Organizational Failure: Handle With Care

Written By Paul Harrow

Accidents in complex systems often result from a combination of technical failures and organizational shortcomings. While technical failures are the immediate triggers, organizational failures create environments where risks to people are underestimated or ignored, leading to disasters.

Key Points

  • The Space Shuttle Challenger disaster was due to O-ring seal failure in cold temperatures, with organizational culture normalizing risky behavior and preventing adequate evaluation or rigor.

  • The Hyatt Regency walkway collapse resulted from a design change not rigorously evaluated, leading to inadequate support and structural failure.

  • Evidence shows the Boeing 737 Max crashes were due to a flawed MCAS system, with organizational failures in communication and a lack of rigor applied to MCAS deployment and design.

  • All three accidents highlight normalization of deviance, emphasizing the need for ongoing, rigorous evaluation and testing, open communication, and caring for people in safety culture.

Accident Overview

These accidents—the Challenger explosion in 1986, the Hyatt Regency walkway collapse in 1981, and the Boeing 737 Max crashes in 2018-2019—show how technical failures, like O-ring issues or design flaws, combined with organizational lapses, led to tragedies. Each case underscores the importance of not just fixing technical problems but also ensuring organizations prioritize safety and care for people.

Technical and Organizational Causes

  • Challenger: O-rings failed in cold weather, NASA’s culture accepted risks, and ignored engineers leading to the 1986 trajedy.

  • Hyatt Regency: A hastily approved design change doubled walkway loads, and was not properly evaluated, causing the 1981 collapse.

  • Boeing 737 Max: The MCAS system malfunctioned due to a single point failure sensor, with Boeing failing to communicate risks, or fully evaluate, leading to crashes in 2018 and 2019.

Practical Lessons for Businesses

Businesses should foster a safety culture that cares for people, evaluate designs rigorously, communicates openly, and learns from mistakes to prevent injuries and accidents.

Detailed Analysis of Three Major Accidents

This detailed analysis examines three significant accidents—the Space Shuttle Challenger disaster, the Hyatt Regency Kansas City walkway collapse, and the Boeing 737 Max crashes—evaluating them from technical, organizational, and moral standpoints. Drawing from various reports and analyses, including Diane Vaughn's "The Challenger Launch Decision," the analysis emphasizes the common thread of normalization of deviance and the need for a comprehensive safety culture that includes caring for people. The content is structured to offer practical lessons for businesses to prevent similar tragedies as of 10:41 PM PDT on Tuesday, March 11, 2025.

Introduction

Accidents in complex systems often stem from a combination of technical failures and organizational shortcomings. However, a deeper moral dimension—caring for people—is crucial to prevent such disasters. This analysis explores three case studies to highlight these dynamics, using the concept of normalization of deviance, where organizations accept increasingly risky behaviors as normal, and integrates a moral component into the safety culture discussion. The findings aim to inform businesses, emphasizing the importance of vigilance, transparency, and empathy in safety management.

Accident Synopses

  1. Space Shuttle Challenger (January 28, 1986, Kennedy Space Center, Florida, USA):

    • On January 28, 1986, the Space Shuttle Challenger exploded 73 seconds after launch, resulting in the loss of all 7 astronauts. The disaster occurred during a cold morning, with temperatures below freezing, which was unusual for launches. Initial investigations, including the Rogers Commission Report (Rogers Commission Report), identified the failure of O-ring seals in the solid rocket boosters as the technical cause, exacerbated by the lack of rigorous testing in cold conditions. Diane Vaughn's "The Challenger Launch Decision" highlights how NASA's culture played a critical role, with the normalization of deviance leading to the acceptance of known risks, potentially neglecting the astronauts' well-being. The Rogers Commission noted that engineers at Morton Thiokol had raised concerns about cold temperatures, but these were overridden by management pressures to maintain launch schedules, as detailed in Challenger disaster Summary, Date, Cause, & Facts Britannica. This incident, remembered 39 years later, underscores the human cost, with memorials like the Space Shuttle Challenger Memorial honoring the crew, as noted in Challenger space shuttle explosion: Remembering disaster 39 years later.

  2. Hyatt Regency Kansas City (July 17, 1981, Kansas City, Kansas, USA):

  3. Boeing 737 Max (October 29, 2018, and March 10, 2019, Java Sea, Indonesia, and near Bishoftu, Ethiopia):

Technical Cause Analysis

The technical causes of each accident are critical to understanding the immediate triggers of failure, as detailed below:

  • Challenger: The O-ring seals in the solid rocket boosters were intended to prevent hot gases from leaking through the joints during propellant burn. In cold temperatures, these seals became less flexible, failing to maintain the seal and allowing hot gases to escape, leading to the explosion. The lack of rigorous testing in cold conditions, as highlighted in the Rogers Commission Report, was a significant factor, with specific findings noting that O-ring erosion had been observed in previous flights but not addressed, as seen in The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA, Enlarged Edition, Vaughn. The Archival: Space Shuttle Challenger Disaster NBC Nightly News YouTube provides visual context of the launch and explosion, underscoring the engineering failure.

  • Hyatt Regency: The collapse resulted from a design flaw where the fourth-floor walkway was supported by rods attached to the second-floor walkway, which was not designed to bear the additional weight. This design change doubled the load on the connections, far exceeding their intended capacity, as documented in the NBS report. The structural engineering principles involved, such as load distribution and connection strength, were not adequately considered, as noted in Understanding the Tragic Hyatt Regency Walkway Collapse. The Walkway Collapse Kansas City Missouri 1981 NIST details the engineering analysis, showing how the design change violated safety standards.

  • Boeing 737 Max: The MCAS system, introduced to prevent stalls by automatically adjusting the aircraft's pitch, relied on a single angle of attack sensor. When this sensor provided faulty data, the system forced the aircraft into repeated nose-down movements, leading to dives that pilots could not control. This flaw was central to both crashes, with the KNKT report for Lion Air and the Ethiopia Accident Investigation Bureau's report for Ethiopian Airlines detailing the technical issues, as seen in Lion Air 737 MAX Final Accident Report Cites AOA Sensor, MCAS Among Multitude of Contributing Factors Avionics International. The Data Analysis of Boeing 737 Max Crashes 2024 provides further technical insights into the sensor failure and system design.

Organizational Cause Analysis

Organizational failures often amplify technical risks, and in these cases, they were pivotal, as follows:

  • Challenger: Diane Vaughn's "The Challenger Launch Decision" introduces the concept of normalization of deviance, where NASA's culture accepted O-ring erosion as routine despite previous flights showing signs of failure. This acceptance was driven by pressures to maintain launch schedules and budgetary constraints, with managers and engineers acting within a culture that normalized risky behavior. The Rogers Commission noted that key information from engineers at Morton Thiokol was not clearly communicated, contributing to the flawed launch decision, as detailed in Group Process in the Challenger Launch Decision (A) Case Faculty & Research Harvard Business School. The Challenger Launch Decision Aerossurance further explores how organizational pressures led to this normalization, potentially reflecting a lack of moral responsibility toward the astronauts, as seen in The Crew of the Space Shuttle Challenger STS-51L Mission NASA.

  • Hyatt Regency: The organizational failure was rooted in a lack of rigorous evaluation and communication during the design process. The design change, where the contractor altered the support rod connections without proper oversight, was not adequately reviewed. The NBS report highlights a miscommunication loop involving the fabricator, engineers, and architects, reflecting corporate neglect and irresponsibility, which normalized the acceptance of the flawed design, with little regard for the moral duty to protect guests and workers, as noted in Hyatt Regency Walkway Collapse Online Ethics. The The Hyatt Regency Walkway Collapse: Kansas City's Darkest Day KC Yesterday discusses the fast-tracked construction and reduced oversight, showing how organizational culture contributed to the tragedy.

  • Boeing 737 Max: Boeing's organizational failures included not communicating the MCAS system's operation to pilots or airlines, omitting it from the flight manual, and not providing specific training. The NTSB and KNKT reports indicate that engineers raised concerns about the system, but these were not addressed, reflecting a culture where cost and schedule pressures may have normalized the risks. The FAA's approval process, influenced by Boeing's self-certification, further compounded the issue, highlighting structural secrecy in decision-making, with a moral failure to prioritize the lives of passengers and crew, as seen in Why Boeing’s Problems with the 737 MAX Began More Than 25 Years Ago Working Knowledge. The After two Boeing 737 Max crashes, families are still seeking answers from DOJ underscores the ongoing impact on families, highlighting the need for ethical responsibility.

Common Thread: Normalization of Deviance

All three accidents share the common thread of normalization of deviance, as articulated by Diane Vaughn. This process involves rationalizing deviations from safety rules, making them nearly invisible within the organizational culture. For Challenger, it was accepting O-ring erosion, as seen in The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA by Diane Vaughn Goodreads; for Hyatt Regency, accepting unverified design changes, as noted in Hyatt Regency Walkways Collapse Linda Hall Library; and for Boeing 737 Max, accepting inadequate communication and testing of the MCAS system, as detailed in Boeing's 737 MAX 8 Disasters Case Study MIT Sloan. This normalization was driven by pressures such as tight schedules, financial constraints, and hierarchical information flow obstructions, making dangers harder to recognize in hindsight, often at the expense of human lives.

Moral Component: Caring for People in Safety Culture

A comprehensive safety culture must extend beyond technical solutions to include a moral component of caring for people. This involves prioritizing the well-being of employees, customers, and the public, ensuring that safety decisions are not just about compliance but about protecting people. As emphasized by the National Association of Safety Professionals (NASP), ethical behavior in workplace safety ensures the health and well-being of employees and fosters a culture of integrity and responsibility (The Importance of Ethics in Workplace Safety NASP). Similarly, the Centers for Disease Control and Prevention (CDC) highlights that a culture of safety in healthcare facilities includes a commitment to worker safety and patient safety, leading to better outcomes for both (Why a Culture of Safety is Important CDC). PSNet's definition of a culture of safety includes open communication and respect for all, aligning with this moral component (Culture of Safety PSNet). For instance, in the Challenger case, a deeper commitment to the astronauts' safety might have prompted more rigorous testing in cold conditions; in Hyatt Regency, focusing on guests' safety could have prevented unverified design changes; and for Boeing 737 Max, caring for passengers and crew could have ensured better deployment, better communication and training on the MCAS system. Businesses must integrate empathy and ethical responsibility into their safety practices, recognizing that technical solutions alone are insufficient without a genuine concern for human lives.

Practical Summary for Business

The lessons from these accidents are vital for businesses to prevent organizational failures leading to injuries, mishaps, and accidents. The following recommendations are derived from the analysis, now incorporating a moral dimension:

Recommendation: Foster a Culture of Safety with Moral ResponsibilityEncourage open communication about safety concerns, ensuring all employees feel empowered to raise issues, with a moral commitment to caring for people, prioritizing their well-being over schedules or costs.Implement Rigorous Testing and EvaluationAll design changes and new systems should be thoroughly tested under various conditions, reflecting a moral duty to protect lives, as seen in the need for cold-temperature testing missed in Challenger.Enhance Communication and Training with EmpathyEnsure all stakeholders, especially those on the front lines like pilots or maintenance crews, are informed about new systems and their operations, with comprehensive training on handling potential failures, always with a focus on protecting human lives, as lacking in the Boeing 737 Max case.Continuous Improvement with a Human-Centered ApproachLearn from past mistakes and near-misses by implementing feedback mechanisms, adapting and improving safety practices, countering the incremental descent into poor judgment observed in all three cases, while always keeping the human impact at the forefront.

To implement these, businesses can create environments where employees feel safe to speak up, as seen in successful safety cultures like those advocated by Updates on Boeing 737-9 MAX Aircraft Federal Aviation Administration, and prioritize leadership that sets the tone for safety and care, as discussed in What was learned from the Hyatt Regency collapse in Kansas City.

Conclusion

This analysis of the Space Shuttle Challenger, Hyatt Regency Kansas City, and Boeing 737 Max accidents reveals the interplay between technical, organizational, and moral failures, with normalization of deviance as a critical factor. By fostering a culture of safety that includes a moral component of caring for people, implementing rigorous testing, enhancing communication with empathy, and continuously improving with a human-centered approach, businesses can prevent similar tragedies. These lessons are applicable to organizations of all sizes, emphasizing the importance of vigilance, transparency, and empathy in safety management.

Key Citations

Paul Harrow
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