Leading up to the Columbia and Challenger accidents, there wasn’t one gross misjudgment, one major miscalculation, or one egregious breach of duty. Rather, “a series of seemingly harmless decisions were made that incrementally moved the space agency” to catastrophe, as sociologist Diane Vaughan writes.51 These were small steps, not giant leaps. The story is a common one. Most corporations perish because they ignore the baby steps, the weak signals, the near misses that don’t immediately affect outcomes.
