NASA Accident Precursor Analysis Handbook, Version 1.0.

Accession Number

N20120003292

Publication Date

Dec 2011

Media Count

112p

Personal Author

A. Hall C. Everett F. Groen S. Insley

Abstract

Catastrophic accidents are usually preceded by precursory events that, although observable, are not recognized as harbingers of a tragedy until after the fact. In the nuclear industry, the Three Mile Island accident was preceded by at least two events portending the potential for severe consequences from an underappreciated causal mechanism. Anomalies whose failure mechanisms were integral to the losses of Space Transportation Systems (STS) Challenger and Columbia had been occurring within the STS fleet prior to those accidents. Both the Rogers Commission Report and the Columbia Accident Investigation Board report found that processes in place at the time did not respond to the prior anomalies in a way that shed light on their true risk implications. This includes the concern that, in the words of the NASA Aerospace Safety Advisory Panel (ASAP), no process addresses the need to update a hazard analysis when anomalies occur; At a broader level, the ASAP noted in 2007 that NASA could better gauge the likelihood of losses by developing leading indicators, rather than continue to depend on lagging indicators. These observations suggest a need to revalidate prior assumptions and conclusions of existing safety (and reliability) analyses, as well as to consider the potential for previously unrecognized accident scenarios, when unexpected or otherwise undesired behaviors of the system are observed. This need is also discussed in NASA's system safety handbook, which advocates a view of safety assurance as driving a program to take steps that are necessary to establish and maintain a valid and credible argument for the safety of its missions.

Keywords

Accident investigation
Aerospace safety
Anomalies
Failure
Handbooks
Hazards
Identifying
Reliability
Reliability analysis
Risk
Safety factors
Space transportation system
Systems engineering


$60.00-COLOR DOCUMENT

Source Agency

National Aeronautics and Space Administration

NTIS Subject Category

84B - Extraterrestial Exploration
84F - Space Safety

Corporate Author

National Aeronautics and Space Administration, Washington, DC.

Document Type

Technical report

Title Note

N/A

NTIS Issue Number

1219

Contract Number

N/A

Science and Technology Highlights

See a sampling of the latest scientific, technical and engineering information from NTIS in the NTIS Technical Reports Newsletter