Fourteen years ago today, seven astronauts died in NASA's worst and most public tragedy to date. Failed O-rings caused the Shuttle to explode, but many organizational causes led to it. More disturbingly, NASA persistently misread, misinterpreted and misused available safety warnings. Vaughan believes the tragedy was further misdiagnosed during the subsequent investigation.
Retrospective fallacy is the imperfect reconstruction of an event, even with the luxury of history.
Despite usually having less information than investigators, participants are expected to have figured everything out at the time. The politics of blame, so satisfying and so natural, are also self-blinding . People in organizations are under great pressure to get along with each other to conform, even if it means going against their better judgment. Rules and regulations don t yell at you when the project is running late or over budget, but the boss probably will. The social and rational construction of risk includes assessing the probability and consequences of being caught.