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The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA.
... Works framing the problem of resilience very well in its complexity, starting from engineering and moving beyond that, are those by Dekker, Perrow, and Vaughan in [18]- [20], respectively. These focus on catastrophic cascade failures and the role that a system's complexity plays in these. ...
... 1) From Challenger to the Columbia: In the Challenger disaster, the low-temperature issue leading to the sealing failure of the "O-rings" [77] was known to the engineers but the consolidated practice of launches at low outside temperature reinforced the view that the risk was an acceptable one. Vaughan called the practice "normalization of deviance" which refers to the attitude of people becoming accustomed to behaviors, events, practices, and processes that they normally would have considered wrong or deviant from their own perspective [20]. Feynman described it as "when playing Russian roulette, the fact that the first shot got off safely is little comfort for the next" [78]. ...
... The after phase finished with the launch of STS-26-R Discovery on 29th September 1988. The restoration included a new safety paradigm and changes in the management at NASA, as it was clear how misjudgment more than a technical failure were the reasons for the explosion [20]. The recovery of the system in the long after phase saw an in-depth understanding of the process dynamics that determined the incident, but failed to remove some of the causes that Vaughan indicates as reasons for the normalization of the deviance. ...
This position paper addresses resilience in complex engineering and engineered systems (CES). It offers a synthesis of academic thinking with an empirical analysis of the challenge. This paper puts forward argumentations and a conceptual framework in support of a new understanding of CES resilience as the product of continuous learning in between disruptive events. CES are in continuous evolution and with each generation they become more complex as they adapt to their environment. While this evolution takes place, new failure modes arise with the engineering of their resilience having to evolve in parallel to cope with them. Our position supports the role of an overarching complexity science framework to investigate the resilience of CES, including their temporal evolution, resilience features, the management and decision layers, and the transparency of boundaries between interconnected systems. The conclusions identify the value of a complexity perspective to address CES resilience. Extending the latest understanding of resilience, we propose a circular framework where features of CES are related to a resilience event and complexity science explains the importance of interconnections with external systems, the increasingly fast system evolution and the stratification of heterogeneous layers.
... (Turner et al., 1978). Vaughan (1996) reprend l'idée que des signaux précurseurs sont disponibles dans l'organisation mais que ceux-ci ne sont pas traités. Elle appelle cette dynamique de l'organisation jusqu'à l'accident «normalisation de la déviance». ...
... Tel que cela est décrit dans la première partie, l'étude des accidents s' Figure 14). Le premier groupe inclue les travaux de Turner et al. (1978), Perrow (1984), et Vaughan (1996). Le second groupe fait référence aux modèles d'arbres de défaillances, et d'analyse probabiliste des risques. ...
... Une modélisation de ce phénomène est proposée dans le schéma ci-dessous ( Figure 33) Dans un contexte où les processus sont dynamiques et l'information continue, l'environnement décisionnel du manager doit être repensé, pour éviter la rupture. Si l'intuition est parfois encouragée (Vaughan, 1996), elle est aussi perçue comme un facteur de risque dans la prise de décision. L'intuition peut favoriser une prise de décision rapide (il n'y a pas de comparaison lente et laborieuse entre plusieurs options), réflexive (car nourrie d'analogies avec des expériences antérieures) et économe en attention demandée au décideur (le mécanisme étant non conscient). ...
L’accident industriel majeur compte parmi les crises les plus destructrices et insupportables. Dans de nombreux cas, les retours d’expérience constatent que la catastrophe aurait probablement pu être évitée. La problématique posée est alors celle de l’anticipation. Au sein de systèmes sociotechniques à hauts risques, quelles sont les voies à suivre pour devancer le déclenchement d’une séquence accidentelle ? Pour répondre à cette problématique, notre approche s’est focalisée sur la prise de décision. Placé dans un environnement contraignant, le manager opérationnel constitue un acteur particulier. Une analyse historique réalisée sur des accidents majeurs montre un décalage entre la vision qu’a le manager du système, et la réalité des opérations. Celui-ci se trouve en situation d’ambigüité, car il doit assurer le compromis entre la rupture demandée par l’obligation de sécurité, et l’absence de rupture imposée par la continuité d’activités. Les défis de la complexité, du temps, et de la décision alors dégradent peu à peu l’environnement décisionnel, et bloquent la prise de décision. La thèse soutenue s’intéresse à comprendre la manière dont l’environnement influe sur sa prise de décision, dans le but de permettre au manager depasser d’une situation contrainte à une situation d’initiative. En décidant un arrêt momentané et préparé, sans rupture subie, il renforce ainsi la capacité d’anticipation des accidents industriels majeurs. Ainsi, en comprenant son écosystème décisionnel, le manager opérationnel peut donc prendre des initiatives assurant le principe de continuité d’activités.
... Vaughan (1982Vaughan ( , 1985Vaughan ( , 1990Vaughan ( , 1999 has consistently attempted to merge theoretical sophistication from the sociology of organisations with criminological research into organisational deviancea concept which focuses on the abilities of organisations to deviate away from their stated mission and the normative frameworks to which they subscribe. In particular, Vaughan's (1997) research into the 1986 Space Shuttle Challenger disaster explores individual mistakes in the analysis of pre-launch data, exacerbated by organisational secrecy and underpinned by external political pressures to give the go-ahead for the launch. This approach of combining the micro-meso-macro approaches is one that has been adopted by criminologists and shall be used in this project on the EIB (such a theoretical framework is proposed in chapter 5). ...
... Within a decade several textbooks appeared that contained collections of essays on corporate crime and organisational deviance (Douglas and Johnsons, 1978;Geiss and Stotland, 1980). Vaughan's (1997) investigation into the Challenger Space Shuttle disaster is perhaps the most advanced study in this area and through her forensic analysis of organisational processes in which she unpacks the culture and practices within NASA and the socialisation of deviant organisational practices that she argues were responsible for the crash. Punch (2000, p. 244) casts doubt on this interpretation suggesting that organisations cannot take decisions themselves but only through the behaviour of individuals who comprise the organisation. ...
In its role as the EU’s financing arm the European Investment Bank (EIB) is an understudied player in Europe’s infrastructure market despite annual lending volumes of nearly €70 billion and its status as the world’s largest international financial institution (Clifton et al, 2017). Not all EIB-financed projects contribute to Europe’s development as per intended and can attract censure from the European Parliament and adverse media coverage. EIB finance for the Castor undersea gas storage plant in Spain, the MOSE and Passante di Mestre projects in the Veneto region of Italy can be characterised in these terms and have been criticised for causing environmental damage and stimulating corruption networks whilst being inconsistent with the bank’s lending criteria and standards.
This thesis aims to better understand how the EIB engages in behaviours that are counter to the legal and regulatory frameworks to which it subscribes - conduct which is viewed as a form of ‘organisational deviance’. In order to support this analysis, the thesis is influenced by two criminological research endeavours (state-corporate crime and crimes of globalization) that, in part, focus on infrastructure projects financed by international financial institutions and therefore overlap significantly with the EIB and its lending activities. However, these bodies of literature remain underdeveloped when addressing the internal processes and organisational settings of the institutions under study that lead to their involvement in financing projects, an inevitable result of the difficulties faced by researchers in accessing such sites. It is at this point where this thesis is positioned. Based on extensive interviewing of EIB officials during fieldwork in Luxembourg in 2016 and 2017, this thesis will track the internal EIB decision making processes that contribute toward it engaging in organisationally deviant behaviour and consequently, it will argue for a reconsideration of the integrated theoretical framework commonly used in the state-corporate crime and crimes of globalization literatures.
... There will be a progression in the research field on the way actors are considered as a part of the system: starting from man as an element of unreliability (e.g., human error) to man under the constraints of his organization (e.g., High-Reliability Organizations). The collective work of Turner (1978), Charles Perrow (1984), Reason (1990), Michel Llory (1999, Mathilde Bourrier (1999), Diane Vaughan (1996) and Weick and Sutcliffe (2001) strongly contribute to enriching the field of so-called human and organizational factors when dealing with technological risks. ...
... Such measures can be used to better understand the context of expertise and to learn from experience feedbacks from practices (successes and failures) in SSEH expertise processes. This experience feedback can be of different kinds: sociological and quasi-ethnological descriptions, such as the description of the Challenger launch decision by NASA as described in Vaughan (1996), or some more compact and resumed descriptions, such as the organizational investigations of accidents in Llory and Montmayeul (2010). This last point can also contribute to the experimental validation. ...
... While recent adaptive sensemaking studies explain how updating can be fostered on a micro-process level within teams (Barton and Sutcliffe, 2009;Christianson, 2019), previous accounts have taken a broader organizational scope to point out the difficulties of adaptive sensemaking. Iconic studies of adaptive sensemaking failures, such as the Challenger disaster (Vaughan, 1996) and the Bhopal chemical disaster (Weick, 1988), have shown that organizational managers and frontline personnel challenge and direct each other's frames during crisis situations. This suggests that power has an important role in the adaptive sensemaking process, but we lack sufficient knowledge on the process of how organizational members influence each other's sensemaking, as is evident in repeated calls for research (Maitlis and Lawrence, 2007;Maitlis and Sonenshein, 2010;Sandberg and Tsoukas, 2015;Weick et al., 2005). ...
... Indications of the relevance of politics for sensemaking are already present in existing crisis sensemaking studies through attention for managerial influence and competing interests (see Vaughan, 1996;Weick, 1988Weick, , 2010. In this study, we moved beyond these indications and theorized how organizational members influence each other's sensemaking by using discursive, symbolic, and situated framing practices. ...
The Dutch armed forces are increasingly involved in domestic and European crisis management. Consequently, they have to collaborate with various civilian crisis organizations which are already actively engaged in these crisis contexts, including the police, fire brigade, volunteer organizations, and NGOs. In practice, this collaboration takes place on the operational level between frontline members of the armed forces and those of civilian crisis agencies. From a military perspective, this raises the question: How do frontline members of the Dutch armed forces shape civil-military collaboration in domestic and European crisis management? I analyzed a domestic and a European case study, using documents, interviews, observations, a field study, and an experiment, to answer this question. My findings show that military frontline members feel a sense of loyalty to the armed forces but also to local, civilian partners and networks. Consequently, they are subject to competing expectations and experience role conflicts. They resolve these role conflict by engaging in organizational politics with their superiors. More specifically, they resist locally inappropriate strategies and promote locally relevant policies. When frontline members enjoy discretion, this organizational politics has beneficial consequences for the collaboration between civilian and military organizations in domestic and European crisis management.
... Significant risk can be downplayed or ignored even when, perhaps ironically especially when, penalties for error are high. Normalization of deviance from rules in the Space Shuttle program (Vaughan, 1996) contributed to the loss of the Space Shuttle Challenger. Signs that could have led to lessons about safety were not taken seriously or acted upon, in part, because they would have delayed the launch schedule. ...
... NASA staff and contractors had long collected information about the O-Ring failures and the foam strikes as well as other dangers to NASA's shuttles, but these indicators did not generate sustained efforts to learn from the accident and find solutions. Rather contractors and managers sought to play down the evidence (Vaughan, 1996;Mahler & Casamayou, 2009) until after the accidents, when analyses of past results was used as a base for making some, but not all, needed evidence-based improvements. Action to make use of the data long collected at the Department of Labor for finding new solutions emerged when serious resource constraints and massive work backlogs confronted the offices. ...
Organizational learning is widely seen as a particularly valuable form of change, driven by professionals closest to the work of the agency and all its challenges. However, the growing literature on this process identifies a large and varied set of requisites for learning. The object here is to survey these requisites and show how they are the many guises of a few basic learning processes, and in doing so distinguish the conditions that stimulate or initiate learning from those that support it. Although all of the paths to learning can be encouraged, the stimuli have been less appreciated for their particular role.
... The space shuttle Challenger exploded 73 s after launch in 1986, killing all seven astronauts on board. As was established by the Challenger investigation, the original source of the disaster was freezing of the O-ring in the lower section of the left solid booster and formation of a gas leak through the O-ring [1]. The Challenger disaster provoked studies of various risks that can lead to similar catastrophic events. ...
... It is widely used in the field of explosive characteristics of liquid propellant all over the world because of the ease of use [21]. Given that the mass of liquid propellant M 0 and explosive yield Y of different modes, the TNT M T can be calculated by using Equation (1). ...
The role of manned space flight in the field of space exploration and utilization is growing. However, the security system of the manned spaceflight is still imperfect. In the case that the rocket explodes, crew modules maybe damaged by the blast wave, which will threaten the safety of the crews. This research aims to obtain the necessary data and information to enable the designers of the launch vehicles and crew modules to develop safer launch systems. To this end, this paper proposes a numerical method using LS-DYNA to study the propagation law of blast waves caused by rocket explosion on the launch pad and to quantify the impact of the blast wave on crew module. The numerical results indicate that the final blast waveform of the model with rocket is conical in the upper and lower parts, and spherical in the middle. At the same time, the third-stage explosion is the most harmful to the crew module, while the first-stage explosion is the least. Furthermore, the model with rocket has a marked effect on explosion strength: the pressure enhancement factor is about 4–17 times. Most importantly, overpressure prediction formula acting on the crew modulesof explosion on the launch pad is established for quick peak overpressure predicting and damage evaluating.
... Vaugh, D. (2016). The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. ...
... As the aforementioned confidential reports suggest, there is a poor safety climate in the companies involved that is at odds with the "just safety culture" required under FRMS. In the absence of "just culture" (Reason, 1997), the bureaucratization of safety associated with production pressure can lead to a "structural secrecy" (Vaughan, 1996) where critical safety problems are filtered, categorised or suppressed. Recent disasters have occurred in "performing" organizations with a strong focus on safety and low rates of negative events (INERIS, 2014). ...
In the fragmented European airline sector, companies are operating in a highly competitive environment amid rising cost of labour, fuel and airport fees. Fatigue risk management systems (FRMS) contribute to flexibly optimizing crew "utilization" through deviations and derogations from prescriptive European limits on duty times and rest durations. However, the flexibility gained comes at a price: it introduces an internal bureaucracy to mitigate the risks associated with crewmembers' fatigue and to develop, maintain and document fatigue related safety performance indicators. This paper questions the effectiveness of the FRMS framework and suggests that the bureaucratic process of the FRMS provides an illusion of fatigue risk control. More specifically four questions will be addressed: Why an operator needs an FRMS? Why the FRMS involves a bureaucratic process? What are the limits of the bureaucratic accountability of the FRMS and, finally, how might we manage fatigue risk effectively while keeping everyone happy, the shareholders as well as stakeholders?
... As the aforementioned confidential reports suggest, there is a poor safety climate in the companies involved that is at odds with the "just safety culture" required under FRMS. In the absence of "just culture" (Reason, 1997), the bureaucratization of safety associated with production pressure can lead to a "structural secrecy" (Vaughan, 1996) where critical safety problems are filtered, categorised or suppressed. Recent disasters have occurred in "performing" organizations with a strong focus on safety and low rates of negative events (INERIS, 2014). ...
In the fragmented European airline sector, companies are operating in a highly competitive environment amid rising cost of labour, fuel and airport fees. Fatigue risk management systems (FRMS) contribute to flexibly optimizing crew “utilization” through deviations and derogations from prescriptive European limits on duty times and rest durations. However, the flexibility gained comes at a price: it introduces an internal bureaucracy to mitigate the risks associated with crewmembers’ fatigue and to develop, maintain and document fatigue related safety performance indicators. This paper questions the effectiveness of the FRMS framework and suggests that the bureaucratic process of the FRMS provides an illusion of fatigue risk control. More specifically four questions will be addressed: Why an operator needs an FRMS? Why the FRMS involves a bureaucratic process? What are the limits of the bureaucratic accountability of the FRMS and, finally, how might we manage fatigue risk effectively while keeping everyone happy, the shareholders as well as stakeholders?
... Se ha encontrado que estas organizaciones logran mayores niveles de atención porque sienten una preocupación constante por los errores y el fracaso, no dejan pasar los detalles, se comprometen a afrontar abiertamente y a superar las situaciones difíciles, y distribuyen el poder de decisión entre todos sus miembros (Weick, Sutcliffe y Obstfeld, 1999). Por ejemplo, los grandes progresos en seguridad aérea se deben en gran medida a que la industria aeronáutica ha hecho esfuerzos mancomunados para compartir sus errores y aprender de ellos (Haunschild y Sullivan, 2002), y varios de los desastres más sonados de la nasa han sido atribuidos a la rigidez y politización de sus procesos de toma de decisiones (Vaughan, 1996). ...
El presente artículo sintetiza e interpreta una selección de investigaciones académicas
publicadas en relación con los beneficios y retos que afrontan las organizaciones
que adoptan innovaciones tecnológicas. Dirigido a tomadores de decisiones
en el área de las tecnologías de información –sean ellos directores
de tecnología, gerentes de línea, pequeños empresarios, entre otros–, el artículo
tiene el propósito de presentar a este público un conjunto de cuatro instrumentos
de análisis que le ayuden a formular expectativas realistas frente a los
retos de adoptar nuevas tecnologías de información y a plantearse preguntas
relevantes previas a la decisión de adoptar una nueva tecnología respecto del
nivel de madurez de dicha tecnología, los resultados obtenidos por las organizaciones
que la han adoptado, sus propias competencias para implementar
y asimilar la tecnología, y sus riesgos de adoptarla o no.
Estos instrumentos son analíticos, dado que se fundamentan en conceptos
previamente investigados para desencadenar procesos de análisis en los
tomadores de decisiones. Los cuatro instrumentos son la curva en S de difusión
de las innovaciones, las modas administrativas, la atención e inatención
organizacional y las brechas de asimilación de las innovaciones tecnológicas.
... It could even be argued that poor performance in projects is in general accepted or even expected, which could be considered a 'normalization of deviance'. This term was first used in the investigation of the Challenger shuttle disaster due to the insensitivity to unresolved technical anomalies that NASA apparently developed (Vaughan, 1996), but it has also been used more recently in other sectors such as health care (Price and Williams, 2018). In order to deliver projects successfully, several design and exploration loops are usually conducted to develop a thorough understanding of the system to be produced and the constraints of the project. ...
Like complex projects in other sectors, space projects frequently exceed cost and schedule performance targets. Reasons frequently cited for this include excessive optimism at the start of projects, political interference, technology development challenges such as design flaws and rework, changes to the work content during the project, and integration issues. Problems with progress can rarely be isolated to just one aspect of a project or system, however, and decisions taken in one part of a project to remedy a perceived problem may have unanticipated consequences later, elsewhere in the project. Based on data from a space science institute, this research presents a model of project progress to understand the effectiveness of the strategies available to managers of complex instrumentation projects. The paper focuses on the decision making around staffing when progress falls behind schedule, and finds that practical challenges in expanding capacity in a team may mean that schedule slippages experienced early in the project lifecycle are unlikely ever to be reversed, even if additional resources are made available. This reinforces the importance of comprehensive risk analysis, thorough cost and schedule estimating at the start of the project, and the availability of realistic funding from the outset.
... The experiment -equipment, protocols, procedures, plans -are subjected to layers upon layers of formalized control and verification before it gets the go ahead. In the planning phase 11 Important discussions of risk control, and its failure, in space operations is found in the post disaster studies of Vaughan's (1996) book The Challenger launch decision and the edited volume by Starbuck and Farjoun (2005) in the aftermath of the Columbia accident. 12 The HRO literature is often regarded as a response to the challenge posed by Charles Perrow's (1984) Normal Accident Theory which argued that the combination of interactive complexity and tight couplings meant that some systems were prone to systemic accidents. ...
The International Space Station (ISS) is research infrastructure enabling experiments in a microgravity environment. Building on a study of one of the ground control rooms in the ISS network, this paper concentrates on low-level operators and their efforts to display accountability in situations of trouble and problem solving. While the research infrastructure around the ISS is permeated by structural (bureaucratic) approaches to accountability (routines, procedures, audits and verifications), we discuss how real-time operations require a more dynamic form of continuously (re-)established accountability in the network of operators. In time-critical situations, operators need to establish accountability 'on the fly' in order to achieve the necessary agency to operate and troubleshoot their system. One key resource for this is the established voice loop system for synchronous communication. With significant constraints on the form and content of speaking turns, operators need to provide appropriate and recognizable accounts that align with the needs and expectations of the network. Based on an extensive multi-method study, with a focus here on recordings of voice loop interactions, we show how accounts of trouble are designed to manage uncertainty in the larger network, while also positioning the operators as competent and reliable members of the network. Conversely, inadequate accounts create uncertainty and delayed resolution of the issue. The design of accounts on the voice loop is crucial for time-critical articulation work in a distributed collaborative setting. The interactional details on the voice loop provide insights into the production and display of accountability, particularly relevant in networked organizations in which personal relations and trust can only play a marginal role and in which temporal constraints are critical. While the research literature has explored a wide variety of dimensions related to coordination and improvisation in distributed, mediated work environments, this study contributes with insights into the functions of verbal accounts in such contexts and how they may serve to supplement formal systems of accountability.
... The phrase appears to be an oxymoron, disasters would seem to be visible by definition. Yet consider the path breaking research by Diane Vaughan (1996) on how organizations hide disaster. Vaughan's careful analysis shows how NASA bureaucratic procedures normalized deviance in the failure of the O-rings that led to the Challenger space shuttle launch disaster. ...
This essay responds to the five articles on Anti-Science in this journal issue by discussing a significant theme identified across all of them: hidden injustice. Some of the ways that injustice is hidden by organizational forces related to anti-science are identified. In response, the essay points to the need for empirical data on anti-science policies, a symmetric approach to anti-science contexts, and institutional analysis of anti-science power imbalances. Additionally, a reflexive question about whether anti-science analysis in STS leads the field toward racial justice is raised. The essay calls for further organizational level research with a critical STS lens to uncover hidden injustice.
... One of my favourite papers to set was Diane Vaughan's account of the National Aeronautics and Space Administration during the Columbia accident investigation published in the American Journal of Sociology (Vaughan, 2006). Written in a lively firstperson rhetorical style, she presents an engaging ethnography of her experience and its relation to her earlier work during the Challenger accident investigation (Vaughan, 1996). The reaction of the engineering students was interesting. ...
I present a short argument for the enlargement of the theoretical foundations of Systems Engineering beyond Systems Science/General Systems Theory.
... Furthermore, in engineering a solution to resource problems, zero-waste systems tend to be imagined as centrally designed and controlled, a design choice that can easily lend itself to systems that resist change or outside input (Winner 1986;Vaughan 1996). ...
Like queer theory, discard studies is interested in uneven remainders, things that don’t fit neatly into categories. Both concern themselves with the strange and imperfect construction of divisions (in discard studies, that between waste and not-waste; in queer theory, those between hetero/homosexual, between male and female) that do violence to humans, cultures, and environments, while still attending to the fact that these divisions have meaning for people, that they are strategic, and that they structure our thought in ways that are almost impossible to escape.
... Conversely, mismanagement practices that generate an internal locus of discrepancy, and are thus controllable, can lead to important financial losses (Coombs 1995;Ferretti et al. 2015). When greenwashing is imputable to a company itself, it can be seen as a signal of moral collapse (Shadnam and Lawrence 2011) or of an unethical corporate culture that promotes and normalizes unethical conduct (Martin et al. 2009;Vaughan 1997). ...
Greenwashing is a phenomenon that is linked to scandals that often occur at the supply-chain level. Nevertheless, research on this subject remains in its infancy; much more is needed to advance our understanding of stakeholders’ reactions to greenwashing. We propose here a new typology of greenwashing, based on the locus of discrepancy, i.e. the point along the supply-chain where the discrepancy between ‘responsible words’ and ‘irresponsible walks’ occurs. With three experiments, we tested how the different forms of greenwashing affect stakeholders’ reactions, from both ethical (blame attributions) and business (intention to invest) perspectives. We developed our hypotheses by building on attribution theory, which seeks to account for how observers construct perceptions about events. We had anticipated that the more internal, controllable and intentional the discrepancy is, the greater the blame attributed to a company is, and the lower the intention to invest will be. When greenwashing occurs at a company level (direct greenwashing), this results in a higher level of blame attribution, while the intention to invest falls. Indirect greenwashing refers to a misbehaviour perpetrated by a supplier who claims to be sustainable, and which results in a less negative impact on a supplied company. We also propose the vicarious greenwashing, which occurs when the behaviour of a supplier is in breach of a company’s claims of sustainability. This type of greenwashing is nevertheless detrimental to investment. The findings here advance our understanding of how greenwashing shapes stakeholders’ reactions, and highlight the need for the careful management of the supply-chain.
... Ils n'ont ainsi pas donné l'alerte à temps, qui aurait pu éviter le désastre. Il en est allé de même avec les navettes Challenger et Columbia (Weick, 1997 ;Weick, 2011). Chaque fois les signaux qui auraient pu alerter que quelque chose ne se passait pas comme prévu ont été interprétés dans un autre cadre de référence. ...
... Previous research on decision making inside organizations has drawn attention to the tacitly held assumptions and taken-for-granted routines that mediate between an organization's explicit goals and the situation in the world on the one hand and what the organization does on the other hand. Sociologists have highlighted how aspects of the practical organization of work in organizations shape organizational output (Cohen, March, and Olson 1972;Molotch and Lester 1975;Fishman 1978;Becker 1982;Vaughan 1996;Desmond 2007;Scheffer 2010;Medvetz 2013;Krause 2014). ...
Drawing on forty in-depth interviews with program managers in nineteen Western international human rights organizations, this article examines how human rights organizations make decisions about how to allocate resources and how to manage their commitments to specific causes, specific people, and specific areas. It argues that organizational routines shape the allocation of resources relatively independently of other factors and it pays particular attention to the role played by intra-organizational “units” of work and planning. Units of work and planning function as candidates for the allocation of resources within organizations. Resources are not allocated directly to issues or causes but rather are distributed on the one hand among a set of range of practices, such as reports and campaigns, and ways of responding, which are considered legitimate, and on the other hand among the thematic and geographical units, which structure human rights organizations. The article concludes by discussing some factors that play a role in the selection among these units. As human rights workers consider where their organizations can make a difference, other organizations and conditions for their work come into view, levers matter, and the way making a difference can be demonstrated plays a role.
... Engaging in buffering strategies, some principals succeeded in encouraging teachers to examine their worldviews critically (e.g., preexisting cognitive frameworks, Coburn, 2001), while communicating that the national reform would fit their needs, thus letting them feel protected and supported. In this sense, Vaughan (1996) defines worldview as the way individual histories and particular sets of experiences shape the way of thinking or cognitive frames people use in interpreting events and information. Table A3 offers examples of principals' perceptions and enactments of shared sensemaking processes while framing a collaborative learning process. ...
This qualitative study explores how 60 Israeli high school principals vary in their perceptions and enactments of shared sense-making processes while engaging in strategic activities to gain teachers’ support during a national reform implementation. Data analysis has yielded three major themes: (a) a common language; (b) a collaborative learning process; and (c) a shared working culture. Leveraging a shared sense-making process can serve as a beneficial framework through which principals and faculty members collectively navigate complexity and uncertainty while implementing policy within their unique contexts. Theoretical and practical implications for faculty members and principals are suggested.
... A just culture is one in which there is trust, with honest mistakes reported without fear of punishment, and clear and known boundaries between acceptable and unacceptable behaviour, with unacceptable behaviour rightly punished (Reason, 1997). At times these principles can change without the organisation recognising it, for example when deviant behaviour is allowed to occur so often that it becomes normal, effectively creating a new set of rules in which the previously unacceptable behaviour becomes acceptable (Pidgeon, 1998), this phenomenon was referred to as normalisation of deviance in Vaughan's (1996) account of the Space Shuttle Challenger disaster. However when a just culture goes hand in hand with a reporting culture the end result is "an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information" (Reason, 1997:195) and everyone is aware of the boundaries between acceptable and unacceptable behaviour, with this understanding facilitated by an environment where compliance with rules and procedures, and safe operating practices, is expected (Dekker, 2012). ...
The Pike River Coal mine disaster, a coal mine explosion which killed 29 men, deeply affected all New Zealanders. This research reviewed the disaster from the perspective of safety culture to understand whether the safety culture at the Pike River Coal mine created conditions that increased the likelihood of accidents and disasters.
Through the literature review the subcomponents of safety culture, namely reporting culture, just culture, flexible culture, learning culture, senior management commitment to safety, and prioritisation of safety and production, were identified. The subcomponents provided a framework to analyse the data and to answer the research question.
The research adopted a qualitative case study approach, using unstructured interviews and documentary analysis. The findings showed significant gaps in each of the subcomponents, meaning that the Pike River Coal mine had an overall ineffective safety culture which created the conditions for a disaster to occur. The main conclusion drawn from this study reinforces the importance of a good safety culture to ensure that the likelihood of accidents and disasters is reduced. Furthermore this study confirms that all subcomponents of safety culture are essential, however the subcomponents of prioritisation of safety and production and management commitment to safety are of particular importance when considering an environment which is subject to financial pressures.
... A key seminal study of this type is Vaughan's (1996) study of events leading up to the Challenger space shuttle disaster, which shed light on the key mistakes perpetrated by those involved and on shortcomings in institutional policy. Other studies of this type have specifically examined policymaking debates at the Council of Europe (Sokolovska, 2017) and in the European Parliament (Wodak, 2011), while offers insight into the work of a Hebrew lan-guage planning committee. ...
This chapter presents the theoretical underpinnings of historical ethnography in the analysis of policy discourse and examines key methodological considerations in studies which take this approach. I begin by situating such research theoretically according to three dimensions, the discursive, ethnographic and historiographic, pointing out existing synergies between relatively distinct theoretical and methodological traditions. To examine how policy analyses can benefit from integrating these approaches, I then present a case study in which this methodology was applied, focussing on the development and implementation of a language policy in Slovenia. I show how the use of historiographic methods of gathering sources and a discursive approach to analysing them allowed me to develop a detailed description of a highly complex policy text despite having no direct access to back-stage political deliberations.
... Acknowledging uncertainty can shift the discussion towards agreeing on a solution that will work in different ways for everyone (e.g., by discussing what needs to be excluded, by whom, and how to proceed), rather than agreeing on a common vision (Kalra et al., 2015). Mismatches between the way technical experts and decision makers interpret uncertainty have contributed to catastrophic misjudgments (Meyer et al., 2006;Vaughan, 1996;Watkins and Bazerman, 2003). Moreover, experts are prone to overconfidence, so it is imperative that researchers be attentive to their subjective biases and the limitations of their results, and to make these clearly visible when they communicate those (Fischhoff et al., 1982;Jasanoff, 2003). ...
Modeling is essential to characterize and explore complex societal and environmental issues in systematic and collaborative ways. Socio-environmental systems (SES) modeling integrates knowledge and perspectives into conceptual and computational tools that explicitly recognize how human decisions affect the environment. Depending on the modeling purpose, many SES modelers also realize that involvement of stakeholders and experts is fundamental to support social learning and decision-making processes for achieving improved environmental and social outcomes. The contribution of this paper lies in identifying and formulating grand challenges that need to be overcome to accelerate the development and adaptation of SES modeling. Eight challenges are delineated: bridging epistemologies across disciplines; multi-dimensional uncertainty assessment and management; scales and scaling issues; combining qualitative and quantitative methods and data; furthering the adoption and impacts of SES modeling on policy; capturing structural changes; representing human dimensions in SES; and leveraging new data types and sources. These challenges limit our ability to effectively use SES modeling to provide the knowledge and information essential for supporting decision making. Whereas some of these challenges are not unique to SES modeling and may be pervasive in other scientific fields, they still act as barriers as well as research opportunities for the SES modeling community. For each challenge, we outline basic steps that can be taken to surmount the underpinning barriers. Thus, the paper identifies priority research areas in SES modeling, chiefly related to progressing modeling products, processes and practices.
... 30,62 In cases where potential failure scenarios caused by irrational system behaviors have been identified, organizations that conduct system failure and risk analysis can sometimes discount such scenarios and not rigorously analyze the potential outcomes. 63,64 The problem of not identifying or discounting identified emergent system behaviors is compounded as SoS are developed by connecting multiple systems together. As the number of systems in an SoS increases, the likelihood of irrational system behaviors increases. ...
System of interest (SoI) failures can sometimes be traced to an unexpected behavior occurring within another system that is a member of the system of systems (SoS) with the SoI. This article presents a method for use when designing an SoI that helps to analyze an SoS for unexpected behaviors from existing SoS members during the SoI's conceptual functional modeling phase of system architecture. The concept of irrationality initiators—unanticipated or unexpected failure flows emitted from one system that adversely impact an SoI, which appear to be impossible or irrational to engineers developing the new system—is introduced and implemented in a quantitative risk analysis method. The method is implemented in the failure flow identification and propagation framework to yield a probability distribution of failure paths through an SoI in the SoS. An example of a network of autonomous vehicles operating in a partially denied environment is presented to demonstrate the method. The method presented in this paper allows practitioners to more easily identify potential failure paths and prioritize fixing vulnerabilities in an SoI during functional modeling when significant changes can still be made with minimal impact to cost and schedule.
... scientists [29], and Vaughan's study of the Challenger Launch Explosion [32] serve as exemplary historical ethnographies in the grounded theory tradition, while Clarke's Situational Analysis [9] serves as a good methodological resource. For answering certain kinds of questions (such as, where did this business of domains come from? ...
This paper re-traverses the author's investigations across several years as he sought to pin-down the meaning of the in vivo category 'domain'. The paper is a methodological reflection on the grounded theory approach to concept development, with a focus on the technical terms: in vivo category, iteration on the code, and sensitizing category. It is also a substantive theoretical contribution, elaborating the concept of a domain in computing, data and information science, and how it has long served as an organizing principle for developing computational systems. Four tricks of the trade for studying the 'logic of domains' are offered as sensitizing concepts to aid future investigations.
... para las compañías y los diseñadores de equipos de trabajo (Schaaf, Lucas & Hale, 1991 ;Hollnagel, Woods & Levenson, 2006 ;Rasmussen & Svedung, 2000 ;Reason, 2004 ;Vaughan, 1996). ...
... 6,8,9 As opposed to manufactured uncertainty, unintentional organizational uncertainty has earlier been labelled 'structural secrecy' by Diane Vaughan's analysis of the Challenger space shuttle disaster. 10 Her analysis was eventually issued as the book 'the Challenger Launch Decision', which described how a known criticality with the space shuttle O-ring seals during cold weather operations was not communicated to all NASA participants. With Vaughan's focus on sociological and organizational factors, she refuted the conventional explanation of a mere engineering and accountability problem, which was the earlier conclusion from the officially appointed Rogers Commission. ...
This paper describes fragmentation of information problems in relation to information dissemination from bleed air contamination reports on aircraft. Chemical contamination of the bleed air supply system may cause crew impairment and can negatively impact flight safety. By comparing and contrasting official investigation reports with other information sources, the validity of the available information is scrutinized. The results display a lack of centralized data about fume events. Additionally, there is inconsistency between data from different sources. Fragmentation of information makes it difficult for pilots and decision makers to accurately assess the extent of the problem.
... Risk communication is seen as part of risk management conducted in an organizational setting. A practiced based approach to risk management as an organizational activity is at the core of several previous studies, for example, the Challenger disaster (Vaughan, 1996), safety documentation (Sauer, 2003), work place safety (Gherardi et al., 1998;Gherardi and Nicolini, 2002;Grytnes, 2018), public transport (Corvellec, 2009;Boholm et al., 2012); transport infrastructure planning and river management (Boholm et al., 2012) and risk assessment (Corvellec, 2010). Practice theory foregrounds "risk work" in organizations (Power, 2016). ...
The study looks at government agency officials’ experiences of what characterizes successful and failed risk communication. It is theoretically positioned within a practice based approach to risk communication and management as an organizational activity, or “risk work”. Risk work in organizations build on sense making, alignment to commonly agreed prudent practices, and learning from experience. The empirical method consists of interviews with practitioners working with risk communication at six government agencies in Sweden, in the policy areas of food, chemicals, environmental protection, housing and building, traffic, and contingency planning and management. The study identifies several factors that according to the practitioners contribute to success and failure of risk communication work practice: strategic planning and decision making; inter-organizational collaboration and assigning of responsibility, predominantly with other agencies but also with external stakeholders; scientific knowledge and understanding of risk issues; interactions with the media; alignment of risk management; and formulating and disseminating the message. An additional finding is the tendency of the practitioners to make attributions in terms of causal explanations, internal or external to the organization, of success and failure in performing risk communication.
... In the 1980s, major and popular safety books had an ethnographic and sociological angle of analysis (e.g. Turner, 1978;Perrow, 1984;Vaughan, 1996), whereas 20 years later, popular books in safety exhibit an engineering oriented rational (starting with Reason, 1997), or a stronger combination of descriptive and normative intent (Hollnagel, 2004(Hollnagel, , 2014Dekker, 2011Dekker, , 2007Hopkins, 1999Hopkins, , 2000. ...
Safety Culture has now been for almost three decades a highly promoted, advocated and debated but contentious notion. This article argues first that one needs to differentiate between two waves of studies, debates, controversies and positions. A first one roughly from the late 1980s/early 1990s to mid-2000s which brought an important distinction between interpretive and functionalist views of safety culture, then a second wave, from mid-2000s to nowadays which brings additional and alternative positions among authors. Four views, some more radical and critical, some more neutral and some more enthusiastic about safety culture are differentiated in this article. It is contended that this evolution of the debate, this second wave of studies, should be understood within a broader historical and social context. It is characterised, borrowing insights from management studies, by patterns of interactions between academics, publishers, consultants, regulators and industries. In this context, safety culture appears in a new light, as a product among other (albeit a central one) of a safety field (and market) which is socially structured by this diversity of actors. This helps sensitise, first, the second wave of studies, debates, controversies and positions on safety culture of the past 15 years as identified in this article. Second, approaching safety culture through this angle is an opportunity to questions safety research more globally and, third, an occasion to pinpoint some of the currently unproblematised network properties of high-risk sociotechnical systems.
... Los problemas de encuadramiento se convirtieron en una constante que permitía a los administradores de los locales realizar actividades que involucraban riesgos mayores con menor inversión en seguridad. Esto produjo una rutinización del desvío (Vaughan, 1996) que se convirtió en modo oficializado de funcionamiento 9 . ...
A partir de un análisis de los resultados consignados en el informe de la Comisión Investigadora, y de otras fuentes secundarias pertinentes, en este capítulo se evalúan las deficiencias en la regulación y control públicos y en la gestión privada de los riesgos en espectáculos públicos que quedaron de manifiesto tras el catastrófico incendio de la discoteca República Cromañón el 30 de diciembre de 2004 en la Ciudad de Buenos Aires, así como los desafíos planteados por el evento en materia de construcción de capacidades institucionales.
Palabras clave: capacidades institucionales, entes de regulación y control de riesgos, gestión de la seguridad, espectáculos públicos, República Cromañón
This article examines regulation’s understanding of technology in American financial markets as means for rethinking the contours and institutional limits of governance in the age of financialization. The article identifies how the Securities and Exchange Commission perceived markets and their conceptual relation to technology throughout much of the long twentieth century by distilling the “ontologies” expressed by the agency’s leadership. Despite the fact that SEC’s commissioners recognized technologies as playing a central role in the market’s current and future operations, these were never effectively brought under regulatory scrutiny even when such action fell under the commission's jurisdictional remit. Rather than regulating technologies as constitutive of markets, the governance of the material devices of finance was discursively kept at arm's-length by presenting them as intractable objects that were external to financial innovation. Triangulating across several techniques of computational text analysis, this article shows how this interpretation of technology mirrored distinct shifts in how regulators understood markets, from being physical trading sites populated by agents that required vetting and certification to a distributed, multi-sited system surveilled through transparency and disclosure. Throughout these ontological transitions, technology’s inscrutability remained, limiting the capacity of the state and its regulatory agencies to shape the evolution of finance and its underlying infrastructures.
This article presents a discourse on the incorporation of organizational factors into probabilistic risk assessment (PRA)/probabilistic safety assessment (PSA), a topic of debate since the 1980s that has spurred discussions among industry, regulatory agencies, and the research community. The main contributions of this article include (1) identifying the four key open questions associated with this topic; (2) framing ongoing debates by considering differing perspectives around each question; (3) offering a categorical review of existing studies on this topic to justify the selection of each question and to analyze the challenges related to each perspective; and (4) highlighting the directions of research required to reach a final resolution for each question. The four key questions are: (I) How significant is the contribution of organizational factors to accidents and incidents? (II) How critical, with respect to improving risk assessment, is the explicit incorporation of organizational factors into PRA? (III) What theoretical bases are needed for explicit incorporation of organizational factors into PRA? (IV) What methodological bases are needed for the explicit incorporation of organizational factors into PRA? Questions I and II mainly analyze PRA literature from the nuclear domain. For Questions III and IV, a broader review and categorization is conducted of those existing cross‐disciplinary studies that have evaluated the effects of organizational factors on safety (not solely PRA‐based) to shed more light on future research needs.
The very beginning of collaborative research endeavors often lies in politically difficult and practically challenging entanglements. The purpose of this paper is to empirically capture and theoretically conceptualize these entanglements. I trace the power-driven prefiguration of my own role in a transdisciplinary project and argue that the early moments (the 'phase zero') of collaborative research are entwined with a tacit, tactical, and relational form of control. In a process that I call 'scripting control,' actors seek to co-determine what a project may become, without being able to forecast or backcast a pathway to get there. Collaborators mutually launch counter-scripts and tacitly shape the possibility space that constrains or enables subsequent interactions. My own transdisciplinary involvement illustrates, however, that counter-scripts proposed by latecomers can fail if the project has passed the phase zero. This argument extends the current use of scripts in Science and Technology Studies to also involve temporal power dynamics. Moreover, in sustainability studies, my argument contributes to a growing critique against the imaginary of co-design, which promotes a managerial idea of ordering collaborative processes in a socially and epistemically inclusive way.
Threats to human health reside in the environment – for example, famine, war, pollution, poverty and disease – and in treatment. To secure further improvements in life expectancy, society must address both the threat without, and the threat within. Lives are in jeopardy not only from global diseases such as Ebola, H1N1 and H5N1, but also from medical error. One of the ironies of medicine is that sometimes the cure kills. Despite investing in patient safety initiatives, each year Britain’s National Health Service (NHS) records around 12,000 ‘avoidable deaths’ (a term coined by the NHS itself). In 2013–2014, NHS England received 174,872 written complaints from patients. In 2017, the NHS carried a contingent liability of over £26 billion for claims alleging medical error. In the United States, the three biggest killers are cancer, heart disease and medical error. The World Health Organisation is very concerned about the human and financial costs of medical error. The risk of medical error can be reduced first, by securing a second opinion, secondly, by actioning patient and employee suggestions and thirdly, by engaging in proactive risk management. The chapter elaborates the latter option, specifically, how a tool used to manage operational risk in commercial aviation could be adapted for use in healthcare.
This article identifies limitations in traditional approaches to engineering ethics pedagogy, reflected in an overreliance on disaster case studies. Researchers in the field have pointed out that these approaches tend to occlude ethically significant aspects of day-to-day engineering practice and thus reductively individualize and decontextualize ethical decision-making. Some have proposed, as a remedy for these defects, the use of research and theory from Science and Technology Studies (STS) to enrich our understanding of the ways in which technology and engineering practice are intricated in social and institutional contexts. While endorsing this approach, this article also argues that STS scholarship may not sufficiently address the kinds of questions about normativity and agency that are essential to engineering ethics. It proposes making use of the growing body of research in a field called “postphenomenology,” an approach that combines STS research with the traditional phenomenological concern with the standpoint of lived-experience. Postphenomenology offers a method of inquiry that combines STS’s investigation into social and institutional dimensions of technology with phenomenological reflection on our lived experience of embodied engagement with technical objects and sociotechnical systems, particularly the ways in which these involvements affect our moral perception and agency. The aim in using this approach in engineering ethics is thus to illuminate moral dimensions of everyday professional life of which practitioners may not typically be aware. The article concludes with some concrete curricular interventions for engineering ethics classrooms.
How, in a context of growing critiques of financialization, can law contribute to protecting the legitimacy of finance? This paper argues that the assignment of responsibilities between individuals and organizations plays a decisive role, using the recent Libor scandal as an empirical illustration. To do so, the paper offers a Foucauldian framework, the differential management of financial illegalisms, dedicated to the study of illegalities in financial capitalism. The comparison of the legal treatment of two manipulations of Libor, this key benchmark in financial markets, reveals how mid‐level traders have been the object of criminal prosecution, while law undervalued the role of top managers and organizations. To capture how differential management is performed in practice, I analyze precisely how the conflict‐resolution devices (criminal trial vs. settlement) and the social categorizations prevailing in the two manipulations of Libor favor different forms of responsibility, individual or organizational. I conclude by exploring the implications of law's relationship to financial legitimacy.
When external events disrupt the normal flow of organizational and relational routines and practices, an organization’s latent capacity to rebound activates to enable positive adaptation and bounce back. This article examines an unexpected organizational crisis (a shooting and standoff in a business school) and presents a model for how resilience becomes activated in such situations. Three social mechanisms describe resilience activation. Liminal suspension describes how crisis temporarily undoes and alters formal relational structures and opens a temporal space for organization members to form and renew relationships. Compassionate witnessing describes how organization members’ interpersonal connections and opportunities for engagement respond to individuals’ needs. And relational redundancy describes how organization members’ social capital and connections across organizational and functional boundaries activate relational networks that enable resilience. Narrative accounts from the incident support the induced model.
Drawing on interviews with 88 middle school counselors tasked with implementing New York City’s high school choice policy, we show that counselors largely question the policy’s legitimacy and the equity of the high school assignments it produces. By highlighting issues of transparency and procedural fairness that threaten counselors’ acceptance of school choice policy, we offer lessons for policymakers and practitioners about how policy design and communication affect policy legitimacy and, as a result, implementation.
The neglect of Goethe, his work in general, and Faust in particular, in English-speaking countries, is notorious. While Shakespeare’s plays have been prominent and widely performed in German-speaking countries, the same is not true for Goethe in the English-speaking world. Focusing non-exclusively on Faust, and cutting a link to Thomas Mann’s Doctor Faustus, I will endeavor to delineate problematic aspects of American ideology, and what it would take, within U.S. sociology, to be cognizant of the latter. Georg Lukacs wrote about Goethe and Faust, and so did Theodor W. Adorno and Leo Loewenthal, highlighting its importance to critical theory. The goal is to delineate a critical theory of American ideology that cannot be developed from a perspective from within the US alone, and of the role Shakespeare’s work has been playing in normalizing the prevalence and workings key aspects of this ideology.
Harm facilitated by corporations has received increased attention in recent years. However, corporate crime and harm remain under-researched themes in relation to labour exploitation, in both theoretical and empirical terms. The purpose of this article is to argue that, in the context of agricultural and food supply networks, harmful labour practices result from structural problems associated with the demand for products. Although individual employers and businesses have a role in facilitating these harmful practices, these practices also emerge from otherwise legitimate agri-food supply network dynamics, such as subcontracted labour, which results in fragmented responsibility. Therefore, labour practices have significant implications for the nature, organization and control of corporate harms, whereby harmful consequences become normalized, accepted and embedded in agri-food supply network practices. Criminological analyses of food production and contemporary markets more widely can begin to address the systemic challenges of harmful labour practices, in both domestic and global supply networks.
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