Bryan O’Connor: Common Themes for Root Causes in HSF Accidents
Bryan O’Connor highlights the six themes for root causes from Apollo 1, Challenger, and Columbia accidents.
Recorded at Masters Forum 18: http://go.nasa.gov/1rtXeQe.
Related Resources
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Apollo 1-Challenger-ColumbiaEvery year as we get back in the saddle, our Remembrance Day signals us to think back to the tragic events of Apollo 1, Challenger and Columbia as well as the context surrounding them. We’re accountable for learning from not just what went wrong, but how we recovered. As an example, read these rules recorded by Wayne Hale, former NASA Flight Director and Space Shuttle Program Manager. By actually applying such lessons from the past to your current work, our actions can honor our lost crews beyond silent reflection.
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Shuttle Software AnomalyCase Study–A few minutes after the Shuttle Endeavour reached orbit for STS-126 on Nov. 14, 2008, mission control noticed that the shuttle did not automatically transfer two communications processes from launch to orbit configuration. Primary communications continued to use S-band frequencies after they should have transferred to the more powerful Ku-band. The link between the shuttle and its payload — the Payload Signal Processor (PSP)–remained configured for a radio link rather than switching.
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Overview on Organizational Silence (SMA-OV-WBT-131)The course is for all NASA personnel and defines the basic knowledge, types, factors and consequences behind organizational silence; identifies organizational silence conditions; and describes tactics and steps to combat organizational silence.
