background interviews with current and former NASA managers and engineers—especially during a visit to NASA’s Johnson Space Center in 2017—provided helpful context. NASA’s own APPEL Knowledge Services portal was extremely helpful. It is an incredible repository of information that links to NASA’s voluminous “Lessons Learned System.”
Karl Weick noticed something unusual: K. E. Weick, “The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster,” Administrative Science Quarterly 38, no. 4 (1993): 628–52.; K. E. Weick, “Drop Your Tools: An Allegory for Organizational Studies,” Administrative Science Quarterly 41, no. 2 (1996): 301–13; K. E. Weick, “Drop Your Tools: On Reconfiguring Management Education,” Journal of Management Education 31, no. 1 (2007): 5–16.
eleven feet per second: R. C. Rothermel, “Mann Gulch Fire: A Race That Couldn’t Be Won,” Department of Agriculture, Forest Service, Intermountain Research Station, General Technical Report INT-299, May 1993.
wildland firefighters continued to lose races with fires: K. E. Weick, “Tool Retention and Fatalities in Wildland Fire Settings,” in Linking Expertise and Naturalistic Decision Making, ed. E. Salas and G. A. Klein (New York: Psychology Press, 2001 [Kindle ebook]).
“like a jet during take off”: USDA, USDI, and USDC, South Canyon Fire Investigation (Report of the South Canyon Fire Accident Investigation Team), U.S. Government Printing Office, Region 8, Report 573-183, 1994.
“still wearing his backpack”; “then I realized I still had my saw”; twenty-three . . . perished beside them: Weick, “Tool Retention and Fatalities in Wildland Fire Settings.”
grabbed it again in the air; “proxy for unlearning”; “regress to what they know best”; “existential crisis”: Weick, “Drop Your Tools: An Allegory for Organizational Studies.”
“a common pattern”: J. Orasanu and L. Martin, “Errors in Aviation Decision Making,” Proceedings of the HESSD ’98 (Workshop on Human Error, Safety and System Development) (1998): 100–107; J. Orasanu et al., “Errors in Aviation Decision Making,” Fourth Conference on Naturalistic Decision Making, 1998.
“If I make a decision”: Weick, “Tool Retention and Fatalities in Wildland Fire Settings.”
“Between the lines, it suggested”: M. Kohut, “Interview with Bryan O’Connor,” NASA’s ASK (Academy Sharing Knowledge) magazine, issue 45 (January 2012).
“you have to use reason”: transcript, Hearings of the Presidential Commission on the Space Shuttle Challenger Accident Vol. 4, February 25, 1986.
“must have been really hard”: Several members of the 48th Rescue Squadron provided invaluable background and corroboration.
“live in the real world”: C. Grupen, Introduction to Radiation Protection (Berlin: Springer, 2010), 90. Shafer’s entire original message is preserved at yarchive/air/perfect_safety.html.
But in the first study: K. S. Cameron and S. J. Freeman, “Cultural Congruence, Strength, and Type: Relationships to Effectiveness,” Research in Organizational Change and Development 5 (1991): 23–58.
effective leaders and organizations had range: K. S. Cameron and R. E. Quinn, Diagnosing and Changing Organizational Culture, 3rd Edition (San Francisco: Jossey-Bass, 2011).
In one experiment: S. V. Patil et al., “Accountability Systems and Group Norms: Balancing the Risks of Mindless Conformity and Reckless Deviation,” Journal of Behavioral Decision Making 30 (2017): 282–303.
Gene Kranz: G. Kranz, Failure Is Not an Option (New York: Simon & Schuster, 2000). See also: M. Dunn, “Remaking NASA one step at a time,” Associated Press, October 12, 2003.
“Monday Notes”; William Lucas . . . “often grew angry”: S. J. Dick, ed., NASA’s First 50 Years (Washington, DC: NASA, 2011 [ebook]). Also, von Braun’s weekly notes are archived at history.msfc.nasa.gov/vonbraun/vb_weekly_notes.html.
“the quality of the notes fell”: R. Launius, “Comments on a Very Effective Communications System: Marshall Space Flight Center’s Monday Notes,” Roger Launius’s Blog, February 28, 2011.
“proper channels”; “stringent and inhibiting”: Columbia Accident Investigation Board, “History as Cause: Columbia and Challenger,” in Columbia Accident Investigation Board Report, vol. 1, August 2003.
Gravity Probe B: Stanford University maintains an archive with copious information (both technical and written for the public) on GP-B, at einstein.stanford.edu. For a scientific deep dive, a special issue of the journal Classical and Quantum Gravity was devoted to GP-B (vol. 32, no. 22 [November 2015]).
technology took twenty years: T. Reichhardt, “Unstoppable Force,” Nature 426 (2003): 380–81.
“was confident that we could succeed”: NASA Case Study, “The Gravity Probe B Launch Decisions,” NASA, Academy of Program/Project and Engineering Leadership.
“a healthy tension in the system”: Geveden also discusses healthy tension in R. Wright et al., eds., NASA at 50: Interviews with NASA’s Senior Leadership (Washington, DC: NASA, 2012).
first direct test: J. Overduin, “The Experimental Verdict on Spacetime from Gravity Probe B,” in Vesselin Petkov, ed., Space, Time, and Spacetime (Berlin: Springer, 2010).
Himalayan mountain climbers: E.M. Anicich et al., “Hierarchical Cultural Values Predict Success and Mortality in High-Stakes Teams,” Proceedings of the National Academy of Sciences of the United States of America 112, no. 5 (2015): 1338–43.
“oculostenotic