NASA NTRS2006
After the Shuttle Columbia catastrophe, the investigation board (CAIB) stated that NASA needs to develop a "learning culture", meaning a capability to learn from past failures by understanding the technical and organizational causes of these mistakes (CAIB report, 2003). While many organizations learn from obvious failures, we argue that it is harder for organizations to learn from near-miss events (i.e., situations where a failure does not occur but nearly did), because these near-misses are processed as successes. For the shuttle program, prior debris problems could have caused a similar failure as on the Columbia mission except that the large pieces missed the highly sensitive portions of the orbiter. This acceptance of foam debris was adopted as a normal occurrence by the shuttle program managers similar to the problems at the time of the Challenger Disaster (detailed in Vaughan, 1996). We extend that work to show that an outcome bias influences people's evaluation of project managers, such that managers of failed missions were perceived more poorly than managers who made the same decisions but whose mission ended in either success or a near-miss. The similarity of ratings between the near-miss and success condition imply that even when a problem occurs that is clearly linked to prior managerial decisions, if the project is not harmed because of good luck, that manager is not held accountable for faculty decision making and neither the individual manager nor the organization learn from the experience potentially increasing the likelihood of a failure in the future.