Apollo, Challenger, and Columbia : The Challenger Syndrome and the Decline of US Organizations and Institutions Book

	Preface	x
	Introduction and Acknowledgments	xxi
Chapter 1	The Columbia Accident	1
	Forecast	1
	The Mystery	4
	Debris Rains on Nacogdoches, Texas	7
	The Internet	9
	The President Speaks	10
	A NASA News Conference	10
	Houston, Texas, Loses Heroes	11
	Reactions at the Cape	12
	The Crew and Its Mission	14
	Possible Causes of the Disaster	17
Chapter 2	The Week Following: Debris, Data, and Fault Trees	19
	Monday, February 3, 2003	20
	Tuesday, February 4, 2003	26
	Wednesday, February 5, 2003	32
	Thursday, February 6, 2003	34
	Friday, February 7, 2003	38
	Saturday, February 8, 2003	41
Chapter 3	Culture and Communication in NASA	47
	Redding's Ideal Managerial Climate	48
	NASA's Culture and Climate	51
	Research and Testing	57
	In-House Technical Capability	58
	Hands-On Experience	59
	Exceptional People	61
	Risk and Failure	62
	Frontier Mentality	64
Chapter 4	Communication and Culture in the Marshall Space Flight Center	67
	A Research Opportunity at MSFC	67
	The Arsenal Concept	70
	Organizational Structure at MSFC: Mitosis	71
	Project Management	72
	Formal Versus Informal Organization	74
	Upward Communication as an Earthquake Prediction System	78
	Shepherd's Three Problems	79
	The Mushroom Problem	81
	The Monday Notes	82
	Monday Notes as Organizational Learning	85
	Automatic Responsibility	87
	Penetration	88
	A Briefing for Shepherd	90
	The Saturn V Control Center Problem	90
	Briefings and Weekly Notes for Headquarters	92
	Briefing for von Braun	93
	Staff and Board Briefing	95
	Saturn V Flies	96
	Return to MSFC	96
	Cultural Categories	99
	Research and Testing	99
	In-House Technical Capability	99
	Hands-On Experience	100
	Exceptional People	101
	Risk and Failure	101
	Frontier Mentality	101
	Open Communication	102
	Topoi and Tradeoffs	104
	Organizational Identification	105
	Unobtrusive Control	107
Chapter 5	The Challenger Accident	111
	Claus Jensen and No Downlink	119
	Feynman's Two Experiments	119
	The 'Challenger Syndrome'	121
	Diane Vaughan and The Challenger Launch Decision	122
	A Faustian Bargain	124
Chapter 6	The Mysteries of Columbia Continue	129
	The Avuncular Anchor	130
	A Changed Culture?	134
	E-Mail Excerpts	138
	O'Keefe Gets Grilled	141
	Ron Dittemore and Others Are Reassigned	142
	CAIB Adds Three New Members to Inquiry	143
	Groupthink?	144
	CAIB Hearing and a Double Meaning	147
	Two More Deaths	147
	Bordering on the Irresponsible?	149
	A Little Bit of an Echo	150
	To Scapegoat or Not	151
	Rescue Try 'Conceivable'	156
	The Wisdom of Yogi Berra	156
	Linda Ham Meets the Press	159
Chapter 7	Reading the CAIB Report: Echoes of Challenger and a Cultural Fence	163
	Fault Tree Analysis	164
1.	Solid Rocket Booster Bolt Catchers	164
2.	Kapton Wiring	165
3.	Hypergolic Fuel Spill	165
4.	Space Weather	165
5.	Asymmetric Boundary Layer Transition	165
6.	Training and On-Orbit Performance	166
7.	Payloads	166
8.	Willful Damage and Security	166
9.	Micrometeoroids and Orbital Debris Risks	166
10.	Foreign Object Damage Prevention	166
	The Mystery of NASA's Culture	169
	Testing Feynman's Hypothesis	171
	Other Communication Problems	174
	Organizational Causes	175
	Fasterbettercheaper	176
	The Safety Culture	179
	Chapter 8 of the CAIB Report	180
8.1	Echoes of Challenger	180
8.2	Failures of Foresight: Two Decision Histories and the Normalization of Deviance	181
8.3	System Effects: The Impact of History and Politics on Risky Work	181
8.4	Organization, Culture, and Unintended Consequences	182
8.5	History as Cause: Two Accidents	182
8.6	Changing NASA's Organizational System	184
	The Two Cultures Argument	185
1.	Research and Testing	187
2.	In-house Technical Capability	187
3.	Hands-on Experience	188
4.	Exceptional People	188
5.	Risk and Failure	188
6.	Open Communication	189
7.	Organizational Identification and Control	190
	A Footnote on Control	190
	Recommendations	195
1.	Near-Term: Return to Flight	195
2.	Mid-Term: Continuing to Fly	195
3.	Long-Term: Future Direction for the United States in Space	196
Chapter 8	The Challenger Syndrome and the Decline of American Organizations and Institutions: 'Speaking Truth to Power'	201
	'Wal-Mart Effect'	212
	The Golden Rule	220
	Notes to Chapter Eight	230
Chapter 9	Chicken Little, the Ostrich, and Spiderman	233
	The CAIB Report and the Press	233
	An Insider's View	236
	Chicken Little and the Ostrich	238
	The Meaning of the Situation as Influencing Behavior	245
	Ideal Managerial Climate	246
	To Scapegoat or Not	247
	The Two-Cultures Hypothesis	249
	The Historical Perspective	250
	Final Recommendation	253
	Ontological Anxiety	254
	Coda	256
	Cast of Characters	261
	Managers at Time of Crash of Columbia	261
	Columbia Astronauts (as given in CAIB)	261
	Debris Search Pilots (Killed in Action)	261
	Columbia Accident Investigation Board (CAIB)	261
	Glossary of Acronyms and Technical Terms	263
	References	271
	Name Index	275
	Subject Index	281