Safety Messages

Lessons From Challenger

 

This Jan. 28, marks the 35th anniversary of the Challenger accident. The loss of the crew was a tragedy felt by their families, friends and coworkers at the agency, as well as people throughout the world.

The Challenger accident taught us tough lessons and brought forward what have become recognizable phrases: normalization of deviance, organizational silence and silent safety program. Sadly, we learned these lessons again in 2003 with the loss of Columbia and her crew. This shows how vital it is that we pause to revisit these lessons and never let them be forgotten. We cannot become complacent. 

In this month's Safety Message, Harmony Myers, director of the NASA Safety Center, discusses the Challenger accident and the lessons it continues to teach us today.

Reminders to Keep You Safe

Welcome to the Office of Safety and Mission Assurance Safety Message archive. This page contains Safety Message presentations and related media. While some of these presentations are not NASA related, all of them have certain aspects that are applicable to NASA. I encourage you to disseminate these to your organizations to promote discussion of these issues and possible solutions.

—W. Russ DeLoach, Chief, Safety and Mission Assurance

New York Chemical Waste-Mixing Incident

Chemical Safety Board Findings

March 01, 2006

April 25, 2002: An explosion in a mixed-use commercial building in downtown Manhattan is responsible for 36 injuries: 16 workers, six firefighters, 14 bystanders. Thirty-one of the injured were treated in hospitals, including four in intensive care. The street was closed for two weeks.

And Some Have Said, "Software Isn't Critical"

Ariane 5

February 01, 2006

On June 4, 1996, the European Space Agency (ESA) launched an Ariane 5 rocket from Kourou, French Guiana. The rocket was destroyed forty seconds after its lift-off. According to the report written by the Inquiry Board (published July 19, 1996) the proximate cause of the loss of the Ariane 501 was the complete loss of guidance and attitude information 37 seconds after main engine ignition sequence start (or about 30 seconds after lift-off). The launch of the Ariane 5 was its first, after a decade of development costing over $7 billion. The destroyed rocket and its cargo were valued at $500 million.

Refinery Ablaze

BP Texas City Refinery Fire

January 27, 2006

On March 23, 2005, a BP Texas City Refinery distillation tower experienced an overpressure event that caused a geyser-like release of highly flammable liquids and gases from a blowdown vent stack. Vapor clouds ignited, killing 15 workers and injuring 170 others. The accident also resulted in significant economic losses and was one of the most serious workplace disasters in the past two decades. The total cost of deaths and injuries, damage to refinery equipment and lost production was estimated to be over $2 billion.

A Tale of Two Failures

Delta II 7925 (1997) and Chinese Long March CZ-3B (1996)

December 01, 2005

"It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way — in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only."
— A Tale of Two Cities, Charles Dickens

Death on the Steppes

Nedelin Rocket Disaster

November 01, 2005

Where: Baikonur Cosmodrome (also known as Tyuratam), Soviet Union
When: Oct. 24, 1960
What Happened: Fuel valves in the second stage of the Soviet's R-16 ICBM prototype were inadvertently opened, and hypergolic propellants mixed and burned into the first stage causing a massive explosion at the launch pad. The number of personnel and visitors in close proximity to the launch pad exceeded safe limits given that technicians were performing repairs on a fully-fueled rocket. At least 74 people died from the fireball and toxic gases, and approximately 50 more died later from the injuries received that day. Marshal of Artillery Mitrofan Nedelin, who was personally in charge of the R-16 Program, was at the launch pad and one of the 74 killed.

Failures, Mishaps and Root Cause Analysis

Hurricane Katrina

October 01, 2005

When looking at failures, such as those that contributed to the significant losses in New Orleans, it is necessary to look at more than just the immediately visible cause, which is often the proximate cause. 

Steam Locomotive Firebox Explosion

Gettysburg Railroad

September 01, 2005

The Accident: Steam locomotive 1278 with six passenger cars had completed two excursions and was preparing for a third and final excursion for the day. During a slow climb up moderate grade, the boiler exploded, seriously burning the engineer and two firemen.

Equilon Refinery Accident

Equilon Refinery Accident, Anacortes, Washington

August 01, 2005

A foreman and operators reviewed the drum temperature sensors and concluded that the drum contents had sufficiently cooled to un-head. The top head of Drum A was removed without incident or any further indication of the temperature of the coke at bottom of Drum A. Using hydraulic controls, employees lower the bottom head of the vessel. In a matter of six seconds, 46,000 gallons of coke, still at auto-ignition temperature, spewed out in all directions from the bottom of the drum. The coke ignited, engulfing six observers and standby workers in flames.

MGM Grand Hotel Fire Disaster

A Turning Point for Fire Protection Codes

July 01, 2005

Sparks from a short circuit in a hotel deli started a major fire at the MGM Grand Hotel in Las Vegas at 7:10 AM on Nov. 21, 1980. The fire engulfed the world’s largest gambling hall in smoke and flames. The fire was concentrated near the casino on the upper entertainment level. Thick black smoke filled the air ducts and escape stairwells in the 21-story guest tower causing panic and death. Eighty-five people died and more than 600 were injured, primarily due to smoke inhalation.

Bhopal: When Hazard Controls Aren't

Bhopal Gas Leak

June 01, 2005

During the nights of Dec. 2 and 3, 1984, a Union Carbide plant in Bhopal, India, began leaking 27 tons of a deadly gas called methyl isocyanate (or MIC). Not one of the six safety systems designed to contain such a leak was operational allowing the gas to spread throughout the city of Bhopal. Half a million people were exposed to the gas. About 8,000 died the first week and 20,000 have died to date. More than 120,000 people still suffer from ailments caused by the accident and subsequent pollution of the plant site. The ailments include blindness, extreme difficulty in breathing and gynecological disorders.

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