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OSMA Safety Message Resource Page

I am pleased to introduce my new OSMA safety message archive.  This page contains my OSMA ViTS safety presentation along with a case study and other related media.  These stories are written as summaries of system failures from which I believe we can all learn.  While many of these cases are not NASA related, each has certain aspects that are applicable to NASA.  I encourage you to disseminate these to your organizations as a tool to promote discussion on the causes of system failures.  Henry Petroski, author of "To Engineer is Human: The Role of Failure in Successful Design," argues that engineers must strive to anticipate the ways in which a design might fail, and these case studies are an excellent way of highlighting many of these failure modes.
Bryan O'Connor Chief Safety and Mission Assurance Officer
Bryan O'Connor
Chief, Safety and Mission Assurance

CONTOUR: An Unstable Foundation

No one knows for certain why the signal from the Comet Nucleus Tour (CONTOUR) spacecraft disappeared on August 15, 2002. CONTOUR was a Discovery Program mission that was left almost entirely in the hands of NASA contractors and academic partners. It was a mission lost because of poor communication, misguided assumptions, and models that were not faithful to reality. The project team had no experience with the Solid Rocket Motor they used, and they relied on the SRM manufacturer and a consultant for expertise. The team also vested much in the strong success record of the particular model they used, but previous designs did not match CONTOUR's specifications. In this study of CONTOUR, look for ways to consider if your project is leaning on insufficient supports or depending on past performance.

Safety Message Archive

ViTS SFCS Video Title
Adobe Acrobat Adobe Acrobat   The Tour not Taken - NASA's Comet Nucleus Tour (CONTOUR)
Adobe Acrobat Adobe Acrobat   Half-Inch to Failure - Minneapolis I-35W Bridge Collapse
Adobe Acrobat Adobe Acrobat   Lost in Translation - The Mars Climate Orbiter
Adobe Acrobat Adobe Acrobat   Triple Threat - Honeywell Chemical Releases
Adobe Acrobat Adobe Acrobat   Shuttle Software Anomaly - (revised 6/4/09)
Adobe Acrobat Adobe Acrobat   Red Light - Ladbroke Grove
Adobe Acrobat Adobe Acrobat   Cover Blown - The WIRE Spacecraft Mishap
Adobe Acrobat Adobe Acrobat   The Unknown Known - B-2 Spirit, Type A Mishap
Adobe Acrobat Adobe Acrobat   Under Pressure - Sonat Separation Vessel Pressure Rupture
Adobe Acrobat Adobe Acrobat   The Million Mile Rescue - SOHO Lost in Space
Adobe Acrobat Adobe Acrobat   That Sinking Feeling - Total Loss of Petrobras P-36
Adobe Acrobat Adobe Acrobat   Fender Bender - DART's Automated Collision
Adobe Acrobat Adobe Acrobat   No Left Turns - United 232
Adobe Acrobat Adobe Acrobat   Tunnel of Terror - "The Big Dig" Ceiling Tile Collapse
Adobe Acrobat Adobe Acrobat   Two Rods Don't Make It Right - Hyatt Regency Walkway Collapse
Adobe Acrobat Adobe Acrobat   Powerless - Northeast Blackout of 2003
Adobe Acrobat Adobe Acrobat   Fire in the Cockpit - The Apollo 1 Tragedy
Adobe Acrobat Adobe Acrobat   Forrestal In Flames - US Aircraft Carrier Forrestal
Adobe Acrobat Adobe Acrobat   Lewis Spins Out of Control - Lewis Space Craft
Adobe Acrobat Adobe Acrobat   Supercritical - SL-1 Nuclear Reactor
Adobe Acrobat Adobe Acrobat View Movie
View Movie
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Almost Perfect - X31 (Videos are NASA Only)
Adobe Acrobat Adobe Acrobat   Rocky Mountain Death Trap: The Mann Gulch Fire - Team Dynamics
Adobe Acrobat Adobe Acrobat   Innovation Pushed Too Far Too Fast - R-101 Dirigible
Adobe Acrobat Adobe Acrobat   Derailed - The Eschede Train Disaster
Adobe Acrobat   View Movie
Close Call - Location: VAB, KSC - Harness Safety
Adobe Acrobat     Atlas Centaur (AC-67) Lightning Strike Mishap 1987
Adobe Acrobat     Radiation Cancer Therapy Machine Mishaps in 1985-86 due to Safety Critical Software Control Errors - Radiation Therapy Overdose
Adobe Acrobat     Mishap at an Explosives R&D Laboratory - ATK Thiokol Explosives Lab
Adobe Acrobat     Ames Arc Jet DC Power Supply Fire
Adobe Acrobat     The Davis-Besse Close Call - Davis-Besse Nuclear Reactor
Adobe Acrobat     Air Force Atlas Mishap Due to Unintended Mixing of LOX and Hydrocarbons 1975 - Air Force Atlas 71F
Adobe Acrobat Adobe Acrobat   SUBSAFE - USS Thresher, SSN 593, Lesson Learned
Adobe Acrobat     Are We Prepared for the Upcoming Hurricane Season?
Adobe Acrobat   View Movie
A Gift - STS-3
Adobe Acrobat     Fatal Mishap Resulting from a Pressure System Operation in Government Laboratory
Adobe Acrobat     Chemical Safety Board's (CSB) Findings in New York Chemical Waste-Mixing Incident - Kaltech Chemical
Adobe Acrobat     And some have said "software isn't critical" - Ariane 5
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Chemical Safety Board's Preliminary Findings in BP Texas City Refinery Accident
Adobe Acrobat   View Movie
A Tale of Two Failures... the difference between a "Bad Day" and a "Nightmare" - Delta II 7925/Long March CZ-3B
Adobe Acrobat Adobe Acrobat   Death on the Steppes - The Nedelin Rocket Disaster
Adobe Acrobat     Failures, Mishaps and Root Cause Analysis - Hurricane Katrina
Adobe Acrobat     Steam Locomotive Firebox Explosion on the Gettysburg Railroad near Gardners, Pennsylvania
Adobe Acrobat     Equilon Refinery Accident Anacortes, WA
Adobe Acrobat     MGM Grand Hotel Fire Disaster, A Turning Point for Fire Protection Codes
Adobe Acrobat     Bhopal: When Hazard Controls Aren't
Adobe Acrobat     USS IWO JIMA Mishap
Adobe Acrobat     Listen to the Hardware, A Case Study in Missed Opportunities - McDonnell Douglas DC-10
Adobe Acrobat     A Deadly Mixture - Chernobyl
Adobe Acrobat     Save a Life, Pass it on... - Strokes
Adobe Acrobat     Need for Scenario-Based Accident Modeling - British Airways' Concorde


last modifed: Oct 23 2009 3:38PM
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