Recurring Causes of Human Spaceflight Mishaps During Flight Tests and Early Operations

An 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 early commercial suborbital operations 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.