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

Administrative Controls for Fire Safety Hazards

December 07, 2015

In the last half of 2015, three separate fire incidents occurred at NASA's Glenn Research Center. All three fires were immediately detected by operators or fire alarm systems and extinguished. Damage was assessed and regular operations resumed within a few days of each incident. Two fires were classified as Close Calls and one was classified as a Type D Mishap.

While response to each fire was excellent, such incidents give us the chance to refine preventive administrative controls by establishing pre-fire plans that address pre-operation checks, maintenance services and rapid detection of incipient fires. Changing weather and holiday leave periods can heighten risk of fire occurrence, while lowering the odds of on-scene employee detection. Some administrative fire prevention controls can even be applied informally to increase home safety. Engineering preventive barriers and firefighting controls are of course essential in the workplace, but administrative controls are important as well.

NASA Aviation Safety

Procurement Quality Assurance

November 02, 2015

Procurement of aircraft parts without specific knowledge and expertise is a significant risk. Each center that operates aircraft currently handles parts acquisition differently, without a standard set of agency-wide processes or procedures. By consolidating aircraft parts purchases at the NASA Shared Services Center (NSSC), we have the ability to standardize the acquisition of quality aircraft parts and services.

However, this is not without its own challenges. While some flying centers will see no impact since they acquire aircraft parts via existing maintenance contracts, other centers possess greater potential issues. Centers no longer have closed-loop systems to ensure that the aircraft parts they are purchasing are the parts that they receive. Non-flying centers may acquire Unmanned Aerial Systems subject to the same risks. If this situation is not addressed properly, we could be increasing risk to our aircraft fleet. Combining the knowledge of aircraft maintenance experts from each center with the NSSC may be the solution to providing parts and supplier assurance.

Workplace Safety on ISS

October 05, 2015

Like any other NASA facility, the International Space Station (ISS) requires regular maintenance and upkeep. Inside the ISS’s dynamic environment, regular cleaning and routine inspections prevent both health and hardware problems. The crew cleans essential systems, work stations and emergency equipment to ensure readiness for use at a moment’s notice. Although the crew is constantly attentive, every six months a crewmember films the entire cabin interior and egress path of the U.S. Orbital Segment so that engineers on the ground can evaluate conditions from a fresh point of view.

If a new perspective is beneficial for the ISS crew, imagine how helpful it can be for you.

Immediately Dangerous to Life and Health

The Cost of Failing To Identify and Mitigate IDLH Hazards

September 08, 2015

On Nov. 15, 2014, four workers died and a fifth was hospitalized after exposure to a 24,000-pound methyl mercaptan leak at a DuPont plant in La Porte, Texas. The leak occurred in a building that was positioned over chemical plant piping, which included a failed valve. The Chemical Safety Board investigation later found that the valve had no documented function and served no manufacturing purpose. The enclosed office space was not designed to be a confined space, and hazard assessments did not identify Immediately Dangerous to Life and Health (IDLH) risks within the space. However, the workers were overcome by toxic gas while doing normal work there.

This month we look at the DuPont La Porte incident and three other incidents where workers were overcome by toxic or oxygen-displacing gases while performing routine work. In each of these situations, the risk of personal exposure to IDLH atmospheres was either not identified or underestimated by management or the workers operating in those environments.

Testing Flight Hardware

Director's Safety Message

August 03, 2015

On May 7, 2007, the composite reflector for the Aquarius spacecraft underwent acoustic testing at the Jet Propulsion Laboratory Environmental Test Chamber. The reflector was damaged by an anomalous test procedure stemming from a deviation from the normal test procedure. Additionally, the test control system software was not up-to-date, and there was no acoustic subject matter expert present during the test. Although Aquarius launched and successfully completed its mission, the test deviation and lack of diligence resulted in a Class A Mishap.

Due diligence is necessary when engineering, operating and maintaining state-of-the-art flight hardware. We test as much as possible in order to assure high rates of success across all of our programs and projects. Testing itself may be viewed as a measure of diligence — perhaps even a luxury during periods of low funding. However, it is necessary that we are thorough and conscientious in our testing procedures as well.

The Value of a Sustained Maintenance Program

A Lesson Learned the Hard Way

July 06, 2015

Maintenance of infrastructure has been a popular topic for news media this past year, with outlets reporting on the degradation of dams, bridges and even the U.S. highway system. At NASA, the challenge of balancing rising maintenance costs and renovating, replacing or repurposing decades-old infrastructure grows with the end of each major program and with flat or declining budgets.

In 2014, the cost of not performing maintenance on a low-risk system became apparent when Langley Research Center’s Transonic Dynamics Tunnel suffered a cooling coil breach and subsequent water intrusion. Due to the unique operating parameters of the tunnel, mitigating the leak was a lengthy and challenging process. Moreover, the inoperative tunnel lost Langley potential testing revenue upwards of $2 million. Although a series of fiscally sound decisions may prevent systematic maintenance in the short run, we must be aware of the long-term risk involved with every system.

NASA and Unmanned Aircraft Systems

Know the Rules

June 01, 2015

NASA projects are flying Unmanned Aircraft Systems (UAS) at an ever-growing rate to complete scientific research, assist other government agencies with emergency response and learn how to safely navigate the National Airspace System along with crewed aircraft. While many weigh just a few pounds, measure flight time in minutes and are limited to line-of-sight control, some weigh thousands of pounds, have international range and utilize satellite-link control. A wide range of potential issues exist.

What are the rules? Who helps researchers and operators understand and follow them? This month's message focuses on SMA requirements for UAS operations in a world of change.

What Role Does NASA Leadership Play in NASA Safety?

Watching for Signals, Keeping the Hunger, Setting the Tone

May 04, 2015

Any time there’s a lull in mishaps or high-visibility close calls, we have a natural tendency to shift focus to other demanding areas (cost, schedule, program risks). This can distract us from noticing the subtle clues that indicate that the next serious incident is about to occur.

Weak signals of danger are always evident, even if we do not notice them over the demands of daily activities. Attentiveness is the single most valuable habit to develop during these lulls. Everyone in the organization can and should stay vigilant to spot these signals and know what to do when they encounter one. In addition, when an indicator is identified, the organization needs to determine if it constitutes an acceptable risk, or if action is necessary.

This month's Safety Message examines situations when signals appeared and were missed, or when a signal was communicated but the risk was not understood.

Backover Accidents

Preventable Tragedies

April 06, 2015

Every year, thousands of children — about 50 a week in the U.S. — are harmed because drivers who were backing up did not see them. These incidents often take place in residential driveways or parking lots. Most of them involve large vehicles, like trucks, vans and SUVs. Most of them involve a parent or close loved one behind the wheel. Please take some time out of your day to reflect on these figures and what you can do to keep your own family and those around you safe.

Return to Flight

The Seven Elements of Flight Rationale

March 02, 2015

This seven-elements approach systematically identifies weaknesses within a given "prove it's safe" argument for flight approval, allowing mitigation options to be discussed. Thus, those with the power to say "yes" to residual flight risk can better understand what is being accepted.

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