The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA (review)

Anyone who assumes that the voluminous Report of the Presidential Commission on the Space Shuttle “Challenger” Accidentis the definitive analysis of a flawed decision to launch should read Diane Vaughan’s study.

The event itself is well known: On 28 January 1986, shuttle mission STS 51-L ended in a fireball barely a minute into Challenger‘s ascent. The vehicle was destroyed, and all seven crew members perished in the most visible and cataclysmic accident in the history of the National Aeronautics and Space Administration (NASA). This mission had received unusual publicity because the crew included a teacher, whose presence as an “ordinary citizen” was meant to demonstrate the safety of routine spaceflight.

The technical cause of the Challengeraccident was traced to a seal (an O-ring) in one of the solid rocket boosters. The O-ring failed in the unusually low temperatures of that Florida morning. On the eve of launch, NASA and the booster manufacturer had held discussions about the effect of low temperature on the O-rings and the possibility of increased risk, but the decision was made to proceed with the launch.

One need not be a sociologist to appreciate Vaughan’s fine detective work in probing the culture in which the launch decision was made. She spent the better part of a decade immersed in the archival records and also conducting her own interviews for an in-depth analysis of the context and behaviors that resulted in the ill-fated launch decision. She began the project expecting to elaborate the conclusions reached by the president’s investigative commission and the House Committee on Science and Technology investigation. What she found instead was a more subtle, more complex explanation of the decision that challenges some of the very conclusions she set out to validate.

The official explanation of the Challengerlaunch decision is that it resulted from production pressures to launch and managerial wrongdoing by the decision makers. Seeking to find the precise connections between pressure and misconduct, Vaughan instead found people acting responsibly within a highly disciplined technical culture. Instead of violations, she found adherence to governing rules and values. Instead of driving external pressures, she found evidence of a formidable internal pressure—the “normalization of deviance”—that was virtually invisible to the people who promulgated it.

To understand the Challengerlaunch decision, Vaughan not only examined data from the critical twenty-four hours preceding the launch but also probed the multiyear history of shuttle launches and solid rocket booster technology. Why had NASA launched shuttles—not once but repeatedly—with a design known to be flawed?

Answering this question, Vaughan’s book does not exonerate the decision makers. They made a tragic mistake. However, it revises the standard account of what happened and makes a compelling case that the flawed reasoning was not a matter of ethical wrongdoing but of inadvertent organizational blindness to increased risk. Her analysis follows three lines of inquiry: the production of work group culture (values and norms) within the shuttle program, especially the normalization of deviance by which technology problems were rationalized and tolerated as acceptable risks; the “culture of production,” in which NASA’s mission came to be seen as providing routine customer services; and structural secrecy, in which information flow and lines of communication were too indirect to bring a hidden problem to light.

Vaughan tells the launch decision story twice, first in its conventional explanation and then, after laying out her investigative and analytical methods, in her revisionist explanation. This technique enables the reader to flip back and forth, comparing the official account with the richer, more convincing retelling.

Following the carefully reasoned and well-supported analysis of the technical culture in which the decision was made, one anticipates an equally cogent summary in the final chapter, “Lessons Learned.” Compared to the heart of the book, however, the conclusion is rather repetitive...