128–9, 133, 141, 144 Mulloy, Larry, 153 NASA, 11–12 ambiguous threat response: Columbia, 220–1, 224–35; confirmatory, 238–9; exploratory alternative, 236–43; organizing modes, 208–18 autonomy, 310–11, 323 CAIB report, 13–18; see also Index of Citations dependence, 89–95 www.ebook3000.com OATZ02 379 06/14/2005, 11:14 AM 380 Subject Index NASA (cont’d) distributed knowledge system, 208–18 diversity, 310–11, 344–5 drift toward failure, 289–301 generic vulnerabilities, 289–301 goals, 309, 313–16, 328–9 historical legacy, 311–13 improving effectiveness of, 309–33; communication, 324–5, 326, 331; culture, 321, 325, 326, 330–1, 332; degrees of freedom, 310–21; influence on environments, 321, 322; performance measurement, 331; priorities, 332; processes guiding adaptation, 321, 326–30, 332; public support, 332, 333; structural change, 321, 322–6, 327 interorganizational network, 316–19 language–culture interplay, 101–2, 105–20, 340–1 McDonald’s observations, 336–46 mechanistic tendencies, 325–6, 332 mindfulness, 159–76 organizational learning lens, 246–7; diffusion process, 253–9, 254, 259–63; facilitating, 259–63; interpretation process, 249–53, 259–63 organizing modes, 208–18; see also R&D–operations balance political legacy, 311–13 political pressures, 313–16, 328, 332–3; see also political environment privatization, 332–3 relational analysis, 81, 85, 86–7, 89–95, 342 resilience engineering, 290, 301–5 responses to external recommendations, 36–8, 323; integration, 199; McDonald’s observations, 342–4; organizational learning, 61; Presidential Commission, 46–9, 55; relational analysis, 92, 342; revising assessments of risk, 301; safety drift, 66, 69, 74–5, 76–7; system effects, 46–9, 51–7; system safety, 284–5 risk-taking, 140–55 safety drift, 60–1, 65–78, 337, 338–40 space shuttle history, 21–38, 60–1, 65–77 OATZ02 380 structurally induced inaction, 179, 180, 191–8 symbolic importance, 319–21, 322 system effects, 41–57 systems approach to safety, 272–85, 344 temporal uncertainty, 130–6 NASA Engineering and Safety Center (NESC), 52, 53, 323, 327 NASA Operations Council, 323 Navy “having the bubble,” 170–1 reactors program, 70, 233–4 safety function independence, 276 safety working groups, 277 negative patterns, repeating, 47–9, 54–7 Nixon Administration, 24, 25, 228, 313, 317 “no safety of flight issue” communication protocols, 232 drift toward failure, 291–2 organizational learning lens, 258 vocabulary of safety, 111, 117 Node goal, see International Space Station (ISS) programs, Node goal norm theory, reference points, 124 Normal Accident Theory (NAT), 64, 115, 142–3, 154–5, 209, 222 normalization of deviance, 42–3, 44, 50, 51, 52, 54–6 recovery window, 222 vocabulary of safety and, 114, 115, 118, 119 norms cultural, 233–4 shared temporal, 125–6, 127 Northrop Grumman, 317 “not a safety of flight issue” decision-making processes, 152–3, 192 McDonald’s observations, 340 vocabulary of safety, 111, 112, 113–14, 116, 119 noticing, action of, 259–60 O’Connor, Bryan, 16, 156 Office of Management and Budget (OMB), 31, 34, 69, 339, 346 O’Keefe, Sean appointment of the CAIB, 12 decision-making processes and, 148 06/14/2005, 11:14 AM Subject Index 381 history of shuttle program, 34–5, 37, 69–70 improving NASA’s effectiveness, 324 interorganizational network, 317 McDonald’s observations, 340 organizational learning, 75, 76–7 organizing modes, 209 temporal uncertainty, 130, 132 ombudsmen, 324–5 “One NASA” initiative, 326 operations balance with R&D, see R&D–operations balance sensitivity to, 166, 170–3 organizational change, see change; NASA, improving effectiveness of organizational culture, see culture organizational interfaces, see relational analysis organizational learning, see learning, organizational organizational structure, see structural change; structural components; structural independence; structural secrecy; structurally induced inaction organizational systems, see system design; system effects; system failure; systems approaches to safety organizing modes, 204–8 NASA, 208–18 see also R&D–operations balance Osheroff, Douglas, 148, 240 “out-of-family anomaly” Columbia’s recovery window, 227 data indeterminacy, 210–14, 216 mindful processing, 168–9 structurally induced inaction, 191 vocabulary of safety, 116–17, 119 Page, Bob, imagery request, 16 attention allocation, 151 organizational learning lens, 254, 255 structurally induced inaction, 191, 192 partnering relationships, 319 perceptions of NASA, 319–21, 322, 328, 329, 332, 333 perceptually based knowing, 163, 164, 165–76 performance measurement, 331 personnel selection, 331 photos of foam debris damage, see imagery of foam debris damage planning fallacy, 128–30 political environment administrational redundancy, 87 CAIB recommendations, 51, 52 Columbia’s recovery window, 228 decision-making processes and, 143, 148, 150, 169–70, 171 history of shuttle program, 312–13; birth in 1960s/70s, 24, 25, 283–4, 313, 317; 1981–6: 25–6; after Challenger, 27, 28, 29, 148, 149, 313; during Goldin’s tenure, 29, 30, 32, 33–4, 65, 69; key observations, 36, 37; safety drift, 65, 69 improving NASA’s effectiveness, 322, 323, 328, 332–3 legacy to NASA, 311–13 mindful processing, 169–70, 171 NASA’s autonomy, 310 NASA’s goals and, 313–16, 328 NASA’s interorganizational network, 317, 318 organizing modes and, 208, 209 relational analysis, 90 safety drift, 65, 69, 75, 77 system effects, 48, 49–50, 51, 52 systems approaches to safety, 283–4 temporal uncertainty, 122, 130–1, 135–6 power relations improving NASA’s effectiveness, 324 organizational learning, 248, 251, 258, 259, 261 see also engineer–manager tension predictable task performance, 207–8 NASA, 208–18 see also R&D–operations balance Presidential Commission (1986) conclusions, 44, 45–9, 50, 55 preventing failure, 222–4 see also recovery window; systems approaches to safety privatization, 29, 30, 31, 332–3 Problem Resolution Teams, 230 problem-solving distributed, 294–6 fragmented, 299–300 teams, 236–7, 241–2 www.ebook3000.com OATZ02 381 06/14/2005, 11:14 AM 382 Subject Index process model, organizational learning, 248, 249 diffusion, 248, 249, 253–9, 254, 259–63 interpretation, 248, 249–53, 259–63 production, culture of, 43, 44, 47, 48, 50, 51, 52, 56 production–R&D balance, see R&D– operations balance production/safety tradeoffs, 289, 297, 301, 303, 304–5, 346 production schedule, see schedule pressures Program Requirements Control Board, 211 psychological safety, 230–1, 240, 278–9 public perceptions of NASA, 319–21, 322, 328, 329, 332, 333 quality assurance organization, system safety, 273, 274–5, 344 R&D–operations balance ambiguous threat response: organizing modes, 204–18; recovery window, 228–9, 239 decision-making processes and, 148, 149, 170 history of shuttle program, 24–5, 26, 29, 31–2, 33, 35, 37; safety drift, 65, 66, 68 improving NASA’s effectiveness, 329 mindful processing, 170 NASA’s conflicting goals, 314 Presidential Commission recommendations, 46 system effects and, 43, 46, 49–50 Raytheon, 317 RCC panels ambiguous threat response: organizing modes, 211, 213–14, 216; recovery window, 227, 240 drift toward failure, 293–4, 295 McDonald’s observations, 340, 341 mindful decision-making, 164, 169 vocabulary of safety, 113–14, 115, 119, 340, 341 Ready, William, 16, 193 Reagan Administration, 25–6, 228 recovery window, 220–43 Columbia, 220–1, 224–35; cognitive factors, 226–9, 234–5; discounting of OATZ02 382 risk, 225; fragmented analysis, 225, 230; group-level factors, 229–31, 234–5; organization-level factors, 231–5; solution generation, 223, 224; team climate, 230–1, 234; team design, 229–30; threat identification, 223, 224, 226–7; “wait and see” orientation, 225 confirmatory response, 235, 235, 238–9, 238, 240 definition, 220 exploratory response, 235–43, 235; action orientation, 237; benefits, 241–2; costs, 240–1; dissent, 240, 242; experimentation, 239–40; mindset, 237–9; team problem-solving, 236–7, 241–2; threat exaggeration, 236, 240, 241 leadership, 223–4, 236, 237, 240 theoretical framework, 222–4 use of term, 242 windows of opportunity compared, 242 redundancy, 86–8, 90–2, 93, 95, 342–3 reference points decision-making, 142–3, 145–7, 154 temporal, 123–4, 126 reinforced carbon carbon panels, see RCC panels relational analysis, 81–95 Aerospace Corporation, 92–3, 94 coordination neglect, 84–5, 90, 91, 92, 95 dependence, 85–95 high reliability, 82–4 managerial implications, 95 McDonald’s observations, 342 recommendations for NASA, 94–5 the “space between” defined, 82 reliability, see high-reliability organizations (HROs); High Reliability Theory rescue mission possibility, 216 see also recovery window research–operations balance, see R&Doperations balance resilience, mindful organizing, 166, 173–4 resilience engineering, 290, 301–5 resource pressures Aerospace Corporation, 93, 94 CAIB conclusions, 16, 17, 49–50, 51, 52 Columbia’s recovery window, 227, 228 correlation with achievements, 315–16 06/14/2005, 11:14 AM Subject Index 383 culture of production, 43, 47, 48, 52 decision-making processes and, 143, 148, 150, 155 demographic cliff, 278, 283 history of, 312–13 history of shuttle program, see under political environment McDonald’s observations, 342, 343–4, 346 mindful processing, 169–70 NASA’s goal conflicts, 314–16 organizing modes and, 208, 209 Presidential Commission conclusions, 47, 48 production/safety tradeoffs, 297, 346 safety drift: analysis, 73, 74–5; historical narrative, 65, 66, 67–8, 69; theoretical framework, 62, 63, 64; theoretical implications, 77 safety oversight, 277, 278 SIAT recommendations, 339, 342 system effects, 43, 47, 48, 49–50, 51, 52, 56 systems approaches to safety, 282, 283–4 temporal uncertainty, 122–3, 130–1, 135, 136 responsibility, diffusion, 183, 187, 190, 196–8 Ride, Sally, 17, 107 risk discounting of, 225 drift toward failure, 289–301 language and, 101–20, 340–1 recovery window, 223–43 resilience engineering, 301–5 revising assessments of, 300–1 risk build-up historical analysis, 21–38 safety drift, 60–78 system effects, 41–57 risk management, system safety, 270 risk-taking decision-making processes, 140–55 interpersonal, 230–1 robotic missions to Mars, see Mars programs Rocha, Rodney, imagery request, 16 attention allocation, 151, 152, 155 Columbia’s recovery window, 230–1, 232 data indeterminacy, 211, 214 organizational learning lens, 252–3, 254, 255–6, 258 structurally induced inaction, 191, 192, 193, 194–5 Rockwell, 318 Roe, Ralph, 250, 254, 256 Roles, Responsibilities, and Structure Team, 323 Rothenberg, Joseph, 338, 339, 340 sacrifice decisions, 303 safety ambiguous threats to, see ambiguous threat response attention allocated to, 141, 145–53, 154, 155 CAIB conclusions, 16, 17; system effects, 42–4, 47–8, 49, 50–1, 53–4 change recommendations, 47–8, 50, 51 culture of production, 43, 44, 47, 48, 50, 51, 52, 56 drift from, see safety drift drift toward failure, 289–90; charting, 291–6; general patterns, 296–301; hindsight bias, 291; problem-solving process, 294–6, 299–300; resilience engineering, 290, 301–5 historical analysis, 24–5, 26; after Challenger, 27–9, 37, 65, 73, 76; 1981–6: 26; Goldin’s tenure, 30, 31, 32, 33, 34, 65–9, 72–5; key observations, 35–8; O’Keefe’s tenure, 34–5, 69–70, 75; Von Braun era, 149; see also safety drift implementation of change, 51–4, 55–7 improving NASA’s effectiveness, 327–8 language–culture interplay, 101–20, 340–1; analytical method, 105–6; Columbia accident, 112–15, 119–20; Columbia debris assessment, 117–18; in NASA headquarters, 106–9; STS-112 foam debris, 116–17; theoretical framework, 103–5; within space shuttle program, 109–20 McDonald’s observations, 338, 342, 343–5 mindful decision-making, 161, 165, 167 NASA’s goal conflicts, 314 normalization of deviance, 42–3, 44, 50, 51, 52, 54–6 www.ebook3000.com OATZ02 383 06/14/2005, 11:14 AM 384 Subject Index safety (cont’d) organizational independence, 86–95 organizational learning lens, 252–3 organizing modes, 209 Presidential Commission report, 45–6, 47–8, 55 preventing failure, 222–4; see also recovery window; systems approaches to safety psychological, 230–1, 240, 278–9 resilience engineering, 290, 301–5 SIAT recommendations, 339, 342 structural secrecy, 43–4, 50, 51, 52–4 structurally induced inaction, 191–8, 345 system effects, 42–57 systems approaches, see systems approaches to safety temporal uncertainty, 133–4, 135, 136 tradeoffs with production, 289, 297, 301, 303, 304–5, 346 vocabulary of, see vocabularies of organizing and safety safety control structure, 271–2, 271, 285 safety drift, 60–78 analysis of events, 72–7 early warning systems, 276 historical narrative, 65–70, 71 McDonald’s observations, 337, 338–40 practical implications, 77–8 theoretical framework, 62–5, 65 theoretical implications, 77 see also drift toward failure safety failure cycle model, 62–5, 65, 72, 77 safety feedback, 62, 63 “safety of flight” data indeterminacy, 212, 213–14, 215, 216 McDonald’s observations, 340 organizational learning lens, 258 vocabulary of safety, 111–12, 113–14, 115, 117, 119 safety function independence, 275–6, 304–5, 344 safety function influence, 274–5 safety function information, 304, 305 safety function involvement, 304–5 safety function prestige, 274–5 safety information systems, 280–1 OATZ02 384 Safety and Mission Assurance (S&MA), 47, 51, 92, 274, 344, 345 Safety, Reliability and Quality Assurance (SR&QA), Office of, 46, 47, 48, 275–6 see also Safety and Mission Assurance safety-reporting channels, 327–8 Safety Reporting System, 327 safety working groups, 277 schedule pressures ambiguous threat response, 228–9, 238–9; organizing modes, 216–17 attention allocation, 143, 144–53, 154 CAIB conclusions, 16, 17, 43, 49–50, 51 culture of production, 43, 52 history of shuttle program, 25–6, 27, 28–9, 30, 33, 34, 35–6; safety drift, 66, 67, 69, 75 McDonald’s observations, 345–6 mindfulness, 171 partial response graph, 211 Presidential Commission findings, 46, 50 relational analysis, 90 risk-taking and, 141, 143, 144–53, 154 safety drift: analysis, 75; historical narrative, 66, 67, 69; theoretical framework, 62, 63 system effects, 43, 46, 49–50, 51, 52 systems approaches to safety, 282, 284 temporal uncertainty, 122–36; organizational consequences, 126–36; theoretical framework, 123–6 schema-based knowing, 163, 164, 165–76 schema-consistent information, 257–8 Schomburg, Calvin ambiguous threat response, 227, 231 attention allocation, 152 mindful processing, 164 organizational learning lens, 250, 254, 256, 259 structurally induced inaction, 192 secrecy, structural, 43–4, 50, 51, 52–4 selective attention, 105 sensitivity to operations, 166, 170–3 Shack, Paul, 16, 232, 250, 254, 255, 256 shareability constraint, 163 Shoreham Nuclear Power Plant, 129 Shuttle Independent Assessment Team (SIAT), 32–3, 68–9, 338–9, 342–4 see also Index of Citations 06/14/2005, 11:14 AM Subject Index 385 Shuttle Program Office (SPO), 11–12, 254, 339, 340, 342–4, 345 see also Space Flight Operations Contract shuttle program, see space shuttle program Silver, Spencer, 205, 206 simplification, 168–70 skills, 281–3 slippery slopes, 54–7 see also safety drift social behavior, 336 entrainment, 124–6, 127 safety communication, 278–80 social influence recovery window, 224, 240 structurally induced inaction, 183, 187, 190, 195–6 social interaction processes, 272, 278–81, 336 social systems, 42, 269 see also system effects; systems approaches to safety sociotemporal norms, 125–6, 127 space between, 81–95 coordination neglect, 84–5, 90, 91, 92, 95 definition, 82 dependence, 85–95 high reliability, 82–4 managerial implications, 95 relationality, 82–4 Space Flight Operations Contract (SFOC), 11–12, 31, 68 diffuse responsibility, 196–7 relational analysis, 90–1 safety oversight, 277 space shuttle design, 12, 162 historical context, 24–5, 26, 27, 30 Space Shuttle Integration Office, 51, 196, 199 space shuttle program (SSP), 11–12, 13 CAIB conclusions, 16–17 CAIB recommendations, 17–18, 37 decision-making processes, 140–55 history of, 21–38, 313; key events summarized, 22, 71; birth in 1960s/70s, 23–5, 149, 283–4, 313, 317; 1981–6: 25–7; after Challenger, 27–9, 37, 65, 73, 76, 148, 149, 313; Goldin’s tenure, 29–34, 37, 65–9, 72–5; late 1990s– 2003, 32–5, 60–1, 66–77; O’Keefe’s tenure, 34–5, 37, 69–70, 75; key observations, 35–8; safety drift from mid-1990s, 60–1, 65–77 McDonald’s observations, 336–46 risk-taking, 140–55 system effects, 41–57 system safety, see systems approaches to safety temporal uncertainty, 130–6 vocabulary of safety in, 109–20 see also Atlantis; Challenger; Columbia Space Shuttle Program Office (SPO), 11–12, 254, 339, 340, 342–4, 345 see also Space Flight Operations Contract space station, see International Space Station (ISS) programs space transportation, space between in, 81–95 Space Transportation System (STS), 12 see also Challenger; Columbia; space shuttle program specialization, 180–2 coordination neglect, 84–5, 90, 91, 92, 95 structurally induced inaction, 182–4, 198–9; Boston Children’s Hospital, 185–7; Columbia imagery decision, 191–8; friendly fire shootdown, 188–90 stakeholder groups, temporal uncertainty, 122–3, 130–1, 135–6 see also political environment STAMP (Systems-Theoretic Accident Modeling and Processes), 270–2, 285 Stennis Space Center, 316, 323 Strategic Planning Council, 323 structural change improving NASA’s effectiveness, 321, 322–6, 327 system effects, 46–9, 50–1, 52–3, 55–7 structural components organizational accidents, 222; Columbia’s recovery window, 231–3, 234 organizational learning, 256–7, 258, 260 systems approaches to safety, 272, 273–8, 344 structural independence, 93, 94 structural secrecy, 43–4, 50, 51, 52–4 www.ebook3000.com OATZ02 385 06/14/2005, 11:14 AM 386 Subject Index structurally induced inaction, 178–99, 345; Boston Children’s Hospital, 178, 185–7; Columbia imagery decision, 179, 180, 191–8; friendly fire shootdown, 179, 188–90; high-reliability organizations, 179–80; hyper-specialized organizations, 182 structured debate, 261–3 STS-45 mission, see Atlantis, STS-45 mission STS-93 mission, see Columbia, STS-93 mission STS-95 mission, see Discovery, STS-95 mission STS-107 mission, see Columbia, STS-107 mission STS-112 mission, see Atlantis, STS-112 mission subsystems, organizational, 272, 278–81 success, preoccupation with, 166–8 sunk cost error, 226 system design, 222, 231–3 system effects, 41–57 CAIB report, 42–4, 47–51, 52, 53, 55, 57 change recommendations, 46–9, 50–1 culture of production, 43, 44, 47, 48, 50, 51, 52, 56 implementation of change, 51–4, 55–7 institutional environment, 43, 47, 48, 49–50, 51, 52, 56 normalization of deviance, 42–3, 44, 50, 51, 52, 54–6 Presidential Commission report, 44, 45–9, 50, 55 repeating negative patterns, 47–9, 54–7 structural secrecy, 43–4, 50, 51, 52–4 see also relational analysis system failure, component dependence, 87, 88 system resilience, 301–5 System Safety Review Panel (SSRP), 275–6 systems approaches to safety, 269–85 accident causation model, 270–2, 285 McDonald’s observations, 344 new framework for, 284–5 safety control structure, 271–2, 271, 285 social system–system safety relation, 272–3; capability, 272–3; communication, 278–81; culture, 273, 281, 284–5; identity, 273; institutional context, 273; knowledge, 281–3; leadership, 279–80, 281; motivation, OATZ02 386 272–3, 283; organizational structure, 272, 273–8, 344; organizational subsystems, 272, 278–81; safety function independence, 275–6; safety function influence, 274–5; safety function prestige, 274–5; safety information systems, 280–1; safety oversight, 276–8; skills, 281–3; social interaction processes, 272, 278–81; vision, 273; web of relationships, 283–4 STAMP, 270–2, 285 system safety as engineering discipline, 269–72 task partitioning, 84–5, 90, 91, 92, 95 task performance organizing mode, 207–18 see also R&D–operations balance teams, ambiguous threat response, 229–31, 234, 236–7, 240, 241–2 technical anomalies, see anomalies technological design of the shuttle, see space shuttle design technological innovation, NASA’s goal conflicts, 314 see also R&D-operations balance temporal uncertainty, 122–36 coordination of time, 124, 125–7, 131–4 deadlines, 124, 125, 131–5 decision-making, 127–35 definition, 122–3 effect on temporal structure, 126–7, 130–1 entrainment, 124–6, 127 escalation of commitment, 129–30 measurement of time, 123–4 NASA, 130–6 need for closure, 128, 129–30 organizational consequences, 126–36 perception of time, 123–4 planning fallacy, 128–30 reference points, 123–4, 126 sociocultural norms, 125–6, 127 theoretical framework, 123–6 thermal protection system (TPS) attention allocation, 144, 151–3, 155 CAIB conclusions, 13, 15, 340–2 Columbia’s recovery window, 227, 233 data indeterminacy, 211, 213–14, 216 discounting of risk, 225 06/14/2005, 11:14 AM Subject Index 387 drift toward failure, 293–4 McDonald’s observations, 339, 340–2, 343 mindfulness, 164, 169 organizational learning lens, 256 structurally induced inaction, 191–8 systems approaches to safety, 282 vocabulary of safety, 113–15, 117, 119, 340–1 see also imagery of foam debris damage Thompson, Arnold, 281 threat exaggeration, 236, 240, 241 threat identification, 223, 224, 226–7, 343 Threat Rigidity Theory, 221 3M Corporation, 204–6 Tiger Team Apollo 13, 223–4, 240 Columbia, 171–2, 191, 196, 197, 211, 212, 213, 229 McDonald’s observations, 338–9 tile damage attention allocation, 144, 151–3, 155 Columbia’s recovery window, 227, 233 data indeterminacy, 211, 217 discounting of risk, 225 drift toward failure, 293–4, 295 McDonald’s observations, 339, 340–1 mindfulness, 162, 164, 169 structurally induced inaction, 191–8 systems approaches to safety, 282 vocabulary of organizing, 113, 114–15, 117, 119, 340–1 time pressure, effect on decision-making, 131–5, 144, 147–53 see also schedule pressures time stress, 133, 134 time urgency, 133–4 Toyota, Andon cord device, 241 training improving NASA’s effectiveness, 326, 331 leadership, 279–80 simulated anomaly scenarios, 299, 300 trust, safety communication, 278–9 trust-based partnering, 319 TRW Space and Electronics, 317 uncertainty, effects of, 127–8 see also ambiguous conditions, learning under; ambiguous threat response; temporal uncertainty uncertainty absorption, vocabulary for, 110 United Space Alliance, 12 organizational learning lens, 254, 255, 256 partial response graph, 211 relational analysis, 90–1 safety oversight, 277 structurally induced inaction, 198 valence of information, 257 vocabularies of organizing and safety, 102, 103–20 analytical method, 105–6 Columbia accident, 112–15, 119–20 Columbia debris assessment, 117–18 material embodiment principle, 104 McDonald’s observations, 340–1 modularity of systems principle, 104 in NASA headquarters, 106–9 selective attention principle, 105 social construction principle, 104 STS-112 foam debris, 116–17 theoretical framework, 103–5 theorization of systems principle, 105 within space shuttle program, 109–20 Von Braun era, 149 weighed decisions, 262–3 White, Bob, 16, 192, 254, 255 windows of opportunity, 242 see also recovery window wiring problem, 338–9, 342–3 Wolbers, Harry L., 316 workforce reductions CAIB conclusions, 17, 44, 50 demographic cliff, 278, 283 during Goldin’s tenure, 29, 30, 31, 32–3; safety drift and, 65, 66, 67, 68, 69, 73, 74–5 history of employment at NASA, 312–13 interorganizational network, 318 safety oversight, 277 SIAT recommendations, 339 structural secrecy, 44 system effects, 44, 45–6, 48–9, 50 temporal uncertainty, 130–1, 135, 136 X-33 initiative, 31, 32 Young, John, 148 www.ebook3000.com OATZ02 387 06/14/2005, 11:14 AM OATZ02 388 06/14/2005, 11:14 AM ... Lecturer in Organizational Behavior at the Harvard Medical School He has previously been on the faculty of the Graduate School of Education at Harvard University where he co-taught the Organizational... dangers? How can organizations, medium and large, limit their failures, and how can organizations and people increase their resilience when operating at their limits? CHAPTER OVERVIEW The book has... Columbia The authors argue that the decision to launch the Columbia without ascertaining the proper functioning of the heat insulation replicates the disastrous decision to launch the Challenger They