Space Shuttle Challenger accident

One famous example of a special commission was the Kemeny Commission that investigated the Three Mile Island nuclear accident in 1979. Another is the Rogers Commission that investigated the Challenger Space Shuttle accident in 1986. 

One of the earliest comprehensive probabilistic risk assessments conducted was borne out of the Apollo 1 fire in 1967 that killed all three astronauts on board. For the following 20 years, NASA vacillated conducting probabilistic risk assessments for human space flight, at times concerned that the numbers showed that human space flight was too risky. However, the 1986 Challenger space shuttle accident returned NASA to regular probabilistic risk assessments. 

Again, it is very eerie to compare the similarities of the Challenger (1986) and Columba (2003) Space Shuttle accidents, especially with a focus on safety management. Like the previous example and the list of accidents in the Table 4.2, we must all be humble in recognizing that though we may understand the causes of accidents, we don t always know how to not repeat them. Some of the causes of the Columbia accident, which were similar to Challenger, are the following ... 

As noted in the Department of Energy Action Plan Lessons Learned fk>m the Columbia Space Shuttle Accident and Davis-Besse Reactor Pressure-Vessel Head Corrosion Event — When the space shuttle Columbia launched on January 16, 2003, there were 3,233 Criticality 1/lR critical item list hazards that were waived. Hazards that result in Criticahty 1/lR component failures are defined as those that will result in loss of the orbiter and crew. In both, the Challenger and Columbia accidents The machine was talking to us, but nobody was hstening. (US DOE, 2005)... 

Report of the Presidential Commission on the Space Shuttle Challenger Accident. (1986). Washington, DC U.S. Government Printing Office. 

The results of sleep deprivation have been linked to motor vehicle accidents, major industrial accidents such as the Exxon Valdez, and Three Mile Island, and the Space Shuttle Challenger disaster (2). The U.S. National Highway Traffic Safety Administration (NHTSA) in 1999 estimated that 56,000 police-reported crashes and 4% of all traffic crash fatalities (1550 cases) involved drowsiness and fatigue as principal causes (3). Sleepiness was a probable cause in about one third of all fatal-to-driver motor vehicle accidents involving commercial truck drivers (4). 

During the launch of the space shuttle Challenger on January 28,1986, the reaction became imcontroUed. One minute and 13 seconds after takeoff, the external tank and shuttle exploded, killing the shuttle s seven crew members. The accident was caused by defects in the design of O-rings that joined sections of the solid-fuel booster engines, which are attached to the sides of the shuttle. 

Twenty years later, another Space Shuttle was lost. While the proximate cause for the Columbia accident (foam hitting the wing of the orbiter) was very different than that for Challenger, many of the systemic causal factors were similar and reflected either inadequate fixes of these factors after the Challenger accident or their reemergence in the years between these losses [117]. 

Besides the loss of human hfe, the harm caused by this accident had a financial component. According to NASA, the Space Shuttle Endeavor, the orbiter buUt to replace the Space Shuttle Challenger, cost approximately 1.7 billion. http //www.nasa.gov/centers/kennedy/ about/information/shuttle faq.html l... 

Let s not kid ourselves, even a seasoned engineer can miss the mark by a fair amount. Whenever I make a presentation, I start by showing the graph in Fig. 39.1. This material was taken from the Report of the Presidential Commission on the Space Shuttle Challenger Accident, June 6, 1986, Washington, D.C. 

Major organizational accidents such as the destruction of the space shuttle Challenger in 1986, the explosion of the Chemobyl s nuclear power plant in 1987, the accident with off-shore platform Piper Alpha in 1988 or the destmction of the space shuttle Columbia in 2003, highlighted the relevance of hmnan contributions to organizational safety. Investigations traditionally considered technical and human factors in the development and prevention of these negative events but, in spite of such operational perspective, statistics have revealed the preponderance of human factors in up to 60-70 percent of the situations (e.g., Deldcer, 2002). 

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