Abstract

Diane Vaughan’s popular book, The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA, advances a thesis that I termed the “cog in the machine manifesto”: since the Challenger disaster was the result of the determined, mechanistic movement of the parts of the organizational system; once the mechanism was set in motion, the disaster was inevitable, and could not have been prevented. In order to expose the fallacies of the cog in the machine manifesto, I consider an alternative umbrella thesis and four sub-theses. The umbrella thesis proposes that the causes of the Challenger disaster were the lack of an overall 'safety first' ethos, and irresponsible choice and poor decision-making practices in the lead up to and including the final risky decision. The four sub-theses are as follows: (1) the widespread justification that one always faces inherent risk when one operates in the realm of risky technology (a thesis foreshadowed by Vaughan’s book) is an illicit and misleading justification when one considers that there is no binding necessity to employ the risky technology; (2) the real culprit is not so much "risky technology," which locates the risk in the technology, but "risky assessment," which locates the risk in the decision to employ technology while not basing that decision on known safe designs and continued use on performance data; (3) the decision to choose an Orbiter without a passenger and crew abort system is proof in and of itself of a lack of a "safety first" management priority; (4) an analysis of the fateful eve of the Challenger launch teleconference launch decision makes it impossible to construe it as a banal, routine and inevitable organizational mistake. A careful examination of the “cog in the machine manifesto” and similar frameworks that purport to explain moral disasters will reveal that the language of risky technology, organizational complexity, and inevitable accidents is deeply pernicious and should thus be avoided at all costs.