Managing Safety Performance NewsFlash

Missing The Obvious

Fifty years ago, astronaut Neil Armstrong became the first human to set foot on the Moon. The scientists and engineers at NASA succeeded in taking on the greatest technical challenge – and riskiest human endeavor – of the twentieth century. 
Over the first decade of manned spaceflight in the US, no human life was lost in space. In managing risk, there no greater success story.
That’s not to say that no lives were lost in the pursuit of this ambitious goal. In 1967, a fatal accident claimed the lives of three astronauts on the ground: at the launchpad, practicing for lift off in an oxygen enriched sealed up space capsule, when fire broke out.  Rescue proved impossible, in part because 28 latches sealed the entry port.
In retrospect, this was an event that was not only preventable but obvious: a pure oxygen atmosphere at 16 PSI, with one of NASA’s better inventions – Velcro – stuck everywhere.
Fuel, oxygen; all that was missing was a heat source, and not much of one needed to trigger the Fire Triangle. Why do you think all those scientists and engineers missed that potentially fatal hazard?
Could it be because the capsule and crews were sitting on the ground? It hadn’t happened before? This was just a training exercise? The situation was just too obvious?

Paul Balmert
July 2019

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