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It is something of an insult to the accident investigators to suggest that someone just "reached for some pet theory" to explain the Challenger crash (and that
by mannykannot 8y ago
It is something of an insult to the accident investigators to suggest that someone just "reached for some pet theory" to explain the Challenger crash (and that of Columbia, for that matter.) There was a very thorough investigation, that clearly established that there had been a normalization of deviance leading up to the final showdown over whether to launch. The commission would have come to a shallow and unsatisfactory conclusion if it had looked at that showdown alone and not recognized the normalization of deviance that had set the stage for it.
I encourage you to read both reports, available from NASA:
https://history.nasa.gov/sts51l.html https://history.nasa.gov/sts51l.html
https://www.nasa.gov/columbia/home/CAIB_Vol1.html https://www.nasa.gov/columbia/home/CAIB_Vol1.html
The term 'nomalization of deviance' was coined precisely because accident investigators have found a recurring pattern. The recognition of a recurring pattern is more helpful in accident prevention than simply attributing each incident to "just the ongoing tension between the desires of higher management and the reality that those on the ground know."
Here's another example of it, not involving engineers, and where explicit management pressure was not an issue:
http://www.rapp.org/archives/2015/12/normalization-of-deviance/ http://www.rapp.org/archives/2015/12/normalization-of-devian...
- petermcneeley 8y agothanks for you reply. I would agree that the Columbia and Bedford disasters are a much closer fit for this theory.
- mannykannot 8y agoHa! You are not, of course, agreeing with me (or the accident investigation board) so long as you dismiss normalization of deviance as a key issue in the Challenger crash.