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Recurring Causes of Human Spaceflight Mishaps during Flight Tests and Early Operations n analysis of recurring causes underlying human spaceflight mishaps that occurred during flight tests and early operations was performed. Eight mishaps from the Apollo, Soyuz, Skylab, Space Shuttle, and Constellation Programs (i.e., the Ares-1X test flight) and commercial suborbital systems were included in the study. Detailed event analyses were performed for the historical mishaps and aggregate data analyses conducted to identify recurring issues. The nine most frequent issues were inadequate technical controls or risk management practices, incomplete procedures, system design and development issues, inadequate inspection or secondary verification requirements, failures of organizations to learn from previous incidents, inadequate schedule controls, inadequate task analyses or design processes, flaws in the design of organizations, and issues with organizational safety cultures.
Document ID
20200003165
Acquisition Source
Langley Research Center
Document Type
Technical Memorandum (TM)
Authors
Timothy S Barth
(Langley Research Center Hampton, Virginia, United States)
Steve K Lilley
(Glenn Research Center Cleveland, Ohio, United States)
Barbara G Kanki
(Ames Research Center Mountain View, California, United States)
Donna M Blankmann-Alexander
(Abacus Technology Corporation)
Blake Parker
(ASRC Federal Analytical Service (United States) Huntsville, Alabama, United States)
Date Acquired
May 6, 2020
Publication Date
March 1, 2020
Subject Category
Space Transportation And Safety
Report/Patent Number
NF1676L-36027
NASA/TM-2020-220573
NESC-RP-12-00823
L-21130
Report Number: NF1676L-36027
Funding Number(s)
WBS: 869021.01.07.01.01
Distribution Limits
Public
Copyright
Public Use Permitted.
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