Mishaps, investigating

Chemists are not alone. The Mars Climate Orbiter crashed into Mars in September 1999 following a confusion in programming of software that modeled forces in English units instead of the metric units that were expected by the thruster controllers and other programs. This incident is related in the delightfully titled NASA document Mars Climate Orbiter Mishap Investigation Report. (Stephenson 1999) The mishap cost around 125,000,000. 

Stephenson, Arthur G (1999), Mishap Investigation Board, Phase I Report , (Washington DC NASA), pp 44. 

Stephenson, A. Mars Climate Orbiter Mishap Investigation Board Report. NASA, November 10, 1999. 

Change analysis. A relatively simple but useful tool that systematically examines changes. Useful as a preventive tool in safety review of proposed changes and as a mishap investigation tool, especially when quick answers are needed or when the specific direct causes of the mishap are obscure. 

Event and causal factors charts. A mishap investigation tool that graphically depicts the vents and conditions involved in a mishap and illustrates how... 

MORT analysis. A detailed, comprehensive 1,500-item fault tree used primarily for mishap investigation. This valuable tool serves as a graphic guide for organizing and conducting an investigation and for writing the accident report. It may also be used as an appraisal or accident-prevention tool. 

The event and causal factors charts used by the Department of Energy as an accident (or mishap) investigation tool is basically the same tool as multilinear event sequencing (MES) and similar to simultaneous timed event programming (STEP)—all based on concepts of Ludwig Benner. It is also called causal factors analysis (CFA). 

Stephenson, A.G., et al. 2000. Report on Project Management in NASA by the Mars Climate Orbiter Mishap Investigation Board. NASA, March 13. 

National Aeronautics and Space Administration. 19% i.NASA Safety Manual, Vol. 2, Guidelines for Mishap Investigation. NHB 1700.1 (V2). Washington, DC National Aeronautics and Space Administration. 

A fish bone diagram is an Ishikawa diagram, which is used to analyze problems and show the various causes of an event. It is sometimes used in accident/ mishap investigations. 

MORT is an analysis technique for identifying SR oversights, errors, and/or omissions that led to the occurrence of a mishap. MORT is primarily a reactive analysis tool for accident/mishap investigation, but it can also be used for the proactive evaluation and control of hazards. MORT analysis is used to trace out and identify all of the causal factors leading to a mishap or UE. MORT utilizes the logic tree structure and rules of FTA, with the incorporation of... 

Identify new hazards and their causal factors by evaluating the subsystem hardware components and software modules. Use analysis aids to help recognize and identify new hazards, such as TLMs, hazard checklists, lesson learned, mishap investigations, and hazards from similar systems. 

---