official

Connecting the parts of NASAʼs organizational system and drawing the parallels with Challenger demonstrate three things. First, despite all the post-Challenger changes at NASA and the agencyʼs notable achievements since, the causes of the institutional failure responsible for Challenger
have not been fixed. Second, the Board strongly believes that if these persistent, systemic flaws are not resolved, the scene is set for another accident. Therefore, the recommendations for change are not only for fixing the Shuttleʼs technical system, but also for fixing each part of the organizational system that produced Columbiaʼs failure. Third,
the Boardʼs focus on the context in which decision making occurred does not mean that individuals are not responsible and accountable. To the contrary, individuals always must assume responsibility for their actions. What it does mean is that NASAʼs problems cannot be solved simply by retirements, resignations, or transferring personnel.

Columbia Accident Investigation Board, [August 2003](http://anon.nasa-global.speedera.net/anon.nasa-global/CAIB/CAIB_lowres_chapter8.pdf)

"Although some individuals are more blameworthy than others, the blame for this episode cannot be said to fall solely on the shoulders of one or two individuals.  The unconscionable events that unfolded in Guatemala in the years 1946 to 1948 also represented an institutional failure of the sort that modern requirements of transparency and accountability are designed to prevent."

Presidential Commission for the Study of Bioethical Iues, [August 29, 2011](https://bioethicsarchive.georgetown.edu/pcsbi/node/324.html)

But today they released this report, and it was a scathing indictment 
of the institution and the institutional failures, so much so that 
these auditors could not issue an opinion as to the fiscal soundness or 
the financial situation of the House of Representatives. They could not 
even issue an opinion. They said the records are so bad, they said we 
had two sets of books during this time period. Now, this is under the 
old Congress. This is under the Congress that was controlled by one 
party for 40 years in a row, so two sets of books. We could not find 
the audit trail sufficiently to be able to tell you what the financial 
conditions of the House of Representatives is today. They said that if 
this was a private business, you could not get a loan, because we could 
not say if your books were solid or not and, furthermore, you would be 
bankrupt.

Kansas Rep. Sam Brownback (R), July 18, 1995

  The history points up a basic institutional failure on the part of 
both the legislative and the executive branches of the Federal 
Government--and a failure that has involved Members of both political 
parties. And this history points unavoidably to the conclusion that we 
must take a fundamentally different approach to the budget process.
  In short, we must provide for external discipline to rein in the 
deficit. Adoption of the balanced budget amendment will impose--by 
constitutional mandate--the requisite discipline on Congress.

West Virginia Rep. Robert Wise (D), [January 26, 1995](https://www.congress.gov/congressional-record/1995/1/26/house-section/article/h700-3?q=%7B%22search%22%3A%5B%22%5C%22institutional+failure%5C%22%22%5D%7D&r=1)

I am greatly troubled about the prospect of an accident in the New York Harbor. Thirty billion gallons of oil of every type are shipped through the Port of New York and New Jersey each year. One billion gallons is lightered from deep water anchorages beyond the Verrazano Narrows. That is 100 times the amount of oil spilled by the Exxon Valdez off the Alaskan
coast. These barges are often single hulled and sometimes have no crew or anchor. The situation in the New York Harbor is doubly dangerous because of an institutional failure to dredge.

New Jersey Rep. Bob Menendez (D), [June 4, 1996](https://www.congress.gov/congressional-record/1996/6/4/extensions-of-remarks-section/article/e989-3?q=%7B%22search%22%3A%5B%22%5C%22institutional+failure%5C%22%22%5D%7D&r=9)

  I would simply say that I think I know most of the legislative 
decisions that were made by the Committee on Appropriations, but I 
certainly cannot verify that there are not some provisions in these 
other portions of the bill which we will wish we had not seen because 
they were managed by many other committees, there were not managed by 
the Committee on Appropriations. This is simply the vehicle by which 
all of that other legislation is getting done.
  You have an immense amount of legislation that has never been 
considered by either body, and, as a result, I think that in many ways, 
unfortunately, this legislation is a case study in institutional 
failure because of the massive amount of somebody else's unfinished 
business that had to be attached to the appropriations legislation.

Wisconsin Rep. Dave Obey (R), [September 28, 1996](https://www.congress.gov/congressional-record/1996/9/28/house-section/article/h12051-2?q=%7B%22search%22%3A%5B%22%5C%22institutional+failure%5C%22%22%5D%7D&r=10)

In two years, the millennium will draw to a close. This Nation's institutions are simply not ready to lead the country into a new one. I  would never in three lifetimes call for a new constitutional convention, because this generation of political leadership in my judgment is highly unlikely to improve on the work of the Founding Fathers. It is much more likely to muck it up. But I do believe we need to have millennium conventions convened for the purpose of examining ways to reshape, redirect and refocus almost all of our institutions, economic, corporate, political, communication, religious and even our international institutions, such as the IMF, the U.N. and NATO. In the political arena, we need special attention paid to the presidential nominating process to try to find ways to reduce the importance of candidates' media skills and increase the role of peer review by people who know the candidates best if both parties are to produce candidates with the qualities necessary to lead this country.

I do not know how we can change the human heart, but we do need to find ways to reshape the major institutions of this society so that there are more incentives to produce a new focus on selflessness. That is the major task we each face as individuals on life's journey. We need more help and less hindrance from the institutions that dominate our lives along the way.

Wisconsin Rep. Dave Obey (R), [September 16, 1998](https://www.congress.gov/congressional-record/1998/9/16/house-section/article/h7903-5?q=%7B%22search%22%3A%5B%22%5C%22institutional+failure%5C%22%22%5D%7D&r=13)