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How Resilience Engineering Can Transform NASA’s Approach to Risky Decision Making
To look forward and envision NASA as a high reliability organization, we need first to look back with clarity unobscured by hindsight bias. Admiral Gehman and the Columbia Accident Investigation Board (CAIB) found the hole in the wing was produced not simply by debris, but by holes in organizational decision making. The factors that produced the holes in decision making are not unique to today’s NASA or limited to the Shuttle program, but are generic vulnerabilities that have contributed to other failures and tragedies across other complex industrial settings.