Organization at the Limit

William H. Starbuck is ITT Professor of Creative Management in the Stern School of Business at New York University. He has been the editor of Administrative Science Quarterly and chaired the screening committee for senior Fulbright awards in business management; he was the President of the Academy of Management, and he is a Fellow in the Academy of Management, American Psychological Association, American Psychological Society, British Academy of Management, and Society for Industrial and Organizational Psychology. He has published more than 120 articles on accounting, bargaining, business strategy, computer programming, computer simulation, forecasting, decision-making, human--computer interaction, learning, organizational design, organizational growth and development, perception, scientific methods, and social revolutions. Moshe Farjoun is an associate professor at the Schulich School of Business, York University, Toronto. His research interests lie in the intersection of strategic management and organization. His research has explored market and organizational dynamics, particularly as they pertain to the processes of strategy formulation, implementation and change. His articles have appeared in Strategic Management Journal, Academy of Management Journal, Organization Science, and Academy of Management Review.

• Notes on contributors. Foreword: Sean O'Keefe.Part I: Introduction.1 Introduction: Organizational Aspects of the Columbia Disaster: Moshe Farjoun and William H. Starbuck (New York University).Part II: The Context of the Disaster.2 History and Policy in the Space Shuttle Program: Moshe Farjoun (New York University).3 System Effects: On Slippery Slopes, Repeating Negative Patterns, and Learning from Mistake? Diane Vaughan (Boston College).4 Organizational Learning and Action in the Midst of Safety Drift: Revisiting the Space Shuttle Program’s Recent History: Moshe Farjoun (New York University).5 The Space Between in Space Transportation: A Relational Analysis of the Failure of STS-107: Karlene H. Roberts, Peter M. Madsen, Vinit M. Desai (University of California – Berkley).Part III: Influences on decision making.6 The Opacity of Risk: Language and the Culture of Safety in NASA’s Space Shuttle Program: Willie Ocasio (Northwestern University).7 Coping with Temporal Uncertainty: When Rigid, Ambitious Deadlines Don’t Make Sense: Sally Blount (New York University), Mary Waller (Tulane University), and Sophie Leroy (New York University).8 Attention to Production Schedule and Safety as Determinants of Risk-Taking in NASA’s Decision to Launch the Columbia Shuttle: Angela Buljan (University of Zagreb) and Zur Shapira (New York University).Part IV: The Imaging Debate.9 Making Sense of Blurred Images: Mindful Organizing in Mission STS-107: Karl Weick (University of Michigan).10 The Price of Progress: Structurally Induced Inaction: Scott A. Snook and Jeffrey C. Connor (Harvard University).11 Data Indeterminacy: One NASA, Two Modes: Raghu Garud and Roger Dunbar (New York University).12 The Recovery Window: Organizational Learning Following Ambiguous Threats: Amy C. Edmondson, Michael A. Roberto, Richard M.J. Bohmer, Erika M. Ferlins, Laura R. Feldman (Harvard University).13 Barriers to the Interpretation and Diffusion of Information about Potential Problems in Organizations: Lessons from the Space Shuttle Columbia: Frances Milliken, Theresa K. Lant, and Ebony Bridwell-Mitchell (New York University).Part V: Beyond Explanation.14 Systems Approaches to Safety: NASA and the Space Shuttle Disasters: Nancy Leveson, Joel Cutcher-Gershenfeld, John S. Carroll, Betty Barrett, Alexander Brown, Nicolas Dulac, Lydia Fraile, and Karen Marais (MIT).15 Creating Foresight: Lessons for Enhancing Resilience from Columbia: David Woods (Ohio State).16 Making NASA More Effective: William H. Starbuck (New York University) and Johnny Stevenson (NASA).17 Observations on the Columbia Accident: Henry McDonald (University of Tennessee).Part VI: Conclusion.18 Conclusion: Moshe Farjoun and William H. Starbuck (New York University).Index

“The authors lift up the heavy curtain of secrecy at NASA to look at the many backstage decisions that led to the Columbia space shuttle disaster. Organizational leaders too often fail to learn from their past mistakes, but readers of this volume will be better equipped to understand and hopefully prevent future catastrophic failures.” Scott D. Sagan, Stanford University “As the influential philosopher Karl Popper observed, to avoid perishing along with our false theories, we systematically try to eliminate our false theories, letting them die in our stead. The Columbia disaster is a stark and tragic lesson in the consequences of false theories. Using the Columbia disaster and NASA as its focal points, Organization at the Limit offers a rich, multifaceted examination that reveals how and why complex organizations using risky technologies often produce and sustain false theories. The analysis yields insights indispensable for those who wish to help such organizations unlearn their false theories, learn more truthful ones, and avoid the disasters that lurk beyond their limits.” Joel A. C. Baum, University of Toronto “The Columbia disaster has much to teach any student and manager of organizations. In this marvellous collection, Professors Farjoun and Starbuck have assembled some of the most profound and relevant thinking about the hitherto hidden vulnerabilities of today’s organizations, their sources, and just how to address them. Readers will be most amply rewarded.” Danny Miller, HEC Montreal “The CAIB report was the most sophisticated official examination of an accident ever. Now we have an exhaustive social science exploration which amplifies, extends, enriches, and even at times contradicts the Board’s analysis. A variety of theoretical perspectives are applied, generating many fresh insights.” Charles Perrow, Yale University Howard Aldrich, Review on Amazon: After two horrible disasters, do you think that NASA has learned from its mistakes, and that it will never happen again? If so, you need to read this book! In 18 well-written chapters, the editors have assembled a set of experts on organizations and disasters to analyze lessons from the Columbia disaster. Because the Challenger disaster foreshadowed many of the problems that subsequently turned up in official investigations of the Columbia disaster, it also figures heavily in this edited book. The authors demonstrate the analytic power of an historically informed organizational analysis of a large governmental agency under strong political pressure to produce results with limited resources. Two points in particular caught my eye. First, after the Challenger disaster, NASA was supposedly reorganized to place greater emphasis on safety. However, because the organization began to define the space exploration program as a problem of meeting production goals and deadlines, "safety" never achieved the priority in the organization than it deserved. Instead of seeing the space shuttle program as a developmental one, exploring the risky frontier of technological knowledge, NASA officials treated it like any other flight program. Second, as anomalies continued to crop up after flights, engineers and officials began to think about deviations from acceptable practices and outcomes as "normal." As deviation was normalized, unusual events were taken for granted and didn't provoke the kind of response than one would expect from life threatening occurrences. Scholars interested in organization studies, organizational learning, systems theory, and other academic disciplines will learn much from this book. However, one can also hope that public officials will take its lessons to heart and look more closely at the design of other risky systems that are operating close to the limits of our scientific knowledge. Amazon