During a Solid Rocket Booster recovery mission, a mishap occurred on the retrieval ship MV Freedom Star, after a tow wire jumped out of the tow chute. Although a crew member was seriously injured, the outcome of this incident could have been much worse. As you will see, this case study highlights the importance of identifying and adhering to safety controls, and also looks at the unintended consequences of failing to manage change within a high-energy system. As is the case in most accident investigations, it was fairly easy to determine how this incident happened. As an organization, though, we’re more interested in taking a look at the conditions that were present to allow the incident to happen. As you read, notice how a thorough safety analysis and hazard identification may have changed this outcome. Additionally, look at the effects of taking on multiple monitoring, operational and decision-making tasks, and how cumulative fatigue — something we all may suffer from, from time to time — may degrade human performance.