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partments after finishing their investigation, some of which were very similar to those made by the Rogers commission after the Challenger accident and investigation. CAIB concluded that the causes of the first shuttle accident were the same as the causes of the second accident (Vaughan, 2006). Their policy recommendations really fell into three areas which targeted organizational system failure. They felt the following needed to be addressed: isolate early warning signs and assure that everyone is aware of them, empower engineers to speak and be heard, and alter the present hierarchical and bureaucratic proceduralism that is embedded in the cultural patterns of the organization.
They also felt that at the organizational level, they needed to deal with the broken safety culture by completely revamping it. They included in their recommendations: creating a an independent safety unit to provide safety oversight and giving decision power to over technical issues to the technical division instead of the Program Management (Vaughan, 2006). Further they felt that at the institutional level there was a need for the White House and Congress to be accountable for their role in causing these accidents and also be accountable for assuring that the future of the program is safe. They felt that the whole of the accidents were initially set in motion by the schedule constraints and the pushing for high risk technology coming from the White House and Congress. This created an atmosphere of safety second.
In looking closely at these recommendations, it is recognized that there may be several classes of approach to change that is needed. This includes the Human processual approach. In this approach, it is recognized that small scale incremental changes over time lead to a major re-configuration of an organization (Banker & Alban, 1997). This may include the handling of data, team building, survey feedback and other issues. This would include the training that needs to be done
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