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20 of 21 found the following review helpful:
 Fascinating account, tortured writing Feb 29, 2004
By GST
"Reader"
Penetrating account of the organizational causes of the Challenger disaster. The author shows that the engineering mistake that led to the disaster was not the result of intentional wrongdoing ("amoral calculator" thesis = managers overruling engineers due to economic and/or political pressures) but that quite on the contrary that the NASA and contractor teams played by the rulebook to a fault and that the mistake was "systematic and socially organized". A must read for everybody interested in organizational dynamics or in how to manage risk in the development of technological innovations.
Given the fascinating subject matter and revisionist thesis it's a pity that the writing is very uneven. Most of the "thick description" of the decisions around the booster joint from the early design days to the post-mortem by the Presidential Commission is quite readable. This core of the text, however, is embedded in an unbearably repetitive and plodding overall narrative flow (the account could probably be reduced in length by 50%) which in places degenerates into (sociological?) opaque language. Taking a cue from the author's concept of "structural secrecy" (things are hidden not on purpose but due to organizational compartmentalization), the argument of the book loses a lot of its force due to the undisciplined way of telling it; the author could profit from a strong editor.
12 of 12 found the following review helpful:
 Reliability/Maintenance/Refinery Engineering Application Aug 05, 2002
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.
10 of 10 found the following review helpful:
Who would have thought.... May 16, 2001
By oldcontractor
"ifrman"
Who would have thought that the most cognizant explanation of the Challenger accident would be written from an industrial psychology perspective? I've worked for NASA contractors for 24 years and have dealt with all of the types of various reviews and "overhead chart" engineering and management discussions and telecons she studied. I read this book when it first came out and have referred others to it as one of the best texts on management, technical decision making, and quality assurance that I can think of. Years of education led me to think that I was a "professional" but, as Ms Vaughn so eloquently demonstrates, there is no real aerospace engineering profession in the context of the NASA/Industry partnership.
7 of 7 found the following review helpful:
Normalization Of Deviance Dec 23, 2004
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.
12 of 14 found the following review helpful:
 Not what I expected, but better Jan 29, 2001
By Jim Kirk
I purchased this book after reading the first chapter in the bookstore. I was very interested in the technical details behind the loss of STS-51L aka the Challenger Disaster. After a brief period of discussion of the specifics of the accident, Vaughn delves incredibly deeply into the culture of NASA and the management culture that in some ways directly led to the loss of the vehicle and her crew. The amount of info Vaughn is able to bring up is incredible, and she must have done hundreds, if not thousands, of interviews to compile all of her data. I was amazed at how freely some people were with their comments (given the subject matter) and here reconstruction of events in fantastic in it's detail. This is not a book to be read lightly. It is an in-depth social analysis more than it is a book about the Challenger Disaster. Of note, it was shelved under sociology (and not Science/Technical) at my local bookstore. Many people who live in cultures where high-risk decisions are made(doctors, law enforcement personell, etc) would benefit from this work.
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