{"id":621162,"date":"2024-03-12T06:53:17","date_gmt":"2024-03-12T10:53:17","guid":{"rendered":"https:\/\/www.nasa.gov\/?p=621162"},"modified":"2024-03-12T06:53:18","modified_gmt":"2024-03-12T10:53:18","slug":"the-next-accident-how-do-we-prevent-it","status":"publish","type":"post","link":"https:\/\/www.nasa.gov\/centers-and-facilities\/nesc\/the-next-accident-how-do-we-prevent-it\/","title":{"rendered":"The Next Accident: How Do We Prevent It?\u00a0"},"content":{"rendered":"\n<p>By Andrew Chaikin, Independent Space Historian and member of the NESC Human Factors Technical Discipline Team <\/p>\n\n\n\n<p><\/p>\n\n\n\n<p>I recently watched NESC Deputy Director Mike Kirsch stand before a roomful of engineers at the Langley Research Center and tell them that with every passing day, NASA breaks a record: the longest stretch without a major accident in the nation\u2019s human spaceflight program since the Space Shuttle Columbia disintegrated during reentry on February 1, 2003. NASA\u2019s challenge, he told them, was to make sure the record keeps being broken.   <\/p>\n\n\n\n<p>Mike\u2019s sobering message set the perfect tone for my presentation of “Principles of Success in Spaceflight,” the class I created with Victoria Kohl on the human behavior elements of success and failure in spaceflight projects. With the NESC\u2019s support, I have given it at every NASA center, and it\u2019s always a rewarding experience. You can\u2019t spend the day with a group of NASA engineers and not experience their keen intelligence, passion, and commitment to excellence. As I lead them through case studies of the Apollo 1 fire in 1967, the Challenger accident in 1986, and Columbia, I tell them that no matter how good we are at the \u201crocket science,\u201d we invite failure if we don\u2019t pay attention to the attitudes, beliefs, and assumptions we bring to the work\u2014in short, our mindset.   <\/p>\n\n\n\n<p><\/p>\n\n\n\n<p>Before the Apollo fire, there was a widespread belief that because Mercury and Gemini had used pure oxygen with no fires, there wouldn\u2019t be any in Apollo. And the Apollo spacecraft program manager missed opportunities to prevent the accident due to his belief that the fire hazard created by combining pure oxygen with exposed wiring and flammable materials was not a \u201creal\u201d problem, one that warranted slowing the train barreling down the tracks to meet John F. Kennedy\u2019s end-of-the-decade deadline for a lunar landing.  <\/p>\n\n\n\n<p>When I talk about the Challenger accident, I caution that it\u2019s essential to pay attention to the stories we tell ourselves. NASA had promised itself and Congress that the Shuttle would make spaceflight routine and affordable, a goal that required unrealistically high flight rates. Mounting schedule pressure in the lead-up to Challenger skewed decision makers\u2019 perceptions of the SRB field joint anomalies that had occurred intermittently on previous launches and were not well understood. In the Columbia discussion, I recount the shocking swiftness with which NASA lost the lessons of Challenger and paved the way for another accident with renewed schedule pressure and a belief that external tank foam shedding was \u201cnot a safety of flight issue.\u201d Accidents jolt us into new awareness, but Columbia is a painful reminder that awareness has a shelf life.    <\/p>\n\n\n\n<p><\/p>\n\n\n\n<p>What will it take to keep breaking the record that Mike spoke about? I believe we must talk to each other regularly about the behaviors that either invite success or lead us down the slippery slope to failure. Are we in the grip of what I call the “reality distortion field,” created by cost, schedule, and\/or political pressure, that clouds our perceptions of risk? Are we unconsciously indulging in hard-wired \u201cus vs. them\u201d tribal behaviors that cut us off from the diverse \u201cspotlights of awareness\u201d we must have to navigate the unforgiving demands of human spaceflight? Are we telling ourselves a story that, under clear-eyed scrutiny, doesn\u2019t hold up? These are the questions we need to ask ourselves again and again. The answers are critical. <\/p>\n\n\n\n<p><\/p>\n\n\n<div id=\"\" class=\"hds-media hds-module wp-block-image\"><div class=\"margin-left-auto margin-right-auto nasa-block-align-inline\"><div class=\"hds-media-wrapper margin-left-auto margin-right-auto\"><figure class=\"hds-media-inner hds-cover-wrapper hds-media-ratio-cover \"><a href=\"https:\/\/www.nasa.gov\/wp-content\/uploads\/2024\/02\/techup2023-pg5-art.png\"><img fetchpriority=\"high\" decoding=\"async\" width=\"2048\" height=\"1365\" src=\"https:\/\/www.nasa.gov\/wp-content\/uploads\/2024\/02\/techup2023-pg5-art.png?w=2048\" class=\"attachment-2048x2048 size-2048x2048\" alt=\"\" style=\"transform: scale(1); transform-origin: 50% 50%; object-position: 50% 50%; object-fit: cover;\" block_context=\"nasa-block\" srcset=\"https:\/\/www.nasa.gov\/wp-content\/uploads\/2024\/02\/techup2023-pg5-art.png 3000w, https:\/\/www.nasa.gov\/wp-content\/uploads\/2024\/02\/techup2023-pg5-art.png?resize=300,200 300w, https:\/\/www.nasa.gov\/wp-content\/uploads\/2024\/02\/techup2023-pg5-art.png?resize=768,512 768w, https:\/\/www.nasa.gov\/wp-content\/uploads\/2024\/02\/techup2023-pg5-art.png?resize=1024,683 1024w, https:\/\/www.nasa.gov\/wp-content\/uploads\/2024\/02\/techup2023-pg5-art.png?resize=1536,1024 1536w, https:\/\/www.nasa.gov\/wp-content\/uploads\/2024\/02\/techup2023-pg5-art.png?resize=2048,1365 2048w, https:\/\/www.nasa.gov\/wp-content\/uploads\/2024\/02\/techup2023-pg5-art.png?resize=400,267 400w, https:\/\/www.nasa.gov\/wp-content\/uploads\/2024\/02\/techup2023-pg5-art.png?resize=600,400 600w, https:\/\/www.nasa.gov\/wp-content\/uploads\/2024\/02\/techup2023-pg5-art.png?resize=900,600 900w, https:\/\/www.nasa.gov\/wp-content\/uploads\/2024\/02\/techup2023-pg5-art.png?resize=1200,800 1200w, https:\/\/www.nasa.gov\/wp-content\/uploads\/2024\/02\/techup2023-pg5-art.png?resize=2000,1333 2000w\" sizes=\"(max-width: 2048px) 100vw, 2048px\" loading=\"eager\" \/><\/a><\/figure><figcaption class=\"hds-caption padding-y-2\"><div class=\"hds-caption-text p-sm margin-0\">A section of the fuselage recovered from Space Shuttle Challenger, left, and the flight deck windows recovered from Space Shuttle Columbia at the Kennedy Space Center Visitor Complex in Florida.\u00a0<\/div><\/figcaption><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"<p>By Andrew Chaikin, Independent Space Historian and member of the NESC Human Factors Technical Discipline Team  I recently watched NESC Deputy Director Mike Kirsch stand before a roomful of engineers at the Langley Research Center and tell them that with every passing day, NASA breaks a record: the longest stretch without a major accident in [...]<\/p>\n","protected":false},"author":275,"featured_media":630502,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"nasa_hds_core_meta_l10n":"en-US","nasa_hds_core_meta_article_editor":"","nasa_hds_core_meta_article_contacts":[],"nasa_hds_core_meta_article_topic":"","nasa_hds_core_meta_linked_locations":[],"nasa_hds_core_meta_article_related_articles":[],"hds_migrate_meta_pr_release_id":"","hds_migrate_meta_pr_release_type":"","nasa_hds_core_meta_location_x":"","nasa_hds_core_meta_location_y":"","nasa_hds_core_meta_gallery_images":[],"footnotes":""},"categories":[2866],"news-tags":[],"internal-terms":[],"coauthors":[10851],"parsely":{"version":"1.1.0","meta":{"@context":"https:\/\/schema.org","@type":"NewsArticle","headline":"The Next Accident: How Do We Prevent 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