USS Thresher Nuclear Submarine

Common Threads Among Catastrophic Mishaps

Lessons Not Learned, Workmanship Shortcomings, Process Control Failures, Failures to Control Ctirical Material Items and Fraud

When we look back at major mishaps in government and industry, it's natural to look for common themes. These themes can be extremely revealing and relevant in assessing the health of NASA’s current operations.

For this month's message, Office of Safety and Mission Assurance Technical Fellow for Quality Engineering Brian Hughitt evaluated catastrophic mishaps from various domains in order to identify common Quality themes. Four predominant themes calling for heightened attention emerged: ineffective corrective action in response to precursor events, fraud and unethical behavior, workmanship shortcomings, and material control inadequacies.