How to Design a Safety Organization: Test Case for Resilience Engineering
In the aftermath of the Columbia space shuttle accident (STS-107), the investigation board found evidence of an organizational accident as NASA failed to balance safety risks with intense production pressure (Gheman, 2003). Ironically, a previous investigation examining a series of failures in Mars exploration missions also focused on breakdowns in organizational decision-making in their recommendations (Stephenson et al., 2000). Both reports diagnosed a process where the pressure for production to be ‘faster, better, cheaper’, combined with poor feedback about eroding safety margins, led management inadvertently to accept riskier and riskier decisions. ...
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