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
"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
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
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
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
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
Her death would be easy to blame on institutional failure to ensure that those in need can access resources or on a general lack of empathy for individuals crippled by addiction. Kriss and Mark have made a conscious effort to use Amber's life, her death, and her ongoing vibrant spirit to wake up the hearts and minds of those who have the power to change fate.
New Hampshire Rep. Amy Kuster (D), January 6, 2016
This is consequential. How consequential? Here is what one of the authors of the study said: "You're remapping the way the planet looks from space with those numbers, not just subtle changes about which neighborhoods are going to be susceptible to storm surge," but remapping the way the planet looks from space. Of course, CO2 levels continue to exceed 400 parts per million against a human history where they were always between 170 and 300 until the industrial era drove it up.
So that is not great news, but here is what is sickening about it. We don't seem to care here. It has all been in the news. Senators read the news. It is not like we are being deprived of information. We just as an institution do not care. That is a defect. That makes us a defective institution, not to be able to receive and process information like this. This is institutional failure, and we don't even care about that because one might say: You know, I don't really care myself about all of this damage, but as a Member of this body, I get that the U.S. Senate ought to care institutionally. It is like secondary caring. I will do my duty. Even if I personally don't care about oceans or reefs or coasts or storms, I am in. I am in, even though it is not my thing, because I know it is important. But we don't even do that. So we really don't care.
Rhode Island Sen. Sheldon Whitehouse (D), April 6, 2017
Mr. President, with each passing week we are finding out more and more about institutional failures within the Department of Veterans Affairs. We recently learned that the Phoenix VA system had a secret waiting list designed to conceal a massive backlog of delayed appointments, and that some of the veterans who were put on this secret waiting list actually died while waiting to get the treatment they deserved.
Texas Sen. John Cornryn (R), May 7, 2014
It speaks well of this Congress that we are willing to do so much to protect our country, to avert a future terrorist attack, but I have 3,000 families in New Jersey who have a husband or a mother or a wife or a child who will never come home. Of the 6,500 potentially dead victims of the New York attack alone, and the hundreds of families in Virginia, the families of New Jersey are going to want to know not simply what are we doing in the future, but what happened in the past.
How did an intelligence community that is larger financially than the military establishments of our largest rivals fail to uncover the intentions of these terrorists? How did all of our technology prove unable to intercept their communications? How, with all of the interceptions that have taken place, were we unable to analyze the information and predict the attack? How, indeed, in law enforcement, given the presence of these same terrorist organizations in previous attacks from the same locations on the same target, were we unable to infiltrate these organizations?
It may well be that there is a good explanation for each of these failures. Indeed, it may prove that everything that was humanly possible was done to the fullest extent conceivable. It may be there are institutional failures and conflicts, so that all the money conceivable will not prevent a future attack if powers are not properly distributed or the proper people do not have authority or there are breakdowns in command or communication.
I cannot predict any of these answers, but what is important is neither can anyone else in this Congress or the administration because without some analysis, as we have done throughout our country's history, we will never know.
New Jersey Sen. Robert Torricelli (D), October 4, 2001