Contributor to "Organization at the Limit: NASA and the Columbia Disaster" (Blackwell) which provides lessons for all organziations. Download the chapter -- Creating Foresight: Lessons for Enhancing Resilience from Columbia:
creating foresight pdf
Testimony to Senate Committee on Commerce, Science and Transportation on the "Future of NASA" following the Columbia accident.
Written testimony: Creating Foresight pdf plus pictures of the hearing at Hearing Pictures html
Press release on Hindsight Bias in learning from Columbia Accident Investigation Board report based Woods' role as consultant to Board. Press Hindsight Bias and Columbia
For how the Columbia Accident reveals other patterns relevant to all organizations, see the preliminary remarks in: 5 Genotypes pdf
Radio interview on WOSU 9-5-03 radio interview mp4
CAIB report available at www.caib.us
Electronic course, Behind Human Error -- building Performance Experts in Safety (PEXiS).
error e-course
Series of papers based on studies of distributed cognition in mission control. papers on mission control
The results from this program of studies address the role of event recognition, distributed anomaly responses, re-planning, handoffs, cross-checks and more. See Making Sense of Change link; Co-Ladder link; Modifying plans in progress; Joint Activity link; Handoffs and shift change link
click on the -> to advance through voice loops as tool for coordination
A model of coordination during anomaly response and replanning. The mdoel synthesizes results from multiple studies of shuttle mission control and new results on space station control activities.
See Chow, R., Christoffersen, K. and Woods, D.D. A Model of Communication in Support of Distributed Anomaly Response and Replanning. In Proceedings of the IEA 2000/HFES 2000 Congress, Human Factors and Ergonomics Society, July, 2000. Co-ladder short pdf
Also R. Chow, K. Christoffersen, D. D. Woods, J. Watts-Perotti, and E. Patterson. Communication during Distributed Anomaly Response and Replanning. . Institute for Ergonomics/Cognitive Systems Engineering Laboratory Report, ERGO-CSEL 00-TR-02, The Ohio State University, Columbus OH, September, 2000.
Organizational accident via production pressure is focus of this board's conclusions.
MCO Board report
Slides from overview of Board's analysis is also available:
MCO board slides
Accident report on the SOHO mission interruption contributors include software, human-computer interation, and organizational factors. SOHO Board report html
The early preliminary account which used human error to downplay the system and organizational factors is at Preliminary SOHO report html
For a complete analysis of the contributors and lessons, see Nancy Leveson's work: Leveson on SOHO
Automation failure; see Accident report (english): Ariane 501 accident report html
Other reactions:
501 resources html
Software engineering notes html
Accident used in simulation study of analysis under data overload: study of analysts pdf