It is crucial to learn and understand as much as possible about the causes of human spaceflight mishaps to prevent them from reoccurring and to make future missions as safe as possible.

Bryan O’Connor was the NASA Chief of Safety and Mission Assurance when he delivered a presentation on Organizational and Cultural Lessons Learned from Challenger and Columbia at APPEL Masters Forum 18. In that forum, O’Connor shared and explained common root causes from the Apollo I, Challenger and Columbia accidents. The definition of root cause is one of multiple factors (events, conditions, or organizational factors) that contributed to or created the proximate cause and subsequent undesired outcome and, if eliminated or modified, would have prevented the undesired outcome. Typically, multiple root causes contribute to an undesired outcome. Please click on the video clip at the top to hear O’Connor discuss root causes in human spaceflight mishaps.

Video key learning points from the Masters Forum presentation:

    • Common root causal factors in human spaceflight mishaps:
    1. 1.

      Communications – a lack of, or ineffective communication is common and usually part of any mishap.

    2. 2.

      Systems Engineering and Integration – need solid integration analysis to be performed on missions.

    3. 3.

      The “Silent Safety Program” – safety personnel need to do a better job working with the program to prevent a mishap.

    4. 4.

      Operational vs. Flight Test Mentality – people start to think that missions have less risk and are routine.

    5. 5.

      Governance – make sure that all the involved people, offices and organizations in the program are able to be heard and make their concerns known.

    6. 6.

      Mission Relevance – do you need to be putting humans at risk to perform the mission’s goals?

Related Resources:

Bryan O’Connor Presentation Slides: Masters Forum 18

Bryan O’Conner Presentation: Failures, Mishaps and Root Cause Analysis

Presentation: Apollo1—Challenger—Columbia Lessons Learned

ASK Magazine Article: Success, Failure, and NASA Culture by Stephen Johnson

Bryan O’Connor NASA Bio

 

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