A C C I D E N T I N V E S T I G A T I O N B O A R D
COLUMBIA
1 9 5R e p o r t V o l u m e I A u g u s t 2 0 0 3
The Board began its investigation with two central ques-
tions about NASA decisions. Why did NASA continue to fly
with known foam debris problems in the years preceding the
Columbia launch, and why did NASA managers conclude
that the foam debris strike 81.9 seconds into Columbiaʼs
flight was not a threat to the safety of the mission, despite
the concerns of their engineers?
8.1 ECHOES OF CHALLENGER
As the investigation progressed, Board member Dr. Sally
Ride, who also served on the Rogers Commission, observed
that there were “echoes” of Challenger in Columbia. Ironi-
cally, the Rogers Commission investigation into Challenger
started with two remarkably similar central questions: Why
did NASA continue to fly with known O-ring erosion prob-
lems in the years before the Challenger launch, and why, on
the eve of the Challenger launch, did NASA managers decide
that launching the mission in such cold temperatures was an
acceptable risk, despite the concerns of their engineers?
The echoes did not stop there. The foam debris hit was not
the single cause of the Columbia accident, just as the failure
of the joint seal that permitted O-ring erosion was not the
single cause of Challenger. Both Columbia and Challenger
were lost also because of the failure of NASA̓ s organiza-
tional system. Part Two of this report cites failures of the
three parts of NASA̓ s organizational system. This chapter
shows how previous political, budgetary, and policy deci-
sions by leaders at the White House, Congress, and NASA
(Chapter 5) impacted the Space Shuttle Programʼs structure,
culture, and safety system (Chapter 7), and how these in turn
resulted in flawed decision-making (Chapter 6) for both ac-
cidents. The explanation is about system effects: how actions
taken in one layer of NASA̓ s organizational system impact
other layers. History is not just a backdrop or a scene-setter.
History is cause. History set the Columbia and Challenger
accidents in motion. Although Part Two is separated into
chapters and sections to make clear what happened in the
political environment, the organization, and managers ̓and
engineers ̓decision-making, the three worked together. Each
is a critical link in the causal chain.
This chapter shows that both accidents were “failures of
foresight” in which history played a prominent role.1 First,
the history of engineering decisions on foam and O-ring
incidents had identical trajectories that “normalized” these
anomalies, so that flying with these flaws became routine
and acceptable. Second, NASA history had an effect. In re-
sponse to White House and Congressional mandates, NASA
leaders took actions that created systemic organizational
flaws at the time of Challenger that were also present for
Columbia. The final section compares the two critical deci-
sion sequences immediately.
The Challenger and Columbia Shuttle DisastersTo be considered co.docxmamanda2
The Challenger and Columbia Shuttle Disasters
To be considered complete, all written assignments must include proper citations within the body of the paper when relevant, as well as a References section. Failure to cite outside sources is plagiarism and will be treated as such! You must also include a title page. Do not include pictures or graphics. All documents must be in Word format and in APA writing styles. The completed assignment must be uploaded in the ASSIGNMENT area by the specified deadline.
The title page must include Student Name, Course Name and Number, Assignment Name, Professor’s Name, and Assignment Date.
The introduction provides sufficient background on the topic and previews major points.
Assignment Description/Scenario
Read the story about the Challenger and Columbia Shuttle Disasters below, and respond to the attached questions, using the specifications above. Each response must be at least a paragraph in length.
STORY:
The
Challenger
Disaster
On January 28, 1986, the space shuttle
Challenger
rose into the sky, its seven crew members strapped into their padded seats while the 2,000-ton vehicle vibrated as it gained speed and altitude. The launch was going perfectly. Seventy seconds had passed since lift-off, and the shuttle was already 50,000 feet above the earth. From NASA Mission Control at Houston’s Johnson Space Center, Spacecraft Communicator Richard Covey instructed, “
Challenger
, go at throttle up.” “Roger, go at throttle up,” replied
Challenger
Commander Dick Scobee.
In the next few seconds, however,
Challenger
experienced some increasingly violent maneuvers. The pilot, Mike Smith, expressed his sudden apprehension: “Uh-oh.” In MissionPage 376 Control, the pulsing digits on the screen abruptly stopped. Mission Control spokesman Steve Nesbitt sat above the four console tiers. For a long moment he stared around the silent, softly lit room. The red ascent trajectory line was stationary on the display screen. Finally he spoke: “Flight controllers here looking very carefully at the situation. Obviously a major malfunction.”
Headed by former Secretary of State William Rogers, the Presidential Commission that was set up to investigate the cause of the
Challenger
disaster had little trouble identifying the physical cause. One of the joints on a booster rocket failed to seal. The “culprit” was one of the synthetic rubber O-rings that were designed to keep the rockets’ superhot gases from escaping from the joints between the booster’s four main segments. When one of the O-rings failed, the resulting flames burned through the shuttle’s external fuel tank. Liquid hydrogen and liquid oxygen then mixed and ignited, causing the explosion that destroyed
Challenger
.
However, the so-called Rogers Commission investigations also revealed a great deal about the internal workings of NASA. It was a geographically dispersed matrix organization. Headquarters were in Washington, DC, where its most senior mana.
The Challenger Disaster A Case-study in Engineering Ethics.docxmamanda2
The Challenger Disaster
A Case-study in Engineering Ethics
• Shuttle Components
– Orbiter
– Liquid Rocket
Booster
– Solid Rocket
Booster
Shuttle Components
Chronology of the Related Events
• 1974
– NASA contracts Morton Thiokol
• 1976
– NASA accepts the design based on the Titan
missiles
– The joints are sealed by
• Two synthetic rubber O-rings,
• 177 clevis pins,
• Heat shield putty
The Cause of the Disaster
Early Problems
• 1977
– Tests at Thiokol show O-ring leakage
– Joint is made stronger by changing sizes
• 1981
– Post-launch investigation showed O-ring
erosion due to hot gages.
Early Problems
• January of 1985 launch
– First cold-weather launch
– Post-launch investigation showed joint failure
– Tests showed O-rings inability to fill the gap
due to joint rotation at lower temperatures
Early Problems
• July 1985
– Thiokol redesigns the joints w/o O-rings – The
design was not ready for Challenger launch
Political Climate
• Congress is unhappy with NASA
• Competition with Russians to be the first to
observe Halley’s comet.
• Pressure to launch before President
Reagan’s State of the Union Address
Days before Launch
• First launch attempt postponed
• The next launch date was set and was to be
attended by Vice President Bush.
• The temperature at launch: 29 degrees F.
Days Before Launch
• NASA starts an investigation of the effect
of low temperatures on the O-ring seals
• Organization involved
– NASA
– Marshall Space Flight Center
– Morton Thiokol
Engineering Investigation Before
Launch
• Players at NASA
– Larry Mulloy: SRB Project Manager at Marshall
• Players at Thiokol
– Roger Boisjoly: A SRB engineer
– Arnie Johnson: A SRB engineer
– Joe Kilminster: SRB engineering manager
– Alan McDonald: SRB engineering director
– Bob Lund: Vice president for engineering
– Jerald Mason: General manager
Engineering Investigation Before
Launch
• Boisjoly and Johnson recommend the
launch to be postponed.
• Bob Lund, the VP for engineering agrees
and makes a similar recommendation.
Investigation Before Launch
• Larry Mulloy, the NASA manager of SRB
asks Joe Kilminister, the SRB manager at
Thiokol, for his opinion.
• Kilminister agrees with other Thiokol
engineers and recommends a launch delay.
Investigation Before Launch
• After discussion with Mason
• Lund reverses his decision regarding
launch!
• Thiokol recommend the launch to proceed
The Launch in January 1986
• The overnight temperatures drop to 8 F
• The temperature of SRB at launch is 28 F
• There is an immediate blow-by of hot gas at
launch. The seal fails quickly over an arc of
70 degrees.
The Launch in January 1986
• The by-products of combustion forms a
glassy oxide that reseals the joint.
• The brittle oxide is shattered
• Hot gases quickly burn through.
Due August 7,2019First, watch the video Personal Potential The.docxmadlynplamondon
Due August 7,2019
First, watch the video "Personal Potential: The Power of One" by Dr. Verna Price at http://library.limestone.edu:2048/login?url=http://digital.films.com/PortalPlaylists.aspx?aid=4891&xtid=44027
Second, in a 500-750 word essay that addresses the following questions:
1. Dr. Price discusses the difference between personal and positional power, describe the difference, and give an example of a time in your life when you used both personal and positional power.
2. How is this idea of personal and/or positional power connected to being a leader? Explain.
First, watch the video "Personal Potential: The Power of One" by Dr. Verna Price at http://library.limestone.edu:2048/login?url=http://digital.films.com/PortalPlaylists.aspx?aid=4891&xtid=44027
Due August 2, 2019 (1-2 pages, APA)
1. What has seemed to be the major problem facing NASA? Apply your knowledge of group dynamics and decision making to identify the problem.
2. What must NASA accomplish to ensure the vitality of the space program? Has groupthink accounted for some of NASA’s problems? If so, what symptoms can you identify?
3. What group-decision making challenges has NASA faced in changing its culture?
Columbia Space Shuttle Disaster and the Future of NASA
Early on February 1, 2003, television viewers watched in disbelief and sadness as the space shuttle Columbia, returning from its mission, seemed simply to break apart. Later in a scathing report, investigators said that NASA’s management practices were as much to blame for the accident that killed seven astronauts as the foam that broke away from the fuel tank and hit the left wing during blastoff. The report concluded that NASA had known of problems with the foam insulation over a long period but had never invested the time or energy to resolve the problem.
Former astronaut and NBC analyst Sally Ride agreed with the findings. She noted that foam had been falling off the external tanks since the first shuttle launch and that it had fallen off on nearly every flight. Ride considered the foam problem an accident waiting to happen, which of course it did. NASA recognized the foam as a serious problem and tried to fix it; unfortunately, it didn’t get as much attention as many other problems NASA faced during the past decade.
Columbia was a sad reminder of the Challenger disaster 17 years earlier. In the case of Challenger, engineers suspected problems with O-rings, but didn’t fix them. It appeared that NASA didn’t learn from its mistakes with Challenger and, more important, that a deeper problem existed: Safety concerns had not been given top priority. According to Ride, while NASA officials did not suppress dissenting views, they did not encourage them. Echoes of Challenger? Ride thought so. The further the Columbia investigation progressed, the more echoes were heard. The Columbia Accident Investigation
Board cited several failures; chief among them a corporate culture at NASA that discouraged the communica ...
The Challenger and Columbia Shuttle DisastersTo be considered co.docxmamanda2
The Challenger and Columbia Shuttle Disasters
To be considered complete, all written assignments must include proper citations within the body of the paper when relevant, as well as a References section. Failure to cite outside sources is plagiarism and will be treated as such! You must also include a title page. Do not include pictures or graphics. All documents must be in Word format and in APA writing styles. The completed assignment must be uploaded in the ASSIGNMENT area by the specified deadline.
The title page must include Student Name, Course Name and Number, Assignment Name, Professor’s Name, and Assignment Date.
The introduction provides sufficient background on the topic and previews major points.
Assignment Description/Scenario
Read the story about the Challenger and Columbia Shuttle Disasters below, and respond to the attached questions, using the specifications above. Each response must be at least a paragraph in length.
STORY:
The
Challenger
Disaster
On January 28, 1986, the space shuttle
Challenger
rose into the sky, its seven crew members strapped into their padded seats while the 2,000-ton vehicle vibrated as it gained speed and altitude. The launch was going perfectly. Seventy seconds had passed since lift-off, and the shuttle was already 50,000 feet above the earth. From NASA Mission Control at Houston’s Johnson Space Center, Spacecraft Communicator Richard Covey instructed, “
Challenger
, go at throttle up.” “Roger, go at throttle up,” replied
Challenger
Commander Dick Scobee.
In the next few seconds, however,
Challenger
experienced some increasingly violent maneuvers. The pilot, Mike Smith, expressed his sudden apprehension: “Uh-oh.” In MissionPage 376 Control, the pulsing digits on the screen abruptly stopped. Mission Control spokesman Steve Nesbitt sat above the four console tiers. For a long moment he stared around the silent, softly lit room. The red ascent trajectory line was stationary on the display screen. Finally he spoke: “Flight controllers here looking very carefully at the situation. Obviously a major malfunction.”
Headed by former Secretary of State William Rogers, the Presidential Commission that was set up to investigate the cause of the
Challenger
disaster had little trouble identifying the physical cause. One of the joints on a booster rocket failed to seal. The “culprit” was one of the synthetic rubber O-rings that were designed to keep the rockets’ superhot gases from escaping from the joints between the booster’s four main segments. When one of the O-rings failed, the resulting flames burned through the shuttle’s external fuel tank. Liquid hydrogen and liquid oxygen then mixed and ignited, causing the explosion that destroyed
Challenger
.
However, the so-called Rogers Commission investigations also revealed a great deal about the internal workings of NASA. It was a geographically dispersed matrix organization. Headquarters were in Washington, DC, where its most senior mana.
The Challenger Disaster A Case-study in Engineering Ethics.docxmamanda2
The Challenger Disaster
A Case-study in Engineering Ethics
• Shuttle Components
– Orbiter
– Liquid Rocket
Booster
– Solid Rocket
Booster
Shuttle Components
Chronology of the Related Events
• 1974
– NASA contracts Morton Thiokol
• 1976
– NASA accepts the design based on the Titan
missiles
– The joints are sealed by
• Two synthetic rubber O-rings,
• 177 clevis pins,
• Heat shield putty
The Cause of the Disaster
Early Problems
• 1977
– Tests at Thiokol show O-ring leakage
– Joint is made stronger by changing sizes
• 1981
– Post-launch investigation showed O-ring
erosion due to hot gages.
Early Problems
• January of 1985 launch
– First cold-weather launch
– Post-launch investigation showed joint failure
– Tests showed O-rings inability to fill the gap
due to joint rotation at lower temperatures
Early Problems
• July 1985
– Thiokol redesigns the joints w/o O-rings – The
design was not ready for Challenger launch
Political Climate
• Congress is unhappy with NASA
• Competition with Russians to be the first to
observe Halley’s comet.
• Pressure to launch before President
Reagan’s State of the Union Address
Days before Launch
• First launch attempt postponed
• The next launch date was set and was to be
attended by Vice President Bush.
• The temperature at launch: 29 degrees F.
Days Before Launch
• NASA starts an investigation of the effect
of low temperatures on the O-ring seals
• Organization involved
– NASA
– Marshall Space Flight Center
– Morton Thiokol
Engineering Investigation Before
Launch
• Players at NASA
– Larry Mulloy: SRB Project Manager at Marshall
• Players at Thiokol
– Roger Boisjoly: A SRB engineer
– Arnie Johnson: A SRB engineer
– Joe Kilminster: SRB engineering manager
– Alan McDonald: SRB engineering director
– Bob Lund: Vice president for engineering
– Jerald Mason: General manager
Engineering Investigation Before
Launch
• Boisjoly and Johnson recommend the
launch to be postponed.
• Bob Lund, the VP for engineering agrees
and makes a similar recommendation.
Investigation Before Launch
• Larry Mulloy, the NASA manager of SRB
asks Joe Kilminister, the SRB manager at
Thiokol, for his opinion.
• Kilminister agrees with other Thiokol
engineers and recommends a launch delay.
Investigation Before Launch
• After discussion with Mason
• Lund reverses his decision regarding
launch!
• Thiokol recommend the launch to proceed
The Launch in January 1986
• The overnight temperatures drop to 8 F
• The temperature of SRB at launch is 28 F
• There is an immediate blow-by of hot gas at
launch. The seal fails quickly over an arc of
70 degrees.
The Launch in January 1986
• The by-products of combustion forms a
glassy oxide that reseals the joint.
• The brittle oxide is shattered
• Hot gases quickly burn through.
Due August 7,2019First, watch the video Personal Potential The.docxmadlynplamondon
Due August 7,2019
First, watch the video "Personal Potential: The Power of One" by Dr. Verna Price at http://library.limestone.edu:2048/login?url=http://digital.films.com/PortalPlaylists.aspx?aid=4891&xtid=44027
Second, in a 500-750 word essay that addresses the following questions:
1. Dr. Price discusses the difference between personal and positional power, describe the difference, and give an example of a time in your life when you used both personal and positional power.
2. How is this idea of personal and/or positional power connected to being a leader? Explain.
First, watch the video "Personal Potential: The Power of One" by Dr. Verna Price at http://library.limestone.edu:2048/login?url=http://digital.films.com/PortalPlaylists.aspx?aid=4891&xtid=44027
Due August 2, 2019 (1-2 pages, APA)
1. What has seemed to be the major problem facing NASA? Apply your knowledge of group dynamics and decision making to identify the problem.
2. What must NASA accomplish to ensure the vitality of the space program? Has groupthink accounted for some of NASA’s problems? If so, what symptoms can you identify?
3. What group-decision making challenges has NASA faced in changing its culture?
Columbia Space Shuttle Disaster and the Future of NASA
Early on February 1, 2003, television viewers watched in disbelief and sadness as the space shuttle Columbia, returning from its mission, seemed simply to break apart. Later in a scathing report, investigators said that NASA’s management practices were as much to blame for the accident that killed seven astronauts as the foam that broke away from the fuel tank and hit the left wing during blastoff. The report concluded that NASA had known of problems with the foam insulation over a long period but had never invested the time or energy to resolve the problem.
Former astronaut and NBC analyst Sally Ride agreed with the findings. She noted that foam had been falling off the external tanks since the first shuttle launch and that it had fallen off on nearly every flight. Ride considered the foam problem an accident waiting to happen, which of course it did. NASA recognized the foam as a serious problem and tried to fix it; unfortunately, it didn’t get as much attention as many other problems NASA faced during the past decade.
Columbia was a sad reminder of the Challenger disaster 17 years earlier. In the case of Challenger, engineers suspected problems with O-rings, but didn’t fix them. It appeared that NASA didn’t learn from its mistakes with Challenger and, more important, that a deeper problem existed: Safety concerns had not been given top priority. According to Ride, while NASA officials did not suppress dissenting views, they did not encourage them. Echoes of Challenger? Ride thought so. The further the Columbia investigation progressed, the more echoes were heard. The Columbia Accident Investigation
Board cited several failures; chief among them a corporate culture at NASA that discouraged the communica ...
Gehman’s axiom number 3 (Columbia Space Shuttle)Cpo Creed
Gehman’s Axiom Number 3: They trivialized the work. They demanded studies, analyses, reviews, meetings, conferences, working groups, and more data. They keep everybody working hard, and they avoided the central issue: Were the crew and the
shuttle in danger? [This was] a classic case where individuals, well-meaning individuals, were swept along by the institution’s overpowering desire to protect itself. The system effectively blocked honest efforts to raise legitimate concerns.
There are several documentaries about the engineering disasters assoc.pdfanshuanil26
There are several documentaries about the engineering disasters associated with Hurricane
Katrina There are equally as many publications on the topic. Review at least three publications
(not blogs or media reports or public opinion-based sources) to address the following questions
What failed Why it failed Possible corrective actions Who was at fault and why Write a 3-5
page review addressing the afore-mentioned topics and include the following as well Describe in
detail what ethical issues may have been partly/wholly responsible for the failure Be sure to
address lack of professionalism or conscientiousness that may have helped lead to this failure
You must cite references appropriately and there must be at least three credible references.
Solution
Engineering Review of the Disaster caused by Hurricane Katrina
Even though 5 engineering review bodies operated separately, all of them reacted to IPET’s
work, the main and finest funded of the study groups. Volumes 2 through 7 of the IPET “draft
final” report divide the results into six broad sections:
1. Geodetic Vertical and Water Level Datums
2. Hurricane Protection System
3. The Storm
4. The Performance of the Levees and Floodwalls
5. Performance of Interior Drainage and Pumping
6. The Consequences; and Engineering and Operational Risk and Reliability Analyses
The report is more than 6,000 pages extensive so far, and the last section on risk and reliability
has not yet appeared. The NAE/NRC team and the ASCE team both prepared their commentary
to conform to the IPET pattern.
In reviewing a study of this kind, it is significant to keep in mind that critiques may address the
quality of the design and construction for facilities in place at the time of the hurricane or the
adequacy of the post-hurricane investigations described in the report. For example, one might
find that the wind and water levels used for the design calculations were not adequate but that the
hind-casting calculations of the hurricane’s effects described in the report are excellent. The
NAE/NRC team and the ASCE team had similar reactions, with some minor differences of
detail.
The detailed study of the geodetic levels revealed considerable room for confusion and error.
Two different benchmark levels were used in creating the levee system. In some cases, the water
levels were expressed against one benchmark and the height of the levees against another.
Furthermore, there seemed to be no consistent effort to monitor subsidence of the levee system
or its components. The focus was on building the levees to the “authorized” elevations without
considering whether the corresponding water elevations were measured from the same base or
whether subsequent settlement and subsidence might make the authorized levels irrelevant.
Ethical Issues:
All of the review teams found that the hurricane protection system was a system in name only.
Planning and system-wide design were confused by political and short-term economic
considerations over.
1 Which typical team challenges refer to those in the book.pdfabhishek483040
1. Which typical team challenges (refer to those in the book) were present in the case? Explain.
2. Which types of decision-making pitfalls were present in this case? Explain.
3. Which symptoms of Groupthink were evidenced in the case? Explain.
4. Which team decision making pitfall prevention mechanisms could be put in place to prevent this from happening again at NASA?
5. Which aspects of the organizational/team environment (blue box in the Team Effectiveness Model) could should be changed so that a
disaster like this could not happen again at NASA? Explain. How could this be done?
6. Which aspects of team design (green box in the Team Effectiveness Model) could should be changed so that a disaster like this could
not happen again at NASA? Explain. How could this be done?
7. Which team processes (orange box in the Team Effectiveness Model) could should be changed so that a disaster like this could not
happen again at NASA? Explain. How could this be done?
shapes and images that are... more repeatedly, thus reducing both the engineering cost and
hardware costs. However, resulting vehicle was not as envisioned. II had severe design flaws, one
of which caused the loss of the Challenger. NASA Planning and Politics: NASA's post-Apollo plans
for the continued manned exploration of space rested on a three legged triad. The first leg was a
reusable space transportation system, the Space Shuttle, which could transport men and cargo to
low earth orbit (LEO) and then land back on Earth to prepare for another mission. The second leg
was a manned orbiting space station which would be resuppled by the Shuttle and would serve as
both a transfer point for activities further from Earth and as a scientific and manufacturing platform.
The final leg was the exploration of Mars, which would start from the Space Station. Unfortunately
the politics and inflation of the early 70 's forced NASA to retreat from its ambitious program. Both
the Space Station and the Journey to Mars were delayed indefinitely and the United States
manned space program was left standing on one leg, the space shuttle. Even worse, the Shuttle
was constantly under attack by a Democratic congress and poorly defended by a Republican
president. To retain Shuttle funding. NASA was forced to make a series of major concessions.
First, facing a highly constrained budget, NASA sacrificed the research and development
necessary to produce a truly reusable shuttle, and instead accepted a design which was only
partially reusable, eliminating one of the features which made the shutlie attractive in the first
place. Solid rocket boosters (SRBs) were used instead of safer liquid fueled boosters because
they required a much smaller research and development effort. Numerous other design changes
were made to reduce the level of research and development required. Second, to increase its
political clout and to guarantee a steady customer base, NASA enlisted the support of the United
States Air Force. The Air Fo.
The Space Shuttle Challenger Disaster
The explosion of the space shuttle Challenger is perhaps the most widely written about case in engineering ethics because of the extensive media coverage at the time of the accident and also because of the many available government reports and transcripts of congressional hearings regarding the explosion. The case illustrates many important ethical issues that engineers face: What is the proper role of the engineer when safety issues are a concern? Who should have the ultimate decision making authority to order a launch? Should the ordering of a launch be an engineering or a managerial decision? This case has already been presented briefly, and we will now take a more in-depth look,
Report on the Loss of the Mars Polar Lander and Deep Space 2 Missions.Om Shukla
The presented report is from Software Engineering and Management point of view, based on the evaluation of the reports provided by NASA and MPIAT. The report focuses on the early Design and Architecture decisions, the biding environment and its effect on the organisation assigned organization. The changes in the Organizational work culture, Risk management strategies, budgeting, staffing and Testing approach.
Zoe is a second grader with autism spectrum disorders. Zoe’s father .docxransayo
Zoe is a second grader with autism spectrum disorders. Zoe’s father recently passed away in a tragic car accident. Zoe, her mom, and two older brothers have temporarily relocated from out-of-state and are now living in her grandparents’ house in a small, rural community.
Because the family had been living out-of state, Zoe has never interacted with her grandparents. She has challenges responding to social cues, including her name and in understanding gestures. She also engages in repetitive body movements. She is fond of her set of dolls and likes lining them up. When Zoe is agitated, her mother plays Mozart, which seems to have a calming effect. Zoe also enjoys macaroni and cheese.
Her grandparents do not understand Zoe’s attempts at communicating. Zoe does not respond well to crowded and noisy environments. Zoe’s mom is working outside the home for the first time.
Because of the move, Zoe has transferred to a new school, which does not currently have any students with ASD. Although her mom is generally very involved with Zoe’s education, she is away from the home much of the time due to a long commute for her new job is a neighboring city.
Zoe’s grandparents are eager and willing to help in any way they can.
Imagine you are serving as an ASD consultant at Zoe’s new school. Using the COMPASS model, create a COMPASS Action Plan for Zoe by complete the following tasks:
Identify the personal challenges for Zoe;
Identify the environmental challenges for Zoe;
Identify potential supports; and
Identify and prioritize teaching goals.
In addition, include a 250-500-word rationale that explains how your action plan for Zoe demonstrates collaboration in a respectful, culturally responsive way while promoting understanding, resolving conflicts, and building consensus around her interventions.
.
Zlatan Ibrahimović – Sports Psychology
Outline
Introduction:
· General Info
· Nationality, Birthplace, Parents
· Childhood What he wanted to do growing up?
· When did he start playing professionally?
· Which teams did he play for?
· Give some of his career statistics and maybe records?
· What trophies has he won with club football and national team of Sweden?
· Style of Play
· What is his personality like? How do people see him in the media?\
·
Body Paragraphs
Connect the following Sports Psychology Concepts (or even those not listed) to Zlatan Ibrahimović
What is his personality type? Type A, B C, or D?
Give examples through research of where he shows this.
CATASTROPHE THEORY… OCCURS WHEN? WHAT DOES THE GRAPH LOOK LIKE
· Arousal: is a blend of physiological and psychological activity in a person and it refers to the intensity dimensions of motivation at a particular moment. It ranges from not aroused, to completely aroused, to highly aroused; this is when individuals are mentally and physically activated.
· Performance increases as arousal increases but when arousal gets too high performance dramatically decreases. This is usually caused by the performer becoming anxious and sometimes making wrong decisions. Catastrophes is caused by a combination of cognitive and somatic anxieties. Cognitive is the internal worries of not performing well while somatic is the physical effects of muscle tension/butterflies and fatigue through playing.
· The graph is an inverted U where the x line is the arousal and the y is the performance. Performance peaks on the top of the inverted U and the catastrophe happens in the fall of the inverted U
HIGH TRAIT ANXIETY ATHLETES… HOW DO THEY PERCEIVE COMPETITION?
· Anxiety: is a negative emotional state in which feelings of nervousness, worry and apprehension are associated with activation or arousal of the body
· Trait Anxiety: is a behavioral disposition to perceive as threatening circumstances that objectively may not be dangerous and to then respond with disproportionate state anxiety.
· Somatic Trait Anxiety: the degree to which one typically perceived heightened physical symptoms (muscle tension)
· Cognitive Trait Anxiety: the degree to which one typically worries or has self doubt
· Concentration Disruption: the degree to which one typically has concentration disruption during competition
People usually with high trait anxiety usually have more state anxiety in highly competitive evaluative situations than do people with lower trait anxiety. Example two athletes are playing basketball and both are physically and statistically the same both have to shoot a final free throw to win the game. Athlete A is more laid back which means his trait anxiety is lower and he doesn't view the final shot as a overly threatening. Athlete B has a high trait anxiety and because of that he perceives the final shot as very threatening. This has an effect on his state anxiety much more than.
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Gehman’s axiom number 3 (Columbia Space Shuttle)Cpo Creed
Gehman’s Axiom Number 3: They trivialized the work. They demanded studies, analyses, reviews, meetings, conferences, working groups, and more data. They keep everybody working hard, and they avoided the central issue: Were the crew and the
shuttle in danger? [This was] a classic case where individuals, well-meaning individuals, were swept along by the institution’s overpowering desire to protect itself. The system effectively blocked honest efforts to raise legitimate concerns.
There are several documentaries about the engineering disasters assoc.pdfanshuanil26
There are several documentaries about the engineering disasters associated with Hurricane
Katrina There are equally as many publications on the topic. Review at least three publications
(not blogs or media reports or public opinion-based sources) to address the following questions
What failed Why it failed Possible corrective actions Who was at fault and why Write a 3-5
page review addressing the afore-mentioned topics and include the following as well Describe in
detail what ethical issues may have been partly/wholly responsible for the failure Be sure to
address lack of professionalism or conscientiousness that may have helped lead to this failure
You must cite references appropriately and there must be at least three credible references.
Solution
Engineering Review of the Disaster caused by Hurricane Katrina
Even though 5 engineering review bodies operated separately, all of them reacted to IPET’s
work, the main and finest funded of the study groups. Volumes 2 through 7 of the IPET “draft
final” report divide the results into six broad sections:
1. Geodetic Vertical and Water Level Datums
2. Hurricane Protection System
3. The Storm
4. The Performance of the Levees and Floodwalls
5. Performance of Interior Drainage and Pumping
6. The Consequences; and Engineering and Operational Risk and Reliability Analyses
The report is more than 6,000 pages extensive so far, and the last section on risk and reliability
has not yet appeared. The NAE/NRC team and the ASCE team both prepared their commentary
to conform to the IPET pattern.
In reviewing a study of this kind, it is significant to keep in mind that critiques may address the
quality of the design and construction for facilities in place at the time of the hurricane or the
adequacy of the post-hurricane investigations described in the report. For example, one might
find that the wind and water levels used for the design calculations were not adequate but that the
hind-casting calculations of the hurricane’s effects described in the report are excellent. The
NAE/NRC team and the ASCE team had similar reactions, with some minor differences of
detail.
The detailed study of the geodetic levels revealed considerable room for confusion and error.
Two different benchmark levels were used in creating the levee system. In some cases, the water
levels were expressed against one benchmark and the height of the levees against another.
Furthermore, there seemed to be no consistent effort to monitor subsidence of the levee system
or its components. The focus was on building the levees to the “authorized” elevations without
considering whether the corresponding water elevations were measured from the same base or
whether subsequent settlement and subsidence might make the authorized levels irrelevant.
Ethical Issues:
All of the review teams found that the hurricane protection system was a system in name only.
Planning and system-wide design were confused by political and short-term economic
considerations over.
1 Which typical team challenges refer to those in the book.pdfabhishek483040
1. Which typical team challenges (refer to those in the book) were present in the case? Explain.
2. Which types of decision-making pitfalls were present in this case? Explain.
3. Which symptoms of Groupthink were evidenced in the case? Explain.
4. Which team decision making pitfall prevention mechanisms could be put in place to prevent this from happening again at NASA?
5. Which aspects of the organizational/team environment (blue box in the Team Effectiveness Model) could should be changed so that a
disaster like this could not happen again at NASA? Explain. How could this be done?
6. Which aspects of team design (green box in the Team Effectiveness Model) could should be changed so that a disaster like this could
not happen again at NASA? Explain. How could this be done?
7. Which team processes (orange box in the Team Effectiveness Model) could should be changed so that a disaster like this could not
happen again at NASA? Explain. How could this be done?
shapes and images that are... more repeatedly, thus reducing both the engineering cost and
hardware costs. However, resulting vehicle was not as envisioned. II had severe design flaws, one
of which caused the loss of the Challenger. NASA Planning and Politics: NASA's post-Apollo plans
for the continued manned exploration of space rested on a three legged triad. The first leg was a
reusable space transportation system, the Space Shuttle, which could transport men and cargo to
low earth orbit (LEO) and then land back on Earth to prepare for another mission. The second leg
was a manned orbiting space station which would be resuppled by the Shuttle and would serve as
both a transfer point for activities further from Earth and as a scientific and manufacturing platform.
The final leg was the exploration of Mars, which would start from the Space Station. Unfortunately
the politics and inflation of the early 70 's forced NASA to retreat from its ambitious program. Both
the Space Station and the Journey to Mars were delayed indefinitely and the United States
manned space program was left standing on one leg, the space shuttle. Even worse, the Shuttle
was constantly under attack by a Democratic congress and poorly defended by a Republican
president. To retain Shuttle funding. NASA was forced to make a series of major concessions.
First, facing a highly constrained budget, NASA sacrificed the research and development
necessary to produce a truly reusable shuttle, and instead accepted a design which was only
partially reusable, eliminating one of the features which made the shutlie attractive in the first
place. Solid rocket boosters (SRBs) were used instead of safer liquid fueled boosters because
they required a much smaller research and development effort. Numerous other design changes
were made to reduce the level of research and development required. Second, to increase its
political clout and to guarantee a steady customer base, NASA enlisted the support of the United
States Air Force. The Air Fo.
The Space Shuttle Challenger Disaster
The explosion of the space shuttle Challenger is perhaps the most widely written about case in engineering ethics because of the extensive media coverage at the time of the accident and also because of the many available government reports and transcripts of congressional hearings regarding the explosion. The case illustrates many important ethical issues that engineers face: What is the proper role of the engineer when safety issues are a concern? Who should have the ultimate decision making authority to order a launch? Should the ordering of a launch be an engineering or a managerial decision? This case has already been presented briefly, and we will now take a more in-depth look,
Report on the Loss of the Mars Polar Lander and Deep Space 2 Missions.Om Shukla
The presented report is from Software Engineering and Management point of view, based on the evaluation of the reports provided by NASA and MPIAT. The report focuses on the early Design and Architecture decisions, the biding environment and its effect on the organisation assigned organization. The changes in the Organizational work culture, Risk management strategies, budgeting, staffing and Testing approach.
Zoe is a second grader with autism spectrum disorders. Zoe’s father .docxransayo
Zoe is a second grader with autism spectrum disorders. Zoe’s father recently passed away in a tragic car accident. Zoe, her mom, and two older brothers have temporarily relocated from out-of-state and are now living in her grandparents’ house in a small, rural community.
Because the family had been living out-of state, Zoe has never interacted with her grandparents. She has challenges responding to social cues, including her name and in understanding gestures. She also engages in repetitive body movements. She is fond of her set of dolls and likes lining them up. When Zoe is agitated, her mother plays Mozart, which seems to have a calming effect. Zoe also enjoys macaroni and cheese.
Her grandparents do not understand Zoe’s attempts at communicating. Zoe does not respond well to crowded and noisy environments. Zoe’s mom is working outside the home for the first time.
Because of the move, Zoe has transferred to a new school, which does not currently have any students with ASD. Although her mom is generally very involved with Zoe’s education, she is away from the home much of the time due to a long commute for her new job is a neighboring city.
Zoe’s grandparents are eager and willing to help in any way they can.
Imagine you are serving as an ASD consultant at Zoe’s new school. Using the COMPASS model, create a COMPASS Action Plan for Zoe by complete the following tasks:
Identify the personal challenges for Zoe;
Identify the environmental challenges for Zoe;
Identify potential supports; and
Identify and prioritize teaching goals.
In addition, include a 250-500-word rationale that explains how your action plan for Zoe demonstrates collaboration in a respectful, culturally responsive way while promoting understanding, resolving conflicts, and building consensus around her interventions.
.
Zlatan Ibrahimović – Sports Psychology
Outline
Introduction:
· General Info
· Nationality, Birthplace, Parents
· Childhood What he wanted to do growing up?
· When did he start playing professionally?
· Which teams did he play for?
· Give some of his career statistics and maybe records?
· What trophies has he won with club football and national team of Sweden?
· Style of Play
· What is his personality like? How do people see him in the media?\
·
Body Paragraphs
Connect the following Sports Psychology Concepts (or even those not listed) to Zlatan Ibrahimović
What is his personality type? Type A, B C, or D?
Give examples through research of where he shows this.
CATASTROPHE THEORY… OCCURS WHEN? WHAT DOES THE GRAPH LOOK LIKE
· Arousal: is a blend of physiological and psychological activity in a person and it refers to the intensity dimensions of motivation at a particular moment. It ranges from not aroused, to completely aroused, to highly aroused; this is when individuals are mentally and physically activated.
· Performance increases as arousal increases but when arousal gets too high performance dramatically decreases. This is usually caused by the performer becoming anxious and sometimes making wrong decisions. Catastrophes is caused by a combination of cognitive and somatic anxieties. Cognitive is the internal worries of not performing well while somatic is the physical effects of muscle tension/butterflies and fatigue through playing.
· The graph is an inverted U where the x line is the arousal and the y is the performance. Performance peaks on the top of the inverted U and the catastrophe happens in the fall of the inverted U
HIGH TRAIT ANXIETY ATHLETES… HOW DO THEY PERCEIVE COMPETITION?
· Anxiety: is a negative emotional state in which feelings of nervousness, worry and apprehension are associated with activation or arousal of the body
· Trait Anxiety: is a behavioral disposition to perceive as threatening circumstances that objectively may not be dangerous and to then respond with disproportionate state anxiety.
· Somatic Trait Anxiety: the degree to which one typically perceived heightened physical symptoms (muscle tension)
· Cognitive Trait Anxiety: the degree to which one typically worries or has self doubt
· Concentration Disruption: the degree to which one typically has concentration disruption during competition
People usually with high trait anxiety usually have more state anxiety in highly competitive evaluative situations than do people with lower trait anxiety. Example two athletes are playing basketball and both are physically and statistically the same both have to shoot a final free throw to win the game. Athlete A is more laid back which means his trait anxiety is lower and he doesn't view the final shot as a overly threatening. Athlete B has a high trait anxiety and because of that he perceives the final shot as very threatening. This has an effect on his state anxiety much more than.
Zia 2Do You Choose to AcceptYour mission, should you choose.docxransayo
Zia 2
Do You Choose to Accept?
Your mission, should you choose to accept it, is to go out and see Mission: Impossible-Fallout. As I sat back in my red-cushioned seat, accompanied by my brothers, I knew I was in for something special. The film takes place two years after two-thousand fifteens hit movie, Mission: Impossible-Rogue Nation. While I had no clue what to expect, I knew I was going to be in for an incredible ride as soon as the movie began with the intense dialogue between Ethan Hunt (Tom Cruise) and Solomon Lane (Sean Harris). From beginning to end, Mission: Impossible- Fallout delivers crazy action-thriller scenes, inventive special effects, and creative cinematography.
Mission: Impossible-Fallout is based on a story of an American agent who must retrieve nuclear weapons from an enemy terrorist organization with help of his specialized IMF team. The film was consistent the first hour with it involving the audience in the mission of the secret organization and trying to figure out the next move of the evil organization known as the Apostles. However, towards the middle of the movie it was revealed that one of the CIA agents was playing the role of a double spy and was on the side of the Apostles. The plot delivered intense action-packed scenes between the opposing groups that personally had me at the edge of my seat. Whether it was a chase on motorcycles, cars, speedboats, or helicopters, each scene had Ethan Hunt running for his life to save the world. Even though I was only viewing the movie from a comfortable movie theater, Hunt zigzagging through the traffic of France on a motorcycle had my fists clenched and adrenaline pumping. However, that was not even the best thriller of the movie. Ethan Hunt trailing Agent Walker in a helicopter with heavy rounds of artillery being fired at each other through the snowcapped mountains of Kashmir may very well be one of the best action scenes in cinematic history. Mission: Impossible-Fallout can be appreciated and enjoyed by all audiences because of its action-packed scenes that keep everyone extremely engaged in the plot.
Mission: Impossible-Fallout brilliantly illustrates the amazing special effects that serve to create the theme and style of the film. From creating bloody wounds to spectacular backgrounds, special effects are abundant throughout the movie. For instance, as Hunt is jumping off an airplane, the special effects of this scene include wind, rain, thunder, and clouds that make the film visually appealing and almost realistic. The thunder striking him as he is skydiving had my jaw wide open simply because of how incredible the illusion was displayed. In almost every fight between Hunt’s team and the Apostles, multiple types of special effects were utilized. Fighting sequences with Hunt angrily running towards Lane and delivering devastating punches accompanied by “POWs” and “AAAHs” seemed so realistic that it had me feeling queasy in my stomach. The gunfire during these fight.
Ziyao LiIAS 3753Dr. Manata HashemiWorking Title The Edu.docxransayo
Ziyao Li
IAS 3753
Dr. Manata Hashemi
Working Title:
The Education Gap
Research Question:
How did the youth of Iran make up the education gap resulted from the Cultural Revolution from 1980 to 1982?
This is a critical question because it involves both education and the youth of Iran. Education and the youth are both very fundamental perspectives for a society to thrive. During the cultural revolution, the education system was shut down, which would undermine the overall quality of a generation. Research of this issue will lead us to the methods used to make up the education gap. It is possible to help other countries suffering similar issues.
Thesis Statement:
After the Iran’s cultural revolution during 1980 to 1982, the youth of Iran made up the education gap caused during the revolution by promoting student movements.
Outline:
· Introduction:
· Cultural Revolution happened in Iran during 1980 to 1982. The education institutions like universities were shut down for the 3-year period. And this gap in education brought significant influence on the youth of Iran at that time. However, the education gap was made up successfully after the revolution.
· State the thesis statement:
· The education gap is made up by the youth in Iran. They promoted the student movement to help the society recover from the revolution.
· The scars left from the revolution
· The revolution lasted 3 years, young people who were supposed to be students had to quit school. The government forced schools to close. The chain of delivering knowledge was broken. And young people cannot find proper things to do when quitting school.
· Student movements
· After the cultural revolution, people in Iran realized they need to correct the current education situation recover the damages resulted from the revolution. Since Iran’s youth has a great number in the society, their power was not to be ignored. They started to fight for their own rights and profits. They were looking for ways to make up the damage has been down. Then the student movement eventually worked for recovering Iran’s education level.
· Conclusion
· The cultural revolution in Iran hurt its education continuity. However, the youth of Iran managed to make up for the damage caused by the cultural revolution. Student movements played the dominant role in this recovering process.
Bibliography:
Khosrow Sobhe (1982) Education in Revolution: is Iran duplicating the Chinese Cultural Revolution?, Comparative Education, 18:3, 271-280, DOI: 10.1080/0305006820180304
Mashayekhi M. The Revival of the Student Movement in Post-Revolutionary Iran. International Journal of Politics, Culture & Society. 2001;15(2):283. doi:10.1023/A:1012977219524.
Razavi, R. (2009). The Cultural Revolution in Iran, with Close Regard to the Universities, and its Impact on the Student Movement. Middle Eastern Studies, 45(1), 1–17. https://doi-org.ezproxy.lib.ou.edu/10.1080/00263200802547586
ZABARDAST, S. (2015). Flourishing of Occid.
Ziyan Huang (Jerry)
Assignment 4
Brand Positioning
Professor Gaur
Target audience:
HR in Ping An Bank Co., Ltd. HRs (interviewers who hire people) from Ping An Bank are usually female, aged 30-40, who look friendly and easy-going. They are sophisticated and skeptic when checking people’s resumes and asking questions during interview. Usually, HRs care about four things: 1. Graduate school ranking. 2. Working experience in bank 3. Oral expression. 4. Personal character. They prefer people who are enthusiastic, energetic and hard-working.
Q1:
Compared to other people who also look for jobs in Ping An Bank, my points of parity would be: 1. I have earned a master degree in a Top 40 U.S. graduate school. 2. I have some intern experience in another bank. My points of differentiation would be: 1. I am confidence in speaking and self-expression. I can serve both Chinese and American clients because I speak fluent Mandarin and English. 2. I am energetic and hard-working. I always have passion in learning something new, which is a key for me to develop working skills.
Q2:
My brand essence: “Energetic, hard-working and modest.”
Q3:
Positioning statement:
Ziyan Huang is for employers from bank,
Who look for excellent employees.
Ziyan Huang is an energetic, hard-working NYU graduate student,
That has passion in developing new working skills.
Because he can speak fluent Mandarin and English,
And have one year working experience in China Merchant Bank,
So that employers can trust him as a reliable candidate.
.
Zhtavius Moye
04/19/2019
BUSA 4126
SWOT Analysis
Dr. Setliff
PORSCHE
Strengths
· Brand Recognition
Not only a brand, but a status symbol for wealth and luxury
· Lean Factory Production
Manpower is low compared to the use of raw materials and supplies
· High Profit Share
The reputation is well-known for good treatment
Weaknesses
· Small automotive manufacture
Porsche has offered the same line of cars for years before extending.
· Limited Customer Sector
Not everyone can afford a Porsche
· Location
Since beginning of time, Porsche has been in Stuttgart, Germany. No space to expand
Opportunities
· Expansion
Deliveries increased in China by 12% but needs more in Asia, Japan, and Indonesia.
· Electric Mobility
A chance to expand Porsche name to many more industries and markets with top competitors such as Tesla.
· S1, O2: Brand recognition extends the range for profitability for the 2020 fully electric Porsche Taycan.
· S3, O1: The annual profitability of the company will encourage others to become a part of the business.
· S2, O1: The cost of a Porsche effects expansion, but by expanding to China could significantly increase rates.
· S3, O1: The location in Germany is a problem for expansion due to limited space of Stuttgart.
Threats
· Technology
Modern technology is advancing to lower cost vehicles.
· Market Competition
Vehicles with similar characteristics at lower cost.
· S3, O2: Weighing heavily on the market Porsche’s reputation will continue to stand abroad its competitors.
· S2, O1: Limited labor will call for more software developers in the more modern technology, especially introducing the fully electric Porsche Taycan.
· S1, O1: Porsche is a company that believes in staying at its classic and luxury perception to their buyers. Still giving all newly updated technology certain things such as an automatic start engine will not be an asset.
· S2, O2: Combined leaves Porsche at a limitation of customers making it hard to expand the market.
VIOLATION OF CIVIL RIGHTS ACT IN ELECTIONS 1
VIOLATION OF CIVIL RIGHTS ACT IN ELECTIONS 2
Violation of Civil Rights Act in Elections
Jake Bookard
Savannah State University
Violation of Civil Rights Act in Elections
Introduction
Despite the assurance of minority voter’s rights by the constitution and the fourteenth amendment, cases of rights violation with regards to the voting process are still on the rise in the US. Minority groups are often discriminated or blocked from participating in the voting process both in ways that they can discern and through cunning plans that can involve the voting process. Some of the main reasons why minorities’ constitutional rights are violated include racial discrimination by majority races, and to manipulate the outcome of the elections so as to keep minority groups out of the political leadership structure. The fourteenth amendment and the constitution do not sufficiently safeguard the rights of minority groups during elections beca.
Zichun Gao Professor Karen Accounting 1AIBM FInancial Stat.docxransayo
Zichun Gao Professor Karen Accounting 1A
IBM FInancial Statement Analysis
Financial Ratios 2019 2018 Formula
Current Ratio 1.02 1.29 CA/CL
Profit Margin 12.22% 12.35% Net Income/Total Revenue
Receiveables Turnover 9.80 10.71 Revenue/Average AR
Average Collection Period 36.72 33.62 365/Receiveables Turnover
Inventory Turnover 25.11 25.36 COST/Average Inventory
Days in Inventory 14.53 14.39 365/Inventory Turnover
Debts to Asset Ratio 0.86 0.86 Total Debts/Total Assets
IBM's days in inventory is around two weeks and this means that goods in the inventory
as efficnetly distributed and that there is a consitantly good inventory control for the
company.
The company's debts to assets ratio is the same for two years and this means that the
company has less debt than asset. However, it is still a relatively poor ratio because this
might show that there are potential problems for the company to generate sufficient
revenue.
The current ratio of the company has decreased over the year, and this means that the
company has less liquid assets to cover its short term liabilities. Since the ratio is
currently approaching 1, the company might be having liquidation problem.
The profit margin for IBM is very stable and it has been about 12% for two years. The
company is performing the profit-generating ability at an average level and it is having
an average profit margin in the industry.
The receiveables turnover is good for the company while between these two years, there
is a decline. As the company is collecting its accounts receiveables around 10 times per
year, the collection is frequent.
The company has been collecting money from customers on credit sales approximately
once every month, and the company usually has fast credit collection, which means that
the risk for credit sales is relatively low.
Inventory turnover measures how many times a company sells and replaces inventory
during a year and for IBM, the number of times is stable and it is constantly around 25.
This means that the company has an efficient control of its goods in the inventory.
Free Cash Flow 11.90 11.90 CF_Operation-Capital Expenditures
Return on Assets 0.06 0.08 Net Income/Total Assets
Asset Turnover 0.51 0.65 Revenue/Assets
Figures From Financial Statement
From Income Statement pg.68
Net Income 9431 9828
Total Revenue 77147 79591
Cost 40657 42655
From Consolidated Balance Sheet pg.70
Current Assets 38420 49146
Current Liabilities 37701 38227
Accounts Receiveables 7870 7432
Inventory 1619 1682
Total Assets 152186 123382
Total Liabilities 131202 106452
From Cash Flow Overview pg.59
Net Cash From Op 14.3 15.6
Capital expenditures 2.4 3.7
The company currently has 11.9 billion dollars free cash flow for two years and this is a
relatively high level of free cash flow. With the high free cash flow, the company can
have more oportunity to expand, invest in new projects, pay dividends, or invest the
money into Resea.
Zheng Hes Inscription This inscription was carved on a stele erec.docxransayo
Zheng He's Inscription
This inscription was carved on a stele erected at a temple to the goddess the Celestial Spouse at Changle in Fujian province in 1431. Message written before his last voyage.
The Imperial Ming Dynasty unifying seas and continents, surpassing the three dynasties even goes beyond the Han and Tang dynasties. The countries beyond the horizon and from the ends of the earth have all become subjects and to the most western of the western or the most northern of the northern countries, however far they may be, the distance and the routes may be calculated. Thus the barbarians from beyond the seas, though their countries are truly distant, "have come to audience bearing precious objects and presents.
The Emperor, approving of their loyalty and sincerity, has ordered us (Zheng) He and others at the head of several tens of thousands of officers and flag-troops to ascend (use) more than one hundred large ships to go and confer presents on them in order to make manifest (make it happen) the transforming power of the (imperial) virtue and to treat distant people with kindness. From the third year of Yongle (1405) till now we have seven times received the commission (official permission) of ambassadors to countries of the western ocean. The barbarian countries which we have visited are: by way of Zhancheng (Champa Cambodia), Zhaowa (Java), Sanfoqi (Palembang- Indonesia) and Xianlo (Siam/Thailand) crossing straight over to Xilanshan (Ceylon- Sri Lanka) in South India, Guli (Calicut) [India], and Kezhi (Cochin India), we have gone to the western regions Hulumosi (Hormuz Between Oman and Iran), Adan (Aden), Mugudushu (Mogadishu- Somalia), altogether more than thirty countries large and small. We have traversed more than one hundred thousand li (distance of 500 meters) of immense water spaces and have beheld in the ocean huge waves like mountains rising sky-high, and we have set eyes on barbarian regions far away hidden in a blue transparency of light vapours, while our sails loftily unfurled like clouds day and night continued their course (rapid like that) of a star, traversing those savage waves as if we were treading a public thoroughfare. Truly this was due to the majesty and the good fortune of the Court and moreover we owe it to the protecting virtue of the divine Celestial Spouse.
The power of the goddess having indeed been manifested in previous times has been abundantly revealed in the present generation. When we arrived in the distant countries we captured alive those of the native kings who were not respectful and exterminated those barbarian robbers who were engaged in piracy, so that consequently the sea route was cleansed and pacified (to make someone or something peaceful) and the natives put their trust in it. All this is due to the favours of the goddess.
We have respectfully received an Imperial commemorative composition (essay/piece of writing) exalting the miraculous favours, which is the highest recompense and.
Zhou 1Time and Memory in Two Portal Fantasies An Analys.docxransayo
Zhou 1
Time and Memory in Two Portal Fantasies: An Analysis of Alice’s Adventure in Wonderland and "Windeye"
Life is a collection of moments, and some memories last forever. Brian Evenson
demonstrated this in “Windeye,”a story of a man who faces mental challenges because of the
life-long memory of his sister. In spite of the fact that his mother insists that the sister did not
exist, the protagonist stuck to this belief until his old age. The basis of the protagonist’s
problems is the intense love and unforgettable memories he shared with his imagined sister.
A great portion of his childhood memories is centered around his sister and their exploration
of the windeye. Windeye, the corruption of the word window, is a portal that causes the
disappearance of the protagonist’s sister. The popular portal fantasy, Alice’s Adventure in Wonderland, illustrates a similar story in the same sub-genre where a girl travels through a
rabbit hole and experiences a fantasy world which chronicles her changes from naive child-
like responses to more adult-like problem solving reactions. In “Windeye,” Brian Evenson
utilizes the portal trope to develop conflict and outcomes while exploring the themes of time
and memory. In both stories, the use of the portal trope creates a distinct world that is
separate from reality; however, the outcomes are different, and ultimately, Alice’s Adventure in Wonderland presents the theme of growth while “Windeye” explores time and memories.
The use of time factors allows the reader to travel back to the origin of the story in “Windeye” and experience the beginning of the central conflict. It is in his past that the
protagonist develops strong childhood memories of a sister, which is the cause of his future
mental challenges. In the present, the narrator is old and rickety as he uses a cane to walk but
is still reminiscent of the past (Evenson). He holds firm to the belief that he might have a
chance of meeting his sister again and thus contemplates the future and the sister’s
appearance. The plot of “Windeye” is composed of distinctive life moments: the past, the
present, and the future, which offer a clear and complete description of the events. The theme
Zhou 2
of time allows the reader to understand why the protagonist profoundly feels that his sister exists. In essence, it is time travel that gives the story a picture of the events that lead to the current situation.
The portal fantasy is a fictional literary device where a character enters into a
fantastical world through a portal or a hole. In Alice’s Adventures in Wonderland, Carroll
uses a rabbit hole as a physical portal to move through time. Comparably, Evenson utilizes
the windeye, a window that can only be seen from one side, as a physical portal. When the
sister touches the windeye, her brother believes that she enters into another reality through
the portal as Alice does. In contrast, the protagonist also experiences a new reality as he is.
Zhang 1
Yixiang Zhang
Tamara Kuzmenkov
English 101
June 2, 2020
Comparing Gas-Powered Cars and Electric Cars
Electric cars have become increasingly popular in the past century. These cars use
electric motors instead of conventional gasoline engines. Electric cars pollute less and utilize
energy more efficiently than gas-powered vehicles; therefore, modern research is focusing on
improving electric vehicles, such as increasing the storage capacity of the batteries. This essay
seeks to identify the differences and similarities between the two types of cars focusing on their
performance, price, and convenience.
An electric car is a car that is primarily powered by electricity. The conventional gas-
powered cars require diesel or gasoline to power the engines. These cars have gas tanks that store
fuel and the engine converts the gas to the energy that powers the motor. Similarly, electric cars
have batteries, or fuel cells that store and convert electricity to energy used to propel electric
motors (What Are Electric Cars?). Four components present in electric cars distinguish it from
the gas-powered cars (Alternative Fuels Data Center: How Do All-Electric Cars Work?). The
first is the charge port. Since electricity powers an electric car, there has to be a port to connect
to an external power source when charging the battery. The second is an electric traction motor
that propels the vehicle. The third is a traction battery pack. This battery serves the same purpose
as the gas tank; thus, it stocks electric power to propel the motor. The forth is a direct current
converter. This component converts the current to low voltage power that is needed to power the
electric engine.
Tamara Kuzmenkov
90000001730094
You need to watch the panapto session for this paper assignment and FOLLOW the instructions I give there. Your topic sentence must follow the patterns set forth by your thesis. So, this first paragraph must have a topic sentence about GAS POWERED cars and PRICE. That is what you have set forth in your thesis. Watch the panapto session. And ask me questions if you do not understand what I mean.
Tamara Kuzmenkov
90000001730094
No, you cannot 'announce' what your essay will do. And this is NOT the thesis I approved. What I approved:"Both gas-powered cars and electric cars are now in use, but their price, performance and convenience may vary, which may influence people's decisions about which type to use."
Zhang 2
Differences between gas-powered cars and electric cars
The initial purchase price of an electric car is much higher than that of a gas-powered car.
Consumers intending to own a vehicle have the option of buying or leasing. The initial cost of a
car depends on an individual's disposable income and savings. Knez et al. noted that "When it
comes to financial features, the most important thing seems to be the total price of the vehicle"
(55). The difference in price between electr.
Zhang �1
Nick Zhang
Mr. Bethea
Lyric Peotry
13 November 2018
Reputation by Taylor Swift
After Taylor Swift fell into disrepute, she was truly reborn. As a creative singer
who reveals a lot of real life emotions and details in her works, she constantly refines
and shares her emotional connection with her audience. In her new album, people find
resonance in her work, connect it with their own lives. "Reputation" is not only the
original efforts of Taylor Swift, but also means that she turned gorgeously and
dominated. This album is like a swearing word from her to the world. Revenge fantasy,
sweet love, painful growth... all the good and bad things that happened in these stages
of life, her music seems to have gone through with us all over again.
But last August, the now 28-year-old singer declared that "the old Taylor is
dead" in her eerie single "Look What You Made Me Do," the beginning of a new era for
Swift (Weatherby). The disclosure of the society, the accusations of rumor makers,
these straight-forward lyrics shred the ugly face of those unscrupulous people. Taylor
Swift did not endure the rumors in the society, but created this rock album after the
silence. If 1989 is still what Taylor hopes to gain the understanding of the public, this
album is really a matter of opening up the past concerns, saying goodbye to the past
as well as being a true Taylor Swift. No longer caring about the so-called "reputation ",
preferring to be burned to death by those ridiculous "images." This air of newfound
jadedness is one of the many ways in which Swift broadcasts her long-overdue loss of
Zhang �2
innocence on “Reputation,” an album that captures the singer during the most
turbulent but commercially successful period of her career. (Primeau)
The cover is black and white, the picture is Taylor's head, and the side is the
newspaper's article and title words. The cover of the album may be a metaphor, it
reveals that Taylor can no longer stand the report of the gossip media, and the chain on
the neck represents depression and breathlessness. The theme and style of the album
are all refined from their own lives. The emotions and themes interpreted in her songs
make the audience feel more deeply that her album is her life. Without even using any
real words, fans can surmise what this means — a reference to the endless headlines
and stories the singer has spurred in recent years. (Primeau) Reputation, come to diss
the past and all opponents.
The lyrics and MV are full of real stalks in Taylor Swift's life , with Taylor's
resentment for circles and industry since his debut. In the era of streaming singles, she
is the rare young star who still worships at the altar of the album, an old-fashioned
instinct that serves her surprisingly well. (Battan) "Look What You Made Me Do" is a
counterattack against Kanye West and Kim Kardashian, Katy Perry and numerous
online "black mold". And .
Zero trust is a security stance for networking based on not trusting.docxransayo
Zero trust is a security stance for networking based on not trusting any users, devices, or applications by default, even those that are already on the network. The zero trust model uses identity and access management (IAM) as a foundation for an organization’s security program. For this assignment:
Research the zero trust model.
Write a report that describes the following:
The purpose of zero trust and what differentiates it from other security models
An overview of how zero trust works in a network environment
How zero trust incorporates least privilege access through role-based access control (RBAC) and/or attribute-based access control (ABAC)
Need 2 pages around 600 words
.
Zero plagiarism4 referencesNature offers many examples of sp.docxransayo
Zero plagiarism
4 references
Nature offers many examples of specialization and collaboration. Ant colonies and bee hives are but two examples of nature’s sophisticated organizations. Each thrives because their members specialize by tasks, divide labor, and collaborate to ensure food, safety, and general well-being of the colony or hive.
In this Discussion, you will reflect on your own observations of and/or experiences with informaticist collaboration. You will also propose strategies for how these collaborative experiences might be improved.
Of course, humans don’t fare too badly in this regard either. And healthcare is a great example. As specialists in the collection, access, and application of data, nurse informaticists collaborate with specialists on a regular basis to ensure that appropriate data is available to make decisions and take actions to ensure the general well-being of patients.
Post
a description of experiences or observations about how nurse informaticists and/or data or technology specialists interact with other professionals within your healthcare organization. Suggest at least one strategy on how these interactions might be improved. Be specific and provide examples. Then, explain the impact you believe the continued evolution of nursing informatics as a specialty and/or the continued emergence of new technologies might have on professional interactions.
.
Zero plagiarism4 referencesLearning ObjectivesStudents w.docxransayo
Zero plagiarism
4 references
Learning Objectives
Students will:
Develop diagnoses for clients receiving psychotherapy*
Analyze legal and ethical implications of counseling clients with psychiatric disorders*
* The Assignment related to this Learning Objective is introduced this week and
submitted
in
Week 4
.
Select a client whom you observed or counseled this week. Then, address the following in your Practicum Journal:
Describe the client (without violating HIPAA regulations) and identify any pertinent history or medical information, including prescribed medications.
Using the
Diagnostic and Statistical Manual of Mental Health Disorders
, 5th edition (DSM-5), explain and justify your diagnosis for this client.
Explain any legal and/or ethical implications related to counseling this client.
Support your approach with evidence-based literature.
.
Zero Plagiarism or receive a grade of a 0.Choose one important p.docxransayo
Zero Plagiarism or receive a grade of a 0.
Choose one important police function: Law enforcement, order maintenance or service, etc.
OR
Choose one important police strategy: Traditional Policing, Community Policing, Data Driven Policing, etc.
Write a research paper describing the strateugy or function in detail and discussing the significance of the strategy or function with respect to the roles in society.
Format: Title Page, Outline, Text, and References
Must have 3 sources
You can use your textbook: Cox, Steven M., et al. (2020). Introduction to Policing. Fourth Edition. Thousand Oaks, CA: SAGE Publications, Inc.
Paper must by 6 pages long
APA Style
.
ZACHARY SHEMTOB AND DAVID LATZachary Shemtob, formerly editor in.docxransayo
ZACHARY SHEMTOB AND DAVID LAT
Zachary Shemtob, formerly editor in chief of the Georgetown Law Review, is a clerk in the US District Court for the Southern District of New York. David Lat is a former federal prosecutor. Their essay originally appeared in the New York Times in 2011.
Executions Should Be Televised
Earlier this month, Georgia conducted its third execution this year. This would have passed relatively unnoticed if not for a controversy surrounding its videotaping. Lawyers for the condemned inmate, Andrew Grant DeYoung, had persuaded a judge to allow the recording of his last moments as part of an effort to obtain evidence on whether lethal injection caused unnecessary suffering.
Though he argued for videotaping, one of Mr. DeYoung’s defense lawyers, Brian Kammer, spoke out against releasing the footage to the public. “It’s a horrible thing that Andrew DeYoung had to go through,” Mr. Kammer said, “and it’s not for the public to see that.”
We respectfully disagree. Executions in the United States ought to be made public.
Right now, executions are generally open only to the press and a few select witnesses. For the rest of us, the vague contours are provided in the morning paper. Yet a functioning democracy demands maximum accountability and transparency. As long as executions remain behind closed doors, those are impossible. The people should have the right to see what is being done in their name and with their tax dollars.
This is particularly relevant given the current debate on whether specific methods of lethal injection constitute cruel and unusual punishment and therefore violate the Constitution.
There is a dramatic difference between reading or hearing of such an event and observing it through image and sound. (This is obvious to those who saw the footage of Saddam Hussein’s hanging in 2006 or the death of Neda Agha-Soltan during the protests in Iran in 2009.) We are not calling for opening executions completely to the public — conducting them before a live crowd — but rather for broadcasting them live or recording them for future release, on the web or TV.
When another Georgia inmate, Roy Blankenship, was executed in June, the prisoner jerked his head, grimaced, gasped, and lurched, according to a medical expert’s affidavit. The Atlanta Journal-Constitution reported that Mr. DeYoung, executed in the same manner, “showed no violent signs in death.” Voters should not have to rely on media accounts to understand what takes place when a man is put to death.
Cameras record legislative sessions and presidential debates, and courtrooms are allowing greater television access. When he was an Illinois state senator, President Obama successfully pressed for the videotaping of homicide interrogations and confessions. The most serious penalty of all surely demands equal if not greater scrutiny.
Opponents of our proposal offer many objections. State lawyers argued that making Mr. DeYoung’s execution public raised safety concerns..
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Zeng Jiawen ZengChenxia Zhu English 3001-015292017Refl.docxransayo
Zeng
Jiawen Zeng
Chenxia Zhu
English 3001-01
5/29/2017
Reflective Essay
Becoming a good writer is a challenging and continuous process that need to constantly improving your writing skills in different area as same as constructive reflection for identification of both progress and directions for further development. My writing competence has improved significantly during the ten weeks of English 3001 Writing Proficiency course in such areas as grammar, use of verb tenses, and content quality.
The most serious problems I faced in writing process previously were grammar issues and poor content of the essays. To be more precise, I used to lack empirical competence in proper use of verb tenses. My confusions of tense forms destroyed all the sense of the essay, and often improper sentence structure made the result of the writing process insufficient to meet the University Writing Skills Requirements. Initially, when I tried to improve my skills in the given area, I only paid attention to the highlighted mistakes and comments of the tutor. Nonetheless, I realized it was not enough. Therefore, I changed this strategy to a more constructive one. To be more precise, I started reading more books in English and wrote essays diverse topics apart from the course tasks. It was an effective type of training since in several weeks my essays revealed particular progress which I took into consideration and continued.
I realize that it does not suffice to finally meet the University Writing Skills Requirements since this is only a fraction of real competence in writing. The next step of self-improvement the given sphere is editing that also has numerous issues and challenges to be dealt with. It means that there are two domains within the notion of writing competence, and both of them have no limits and require constant self-improvement. Therefore, my goal to meet academic requirements is only one more step in the course of acquisition of linguistic competence and capacity to master English in terms of writing essays and academic papers.
Moreover, I know that currently I need to focus more on content issues, persuasive capacity and proper use of diverse materials employed to support evidence which are crucial elements of writing papers per University requirements. On the other hand, I see that all the core problems with linguistic competence which I have faced earlier, are solved, which means that I need to focus on further self-improvement and keep constructive work in order to achieve my next targets in the field of concern. Furthermore, I have considerable progress in such important dimensions of academic paper construction as thesis development, use of testimony and personal observations, and alignment of different ideas into a coherent, justified and credible academic entity. Now I do not permit run-ons, excessive use of articles or comma splices to emerge in my works. It means that flaws of basic and medium level are dealt with, and further self-de.
zClass 44.8.19§ Announcements§ Go over quiz #1.docxransayo
z
Class 4
4.8.19
§ Announcements
§ Go over quiz #1
§ Practice listening quiz
§ Lecture on social organization of Hindustani music
z
Announcements
§ Aashish Khan recital on April 28
§ Assignment #1 will be posted this week
§ Summer course on Indian rhythm
z
Practice listening quiz
z
Terms
§ Socio-musical identity – the connection of social rank to musical
status; prevalent throughout musical communities in South and
Central Asia
§ Soloist – the lead musical role
§ Accompanist – the supporting musical role(s)
§ Heterophony – style of music in which a melody is closely
imitated by another instrument or voice
z
Questions to keep in mind
§ What does social class have to do with music performance?
§ How is authority created and controlled?
§ How is it challenged?
§ What is the relationship between soloist and accompanist?
§ How does this affect music performance?
§ What is the relationship between student and teacher?
z
Social class and caste in South Asia
§ Societies were stratified in a social hierarchy
§ High caste – rulers, priests, elite
§ Low caste – manual laborers
§ Dalits – “untouchables”
§ Caste specialization of artisan trades common among Muslim communities
§ Carpentry, pastoralism, leather making, jewelry making, and music!
§ The community to which you were born determined your social rank and the
opportunities that would be available to you
§ People could ”change” their class through certain strategies
§ Marriage, contesting the hegemony of the upper classes
z
Organization of specialist knowledge
§ Music is a practice of specialized communities
§ Music is your life!
§ No word for “musician”
§ Rather, terms denoting the specialty of the performer are used
§ This categorization indicates musical identity (the instrument one
performs) as well as that person’s social rank and roles
z
Organization of specialist knowledge
§ Dhrupadiya – singer of dhrupad
§ Gawaiya – vocalist
§ Binkar – bin (veena) player
§ Khayalia – singer of khyāl
§ Sitariya – sitar player
§ Sarodiya – sarod player
§ Tabliya – tabla player
§ Sarangiya – sarangi player
§ Rubabi – rubab player
§ Qawwal - singer of Qawwali
z
Instrument association
Soloist
Vocal
Sitar
Rudra veena
Sarod
Dance
Rubab
Surbahar
Bansuri
Accompanist
Sarangi
Tabla
Harmonium
z
Social roles and ranks
§ Relationship between occupation and social identity is very
close
§ Soloists are venerated and have great prestige
§ Accompanists have lower social and musical status
§ They are subservient to soloists in both roles
z
Performance structure
§ Soloist (Dhrupad, khyāl, thumri, ghazal
§ Vocal
§ Instrumental
§ Accompanist
§ Melodic
§ Sarangi
§ Harmonium
§ Student
§ Heterophony
§ Rhythmic
§ Tabla
§ Dholak
§ Drone
§ Tanpura
z
Social roles and ranks
§ Soloists and accompanists belonged to different social class
§ Never intermarried
§ Cousin marriages
§ Soloist class – kalawant
§ Accompanist classes – mirasi, dhari (dhadhi).
zClass 185.13.19§ Announcements§ Review of last .docxransayo
z
Class 18
5.13.19
§ Announcements
§ Review of last class
§ Finish lecture on Qawwali, begin intro to Pakistan
z
Announcements
§ Keshav Batish senior recital, June 5 – Extra credit
§ Exam #1 results posted
§ 2 perfect scores, 25 A’s, 46 B’s, 37 C’s, 17 D and lower
§ Summer course on Indian rhythm (second session)
§ Learn tabla and dholak!
§ Enrollment open now!
z
Last class review
§ Qawwali – “Food for the soul”
§ Sufi devotional poetry set to music
§ Performed at dargah
§ ‘Urs
z
Terms
§ Mehfil – small, intimate gatherings that involve entertainment of
various sorts, including music, poetry, dance etc.
z
Tum Ek Gorakh Dhandha Ho
§ “You are a baffling puzzle”
§ Written by Naz Khialvi (1947-2010)
§ Pakistani lyricist and radio broadcaster
§ Popularized by Ustad Nusrat Fateh Ali Khan (1948-1997)
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Tum Ek Gorakh Dhandha Ho
kabhi yahaan tumhein dhoonda
kabhi wahaan pohancha
tumhaari deed ki khaatir kahaan
kahaan pohancha
ghareeb mit gaye paamaal ho
gaye lekin
kisi talak na tera aaj tak nishaan
pohancha
ho bhi naheen aur har ja ho
tum ik gorakh dhanda ho
At times I searched for you here,
at times I traveled there
For the sake of seeing You, how
far I have come!
Similar wanderers wiped away
and ruined, but
Your sign has still not reached
anyone
You are not, yet You are
everywhere
You are a baffling puzzle
z
Bhar Do Jholi Meri
§ Traditional song
§ Popularized in movie “Bajrangi Bhaijaan” (2015)
z
Bhar Do Jholi Meri
Tere Darbaar Mein
Dil Thaam Ke Woh Aata Hai
Jisko Tu Chaahe
Hey Nabi Tu Bhulata Hai
Tere Dar Pe Sar Jhukaaye
Main Bhi Aaya Hoon
Jiski Bigdi Haye
Nabi Chaahe Tu Banata Hai
Bhar Do Jholi Meri Ya Mohammad
Lautkar Main Naa Jaunga Khaali
They come into Your court
clenching their hearts
Those people whom You desire to
see , O Prophet!
I’ve also come to Your door with
my head bowed down
You’re the One who can fix
broken fates, O Prophet!
Please fill my lap, O Prophet!
I won’t go back empty handed
z
Ustad Nusrat Fateh Ali Khan
(1948-1997)
§ Pakistani vocalist
§ Sang classical (khyāl) but more famous as a Qawwali singer
§ Brought classical performance techniques to Qawwali
§ Visiting artist at University of Washington from 1992-93
§ Legacy carried on through his nephew, Rahat Fateh Ali Khan
z
Introduction to Pakistan
Badshahi Mosque, Lahore
Built in 1671 by Emperor Aurangzeb
z
Pakistan
§ Prominent Bronze Age (3000-1500BCE) settlements of Mohenjo
Daro and Harrapa along Indus River Valley
§ Hinduism widespread during Vedic Age (1500-500BCE)
§ Ruled by series of Hindu, Buddhist, and eventually Muslim
(Persian) dynasties
§ Islam introduced by Sufi missionaries from 7th to 13th centuries
§ Ethnically and linguistically diverse
z
Indus Valley civilization
z
Pakistan ethnicities
z
Modern India and Pakistan
§ By the end of 19th century British rule was in effect over much of
old Mughal Empire territory
§ The Hindu and Muslim divide among this territory was be.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
How to Split Bills in the Odoo 17 POS ModuleCeline George
Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
The Indian economy is classified into different sectors to simplify the analysis and understanding of economic activities. For Class 10, it's essential to grasp the sectors of the Indian economy, understand their characteristics, and recognize their importance. This guide will provide detailed notes on the Sectors of the Indian Economy Class 10, using specific long-tail keywords to enhance comprehension.
For more information, visit-www.vavaclasses.com
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
A C C I D E N T I N V E S T I G A T I O N B O A R DCOLUM.docx
1. A C C I D E N T I N V E S T I G A T I O N B O A R D
COLUMBIA
1 9 5R e p o r t V o l u m e I A u g u s t 2 0 0 3
The Board began its investigation with two central ques-
tions about NASA decisions. Why did NASA continue to fly
with known foam debris problems in the years preceding the
Columbia launch, and why did NASA managers conclude
that the foam debris strike 81.9 seconds into Columbiaʼs
flight was not a threat to the safety of the mission, despite
the concerns of their engineers?
8.1 ECHOES OF CHALLENGER
As the investigation progressed, Board member Dr. Sally
Ride, who also served on the Rogers Commission, observed
that there were “echoes” of Challenger in Columbia. Ironi-
cally, the Rogers Commission investigation into Challenger
started with two remarkably similar central questions: Why
did NASA continue to fly with known O-ring erosion prob-
lems in the years before the Challenger launch, and why, on
the eve of the Challenger launch, did NASA managers decide
that launching the mission in such cold temperatures was an
acceptable risk, despite the concerns of their engineers?
The echoes did not stop there. The foam debris hit was not
the single cause of the Columbia accident, just as the failure
of the joint seal that permitted O-ring erosion was not the
single cause of Challenger. Both Columbia and Challenger
were lost also because of the failure of NASA
̓ s organiza-
2. tional system. Part Two of this report cites failures of the
three parts of NASA
̓ s organizational system. This chapter
shows how previous political, budgetary, and policy deci-
sions by leaders at the White House, Congress, and NASA
(Chapter 5) impacted the Space Shuttle Programʼs structure,
culture, and safety system (Chapter 7), and how these in turn
resulted in flawed decision-making (Chapter 6) for both ac-
cidents. The explanation is about system effects: how actions
taken in one layer of NASA
̓ s organizational system impact
other layers. History is not just a backdrop or a scene-setter.
History is cause. History set the Columbia and Challenger
accidents in motion. Although Part Two is separated into
chapters and sections to make clear what happened in the
political environment, the organization, and managers ̓and
engineers ̓decision-making, the three worked together. Each
is a critical link in the causal chain.
This chapter shows that both accidents were “failures of
foresight” in which history played a prominent role.1 First,
the history of engineering decisions on foam and O-ring
incidents had identical trajectories that “normalized” these
anomalies, so that flying with these flaws became routine
and acceptable. Second, NASA history had an effect. In re-
sponse to White House and Congressional mandates, NASA
leaders took actions that created systemic organizational
flaws at the time of Challenger that were also present for
Columbia. The final section compares the two critical deci-
sion sequences immediately before the loss of both Orbit-
ers – the pre-launch teleconference for Challenger and the
post-launch foam strike discussions for Columbia. It shows
history again at work: how past definitions of risk combined
with systemic problems in the NASA organization caused
both accidents.
Connecting the parts of NASA
̓ s organizational system and
3. drawing the parallels with Challenger demonstrate three
things. First, despite all the post-Challenger changes at
NASA and the agencyʼs notable achievements since, the
causes of the institutional failure responsible for Challenger
have not been fixed. Second, the Board strongly believes
that if these persistent, systemic flaws are not resolved,
the scene is set for another accident. Therefore, the recom-
mendations for change are not only for fixing the Shuttleʼs
technical system, but also for fixing each part of the orga-
nizational system that produced Columbiaʼs failure. Third,
the Boardʼs focus on the context in which decision making
occurred does not mean that individuals are not responsible
and accountable. To the contrary, individuals always must
assume responsibility for their actions. What it does mean
is that NASA
̓ s problems cannot be solved simply by retire-
ments, resignations, or transferring personnel.2
The constraints under which the agency has operated
throughout the Shuttle Program have contributed to both
CHAPTER 8
History As Cause:
Columbia and Challenger
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4. Shuttle accidents. Although NASA leaders have played
an important role, these constraints were not entirely of
NASA
̓ s own making. The White House and Congress must
recognize the role of their decisions in this accident and take
responsibility for safety in the future.
8.2 FAILURES OF FORESIGHT: TWO DECISION
HISTORIES AND THE NORMALIZATION OF
DEVIANCE
Foam loss may have occurred on all missions, and left bipod
ramp foam loss occurred on 10 percent of the flights for
which visible evidence exists. The Board had a hard time
understanding how, after the bitter lessons of Challenger,
NASA could have failed to identify a similar trend. Rather
than view the foam decision only in hindsight, the Board
tried to see the foam incidents as NASA engineers and man-
agers saw them as they made their decisions. This section
gives an insider perspective: how NASA defined risk and
how those definitions changed over time for both foam debris
hits and O-ring erosion. In both cases, engineers and manag-
ers conducting risk assessments continually normalized the
technical deviations they found.3 In all official engineering
analyses and launch recommendations prior to the accidents,
evidence that the design was not performing as expected was
reinterpreted as acceptable and non-deviant, which dimin-
ished perceptions of risk throughout the agency.
The initial Shuttle design predicted neither foam debris
problems nor poor sealing action of the Solid Rocket Boost-
er joints. To experience either on a mission was a violation
of design specifications. These anomalies were signals of
potential danger, not something to be tolerated, but in both
cases after the first incident the engineering analysis con-
cluded that the design could tolerate the damage. These en-
5. gineers decided to implement a temporary fix and/or accept
the risk, and fly. For both O-rings and foam, that first deci-
sion was a turning point. It established a precedent for ac-
cepting, rather than eliminating, these technical deviations.
As a result of this new classification, subsequent incidents of
O-ring erosion or foam debris strikes were not defined as
signals of danger, but as evidence that the design was now
acting as predicted. Engineers and managers incorporated
worsening anomalies into the engineering experience base,
which functioned as an elastic waistband, expanding to hold
larger deviations from the original design. Anomalies that
did not lead to catastrophic failure were treated as a source
of valid engineering data that justified further flights. These
anomalies were translated into a safety margin that was ex-
tremely influential, allowing engineers and managers to add
incrementally to the amount and seriousness of damage that
was acceptable. Both O-ring erosion and foam debris events
were repeatedly “addressed” in NASA
̓ s Flight Readiness
Reviews but never fully resolved. In both cases, the engi-
neering analysis was incomplete and inadequate. Engineers
understood what was happening, but they never understood
why. NASA continued to implement a series of small correc-
tive actions, living with the problems until it was too late.4
NASA documents show how official classifications of risk
were downgraded over time.5 Program managers designated
both the foam problems and O-ring erosion as “acceptable
risks” in Flight Readiness Reviews. NASA managers also
assigned each bipod foam event In-Flight Anomaly status,
and then removed the designation as corrective actions
were implemented. But when major bipod foam-shedding
occurred on STS-112 in October 2002, Program manage-
ment did not assign an In-Flight Anomaly. Instead, it down-
graded the problem to the lower status of an “action” item.
Before Challenger, the problematic Solid Rocket Booster
6. joint had been elevated to a Criticality 1 item on NASAʼs
Critical Items List, which ranked Shuttle components by
failure consequences and noted why each was an accept-
able risk. The joint was later demoted to a Criticality 1-R
(redundant), and then in the month before Challengerʼs
launch was “closed out” of the problem-reporting system.
Prior to both accidents, this demotion from high-risk item
to low-risk item was very similar, but with some important
differences. Damaging the Orbiterʼs Thermal Protection
System, especially its fragile tiles, was normalized even be-
fore Shuttle launches began: it was expected due to forces
at launch, orbit, and re-entry.6 So normal was replacement
of Thermal Protection System materials that NASA manag-
ers budgeted for tile cost and turnaround maintenance time
from the start.
It was a small and logical next step for the discovery of foam
debris damage to the tiles to be viewed by NASA as part of an
already existing maintenance problem, an assessment based
on experience, not on a thorough hazard analysis. Foam de-
bris anomalies came to be categorized by the reassuring
term “in-family,” a formal classification indicating that new
occurrences of an anomaly were within the engineering ex-
perience base. “In-family” was a strange term indeed for a
violation of system requirements. Although “in-family” was
a designation introduced post-Challenger to separate prob-
lems by seriousness so that “out-of-family” problems got
more attention, by definition the problems that were shifted
into the lesser “in-family” category got less attention. The
Boardʼs investigation uncovered no paper trail showing es-
calating concern about the foam problem like the one that
Solid Rocket Booster engineers left prior to Challenger.7
So ingrained was the agencyʼs belief that foam debris was
not a threat to flight safety that in press briefings after the
Columbia accident, the Space Shuttle Program Manager
still discounted the foam as a probable cause, saying that
7. Shuttle managers were “comfortable” with their previous
risk assessments.
From the beginning, NASA
̓ s belief about both these prob-
lems was affected by the fact that engineers were evaluat-
ing them in a work environment where technical problems
were normal. Although management treated the Shuttle
as operational, it was in reality an experimental vehicle.
Many anomalies were expected on each mission. Against
this backdrop, an anomaly was not in itself a warning sign
of impending catastrophe. Another contributing factor was
that both foam debris strikes and O-ring erosion events were
examined separately, one at a time. Individual incidents
were not read by engineers as strong signals of danger.
What NASA engineers and managers saw were pieces of ill-
structured problems.8 An incident of O-ring erosion or foam
bipod debris would be followed by several launches where
the machine behaved properly, so that signals of danger
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were followed by all-clear signals – in other words, NASA
managers and engineers were receiving mixed signals.9
Some signals defined as weak at the time were, in retrospect,
warnings of danger. Foam debris damaged tile was assumed
(erroneously) not to pose a danger to the wing. If a primary
8. O-ring failed, the secondary was assumed (erroneously)
to provide a backup. Finally, because foam debris strikes
were occurring frequently, like O-ring erosion in the years
before Challenger, foam anomalies became routine signals
– a normal part of Shuttle operations, not signals of danger.
Other anomalies gave signals that were strong, like wiring
malfunctions or the cracked balls in Ball Strut Tie Rod As-
semblies, which had a clear relationship to a “loss of mis-
sion.” On those occasions, NASA stood down from launch,
sometimes for months, while the problems were corrected.
In contrast, foam debris and eroding O-rings were defined
as nagging issues of seemingly little consequence. Their
significance became clear only in retrospect, after lives had
been lost.
History became cause as the repeating pattern of anomalies
was ratified as safe in Flight Readiness Reviews. The official
definitions of risk assigned to each anomaly in Flight Readi-
ness Reviews limited the actions taken and the resources
spent on these problems. Two examples of the road not taken
and the devastating implications for the future occurred close
in time to both accidents. On the October 2002 launch of
STS-112, a large piece of bipod ramp foam hit and dam-
aged the External Tank Attachment ring on the Solid Rocket
Booster skirt, a strong signal of danger 10 years after the last
known bipod ramp foam event. Prior to Challenger, there
was a comparable surprise. After a January 1985 launch, for
which the Shuttle sat on the launch pad for three consecutive
nights of unprecedented cold temperatures, engineers discov-
ered upon the Orbiter s̓ return that hot gases had eroded the
primary and reached the secondary O-ring, blackening the
putty in between – an indication that the joint nearly failed.
But accidents are not always preceded by a wake-up call.10
In 1985, engineers realized they needed data on the rela-
tionship between cold temperatures and O-ring erosion.
9. However, the task of getting better temperature data stayed
on the back burner because of the definition of risk: the
primary erosion was within the experience base; the sec-
ondary O-ring (thought to be redundant) was not damaged
and, significantly, there was a low probability that such cold
Florida temperatures would recur.11 The scorched putty, ini-
tially a strong signal, was redefined after analysis as weak.
On the eve of the Challenger launch, when cold temperature
became a concern, engineers had no test data on the effect
of cold temperatures on O-ring erosion. Before Columbia,
engineers concluded that the damage from the STS-112
foam hit in October 2002 was not a threat to flight safety.
The logic was that, yes, the foam piece was large and there
was damage, but no serious consequences followed. Further,
a hit this size, like cold temperature, was a low-probability
event. After analysis, the biggest foam hit to date was re-
defined as a weak signal. Similar self-defeating actions and
inactions followed. Engineers were again dealing with the
poor quality of tracking camera images of strikes during
ascent. Yet NASA took no steps to improve imagery and
took no immediate action to reduce the risk of bipod ramp
foam shedding and potential damage to the Orbiter before
Columbia. Furthermore, NASA performed no tests on what
would happen if a wing leading edge were struck by bipod
foam, even though foam had repeatedly separated from the
External Tank.
During the Challenger investigation, Rogers Commis-
sion member Dr. Richard Feynman famously compared
launching Shuttles with known problems to playing Russian
roulette.12 But that characterization is only possible in hind-
sight. It is not how NASA personnel perceived the risks as
they were being assessed, one launch at a time. Playing Rus-
sian roulette implies that the pistol-holder realizes that death
might be imminent and still takes the risk. For both foam
10. debris and O-ring erosion, fixes were in the works at the time
of the accidents, but there was no rush to complete them be-
cause neither problem was defined as a show-stopper. Each
time an incident occurred, the Flight Readiness process
declared it safe to continue flying. Taken one at a time, each
decision seemed correct. The agency allocated attention and
resources to these two problems accordingly. The conse-
quences of living with both of these anomalies were, in its
view, minor. Not all engineers agreed in the months immedi-
ately preceding Challenger, but the dominant view at NASA
– the managerial view – was, as one manager put it, “we
were just eroding rubber O-rings,” which was a low-cost
problem.13 The financial consequences of foam debris also
were relatively low: replacing tiles extended the turnaround
time between launches. In both cases, NASA was comfort-
able with its analyses. Prior to each accident, the agency saw
no greater consequences on the horizon.
8.3 SYSTEM EFFECTS: THE IMPACT OF HISTORY
AND POLITICS ON RISKY WORK
The series of engineering decisions that normalized technical
deviations shows one way that history became cause in both
accidents. But NASA
̓ s own history encouraged this pattern
of flying with known flaws. Seventeen years separated the
two accidents. NASA Administrators, Congresses, and po-
litical administrations changed. However, NASA
̓ s political
and budgetary situation remained the same in principle as it
had been since the inception of the Shuttle Program. NASA
remained a politicized and vulnerable agency, dependent on
key political players who accepted NASA
̓ s ambitious pro-
posals and then imposed strict budget limits. Post-Challeng-
er policy decisions made by the White House, Congress, and
NASA leadership resulted in the agency reproducing many
of the failings identified by the Rogers Commission. Policy
constraints affected the Shuttle Programʼs organization cul-
11. ture, its structure, and the structure of the safety system. The
three combined to keep NASA on its slippery slope toward
Challenger and Columbia. NASA culture allowed flying
with flaws when problems were defined as normal and rou-
tine; the structure of NASA
̓ s Shuttle Program blocked the
flow of critical information up the hierarchy, so definitions
of risk continued unaltered. Finally, a perennially weakened
safety system, unable to critically analyze and intervene, had
no choice but to ratify the existing risk assessments on these
two problems. The following comparison shows that these
system effects persisted through time, and affected engineer-
ing decisions in the years leading up to both accidents.
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The Board found that dangerous aspects of NASAʼs 1986
culture, identified by the Rogers Commission, remained
unchanged. The Space Shuttle Program had been built on
compromises hammered out by the White House and NASA
headquarters.14 As a result, NASA was transformed from a
research and development agency to more of a business,
with schedules, production pressures, deadlines, and cost
efficiency goals elevated to the level of technical innovation
and safety goals.15 The Rogers Commission dedicated an
entire chapter of its report to production pressures.16 More-
over, the Rogers Commission, as well as the 1990 Augus-
12. tine Committee and the 1999 Shuttle Independent Assess-
ment Team, criticized NASA for treating the Shuttle as if it
were an operational vehicle. Launching on a tight schedule,
which the agency had pursued as part of its initial bargain
with the White House, was not the way to operate what
was in fact an experimental vehicle. The Board found that
prior to Columbia, a budget-limited Space Shuttle Program,
forced again and again to refashion itself into an efficiency
model because of repeated government cutbacks, was beset
by these same ills. The harmful effects of schedule pressure
identified in previous reports had returned.
Prior to both accidents, NASA was scrambling to keep up.
Not only were schedule pressures impacting the people
who worked most closely with the technology – techni-
cians, mission operators, flight crews, and vehicle proces-
sors – engineering decisions also were affected.17 For foam
debris and O-ring erosion, the definition of risk established
during the Flight Readiness process determined actions
taken and not taken, but the schedule and shoestring bud-
get were equally influential. NASA was cutting corners.
Launches proceeded with incomplete engineering work on
these flaws. Challenger-era engineers were working on a
permanent fix for the booster joints while launches contin-
ued.18 After the major foam bipod hit on STS-112, manage-
ment made the deadline for corrective action on the foam
problem after the next launch, STS-113, and then slipped it
again until after the flight of STS-107. Delays for flowliner
and Ball Strut Tie Rod Assembly problems left no margin in
the schedule between February 2003 and the management-
imposed February 2004 launch date for the International
Space Station Node 2. Available resources – including time
out of the schedule for research and hardware modifications
– went to the problems that were designated as serious –
those most likely to bring down a Shuttle. The NASA
culture encouraged flying with flaws because the schedule
13. could not be held up for routine problems that were not de-
fined as a threat to mission safety.19
The question the Board had to answer was why, since the
foam debris anomalies went on for so long, had no one rec-
ognized the trend and intervened? The O-ring history prior
to Challenger had followed the same pattern. This question
pointed the Boardʼs attention toward the NASA organiza-
tion structure and the structure of its safety system. Safety-
oriented organizations often build in checks and balances
to identify and monitor signals of potential danger. If these
checks and balances were in place in the Shuttle Program,
they werenʼt working. Again, past policy decisions pro-
duced system effects with implications for both Challenger
and Columbia.
Prior to Challenger, Shuttle Program structure had hindered
information flows, leading the Rogers Commission to con-
clude that critical information about technical problems was
not conveyed effectively through the hierarchy.20 The Space
Shuttle Program had altered its structure by outsourcing
to contractors, which added to communication problems.
The Commission recommended many changes to remedy
these problems, and NASA made many of them. However,
the Board found that those post-Challenger changes were
undone over time by management actions.21 NASA ad-
ministrators, reacting to government pressures, transferred
more functions and responsibilities to the private sector.
The change was cost-efficient, but personnel cuts reduced
oversight of contractors at the same time that the agencyʼs
dependence upon contractor engineering judgment in-
creased. When high-risk technology is the product and lives
are at stake, safety, oversight, and communication flows are
critical. The Board found that the Shuttle Programʼs normal
chain of command and matrix system did not perform a
check-and-balance function on either foam or O-rings.
14. The Flight Readiness Review process might have reversed
the disastrous trend of normalizing O-ring erosion and foam
debris hits, but it didnʼt. In fact, the Rogers Commission
found that the Flight Readiness process only affirmed the
pre-Challenger engineering risk assessments.22 Equally
troubling, the Board found that the Flight Readiness pro-
cess, which is built on consensus verified by signatures of
all responsible parties, in effect renders no one accountable.
Although the process was altered after Challenger, these
changes did not erase the basic problems that were built into
the structure of the Flight Readiness Review.23 Managers at
the top were dependent on engineers at the bottom for their
engineering analysis and risk assessments. Information was
lost as engineering risk analyses moved through the process.
At succeeding stages, management awareness of anomalies,
and therefore risks, was reduced either because of the need
to be increasingly brief and concise as all the parts of the
system came together, or because of the need to produce
consensus decisions at each level. The Flight Readiness
process was designed to assess hardware and take corrective
actions that would transform known problems into accept-
able flight risks, and that is precisely what it did. The 1986
House Committee on Science and Technology concluded
during its investigation into Challenger that Flight Readi-
ness Reviews had performed exactly as they were designed,
but that they could not be expected to replace engineering
analysis, and therefore they “cannot be expected to prevent
a flight because of a design flaw that Project management
had already determined an acceptable risk.”24 Those words,
true for the history of O-ring erosion, also hold true for the
history of foam debris.
The last line of defense against errors is usually a safety
system. But the previous policy decisions by leaders de-
scribed in Chapter 5 also impacted the safety structure
15. and contributed to both accidents. Neither in the O-ring
erosion nor the foam debris problems did NASAʼs safety
system attempt to reverse the course of events. In 1986,
the Rogers Commission called it “The Silent Safety Sys-
tem.”25 Pre-Challenger budget shortages resulted in safety
personnel cutbacks. Without clout or independence, the
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safety personnel who remained were ineffective. In the
case of Columbia, the Board found the same problems
were reproduced and for an identical reason: when pressed
for cost reduction, NASA attacked its own safety system.
The faulty assumption that supported this strategy prior to
Columbia was that a reduction in safety staff would not
result in a reduction of safety, because contractors would
assume greater safety responsibility. The effectiveness
of those remaining staff safety engineers was blocked by
their dependence on the very Program they were charged
to supervise. Also, the Board found many safety units with
unclear roles and responsibilities that left crucial gaps.
Post-Challenger NASA still had no systematic procedure
for identifying and monitoring trends. The Board was sur-
prised at how long it took NASA to put together trend data
in response to Board requests for information. Problem
reporting and tracking systems were still overloaded or
16. underused, which undermined their very purpose. Mul-
tiple job titles disguised the true extent of safety personnel
shortages. The Board found cases in which the same person
was occupying more than one safety position – and in one
instance at least three positions – which compromised any
possibility of safety organization independence because the
jobs were established with built-in conflicts of interest.
8.4 ORGANIZATION, CULTURE, AND
UNINTENDED CONSEQUENCES
A number of changes to the Space Shuttle Program structure
made in response to policy decisions had the unintended
effect of perpetuating dangerous aspects of pre-Challenger
culture and continued the pattern of normalizing things that
were not supposed to happen. At the same time that NASA
leaders were emphasizing the importance of safety, their
personnel cutbacks sent other signals. Streamlining and
downsizing, which scarcely go unnoticed by employees,
convey a message that efficiency is an important goal.
The Shuttle/Space Station partnership affected both pro-
grams. Working evenings and weekends just to meet the
International Space Station Node 2 deadline sent a signal
to employees that schedule is important. When paired with
the “faster, better, cheaper” NASA motto of the 1990s and
cuts that dramatically decreased safety personnel, efficiency
becomes a strong signal and safety a weak one. This kind of
doublespeak by top administrators affects peopleʼs decisions
and actions without them even realizing it.26
Changes in Space Shuttle Program structure contributed to
the accident in a second important way. Despite the con-
straints that the agency was under, prior to both accidents
NASA appeared to be immersed in a culture of invincibility,
in stark contradiction to post-accident reality. The Rogers
Commission found a NASA blinded by its “Can-Do” atti-
17. tude,27 a cultural artifact of the Apollo era that was inappro-
priate in a Space Shuttle Program so strapped by schedule
pressures and shortages that spare parts had to be cannibal-
ized from one vehicle to launch another.28 This can-do atti-
tude bolstered administrators ̓belief in an achievable launch
rate, the belief that they had an operational system, and an
unwillingness to listen to outside experts. The Aerospace
Safety and Advisory Panel in a 1985 report told NASA
that the vehicle was not operational and NASA should stop
treating it as if it were.29 The Board found that even after the
loss of Challenger, NASA was guilty of treating an experi-
mental vehicle as if it were operational and of not listening
to outside experts. In a repeat of the pre-Challenger warn-
ing, the 1999 Shuttle Independent Assessment Team report
reiterated that “the Shuttle was not an ʻoperational ̓vehicle
in the usual meaning of the term.”30 Engineers and program
planners were also affected by “Can-Do,” which, when
taken too far, can create a reluctance to say that something
cannot be done.
How could the lessons of Challenger have been forgotten
so quickly? Again, history was a factor. First, if success
is measured by launches and landings,31 the machine ap-
peared to be working successfully prior to both accidents.
Challenger was the 25th launch. Seventeen years and 87
missions passed without major incident. Second, previous
policy decisions again had an impact. NASAʼs Apollo-era
research and development culture and its prized deference
to the technical expertise of its working engineers was
overridden in the Space Shuttle era by “bureaucratic ac-
countability” – an allegiance to hierarchy, procedure, and
following the chain of command.32 Prior to Challenger, the
can-do culture was a result not just of years of apparently
successful launches, but of the cultural belief that the Shut-
tle Programʼs many structures, rigorous procedures, and
18. detailed system of rules were responsible for those success-
es.33 The Board noted that the pre-Challenger layers of pro-
cesses, boards, and panels that had produced a false sense of
confidence in the system and its level of safety returned in
full force prior to Columbia. NASA made many changes to
the Space Shuttle Program structure after Challenger. The
fact that many changes had been made supported a belief in
the safety of the system, the invincibility of organizational
and technical systems, and ultimately, a sense that the foam
problem was understood.
8.5 HISTORY AS CAUSE: TWO ACCIDENTS
Risk, uncertainty, and history came together when unprec-
edented circumstances arose prior to both accidents. For
Challenger, the weather prediction for launch time the next
day was for cold temperatures that were out of the engineer-
ing experience base. For Columbia, a large foam hit – also
outside the experience base – was discovered after launch.
For the first case, all the discussion was pre-launch; for
the second, it was post-launch. This initial difference de-
termined the shape these two decision sequences took, the
number of people who had information about the problem,
and the locations of the involved parties.
For Challenger, engineers at Morton-Thiokol,34 the Solid
Rocket Motor contractor in Utah, were concerned about
the effect of the unprecedented cold temperatures on the
rubber O-rings.35 Because launch was scheduled for the
next morning, the new condition required a reassessment of
the engineering analysis presented at the Flight Readiness
Review two weeks prior. A teleconference began at 8:45
p.m. Eastern Standard Time (EST) that included 34 people
in three locations: Morton-Thiokol in Utah, Marshall, and
Kennedy. Thiokol engineers were recommending a launch
delay. A reconsideration of a Flight Readiness Review risk
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assessment the night before a launch was as unprecedented
as the predicted cold temperatures. With no ground rules or
procedures to guide their discussion, the participants auto-
matically reverted to the centralized, hierarchical, tightly
structured, and procedure-bound model used in Flight Read-
iness Reviews. The entire discussion and decision to launch
began and ended with this group of 34 engineers. The phone
conference linking them together concluded at 11:15 p.m.
EST after a decision to accept the risk and fly.
For Columbia, information about the foam debris hit was
widely distributed the day after launch. Time allowed for
videos of the strike, initial assessments of the size and speed
of the foam, and the approximate location of the impact to
be dispersed throughout the agency. This was the first de-
bris impact of this magnitude. Engineers at the Marshall,
Johnson, Kennedy, and Langley centers showed initiative
and jumped on the problem without direction from above.
Working groups and e-mail groups formed spontaneously.
The size of Johnsonʼs Debris Assessment Team alone neared
and in some instances exceeded the total number of partici-
pants in the 1986 Challenger teleconference. Rather than a
tightly constructed exchange of information completed in a
20. few hours, time allowed for the development of ideas and
free-wheeling discussion among the engineering ranks. The
early post-launch discussion among engineers and all later
decision-making at management levels were decentralized,
loosely organized, and with little form. While the spontane-
ous and decentralized exchanging of information was evi-
dence that NASA
̓ s original technical culture was alive and
well, the diffuse form and lack of structure in the rest of the
proceedings would have several negative consequences.
In both situations, all new information was weighed and
interpreted against past experience. Formal categories and
cultural beliefs provide a consistent frame of reference in
which people view and interpret information and experi-
ences.36 Pre-existing definitions of risk shaped the actions
taken and not taken. Worried engineers in 1986 and again
in 2003 found it impossible to reverse the Flight Readiness
Review risk assessments that foam and O-rings did not pose
safety-of-flight concerns. These engineers could not prove
that foam strikes and cold temperatures were unsafe, even
though the previous analyses that declared them safe had
been incomplete and were based on insufficient data and
testing. Engineers ̓ failed attempts were not just a matter
of psychological frames and interpretations. The obstacles
these engineers faced were political and organizational.
They were rooted in NASA history and the decisions of
leaders that had altered NASA culture, structure, and the
structure of the safety system and affected the social con-
text of decision-making for both accidents. In the following
comparison of these critical decision scenarios for Columbia
and Challenger, the systemic problems in the NASA orga-
nization are in italics, with the system effects on decision-
making following.
NASA had conflicting goals of cost, schedule, and safety.
Safety lost out as the mandates of an “operational system”
21. increased the schedule pressure. Scarce resources went to
problems that were defined as more serious, rather than to
foam strikes or O-ring erosion.
In both situations, upper-level managers and engineering
teams working the O-ring and foam strike problems held
opposing definitions of risk. This was demonstrated imme-
diately, as engineers reacted with urgency to the immediate
safety implications: Thiokol engineers scrambled to put
together an engineering assessment for the teleconference,
Langley Research Center engineers initiated simulations
of landings that were run after hours at Ames Research
Center, and Boeing analysts worked through the weekend
on the debris impact analysis. But key managers were re-
sponding to additional demands of cost and schedule, which
competed with their safety concerns. NASA
̓ s conflicting
goals put engineers at a disadvantage before these new situ-
ations even arose. In neither case did they have good data
as a basis for decision-making. Because both problems had
been previously normalized, resources sufficient for testing
or hardware were not dedicated. The Space Shuttle Program
had not produced good data on the correlation between cold
temperature and O-ring resilience or good data on the poten-
tial effect of bipod ramp foam debris hits.37
Cultural beliefs about the low risk O-rings and foam debris
posed, backed by years of Flight Readiness Review deci-
sions and successful missions, provided a frame of refer-
ence against which the engineering analyses were judged.
When confronted with the engineering risk assessments, top
Shuttle Program managers held to the previous Flight Readi-
ness Review assessments. In the Challenger teleconference,
where engineers were recommending that NASA delay the
launch, the Marshall Solid Rocket Booster Project manager,
Lawrence Mulloy, repeatedly challenged the contractorʼs
risk assessment and restated Thiokolʼs engineering ratio-
22. nale for previous flights.38 STS-107 Mission Management
Team Chair Linda Ham made many statements in meetings
reiterating her understanding that foam was a maintenance
problem and a turnaround issue, not a safety-of-flight issue.
The effects of working as a manager in a culture with a cost/
efficiency/safety conflict showed in managerial responses. In
both cases, managers ̓techniques focused on the information
that tended to support the expected or desired result at that
time. In both cases, believing the safety of the mission was
not at risk, managers drew conclusions that minimized the
risk of delay.39 At one point, Marshall s̓ Mulloy, believing
in the previous Flight Readiness Review assessments, un-
convinced by the engineering analysis, and concerned about
the schedule implications of the 53-degree temperature limit
on launch the engineers proposed, said, “My God, Thiokol,
when do you want me to launch, next April?”40 Reflecting the
overall goal of keeping to the Node 2 launch schedule, Ham s̓
priority was to avoid the delay of STS–114, the next mis-
sion after STS-107. Ham was slated as Manager of Launch
Integration for STS-114 – a dual role promoting a conflict of
interest and a single-point failure, a situation that should be
avoided in all organizational as well as technical systems.
NASA s̓ culture of bureaucratic accountability emphasized
chain of command, procedure, following the rules, and go-
ing by the book. While rules and procedures were essential
for coordination, they had an unintended but negative effect.
Allegiance to hierarchy and procedure had replaced defer-
ence to NASA engineers ̓technical expertise.
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In both cases, engineers initially presented concerns as well
as possible solutions – a request for images, a recommenda-
tion to place temperature constraints on launch. Manage-
ment did not listen to what their engineers were telling them.
Instead, rules and procedures took priority. For Columbia,
program managers turned off the Kennedy engineers ̓initial
request for Department of Defense imagery, with apologies
to Defense Department representatives for not having fol-
lowed “proper channels.” In addition, NASA administrators
asked for and promised corrective action to prevent such
a violation of protocol from recurring. Debris Assessment
Team analysts at Johnson were asked by managers to dem-
onstrate a “mandatory need” for their imagery request, but
were not told how to do that. Both Challenger and Columbia
engineering teams were held to the usual quantitative stan-
dard of proof. But it was a reverse of the usual circumstance:
instead of having to prove it was safe to fly, they were asked
to prove that it was unsafe to fly.
In the Challenger teleconference, a key engineering chart
presented a qualitative argument about the relationship be-
tween cold temperatures and O-ring erosion that engineers
were asked to prove. Thiokolʼs Roger Boisjoly said, “I had
no data to quantify it. But I did say I knew it was away from
goodness in the current data base.”41 Similarly, the Debris
Assessment Team was asked to prove that the foam hit was
a threat to flight safety, a determination that only the imag-
ery they were requesting could help them make. Ignored by
management was the qualitative data that the engineering
24. teams did have: both instances were outside the experience
base. In stark contrast to the requirement that engineers ad-
here to protocol and hierarchy was managementʼs failure to
apply this criterion to their own activities. The Mission Man-
agement Team did not meet on a regular schedule during the
mission, proceeded in a loose format that allowed informal
influence and status differences to shape their decisions, and
allowed unchallenged opinions and assumptions to prevail,
all the while holding the engineers who were making risk
assessments to higher standards. In highly uncertain circum-
stances, when lives were immediately at risk, management
failed to defer to its engineers and failed to recognize that
different data standards – qualitative, subjective, and intui-
tive – and different processes – democratic rather than proto-
col and chain of command – were more appropriate.
The organizational structure and hierarchy blocked effective
communication of technical problems. Signals were over-
looked, people were silenced, and useful information and
dissenting views on technical issues did not surface at higher
levels. What was communicated to parts of the organization
was that O-ring erosion and foam debris were not problems.
Structure and hierarchy represent power and status. For both
Challenger and Columbia, employees ̓positions in the orga-
nization determined the weight given to their information,
by their own judgment and in the eyes of others. As a result,
many signals of danger were missed. Relevant information
that could have altered the course of events was available
but was not presented.
Early in the Challenger teleconference, some engineers who
had important information did not speak up. They did not
define themselves as qualified because of their position: they
were not in an appropriate specialization, had not recently
25. worked the O-ring problem, or did not have access to the
“good data” that they assumed others more involved in key
discussions would have.42 Geographic locations also re-
sulted in missing signals. At one point, in light of Marshallʼs
objections, Thiokol managers in Utah requested an “off-line
caucus” to discuss their data. No consensus was reached,
so a “management risk decision” was made. Managers
voted and engineers did not. Thiokol managers came back
on line, saying they had reversed their earlier NO-GO rec-
ommendation, decided to accept risk, and would send new
engineering charts to back their reversal. When a Marshall
administrator asked, “Does anyone have anything to add to
this?,” no one spoke. Engineers at Thiokol who still objected
to the decision later testified that they were intimidated by
management authority, were accustomed to turning their
analysis over to managers and letting them decide, and did
not have the quantitative data that would empower them to
object further.43
In the more decentralized decision process prior to
Columbia s̓ re-entry, structure and hierarchy again were re-
sponsible for an absence of signals. The initial request for
imagery came from the “low status” Kennedy Space Center,
bypassed the Mission Management Team, and went directly
to the Department of Defense separate from the all-power-
ful Shuttle Program. By using the Engineering Directorate
avenue to request imagery, the Debris Assessment Team was
working at the margins of the hierarchy. But some signals
were missing even when engineers traversed the appropriate
channels. The Mission Management Team Chair s̓ position in
the hierarchy governed what information she would or would
not receive. Information was lost as it traveled up the hierar-
chy. A demoralized Debris Assessment Team did not include
a slide about the need for better imagery in their presentation
to the Mission Evaluation Room. Their presentation included
the Crater analysis, which they reported as incomplete and
26. uncertain. However, the Mission Evaluation Room manager
perceived the Boeing analysis as rigorous and quantitative.
The choice of headings, arrangement of information, and size
of bullets on the key chart served to highlight what manage-
ment already believed. The uncertainties and assumptions
that signaled danger dropped out of the information chain
when the Mission Evaluation Room manager condensed the
Debris Assessment Team s̓ formal presentation to an infor-
mal verbal brief at the Mission Management Team meeting.
As what the Board calls an “informal chain of command”
began to shape STS-107ʼs outcome, location in the struc-
ture empowered some to speak and silenced others. For
example, a Thermal Protection System tile expert, who was
a member of the Debris Assessment Team but had an office
in the more prestigious Shuttle Program, used his personal
network to shape the Mission Management Team view and
snuff out dissent. The informal hierarchy among and within
Centers was also influential. Early identifications of prob-
lems by Marshall and Kennedy may have contributed to the
Johnson-based Mission Management Teamʼs indifference to
concerns about the foam strike. The engineers and managers
circulating e-mails at Langley were peripheral to the Shuttle
Program, not structurally connected to the proceedings, and
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27. therefore of lower status. When asked in a post-accident
press conference why they didnʼt voice their concerns to
Shuttle Program management, the Langley engineers said
that people “need to stick to their expertise.”44 Status mat-
tered. In its absence, numbers were the great equalizer.
One striking exception: the Debris Assessment Team tile
expert was so influential that his word was taken as gospel,
though he lacked the requisite expertise, data, or analysis
to evaluate damage to RCC. For those with lesser standing,
the requirement for data was stringent and inhibiting, which
resulted in information that warned of danger not being
passed up the chain. As in the teleconference, Debris As-
sessment Team engineers did not speak up when the Mission
Management Team Chair asked if anyone else had anything
to say. Not only did they not have the numbers, they also
were intimidated by the Mission Management Team Chairʼs
position in the hierarchy and the conclusions she had already
made. Debris Assessment Team members signed off on the
Crater analysis, even though they had trouble understanding
it. They still wanted images of Columbiaʼs left wing.
In neither impending crisis did management recognize how
structure and hierarchy can silence employees and follow
through by polling participants, soliciting dissenting opin-
ions, or bringing in outsiders who might have a different
perspective or useful information. In perhaps the ultimate
example of engineering concerns not making their way
upstream, Challenger astronauts were told that the cold tem-
perature was not a problem, and Columbia astronauts were
told that the foam strike was not a problem.
NASA structure changed as roles and responsibilities were
transferred to contractors, which increased the dependence
on the private sector for safety functions and risk assess-
ment while simultaneously reducing the in-house capability
28. to spot safety issues.
A critical turning point in both decisions hung on the discus-
sion of contractor risk assessments. Although both Thiokol
and Boeing engineering assessments were replete with
uncertainties, NASA ultimately accepted each. Thiokolʼs
initial recommendation against the launch of Challenger
was at first criticized by Marshall as flawed and unaccept-
able. Thiokol was recommending an unheard-of delay on
the eve of a launch, with schedule ramifications and NASA-
contractor relationship repercussions. In the Thiokol off-line
caucus, a senior vice president who seldom participated in
these engineering discussions championed the Marshall
engineering rationale for flight. When he told the managers
present to “Take off your engineering hat and put on your
management hat,” they reversed the position their own
engineers had taken.45 Marshall engineers then accepted
this assessment, deferring to the expertise of the contractor.
NASA was dependent on Thiokol for the risk assessment,
but the decision process was affected by the contractorʼs
dependence on NASA. Not willing to be responsible for a
delay, and swayed by the strength of Marshallʼs argument,
the contractor did not act in the best interests of safety.
Boeingʼs Crater analysis was performed in the context of
the Debris Assessment Team, which was a collaborative
effort that included Johnson, United Space Alliance, and
Boeing. In this case, the decision process was also affected
by NASA
̓ s dependence on the contractor. Unfamiliar with
Crater, NASA engineers and managers had to rely on Boeing
for interpretation and analysis, and did not have the train-
ing necessary to evaluate the results. They accepted Boeing
engineers ̓use of Crater to model a debris impact 400 times
outside validated limits.
NASA s̓ safety system lacked the resources, independence,
29. personnel, and authority to successfully apply alternate per-
spectives to developing problems. Overlapping roles and re-
sponsibilities across multiple safety offices also undermined
the possibility of a reliable system of checks and balances.
NASA
̓ s “Silent Safety System” did nothing to alter the deci-
sion-making that immediately preceded both accidents. No
safety representatives were present during the Challenger
teleconference – no one even thought to call them.46 In the
case of Columbia, safety representatives were present at
Mission Evaluation Room, Mission Management Team, and
Debris Assessment Team meetings. However, rather than
critically question or actively participate in the analysis, the
safety representatives simply listened and concurred.
8.6 CHANGING NASAʼS ORGANIZATIONAL
SYSTEM
The echoes of Challenger in Columbia identified in this
chapter have serious implications. These repeating patterns
mean that flawed practices embedded in NASA
̓ s organiza-
tional system continued for 20 years and made substantial
contributions to both accidents. The Columbia Accident
Investigation Board noted the same problems as the Rog-
ers Commission. An organization system failure calls for
corrective measures that address all relevant levels of the
organization, but the Boardʼs investigation shows that for all
its cutting-edge technologies, “diving-catch” rescues, and
imaginative plans for the technology and the future of space
exploration, NASA has shown very little understanding of
the inner workings of its own organization.
NASA managers believed that the agency had a strong
safety culture, but the Board found that the agency had
the same conflicting goals that it did before Challenger,
when schedule concerns, production pressure, cost-cut-
30. ting and a drive for ever-greater efficiency – all the signs
of an “operational” enterprise – had eroded NASA
̓ s abil-
ity to assure mission safety. The belief in a safety culture
has even less credibility in light of repeated cuts of safety
personnel and budgets – also conditions that existed before
Challenger. NASA managers stated confidently that every-
one was encouraged to speak up about safety issues and that
the agency was responsive to those concerns, but the Board
found evidence to the contrary in the responses to the Debris
Assessment Teamʼs request for imagery, to the initiation of
the imagery request from Kennedy Space Center, and to the
“we were just ʻwhat-iffingʼ” e-mail concerns that did not
reach the Mission Management Team. NASA
̓ s bureaucratic
structure kept important information from reaching engi-
neers and managers alike. The same NASA whose engineers
showed initiative and a solid working knowledge of how
to get things done fast had a managerial culture with an al-
legiance to bureaucracy and cost-efficiency that squelched
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the engineers ̓ efforts. When it came to managers ̓ own ac-
tions, however, a different set of rules prevailed. The Board
found that Mission Management Team decision-making
operated outside the rules even as it held its engineers to
a stifling protocol. Management was not able to recognize
31. that in unprecedented conditions, when lives are on the line,
flexibility and democratic process should take priority over
bureaucratic response.47
During the Columbia investigation, the Board consistently
searched for causal principles that would explain both the
technical and organizational system failures. These prin-
ciples were needed to explain Columbia and its echoes of
Challenger. They were also necessary to provide guidance
for NASA. The Boardʼs analysis of organizational causes in
Chapters 5, 6, and 7 supports the following principles that
should govern the changes in the agencyʼs organizational
system. The Boardʼs specific recommendations, based on
these principles, are presented in Part Three.
Leaders create culture. It is their responsibility to change
it. Top administrators must take responsibility for risk,
failure, and safety by remaining alert to the effects their
decisions have on the system. Leaders are responsible for
establishing the conditions that lead to their subordinates ̓
successes or failures. The past decisions of national lead-
ers – the White House, Congress, and NASA Headquarters
– set the Columbia accident in motion by creating resource
and schedule strains that compromised the principles of a
high-risk technology organization. The measure of NASA
̓ s
success became how much costs were reduced and how ef-
ficiently the schedule was met. But the Space Shuttle is not
now, nor has it ever been, an operational vehicle. We cannot
explore space on a fixed-cost basis. Nevertheless, due to
International Space Station needs and scientific experiments
that require particular timing and orbits, the Space Shuttle
Program seems likely to continue to be schedule-driven.
National leadership needs to recognize that NASA must fly
only when it is ready. As the White House, Congress, and
NASA Headquarters plan the future of human space flight,
the goals and the resources required to achieve them safely
32. must be aligned.
Changes in organizational structure should be made only
with careful consideration of their effect on the system and
their possible unintended consequences. Changes that make
the organization more complex may create new ways that it
can fail.48 When changes are put in place, the risk of error
initially increases, as old ways of doing things compete with
new. Institutional memory is lost as personnel and records
are moved and replaced. Changing the structure of organi-
zations is complicated by external political and budgetary
constraints, the inability of leaders to conceive of the full
ramifications of their actions, the vested interests of insiders,
and the failure to learn from the past.49
Nonetheless, changes must be made. The Shuttle Programʼs
structure is a source of problems, not just because of the
way it impedes the flow of information, but because it
has had effects on the culture that contradict safety goals.
NASAʼs blind spot is it believes it has a strong safety cul-
ture. Program history shows that the loss of a truly indepen-
dent, robust capability to protect the systemʼs fundamental
requirements and specifications inevitably compromised
those requirements, and therefore increased risk. The
Shuttle Programʼs structure created power distributions that
need new structuring, rules, and management training to
restore deference to technical experts, empower engineers
to get resources they need, and allow safety concerns to be
freely aired.
Strategies must increase the clarity, strength, and presence
of signals that challenge assumptions about risk. Twice in
NASA history, the agency embarked on a slippery slope that
resulted in catastrophe. Each decision, taken by itself, seemed
correct, routine, and indeed, insignificant and unremarkable.
33. Yet in retrospect, the cumulative effect was stunning. In
both pre-accident periods, events unfolded over a long time
and in small increments rather than in sudden and dramatic
occurrences. NASA
̓ s challenge is to design systems that
maximize the clarity of signals, amplify weak signals so they
can be tracked, and account for missing signals. For both ac-
cidents there were moments when management definitions
of risk might have been reversed were it not for the many
missing signals – an absence of trend analysis, imagery data
not obtained, concerns not voiced, information overlooked
or dropped from briefings. A safety team must have equal
and independent representation so that managers are not
again lulled into complacency by shifting definitions of risk.
It is obvious but worth acknowledging that people who are
marginal and powerless in organizations may have useful
information or opinions that they donʼt express. Even when
these people are encouraged to speak, they find it intimidat-
ing to contradict a leader s̓ strategy or a group consensus.
Extra effort must be made to contribute all relevant informa-
tion to discussions of risk. These strategies are important for
all safety aspects, but especially necessary for ill-structured
problems like O-rings and foam debris. Because ill-structured
problems are less visible and therefore invite the normaliza-
tion of deviance, they may be the most risky of all.
Challenger launches on the ill-fated STS-33/51-L mission on
Janu-
ary 28, 1986. The Orbiter would be destroyed 73 seconds later.
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34. ENDNOTES FOR CHAPTER 8
The citations that contain a reference to “CAIB document” with
CAB or
CTF followed by seven to eleven digits, such as CAB001-0010,
refer to a
document in the Columbia Accident Investigation Board
database maintained
by the Department of Justice and archived at the National
Archives.
1 Turner studied 85 different accidents and disasters, noting a
common
pattern: each had a long incubation period in which hazards and
warning signs prior to the accident were either ignored or
misinterpreted.
He called these “failures of foresight.” Barry Turner, Man-made
Disasters,
(London: Wykeham, 1978); Barry Turner and Nick Pidgeon,
Man-made
Disasters, 2nd ed. (Oxford: Butterworth Heinneman,1997).
2 Changing personnel is a typical response after an organization
has
some kind of harmful outcome. It has great symbolic value. A
change in
personnel points to individuals as the cause and removing them
gives the
false impression that the problems have been solved, leaving
unresolved
organizational system problems. See Scott Sagan, The Limits of
Safety.
Princeton: Princeton University Press, 1993.
3 Diane Vaughan, The Challenger Launch Decision: Risky
35. Technology,
Culture, and Deviance at NASA (Chicago: University of
Chicago Press.
1996).
4 William H. Starbuck and Frances J. Milliken, “Challenger:
Fine-tuning
the Odds until Something Breaks.” Journal of Management
Studies 23
(1988), pp. 319-40.
5 Report of the Presidential Commission on the Space Shuttle
Challenger
Accident, (Washington: Government Printing Office, 1986),
Vol. II,
Appendix H.
6 Alex Roland, “The Shuttle: Triumph or Turkey?” Discover,
November
1985: pp. 29-49.
7 Report of the Presidential Commission, Vol. I, Ch. 6.
8 Turner, Man-made Disasters.
9 Vaughan, The Challenger Launch Decision, pp. 243-49, 253-
57, 262-64,
350-52, 356-72.
10 Turner, Man-made Disasters.
11 U.S. Congress, House, Investigation of the Challenger
Accident,
(Washington: Government Printing Office, 1986), pp. 149.
12 Report of the Presidential Commission, Vol. I, p. 148; Vol.
IV, p. 1446.
13 Vaughan, The Challenger Launch Decision, p. 235.
14 Report of the Presidential Commission, Vol. I, pp. 1-3.
36. 15 Howard E. McCurdy, “The Decay of NASAʼs Technical
Culture,” Space
Policy (November 1989), pp. 301-10.
16 Report of the Presidential Commission, Vol. I, pp. 164-177.
17 Report of the Presidential Commission, Vol. I, Ch. VII and
VIII.
18 Report of the Presidential Commission, Vol. I, pp. 140.
19 For background on culture in general and engineering culture
in
particular, see Peter Whalley and Stephen R. Barley, “Technical
Work
in the Division of Labor: Stalking the Wily Anomaly,” in
Stephen R.
Barley and Julian Orr (eds.) Between Craft and Science, (Ithaca:
Cornell
University Press, 1997) pp. 23-53; Gideon Kunda, Engineering
Culture:
Control and Commitment in a High-Tech Corporation,
(Philadelphia:
Temple University Press, 1992); Peter Meiksins and James M.
Watson,
“Professional Autonomy and Organizational Constraint: The
Case of
Engineers,” Sociological Quarterly 30 (1989), pp. 561-85;
Henry
Petroski, To Engineer is Human: The Role of Failure in
Successful Design
(New York: St. Martinʼs, 1985); Edgar Schein. Organization
Culture and
Leadership, (San Francisco: Jossey-Bass, 1985); John Van
Maanen and
Stephen R. Barley, “Cultural Organization,” in Peter J. Frost,
Larry F.
Moore, Meryl Ries Louise, Craig C. Lundberg, and Joanne
37. Martin (eds.)
Organization Culture, (Beverly Hills: Sage, 1985).
20 Report of the Presidential Commission, Vol. I, pp. 82-111.
21 Harry McDonald, Report of the Shuttle Independent
Assessment Team.
22 Report of the Presidential Commission, Vol. I, pp. 145-148.
23 Vaughan, The Challenger Launch Decision, pp. 257-264.
24 U. S. Congress, House, Investigation of the Challenger
Accident,
(Washington: Government Printing Office, 1986), pp. 70-71.
25 Report of the Presidential Commission, Vol. I, Ch.VII.
26 Mary Douglas, How Institutions Think (London: Routledge
and Kegan
Paul, 1987); Michael Burawoy, Manufacturing Consent
(Chicago:
University of Chicago Press, 1979).
27 Report of the Presidential Commission, Vol. I, pp. 171-173.
28 Report of the Presidential Commission, Vol. I, pp. 173-174.
29 National Aeronautics and Space Administration, Aerospace
Safety
Advisory Panel, “National Aeronautics and Space
Administration Annual
Report: Covering Calendar Year 1984,” (Washington:
Government
Printing Office, 1985).
30 Harry McDonald, Report of the Shuttle Independent
Assessment Team.
31 Richard J. Feynman, “Personal Observations on Reliability
of the
38. Shuttle,” Report of the Presidential Commission, Appendix F:1.
32 Howard E. McCurdy, “The Decay of NASAʼs Technical
Culture,” Space
Policy (November 1989), pp. 301-10; See also Howard E.
McCurdy,
Inside NASA (Baltimore: Johns Hopkins University Press,
1993).
33 Diane Vaughan, “The Trickle-Down Effect: Policy
Decisions, Risky Work,
and the Challenger Tragedy,” California Management Review,
39, 2,
Winter 1997.
34 Morton subsequently sold its propulsion division of Alcoa,
and the
company is now known as ATK Thiokol Propulsion.
35 Report of the Presidential Commission, pp. 82-118.
36 For discussions of how frames and cultural beliefs shape
perceptions, see,
e.g., Lee Clarke, “The Disqualification Heuristic: When Do
Organizations
Misperceive Risk?” in Social Problems and Public Policy, vol.
5, ed. R. Ted
Youn and William F. Freudenberg, (Greenwich, CT: JAI, 1993);
William
Starbuck and Frances Milliken, “Executive Perceptual Filters –
What They
Notice and How They Make Sense,” in The Executive Effect,
Donald C.
Hambrick, ed. (Greenwich, CT: JAI Press, 1988); Daniel
Kahneman,
Paul Slovic, and Amos Tversky, eds. Judgment Under
39. Uncertainty:
Heuristics and Biases (Cambridge: Cambridge University Press,
1982);
Carol A. Heimer, “Social Structure, Psychology, and the
Estimation of
Risk.” Annual Review of Sociology 14 (1988): 491-519;
Stephen J. Pfohl,
Predicting Dangerousness (Lexington, MA: Lexington Books,
1978).
37 Report of the Presidential Commission, Vol. IV: 791;
Vaughan, The
Challenger Launch Decision, p. 178.
38 Report of the Presidential Commission, Vol. I, pp. 91-92;
Vol. IV, p. 612.
39 Report of the Presidential Commission, Vol. I, pp. 164-177;
Chapter 6,
this Report.
40 Report of the Presidential Commission, Vol. I, p. 90.
41 Report of the Presidential Commission, Vol. IV, pp. 791. For
details of
teleconference and engineering analysis, see Roger M. Boisjoly,
“Ethical
Decisions: Morton Thiokol and the Space Shuttle Challenger
Disaster,”
American Society of Mechanical Engineers, (Boston: 1987), pp.
1-13.
42 Vaughan, The Challenger Launch Decision, pp. 358-361.
43 Report of the Presidential Commission, Vol. I, pp. 88-89, 93.
44 Edward Wong, “E-Mail Writer Says He was Hypothesizing,
Not
40. Predicting Disaster,” New York Times, 11 March 2003, Sec. A-
20, Col. 1
(excerpts from press conference, Col. 3).
45 Report of the Presidential Commission, Vol. I, pp. 92-95.
46 Report of the Presidential Commission, Vol. I, p. 152.
47 Weick argues that in a risky situation, people need to learn
how to “drop
their tools:” learn to recognize when they are in unprecedented
situations
in which following the rules can be disastrous. See Karl E.
Weick, “The
Collapse of Sensemaking in Organizations: The Mann Gulch
Disaster.”
Administrative Science Quarterly 38, 1993, pp. 628-652.
48 Lee Clarke, Mission Improbable: Using Fantasy Documents
to Tame
Disaster, (Chicago: University of Chicago Press, 1999); Charles
Perrow,
Normal Accidents, op. cit.; Scott Sagan, The Limits of Safety,
op. cit.;
Diane Vaughan, “The Dark Side of Organizations,” Annual
Review of
Sociology, Vol. 25, 1999, pp. 271-305.
49 Typically, after a public failure, the responsible organization
makes
safety the priority. They sink resources into discovering what
went wrong
and lessons learned are on everyoneʼs minds. A boost in
resources goes
to safety to build on those lessons in order to prevent another
failure.
But concentrating on rebuilding, repair, and safety takes energy
41. and
resources from other goals. As the crisis ebbs and normal
functioning
returns, institutional memory grows short. The tendency is then
to
backslide, as external pressures force a return to operating
goals.
William R. Freudenberg, “Nothing Recedes Like Success? Risk
Analysis
and the Organizational Amplification of Risks,” Risk: Issues in
Health and
Safety 3, 1: 1992, pp. 1-35; Richard H. Hall, Organizations:
Structures,
Processes, and Outcomes, (Prentice-Hall. 1998), pp. 184-204;
James G.
March, Lee S. Sproull, and Michal Tamuz, “Learning from
Samples of
One or Fewer,” Organization Science, 2, 1: February 1991, pp.
1-13.
Understanding the Challenger Disaster: Organizational
Structure and the Design of Reliable
Systems
Author(s): C. F. Larry Heimann
Source: The American Political Science Review, Vol. 87, No. 2
(Jun., 1993), pp. 421-435
Published by: American Political Science Association
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American Political Science Review Vol. 87, No. 2 June 1993
UNDERSTANDING THE CHALLENGER DISASTER:
ORGANIZATIONAL
STRUCTURE AND THE DESIGN OF RELIABLE SYSTEMS
C. F. LARRY HEIMANN Michigan State University
e destruction of the space shuttle Challenger was a tremendous
blow to American space
policy. To what extent was this loss the result of organizational
43. factors at the National
.1.. Aeronautics and Space Administration? To discuss this
question analytically, we need a
theory of organizational reliability and agency behavior. Martin
Landau's work on redundancy and
administrative performance provides a good starting point for
such an effort. Expanding on Landau's
work, Iformulate a more comprehensive theory of
organizational reliability that incorporates both type
I and type II errors. These principles are then applied in a study
of NASA and its administrative
behavior before and after the Challenger accident.
O n 28 January 1986, the entire nation focused
on a single event. Seventy-three seconds after
lift-off, the space shuttle Challenger was de-
stroyed in a powerful explosion fifty thousand feet
above the Kennedy Space Center. The losses result-
ing from this catastrophe were quite high. Seven
astronauts, including Teacher-in-Space Christa
McAuliffe, were killed as the shuttle broke apart and
fell into the sea. The shuttle itself had to be replaced
at a cost of over two billion dollars. The launch of
many important commercial and military satellites
had to be delayed as American space policy ground to
a complete halt. The accident had a profound impact
on the National Aeronautics and Space Administra-
tion (NASA), as well. The agency's credibility and its
reputation for flawless execution of complex techno-
logical tasks were lost, along with the Challenger. To
this day, the legacy of the Challenger haunts the
decisions of both the agency and its political superi-
ors in Congress and the White House.
44. An examination of the shuttle remnants and other
launch data revealed the technical cause of the acci-
dent. The shuttle was destroyed when an O-ring seal
on the right solid rocket motor failed, allowing the
escaping hot gases to burn through and ignite the
main fuel tank of liquid hydrogen and liquid oxygen.
Although identifying the technical cause of this dis-
aster is important, it represents only one aspect of the
problem. Perrow (1984) has argued that organiza-
tional and technological failures have become so
intimately linked that to fully understand the cause of
most major accidents, we must analyze both the
administrative and technical aspects of the situation.
While there have been some administrative critiques
of NASA in the wake of this disaster, almost all have
centered on issues of bureaucratic culture, such as the
agency's propensity to ignore key evidence and its
myopic view of its mission. Surprisingly little has
been done on a systematic analysis of the NASA
organization structure and how it may or may not
have contributed to the loss of the Challenger.
One reason for this void is that the analytical tool
necessary-a comprehensive theory of organizational
reliability-is still lacking. Those involved in the
debate over structural design have adopted two op-
posing stances. The traditional public administration
focus on organizational design has involved the pur-
suit of efficiency in the sense of minimizing costs for
a given level of output. Implicit in this traditional
analysis is that the reliable performance of the orga-
nization was constant. The critical question, there-
fore, has usually been how one might achieve same
level of services at a lower cost. As a result, the policy
recommendations from this traditional line of think-
45. ing have been to streamline administrative systems
and reduce organizational redundancy as much as
possible.
The work of Martin Landau (1969) on redundancy
in organizations was a particularly important contri-
bution to this debate, inasmuch as he recognized that
administrative reliability is dependent on structural
factors. In breaking with conventional wisdom,
Landau's landmark 1969 essay, "Redundancy, Ration-
ality, and the Problem of Duplication and Overlap,"
asserted that the critical question was not how to cut
the costs of administrative performance but, rather,
how to ensure the organization's effectiveness.
Landau began by noting that, "no matter how much
a part is perfected, there is always the chance that it
will fail" (p. 350). As he observed, a streamlined
system requires only one part to fail for the entire
system to fail. Drawing on concepts from engineering
reliability theory, Landau argued that redundancy
built into the system can make an organization more
reliable than any of its parts. Therefore, Landau
concluded, administrative redundancy and duplica-
tion can be an important part of effective govern-
ment.
Some work has been done to extend Landau's
initial insights regarding organizational redundancy
and administrative reliability, primarily by students
and colleagues of Landau. Jon Bendor's (1985) Parallel
Systems, originally written as a dissertation under
Landau, was the most comprehensive effort to follow
up on these ideas. Bendor formalized many of Land-
au's concepts and was the first to conduct empirical
testing of these propositions, focusing on transporta-
tion planning and operations in three American met-
46. 421
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Understanding the Challenger Disaster June 1993
ropolitan areas. Donald Chisholm's (1989) Coordina-
tion without Hierarchy, also written originally as a
dissertation under Landau, discussed the notion of
reliability and redundancy as it existed in informal
organizational structures. Others have extended
some of Landau's concepts of reliability to the oper-
ations of air traffic controllers and aircraft carrier
battle groups (LaPorte and Consolini 1991; Rochlin,
LaPorte, and Roberts 1987).
The policy prescriptions that follow from these two
positions are thus quite different. The tradition-
alist argument tells us to reduce redundancy and
streamline administrative systems whenever possi-
ble, whereas Landau advocates increasing redun-
dancy by adding parallel units to the system. Most
interesting, however, is the fact that an analysis of
the organizational changes at NASA reveals that
neither the traditionalists nor Landau are fully cor-
rect. Certain parts of the space agency followed a
traditionalist policy of streamlining, while other seg-
ments of NASA adopted the Landau perspective by
generating new parallel linkages. Yet (as I shall
show), both these decisions were wrong and contrib-
uted to the untimely destruction of the Challenger.
47. How can this be? The reason is a fundamental
limitation in the current framework for discussing
organizational reliability. Most work in this area has
implicitly assumed that there was only one kind of
institutional failure and thus only two possible states
for organizational performance: the agency either
adopted the proper policy or not. But it should be
recognized that the latter possibility conceals two
different problems: the agency can simply fail to act,
or it can adopt an improper policy. Considering the
impact of both forms of error is important, because it
leads us to a different set of policy prescriptions. An
organizational structure that is effective at preventing
one type of error may not be equally effective at
preventing the other type of error.
To date, Bendor alone has formally recognized this
distinction; but his analysis was limited (1985, 49-52).
I shall extend our understanding of organizational
reliability by exploring how each kind of failure is
affected by different kinds of administrative struc-
tures. I shall lay a foundation for an analysis of
multiple forms of administrative failure by describing
the principles from engineering reliability theory,
then show how different kinds of structures leave the
agency vulnerable to different kinds of errors. Apply-
ing these arguments to the structure and decision-
making process of NASA in the pre- and post-
Challenger eras, I shall argue that the disaster had its
roots in the structural changes adopted by the space
agency in the 1970s and 1980s.
Although occasionally cited by students of public
administration, Landau's work on institutional per-
formance and reliability has received little attention
48. from political scientists. One possible reason for this
stems from the engineering roots of reliability theory.
Political scientists may have considered the issue of
organizational redundancy and reliability simply to
be a technocratic problem that could be solved by
reference to engineering formulas that dictate the
appropriate structural form and do not raise political
issues. Indeed, if we limit the scope of the problem to
two-state devices, this apolitical view of structural
design has some merit. But in a system with multiple
types of errors, trade-offs between the errors must be
made; and this moves us into the realm of politics.
Which goals will be embraced? How will resources be
allocated to combat each kind of error? Answers to
these questions are ultimately political issues.
TWO TYPES OF
ADMINISTRATIVE ERRORS
Before proceeding further, it is important to discuss
more thoroughly what is meant by the term policy
failure. As just noted, administrative problems often
have a richer structure than the simple two-state
(operating/failed) model can incorporate. In particu-
lar, bureaucracies are often in the position to commit
two types of errors; (1) implemention of the wrong
policy, an error of commission; and (2) failure to act
when action is warranted, an error of omission. If we
consider the agency's decision to take action to be
comparable to the acceptance of a hypothesis, we can
relate these two kinds of failures to the more familiar
type I and type II errors often studied in statistics.
To establish this link, we must first define the null
and alternative hypothesis in terms of potential bu-
49. reaucratic action. Since presumption often favors the
status quo, let us consider the null hypothesis to be
that the agency should not take any new action and
the alternative hypothesis to be that the bureau
should take such action. Therefore, if the agency
chooses to act when it is improper to do so (rejects the
null hypothesis when it is true), a type I error has
been committed. Likewise, if the bureau fails to act in
a situation where it should (accepts the null hypoth-
esis when it is false), then a type II error has been
committed.
To illustrate the concept of type I and type II errors
in organizational systems, let us consider the exam-
ple of NASA and its decision to launch the space
shuttle. The space agency traditionally approaches
the launch decision with the assumption that a mis-
sion is not safe to fly. Subordinates are then required
to prove that such is not the case before the launch
is permitted. The null hypothesis, therefore, is that
the mission should be aborted. If NASA were to
reject the null hypothesis by launching a mission that
is actually unsafe, it would be committing a type I
error. On the other hand, if NASA decided not to
launch a mission that was technologically sound,
then it would have committed a type II error. The
agency's choices and consequences are summarized
in Figure 1.
Each form of failure is associated with a different
set of costs. By committing a type II error, NASA
loses the opportunity to achieve its objectives and
wastes time, effort, and materials that could have
422
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American Political Science Review Vol. 87, No. 2
Summary of NASA Responses and Possible Errors
Regarding Launch Decisions
The proper course of action:
Launch Abort
Correct Type I1 Error
0 : Decision
e Mission Accident occurs; co cu~ision Possible loss of
. successful life and/or
successful equipment
< U Type 11 Correct
Z o Error Decision
.:
Missed opportunity; Accident
wasted resources avoided
null hypothesis: the mission should be aborted.
been usefully employed elsewhere. For example, the
shuttle's propellants in the external tank, liquid hy-
drogen and liquid oxygen, are lost if the mission is
scrubbed and have alone been valued at approxi-
mately five hundred thousand dollars. Furthermore,
51. the agency may forfeit the opportunity to carry out
rare scientific research, as was the case when NASA
missed the launch date for its ASTRO mission to
study Halley's Comet. The Challenger accident clearly
demonstrated, however, that a type I failure may be
far more costly. The destroyed shuttle was replaced
by the Endeavour at an expense over two billion
dollars, and the death of the seven astronauts repre-
sents an incalculable loss. Certainly, in the case of
NASA, type I errors are associated with greater costs
than type II failures. The exact cost trade-off between
these types of failure would vary, of course, for
different agencies and according to the individual
circumstances prevailing at the time of each decision.
For this reason, it is important to develop a general
approach to the study of organizational reliability that
recognizes both types of errors and identifies the
consequences associated with them.
By recognizing both forms of potential failure, we
are better able to understand the nature of the trade-
offs demanded. As with hypothesis testing, gains in
type I reliability often come at the expense of type II
reliability. However, just as it is conceivable to reduce
both a and , in hypothesis testing by increasing the
sample size, it is possible to increase both type I and
type II reliability by raising an agency's resource
levels. But because of resource limitations in the real
world, it is inevitable that bureaucrats and their
political superiors will have to strike a balance be-
tween each type of reliability. On the whole, three-
state devices allow us to consider both forms of error
and thus provide a richer framework for studying the
issue of organizational reliability.1
52. BASIC CONCEPTS OF STRUCTURE
AND RELIABILITY
General Assumptions
Throughout this discussion I will be contrasting com-
ponent and system reliability. It is important to clarify,
in advance, what is meant by these terms. A system
is a collection of subunits, known as components,
which are linked together in a particular structure. In
administrative theory, identifying components is de-
pendent on the system level in question. If one were
concentrating on the behavior of an agency, then the
agency as a whole is the system, and the offices
within it are the components. Alternatively, if one
were looking at the executive branch as a whole, that
would be the system and each agency a component
within the system. In an organizational context, de-
termining what the components are depends largely
on the system with which you are concerned. In this
case study of NASA, the system of concern is the
agency, and each component represents an office or
division inside NASA.
Three other assumptions of this work must also be
specified. First, I start by assuming that the probabil-
ity of failure for each component in the system has
already been determined either by testing or past
history,2 then, later, relax this assumption, demon-
strating that the theoretical framework is valuable
even when the exact probabilities of component fail-
ure are not known. Making this assumption at the
onset, however, is useful for developing the theory;
since the components are assumed to be known
quantities, the remaining question is how to assemble
these components into a reliable network. Second, I
53. assume that organizational reliability is static, not
dynamic. In the engineering literature, reliability is
often treated as time-dependent so as to simulate the
breakdown of mechanical components; the probabil-
ity of such failure naturally increases with age. For
administrative systems, however, it is not clear how
component reliability would change over time. One
might argue that agents become more reliable over
time because they have greater experience and exper-
tise with the issues and are thus better able to address
them. On the other hand, it could be said that agents
are less reliable over time because they are more
secure in their positions and lose their incentive to
perform well. Additionally, interest-group capture of
some public agency may affect the reliability of its
performance. While these ideas raise interesting
questions, static models of administrative reliability
will provide sufficient insight for our needs here.
Finally, I assume that the states of all components are
statistically independent. In other words, the failure
of one component or subsystem does not affect the
probability of failure of other components. Those
who study public administration may question the
423
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Understanding the Challenger Disaster June 1993
Redundant System in Parallel
54. (a) serial configuration
(b) parallel configuration
validity of this assumption. Bendor, however, proves
a theorem demonstrating that some degree of com-
ponent interaction does not negate the general results
of reliability theory (1985, 44 49). Therefore, the as-
sumption of component independence is a useful sim-
plifying assumption that does not undercut the gener-
alizability of the results. With these assumptions in
hand, we can now focus our attention on the structural
configurations commonly found in organizations.
Types of Organizational Structures
There are several basic organizational forms em-
ployed in the development of administrative sys-
tems. The first is a serial structure, a form often found
in organizations. In a traditional serial structure,
pictured in Figure 2, the first component must cor-
rectly process a policy initiative before sending it on
to the'next component. To be effective, policy must
successfully pass through each of these components.
The result is that in order for the system as a whole to
fail, it is only necessary for one of the components in
series to fail. If any one component were to fail to
pass the policy to the next unit, then all the compo-
nents that followed it would be unable to act, and the
policy could not get through the system.
Another possible organizational form is the estab-
lishment of parallel linkages between components. In
a parallel structure, such as the one illustrated in
Figure 2, a policy may pass through any one of the
components in order to get to the implementation
55. stage. It is different from the serial structure inasmuch
as even if one or more units fail to pass the policy along,
it may still be able to make it through the system. The
end result is that for a policy to fail to get through this
type of system, all components must fail.
One variation of this structural form is the k-out-
of-m unit network. In certain cases, we require that a
certain number, k, of the m units in an active parallel
redundant system must work for the system to be
successful. One example of this type of system might
be the requirement that at least two of the space
shuttle's four major computers be on-line for launch.
An organizational application of this system would
be an agency director's decision rule not to imple-
ment any policy that a majority of the staff cannot
agree upon (k = + 1).
There are two special cases of the k-out-of-m unit
network which merit attention. The first instance is
where k = 1, in which case we are back to a simple
parallel system. The second case is where k = m,
which effectively reduces the structure to a serial
system. (See Appendix for proof.) In the latter case,
although the network is configured as an active
parallel system, in terms of reliability it is behaving as
a serial structure. To differentiate between this type
of system and a traditional serial network, we will
classify this type of structure as a serially independent
system. This name signifies that while the system is
essentially a serial one, its components operate com-
pletely independently from each other.
In an organizational context, an important distinc-
tion between a serially independent system and the
56. traditional serial structure is the difference in process-
ing time. In a traditional serial system, the first
component must process the information, then pass
it on to the next component for processing. This
continues until all the components have processed
the information. The total processing time of the
system is the sum of processing times for each
component plus some factor to account for transmis-
sion delay between units. In contrast, the serially
independent system allows all components to oper-
ate simultaneously. The time needed for the serially
independent system to complete its task is simply the
time it takes the slowest component to finish its
operations. So while both structures yield the same
level of reliability, serially independent systems re-
quire less processing time.
Larger organizations often utilize combinations of
serial and parallel structural forms. Two examples of
this can be seen in Figure 3. In a series-parallel system
there are several parallel subsystems linked together in
a serial fashion. A parallel-series configuration is the
result of several serial substructures combined into a
larger parallel network. As these two examples illus-
trate, most large and complex structures can be decom-
posed into smaller units for easier analysis.
THE ADVANTAGE OF PARALLEL
SYSTEMS IN A TWO-STATE WORLD
Components aligned in a series configuration are
perhaps the easiest systems to analyze, as well as the
most commonly encountered. As I noted earlier, in
order for the system as a whole to fail, only one of the
components in series has to fail. Defining the proba-
bility of failure for component i as fi, a mathematical
57. statement of the reliability of a serial system with m
components would be
m
i = 1
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American Political Science Review Vol. 87, No. 2
Combinations of Structures with m Units in Series
and n Units in Parallel
1,1 1,21,
2. 1 2.. . .. . . . . ..r
21,1 2,2 L 2,m
(a) Series-Parallel Configuration
1,1 ~~~1,2 . ..... 1.m
By...~~~~~~~~.......... 2,1 222,m
(b) Parallel-Series Configuration
We can see that two factors determine the reliability
of a series system: component reliability and the
number of components in the system. In order to
58. increase the reliability of this type of system, one
must either increase the reliability of the components
or decrease the total number of components em-
ployed. As illustrated in Figure 4, marginal gains in
system reliability from increasing component perfor-
mance decrease as component reliability increases.
Because the costs of increasing component reliability
often rise exponentially, it is more effective in many
cases to reduce the total number of components in
series to reach reliability goals.
Perhaps the most common means of increasing
reliability in a two-state world is to add parallel
components to a system. It is assumed that all
branches are active and that a signal needs to pass
through only one branch to be successfully transmit-
ted. Since it is assumed that all branches must fail in
order for the system to fail, the reliability function for
a parallel system with n components is simply
n
i = 1
Figure 7 illustrates the relationship between compo-
nent reliability, the number of parallel elements, and
overall system reliability. In this case, we see that the
Declining Reliability of Serial Systems
0.90 , R = 0.99
n 0.80 '= 0.98
0
0.70 .
59. 2 ~~~~~~~~0
4.. ~~~~~~~0
* 0.60 o
l _ ?0 R=0.95
0.50 R Component Reliability | 0
0
0.40 ..............
1 3 5 7 9 11 13 15
Number of Components In Series
marginal gains from adding parallel channels de-
crease as the number of parallel components in-
creases.
In comparing Figures 4 and 5, the attractiveness of
parallel systems in a two-state world is clear. Holding
component reliability constant, the addition of redun-
dancy in a parallel fashion will raise the reliability of
the overall system, while creating serial redundancies
decreases total system reliability. It is not surprising,
therefore, that many scholars in this area have
spurned serial systems and focused, instead, on
parallel linkages when discussing this issue. Press-
man and Wildavsky (1973) have criticized the exist-
ence of "multiple clearance points" (a serial system)
for an implementive decision because it reduces the
likelihood that any policy can ever be executed.
Landau (1969) directs the same logic against "stream-
lined" serial structures, claiming that such systems
are more susceptible to failure than those with paral-
60. Increasing Reliability with Parallel Systems
1.00n 4
0.90 n=
0.80 n=2
cc 0.70
E
, 0.60
n=
n = number of parallel components
0.50
0.40 I l l l l I l l l
0.50 0.55 0.60 0.65 0.70 0.75 0.80 0.85 0.90 0.95 1.00
Component Reliability
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Understanding the Challenger Disaster June 1993
lel redundancies. As a result, the major policy pre-
scription of the work of Landau (1969, 1973, 1991) and
61. others (Bendor 1985; Lerner 1986) has been to empha-
size the use of parallel linkages in order to create
more reliable organizations.
However, if it is true that serial systems are gener-
ally less reliable, why are such structures ever
adopted by organizations? To answer this question
fully, we must go beyond the two-state world to
allow for multiple forms of error.
TYPE I AND TYPE II ERRORS IN AN
ADMINISTRATIVE SETTING
The Advantages of Serial Systems in a
Three-State World
As we have seen in the two-state world, serial struc-
tures are less reliable than others of comparable size.
Nonetheless, it is clear that this structural form has
been employed repeatedly in the development of
bureaucracies. The reason this type of organizational
structure has survived, I will suggest, is that it is
valuable when we must design systems to accommo-
date multiple types of error. I previously assumed
that there existed only two states for every compo-
nent: good (operating) and failed (not operating). I
shall now elaborate a'theory of organizational reliabil-
ity that allows for the existence of both type I and
type II errors.
In general, a series structure is better suited to stop
type I errors from occurring. Since the null hypothe-
sis is that the agency should not take any action, if
any component chooses to pass the proposed policy
through its part of the system, then it is rejecting the
null hypothesis. For any policy to pass through a
62. serial system successfully, all units must agree to pass
it along. If rejecting the null hypothesis was actually
the incorrect decision (a type I error), then all units
must commit such an error for the serial system as a
whole to fail. Mathematically, we can identify both
the probability of a type I failure occurring in the
system (Fa) and the reliability of the system against
this error (Ra) as
m
Fa= [I ai
m
Ra = 1 - H ai,
i= 1
where ca is the probability of a type I error occurring
in the ith component and m is the number of compo-
nents linked in series.
For an example, consider NASA's launch decision
process. We would find that a serial structure is more
effective in preventing unsafe launches. In order to
approve an unsafe launch in a serial system, every
unit must err. The more hurdles are established (via
increasing numbers of serial components), the harder
it is for an unsafe launch proposal to pass through the
system unopposed.
With regard to type II errors, however, series
structures are less effective. Consider the fact that if
one unit accepts the null hypothesis of no new action,
then the policy cannot be passed through the rest of
63. the serial system. If accepting the null hypothesis was
actually incorrect (a type II error), then the whole
system would have failed. Thus, in order for a type II
error to occur at the system level, only one compo-
nent in series must fail in this manner for the system
to fail. The more components added in series, the
greater the probability that a component will commit
a type II error, causing the system to fail (Fit). The
reliability of a series structure with regards to type II
errors (RB) can be represented as
m
F03l rl -oi)
i = 1
m
i= 1
where f3i is the probability of a type II error occurring
in the ith component and m is the number of compo-
nents linked in series.
We may also be interested in the overall reliability
of the system-the likelihood that an agency would
commit either a type I or type II error. To find this, we
assume that for a given event at a given time, it is not
possible for an administrative system to commit both
a type I and a type II error simultaneously. This
assumption is not unreasonable. A type I error re-
quires that the agency act, while a type II error
demands that the agency postpone any action. An
organization cannot both act and not act at the same
time. Consider NASA's decision to launch the shut-
tle. The space agency can either decide to launch the
64. shuttle now (possibly resulting in a type I error) or
abort the launch until another time (possibly result-
ing in a type II error). It cannot decide to both launch
and abort at the same time.
Given this argument, we can conclude that type I
and type II errors are, at any point in time, mutually
exclusive events. Therefore, the probability of either a
type I or type II error in a serial system can be found
as
P(Fa U Fa) = P(Fa) + P(FO) =
m e m
niai+1 rl (1-oi)
i=1 i=+
The overall reliability of the serial system is then
found to be
Rsys = 1 - P(Fa U Fp)
1 - (fi a i+ 1 -fi(1 ni ))
426
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American Political Science Review Vol. 87, No. 2
m m