学着放下熟悉的工具
239 那是秋日的一天，中午刚过：2016年10月，马克斯·巴泽曼（Max Bazerman）教授热情地允许我在哈佛商学院观察卡特赛车队的案例研讨课，为期两天。［该案例研究由杰克·W. 布里坦（Jack W.Brittain）和西姆·B. 西特金（Sim B.Sitkin）于1986年创建。］
246 “所有参与者”：F. Lighthall, “Launching the Space Shuttle Challenger: Disciplinary Deficiencies in the Analysis of Engineering Data,” IEEE Transactions on Engineering Management 38, no. 1 (1991): 63—74. Boisjoly’s “away from goodness” 引自1986年2月25日总统委员会听证会议的文字记录。
249 罗杰·博伊斯乔利亲自去检查：R. P. Boisjoly et al. “Roger Boisjoly and the Challenger Disaster,” Journal of Business Ethics 8, no. 4 (1989): 217—230. 博伊斯乔利的 “away from goodness” 引自1986年2月25日总统委员会听证会议的文字记录。
250 航天飞机是人类所完成的最精密复杂的机器：J. M. Logsdon, “Was the Space Shuttle a Mistake?,” MIT Technology Review, July 6, 2011.
250 麦克唐纳和另外两位莫顿聚硫橡胶公司的副总裁：总统委员会听证会议的文字记录提供了本章中的信息和引文，读者可在网站https://history.nasa.gov/rogersrep/genindex.htm.上查阅。阿伦·麦克唐纳还针对调查和航天飞机中重返飞行的过程进行了大量精彩描述，参见他的著作《真相、谎言和O型圈》Truth, Lies, and O-Rings (Gainesville: University Press of Florida, 2009)。
250 “他们说，因为他们曾在53华氏度的气温下发射过”：摘自黛安·沃恩（Diane Vaughan）的著作，书中包括对决策过程中“越轨行为正常化”的精彩探索： The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA (Chicago: University of Chicago Press, 1996).
251 “我们信仰上帝，其他的就拿数据说话”：对现任和前任NASA管理人员和工程师的一些背景采访——特别是于2007年访问NASA约翰逊航天中心的记录——提供了非常有用的信息。NASA工程领导力学院的门户网站是资源丰富的信息库。它能链接到NASA庞大的“经验教训系统”。
251 卡尔·维克……发现了……一些不同寻常的现象：K. E. Weick, “The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster,” Administrative Science Quarterly 38, no. 4 (1993): 628—52.; K. E. Weick, “Drop Your Tools: An Allegory for Organizational Studies,” Administrative Science Quarterly 41, no. 2 (1996): 301—13; K. E. Weick, “Drop Your Tools: On Reconfiguring Management Education,” Journal of Management Education 31, no. 1 (2007): 5—16.
252 每秒11英尺：R. C. Rothermel, “Mann Gulch Fire: A Race That Couldn’t Be Won,” Department of Agriculture, Forest Service, Intermountain Research Station, General Technical Report INT-299, May 1993.
252 野外消防员始终无法逃脱大火的魔爪：K. E. Weick, “Tool Retention and Fatalities in Wildland Fire Settings,” in Linking Expertise and Naturalistic Decision Making, ed. E. Salas and G. A. Klein (New York: Psychology Press, 2001 ［Kindle ebook］).
252 “起飞时的直升机”：USDA, USDI, and USDC, South Canyon Fire Investigation (Report of the South Canyon Fire Accident Investigation Team), U.S. Government Printing Office, Region 8, Report 573-183, 1994.
252 “还背着背包”；“这时我才发现自己肩上还背着锯”；23名野外消防精英……同归于尽：Weick, “Tool Retention and Fatalities in Wildland Fire Settings.”
253 他又在空中抓住了杆子；“放弃工具就代表着故意遗忘”；“坚守自己最熟悉的领域”；“生存危机”：Weick, “Drop Your Tools: An Allegory for Organizational Studies.”
254 “常见的应对”：J. Orasanu and L. Martin, “Errors in Aviation Decision Making,” Proceedings of the HESSD’98 (Workshop on Human Error, Safety and System Development) (1998): 100—107; J. Orasanu et al., “Errors in Aviation Decision Making,” Fourth Conference on Naturalistic Decision Making, 1998.
255 “如果我做出决策”：Weick, “Tool Retention and Fatalities in Wildland Fire Settings.”
256 “这句话字里行间就在提示”：M. Kohut, “Interview with Bryan O’Connor,” NASA’s ASK (Academy Sharing Knowledge) magazine, issue 45 (January 2012).
256 “你必须要保持理性”：引自1986年2月25日总统委员会听证会议的文字记录。
260 “救援肯定会很困难”：第48救援中队的几名成员提供了宝贵的背景和佐证。
261 “活在现实世界”：C. Grupen, Introduction to Radiation Protection (Berlin: Springer, 2010), 90. 沙弗农的全部原始语料可在 https://yarchive.net/air/perfect_safety.html 上查阅。
262 首次针对行业内各类机构的研究：K. S. Cameron and S. J. Freeman, “Cultural Congruence, Strength, and Type: Relationships to Effectiveness,” Research in Organizational Change and Development 5 (1991): 23—58.
262 最有效率的领导者和组织都具备广度：K. S. Cameron and R. E. Quinn, Diagnosing and Changing Organizational Culture, 3rd Edition (San Francisco: Jossey-Bass, 2011).
262 在一项实验中：S. V. Patil et al., “Accountability Systems and Group Norms: Balancing the Risks of Mindless Conformity and Reckless Deviation,” Journal of Behavioral Decision Making 30 (2017): 282—303.
264 吉恩·克兰兹：G. Kranz, Failure Is Not an Option (New York: Simon & Schuster, 2000). See also: M. Dunn, “Remaking NASA one step at a time,” Associated Press, October 12, 2003.
265 “周一笔记”；威廉·卢卡斯……“常常一看到问题就发怒”：S. J. Dick, ed., NASA’s First 50 Years (Washington, DC: NASA, 2011 ［ebook］). 同时，冯·布劳恩的笔记可在 https://history.msfc.nasa.gov/vonbraun/vb_weekly_notes.html 上查阅。
266 “笔记的质量立刻下降了”：R. Launius, “Comments on a Very Effective Communications System: Marshall Space Flight Center’s Monday Notes,” Roger Launius’s Blog, February 28, 2011.
266 “恰当的渠道”；“是严格的，也是抑制性的”：Columbia Accident Investigation Board, “History as Cause: Columbia and Challenger,” in Columbia Accident Investigation Board Report, vol. 1, August 2003.
267 引力探测器B：斯坦福大学在网站einstein in.stanford.edu上维护了一个档案馆，里面有大量关于引力探测器B的信息（包括技术信息和为公众编写的信息）。为了进行科学的深度潜水，《经典和量子引力》杂志Classical and Quantum Gravity (vol. 32, no. 22 ［November 2015］)专门出版了一期关于引力探测器B的内容。
267 这项技术经过二十年的研发：T. Reichhardt, “Unstoppable Force,” Nature 426 (2003): 380—81.
268 “非常自信，认为发射能够成功”：NASA Case Study, “The Gravity Probe B Launch Decisions,” NASA, Academy of Program/Project and Engineering Leadership.
269 “我们的系统没有健康的张力”：格韦登也在如下文献中讨论健康张力问题：R. Wright et al., eds., NASA at 50: Interviews with NASA’s Senior Leadership (Washington, DC: NASA, 2012).
270 第一个证明该理论的直接实验：J. Overduin, “The Experimental Verdict on Spacetime from Gravity Probe B,” in Vesselin Petkov, ed., Space, Time, and Spacetime (Berlin: Springer, 2010).
271 喜马拉雅山登山队伍：E.M. Anicich et al., “Hierarchical Cultural Values Predict Success and Mortality in High-Stakes Teams,” Proceedings of the National Academy of Sciences of the United States of America 112, no. 5 (2015): 1338—43.
272 “目视狭窄反射”：埃里克·托波尔（Eric Topol）是创造这个词的心脏病专家。（但对于真正心脏病发作的患者，支架可以挽救生命。）
272 每五十名被植入支架的患者中就有一名：K. Stergiopoulos and D. L. Brown, “Initial Coronary Stent Implantation With Medical Therapy vs Medical Therapy Alone for Stable Coronary Artery Disease: Meta-analysis of Randomized Controlled Trials,” Archives of Internal Medicine 172, no. 4 (2012): 312—19.
272 无法相信支架会不起作用：G. A. Lin et al., “Cardiologists’ Use of Percutaneous Coronary Interventions for Stable Coronary Artery Disease,” Archives of Internal Medicine 167, no. 15 (2007): 1604—09.
273 死亡的可能性就会降低：A. B. Jena et al., “Mortality and Treatment Patterns among Patients Hospitalized with Acute Cardiovascular Conditions during Dates of National Cardiology Meetings,” JAMA Internal Medicine 175, no. 2 (2015): 237– 44. See also: A. B. Jena et al., “Acute Myocardial Infarction during Dates of National Interventional Cardiology Meetings,” Journal of the American Heart Association 7, no. 6 (2018): e008230.
273 “在大型的心脏病学会议上”：R. F. Redberg, “Cardiac Patient Outcomes during National Cardiology Meetings,” JAMA Internal Medicine 175, no. 2 (2015): 245.
273 比较了“真假手术”：R. Sihvonen et al., “Arthroscopic Partial Meniscectomy Versus Sham Surgery for a Degenerative Meniscal Tear,” New England Journal of Medicine 369 (2013): 2515—24. 可以在以下文献中找到指向其他几项研究的超链接，其中包含支持的研究结果：D. Epstein, “When Evidence Says No, But Doctors Say Yes,” ProPublica, February 22, 2017.
