What was the fatal flaw that caused the Space Shuttle Challenger disaster?
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> While physical systems failures played an important role in both the Challenger and Columbia disasters, they cannot be categorized as normal accidents because in both cases the failures that caused the accidents were known to occur. Instead, true failures in these cases were the fault of NASA itself. The agency had become institutionalized due to the normalization of deviance as well as its internal culture of success at all costs. The deviant behaviors were compounded by the stresses put on NASA by its stakeholders to complete projects quickly and with a pitifully low budget. The organizational structure of NASA was a significant factor that contributed to safety having a low priority in the agency. Those who expressed concerns were actively ostracized, and the ability for concerns to even be heard by top level management was nearly impossible due to the confusing procedures put in place for reporting concerns and the levels of bureaucracy through which concerns had to flow.
https://www.researchgate.net/profile/Celia-Zeinert/publication/325261235_THE_CHALLENGER_AND_COLUMBIA_DISASTERS_NOT-SO-NORMAL_ACCIDENTS/links/5b01f0cfaca2720ba097e983/THE-CHALLENGER-AND-COLUMBIA-DISASTERS-NOT-SO-NORMAL-ACCIDENTS
Nancy Leveson, MIT, has written extensively about the Challenger accident from a systems perspective.
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