| | TABLE OF CONTENTS: List of Figures ix
Preface xi
Acknowledgments xiii
List of Abbreviations xv
1. Introduction: How In the World Could This Happen? 3
Motivation: To Learn from and Correct Our Mistakes 7
Theoretical Domain: A Normal Accident in a Highly Reliable Organization 10
Data: We Know Exactly "What" Happened 15
Analytical Strategy: Constructing a Causal Map 18
Outline of the Book: An Explanation Across Levels 22
2. The Shootdown: A Thin Description 26
Background: Context Is Important 26
Command and Control: Dense Webs of Crosscutting Guidance 31
The Players: SAVVY, COUGAR, MAD DOG, DUKE, EAGLEs, and TIGERs 40
The Shootdown: A Deadly Dance 52
Multiple Explanations: A Walk Through the Causal Map 65
3. Individual-Level Account: Why Did the F-15 Pilots Misidentify the Black Hawks? 71
Making Sense: Seeing Through the Mind's Eye 75
Ambiguous Stimulus: What Did They Actually See? 76
Expectations: What Did They Expect to See? 80
Desire: What Did They Want to See? 94
Summary: Why They Saw What They Saw 96
4. Group-Level Account: Why Did the AWACS Crew Fail to Intervene? 99
A Weak Team: Overmatched 104
Diffuse Responsibility: When Everyone's Responsible No One Is 119
Summary: The Fallacy of Social Redundancy 135
Organizational-Level Account: Why Wasn't Eagle Flight Integrated into Task Force Operations? 136
Differentiation and Integration: Whatever You Divide, You Have to Put Back Together Again 143
Interdependence: Multiple Failures to Coordinate 152
Summary: How It All Came Apart 177
6. Cross-Levels Account: A Theory of Practical Drift 179
Practical Action: A Core Category 182
Practical Drift: A Theory 186
7. Conclusions: There But by the Grace of God 202
On Theoretical Reminders: Normal Behavior Abnormal Outcome 204
On Practical Drift: Or Is It Sailing? 220
Implications: Let's Build a Library 232
Appendixes
1. Method 237
2. Friendly Fire Applied: Lessons for Your Organization? 239
References 241
Index 251
Return to Book Description File created: 4/25/2013 |
