Ariane Analysis

     Competing demands can co-exist on a daily basis between the patient care practitioner and the organization. Predictably, the conflict eventually may result in failures with direct safety consequences. In the sharp end/blunt end dichotomy, conflicting incentives and demands are usually managed without incident as workers actively and intuitively create safety through workarounds, detection, anticipation of hazard, and recovery from mis-assessments and miscommunication. However, in the OR Refrigerator case the ongoing gap between the sharp and blunt end eventually resulted in a system failure with direct patient consequence:

• Resource constraints, time pressure and production pressures influenced the organization's decisions about software development and implementation.
• Ariane 5 differed from Ariane 4 in preparation sequence, trajectory, and alignment.
• Industry pressure to use the improved launcher in a timely manner as a demonstration of the efficiency and economy of the European Space Agency.
• Software was assumed correct until proven faulty with random hardware checks to test.