NASA NTRS2009
There have been a number of studies done in the past drawn on lessons learned with regard to human loss-of-life events. Generally, the systemic causes and proximate causes for fatal events have both been examined in considerable detail. However, an examination of near-fatal accidents and failures that narrowly missed being fatal could be equally useful, not only in detecting causes, both proximate and systemic, but also for determining what factors averted disaster, what design decisions and/or operator actions prevented catastrophe. Additionally, review of risk factors for upcoming or future programs will often look at trending statistics, generally focusing on failure/success statistics. Unfortunately, doing so can give a skewed or misleading view of past reliability or a reliability that cannot be presumed to apply to a new program. One reason for this might be that failure/success criteria aren't the same across programs, but also that apparent success can hide systemic faults that, under other circumstances, can be fatal to a program with different parameters. A program with a number of near misses can look more reliable than a consistently healthy program with a single out-of-family failure and provide very misleading data if it is not examined in detail. This is particularly true for a manned space program where failure/success includes more than making a particular orbit. Augmenting reliability evaluations with this near miss data can provide insight and expand on the limitations of a strictly pass/fail evaluation. Even more importantly, a thorough understanding of these near miss events can identify conditions that prevented fatalities. Those conditions may be key to a programs reliability, but, without insight to the repercussions if such conditions were not in place, their importance may not be readily clear. As programs mature and political and fiscal responsibilities come to the fore, often there is considerable incentive to eliminate unnecessary conservatism, design margin, redundancy, operational support, testing, training, or safety oversight. An evaluation that demonstrates how these features and capabilities averted disaster can ensure processes that saved lives or missions are not discarded without appropriate review and understanding. Close examination of accidents that almost were can also highlight differences in design from one program to another, either justifying reliability comparisons or negating them. It can also provide considerable insight into how those saving factors were developed and implemented so that similar methods can be used to ensure appropriate life-saving and mission saving factors can be developed, even for a dissimilar space program. The lessons are appropriate for seasoned manned space programs and agencies, but crucial for untried agencies and organizations that are interested in sending man into space. The large body of publicly available near miss and accident data available provide invaluable insight into programmatic, technical, and even political issues that can be addressed before they impact safety. In this paper, we examine a number of these near misses and accidents and steps a program, agency, or potential spacefaring company might take to improve their chances of success and avoid mission or safety disasters using this data.