42 Lessons Learned
Learning from Past Mistakes to Safeguard Spaceflight’s Future “No one wants to learn by mistakes, but we cannot learn enough from successes to go beyond the state of the art.” - Henry Petroski, To Engineer is Human An unprecedented number of human spaceflight systems are entering their crewed test flight and early operational phases, including systems developed by NASA and its contractors, commercial crew partners, and at least two commercial suborbital space tourism operators. But the start of every human spaceflight program since the 1967 Apollo 1 fire has been marred by major mishaps and significant close calls. Recently, the NESC and NASA Safety Center (NSC) completed an in-depth study of these historical mishaps, which has provided a rich dataset to help advance the state of the art in system safety and, as a result, raise the bar for flight and ground crew safety. A Study of Early Program Mishaps Looking at mishaps that occurred during testing and early operations, the NESC/NSC team chose eight for their study, including mishaps from the Apollo, Soyuz, Skylab, Space Shuttle, and Constellation (Ares 1-X test flight) Programs as well as commercial suborbital systems. Prior studies by NASA and others have cataloged close calls and mishaps by flight phase (ref. Significant Incidents and Close Calls in Human Spaceflight, JSC Safety and Mission Assurance https://spaceflight.nasa. gov/outreach/SignificantIncidents/index.html). The NESC/NSC study further advanced our understanding of systemic safety issues that affected multiple programs. The study’s goal was to identify recurring organizational causes that, if addressed within the broader context of support systems and processes, would have a maximum impact on reducing the frequency and/or severity of incidents, especially those in integrated test flight and early operational phases. While seldom identified as root causes, these recurring causes may be overlooked or inadequately addressed by actions resulting from a single investigation board’s findings and recommendations.
Top: The Artemis missions will depend on innovative but complex systems and technologies. Systems safety will be of utmost importance. Middle: Parts of the Apollo 1 command module after the fire. Bottom: During the launch of STS-1, a low estimate of the pressure spike generated by the reflection of the solid rocket booster initial overpressure wave resulted in nearly catastrophic damage to the orbiter.
