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The “Cog in the Machine” Manifesto: The Banality and the Inevitability of Evil - The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA Diane Vaughan Chicago and London: The University of Chicago Press, 1996, 575 pp.

Published online by Cambridge University Press:  23 January 2015

Robert E. Allinson
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Review Articles
Information
Business Ethics Quarterly , Volume 8 , Issue 4 , October 1998 , pp. 743 - 756
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Copyright © Society for Business Ethics 1998

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References

Notes

1 Diane Vaughan, The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA (Chicago and London: The University of Chicago Press, 1996), p. 365.

2 Ibid., p. 410.

3 Charles Perrow, “The Limits of Safety: The Enhancement of a Theory of Accidents,” Journal of Contingencies and Crisis Management, Vol. 2, No. 4, December 1994, p. 218; Karl E. Weick, “Enacted Sensemaking in Crisis Situations,” Journal of Management Studies, Vol. 25, No. 4, July 1988, p. 316.

4 Vaughan, p. 268.

5 Ibid., p. xiv.

6 Ibid., p. 23.

7 Ibid., p. 213.

8 Ibid., p. 415.

9 Ibid., pp. 403, 415.

10 Ibid., p. 389.

11 Ibid.

12 Ibid., p. 394.

13 Ibid., p. 15. Senior Editor Trudy E. Bell and Karl Esch list inadequate original design of the booster joint as the chief cause of the Challenger disaster. Cf. Trudy E. Bell and Karl Esch, “The Space Shuttle: A case of subjective engineering,” IEEE Spectrum [a professional engineering journal], Vol. 26, No. 6, June 1989, p. 44. Sadly, this key source is not employed by Ms. Vaughan.

14 Vaughan states, “The public did not learn that competent technical experts doing the risk assessments, following rules and using all the usual precautions, made a mistake.” Cf. Vaughan, p. 390; Richard Feynman, What Do You Care What Other People Think? (London: Unwin Hyman, Ltd., l989), p. 165.

15 Malcolm McConnell, Challenger: A Major Malfunction (London: Simon & Schuster, 1987), p. 119.

16 Ibid., p. 224.

17 Robert E. Allinson, Global Disasters: Inquiries into Management Ethics (New York, Prentice-Hall, 1993), pp. 146–7 and Eliot Marshall, “Feynman issues his own shuttle report, attacking NASA’s risk estimates,” Science, Vol. 232, June 1986, p. 1596. For a discussion of Morton Thiokol’s managers attempting to justify high levels of risk by appropriating the expert role of risk measurement and representing it to others as engineering judgment, see Joseph R. Herkert, “Management’s hat trick; misuse of Engineering Judgement in the Challenger incident,” Journal of Business Ethics, Vol. 10, No. 8, August 1991, pp. 617–20. Cf. also General Alton D. Slay, Post-Challenger Evaluation of Space Shuttle Risk Assessment and Management, prepared by the Committee on Shuttle Criticality, Review and Hazard Analysis Audit of the Aeronautics and Space Engineering Board (Washington, D. C.: National Academy Press, 1988). All four of these important sources are not consulted by Ms. Vaughan.

18 Vaughan, pp. 68, 76, 82, 273. Ms. Vaughan does not speak to the ethical issue of whether the astronauts or the civilian passengers were informed of the problems with the O-rings. This has been discussed by Mike W. Martin, Roland Schinzinger, Roger Boisjoly, Malcolm McConnell, the science editor for Reader’s Digest, myself and others. Martin, a professor of philosophy and honors at Chapman College, and Schinzinger, of the School of Engineering at the University of California, Irvine, write, “But it has also been revealed that the Challenger astronauts were not informed of particular problems such as the field joints. They were not asked for their consent to be launched under circumstances which experienced engineers had claimed to be unsafe.” Mike W. Martin and Roland Schinzinger, Ethics in Engineering, Second Edition (New York: McGraw-Hill Company, 1989), p. 82. McConnell writes, “As far as anyone in the astronaut corps had been informed, there had never been a problem with the SRB field joints.” McConnell, p. 6. For an informed inside view which confirms these authors, cf. the evidence presented by Roger Boisjoly in Mark Maier and Roger Boisjoly, Roger Boisjoly and the Space Shuttle Challenger disaster (Binghamton: SUNY-Binghamton School of Education and Human Development, Career and Interdisciplinary Studies Division, 1988), Videotape instructional package. Cf. Allinson, p. 155. Ms. Vaughan makes no mention in her book of the opinions of these sources which speak to the important issue that neither the astronauts nor the civilian passengers were informed of the O-ring dangers. Martin and Schinzinger’s highly relevant book does not form part of Ms. Vaughan’s data base. Strangely, a book that is frequently cited and thus does form part of Ms. Vaughan’s data base, Richard S. Lewis’s book, Challenger, The Final Voyage (New York: Columbia University Press, 1988), makes the point a number of times that the astronauts were not informed of the O-ring problem: “Along with the general public, the astronauts who were flying the shuttle were unaware of the escalating danger of joint seal failure. So were the congressional committees charged with overseeing the shuttle program. NASA never told them that the shuttle had a problem.” (p. 76) Lewis also quotes the Presidential Commission report: “Chairman Rogers raised the question of whether any astronaut office representative was aware [of the O-ring problem].” Weitz [a representative] answered: “We were not aware of any concern with the O-rings, let alone the effect of weather on the O-rings.” (p. 183)

18 Allinson, pp. 157–9.

19 Ibid., p. 158.

20 Vaughan, p. 423.

21 Ibid., p. 424.

22 Ibid.

23 Ibid., pp. 333, 423.

24 McConnell, p. 49.

25 Allinson, p. 162. Some of the confusion as to whether an abort system was possible (including Bell and Esch’s opinion which she cites which is based on the actually chosen design, not on any possible design) may have arisen because of ambiguity as to whether one is referring to ejection when solid rocket fuel is utilized or liquid rocket fuel. But, there was no necessity in the choice of solid fuel rockets which von Braun likened to sending the astronauts and civilians up on a roman candle. Ibid., p. 158. (A roman candle, once lit, cannot be put out. Liquid fuel rockets (the Russians will use no other kind) can be shut off. According to NASA, “Crew escape and launch abort studies will be complete on October 1, 1986, with an implementation decision in December 1986.” Apparently, this would imply (if the word implementation has any meaning at all) that an abort system is practical and feasible and was thought to be so by NASA. Cf. Recommendation 7, National Aeronautics and Space Administration, Report to the President, Actions to Implement the Recommendations of the Presidential Commission on the Space Shuttle Challenger Accident, Executive Summary (Washington, D. C.: GPO, 1986), p. 4. [This is yet another crucial source which mysteriously is not referred to by Ms. Vaughan.] Oddly enough, according to a source with which she is familiar, it was not an issue of possibility that the Challenger was not equipped with an abort system, but an issue of policy: “The question of whether such [abort] systems are feasible for the orbiter is not one of engineering, but of policy.” Lewis, p. 178. Earlier spacecraft had been equipped with launch escape systems, thus proving by fact that escape systems were not only possible, but were actual. “Unlike Mercury, Gemini and Apollo spacecraft, the orbiter was not equipped with a launch escape system during the solid rocket booster phase, the first stage of flight ascent. Such a system had been considered during development of the shuttle, but had been dropped, except for the temporary installation of aircraft-style ejection seats in Columbia, because failure of the solid rocket boosters after launch was considered highly improbable.” Lewis, pp. 3–4. [One might ask here whether the concept of improbability was one which took the O-ring problem into account, but the central point was not that an escape system was impossible, but that it was thought not to be necessary.]

26 Vaughan, p. 425.

27 Ibid., p. 425. According to Lewis, given that “the probable cause of death was ocean impact . . . a crew module equipped with a parachute descent system would have saved them—and averted the most horrendous result of the accident [sic].” Lewis, p. 178.

28 Vaughan, p. 403.

29 Ibid., pp. 344–5.

30 Ibid., p. 343.

31 Ibid., p. 39.

32 Feynman, p. 151.

33 Report to the President, Report at a Glance, by the Presidential Commission on the Space Shuttle Challenger Accident (Washington, D. C.: GPO, 1986), Chapter IV. [Unaccountably, this helpful source is also not utilized by Ms. Vaughan.]

34 Vaughan, p. 463. Ironically, key details are missing in her account; e.g., that the Senior Editor of an engineering journal cites inadequate original design of the boosters as the leading cause of the disaster, that the astronauts and civilian passengers were not informed of the O-ring problems, that there was no necessity to omit an escape system for the crew and passengers (and that such an omission is ethically unpardonable).

35 Vaughan, p. 10.

36 Report to the President, Chapters III, IV, and Conclusion. Cf. Patricia H. Werhane, “Engineers and management: The challenge of the Challenger incident,” Journal of Business Ethics, Vol. 10, No. 8, August 1991. [This last article is still one more illuminating and useful source that is not to be found in Ms. Vaughan’s bibliography.]

37 Vaughan, p. 398.

38 Ibid., p. 399.

39 Ibid., p. 407.

40 Ibid., p. 68.