Preventing the Next Accident: Strategies for a Safer Future

Authored by Andrew Chaikin, an esteemed Independent Space Historian and a valued contributor to the NESC Human Factors Technical Discipline Team, this piece delves into the heart of NASA’s enduring quest for safety and excellence in human spaceflight.

In a recent gathering at the Langley Research Center, NESC Deputy Director Mike Kirsch delivered a poignant reminder to a room filled with engineers. He highlighted that NASA is currently experiencing its longest period without a significant mishap in the history of America’s manned space endeavors since the tragic loss of the Space Shuttle Columbia upon reentry on February 1, 2003. Kirsch’s challenge to the team was clear: continue to extend this record of safety.

This grave yet inspiring prelude set the stage for my lecture on “Principles of Success in Spaceflight,” a course I co-developed with Victoria Kohl, focusing on the critical human behavioral aspects that influence the outcomes of spaceflight missions. Supported by the NESC, I’ve had the privilege of presenting this course across all NASA centers, an experience that has been consistently enriching. Engaging with NASA engineers is to witness firsthand their brilliant minds, fervent passion, and unwavering dedication to achieving excellence. Through examining case studies such as the Apollo 1 fire in 1967, the Challenger disaster in 1986, and the Columbia tragedy, I emphasize a crucial message: our mastery of “rocket science” alone is insufficient. Ignoring the attitudes, beliefs, and assumptions we bring to our work—our collective mindset—invites failure.

The Apollo fire tragedy was underpinned by a misplaced confidence stemming from the success of the Mercury and Gemini missions, which used pure oxygen without incident. This overconfidence, coupled with the Apollo spacecraft program manager’s dismissal of the fire risks posed by pure oxygen in conjunction with exposed wiring and flammable materials, missed crucial opportunities to avert disaster. This oversight was partly due to the intense pressure to meet President John F. Kennedy’s ambitious deadline for a lunar landing by the end of the 1960s.

In discussing the Challenger disaster, I stress the importance of critically examining the narratives we construct. NASA’s commitment to making spaceflight routine and affordable led to unrealistic expectations of high flight frequencies. This, in turn, created immense schedule pressures that distorted decision-makers’ perceptions of the risks associated with the Space Shuttle’s solid rocket booster (SRB) field joint anomalies, which had been observed in previous launches but were poorly understood.

The Columbia tragedy serves as a stark reminder of how quickly the lessons from past accidents can be forgotten. Renewed schedule pressures and the dismissal of external tank foam shedding as a non-issue for flight safety set the stage for another catastrophic failure. These accidents painfully underscore that awareness is perishable.

What does it take to continue setting new safety records, as Mike Kirsch urged? It requires ongoing dialogue about the behaviors that either pave the way to success or lead us toward failure. We must question whether we are being influenced by a “reality distortion field,” created by cost, schedule, and political pressures, that obscures our risk assessment. We need to be wary of falling into “us vs. them” tribal mentalities that blind us to the diverse perspectives essential for navigating the relentless challenges of human spaceflight. It’s about scrutinizing the stories we tell ourselves and ensuring they withstand objective analysis. These questions are vital, and the answers are crucial for the future of space exploration.