National Aeronautics and Space Administration

Case Studies

Case studies take an in-depth look at a particular topic or situation. The two primary case studies produced by the NASA Safety Center are the Safety and Mission Assurance (SMA) Focus and the System Failure Case Study. The SMA Focus provides important information, reminders, tips and guidance on various SMA topics for specific audiences within the SMA community, while the System Failure Case Study examines failures of complex, coupled systems both within and outside NASA.

Laboratory Pressure Vessel Explosion

Avoid Needless Risk: Consult Your Pressure Systems Manager
16-minute read

Many educational and research organizations, including NASA, make use of pressure systems to further their work. However, there are serious risks associated with pressure systems when they are not adequately designed, reviewed or constructed. For example, in March 2016, the University of Hawaii experienced a catastrophic pressure vessel failure that severely injured a postdoctoral researcher. This case study’s purpose is to illustrate the importance of thorough hazard assessment and the expert advice of a center Pressure Systems Manager to help researchers work safely in each NASA lab.

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Pushing the Envelope of Flight Test Safety

Technical, Physical and System Issues Behind AC-130J Flight Test Mishap
16-minute read

On April 21, 2015, an AC-130J, assigned to the 413th Flight Test Squadron at Eglin Air Force Base in Florida, departed controlled flight over water about 41 nautical miles south of the Air Force base. Even before the crew boarded the aircraft, missed red flags, procedural gaps, incomplete predictive data and documentation anomalies raised the stakes of an already rigorous test plan. Once on board and in the midst of executing an aggressive test maneuver, the collective oversights set the stage for an extraordinary in-flight emergency. Further complicated by insufficient instrumentation and human factors, the crew worked as a team to save their own lives, but the aircraft was not so fortunate. The cost of damages totaled $115,600,000, including the total loss of the aircraft.

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Hidden Hazards

Valukas Report Reveals Social and Technical Issues Behind Faulty GM Ignition Switch
17-minute read

In March 2010, a 29-year-old shift nurse left her job in Atlanta, Georgia and headed to her boyfriend’s house. She was driving her 2005 Chevy Cobalt on a two-lane road as she approached a half-mile downhill straightaway. As the road leveled after the straightaway, she approached an area where some rainwater had accumulated. Shortly after encountering this section of roadway, she apparently lost control of her Cobalt as it hydroplaned across the center line.

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Smoke and Mirrors

What Went Wrong at L’Enfant Plaza
14-minute read

On Jan. 12, 2015, Washington Metropolitan Area Transit Authority (WMATA) experienced one of its "more serious" train accidents to date, according to the Federal Transit Administration (FTA). At 3:15 p.m. EST, train 302, which was headed southbound on the Yellow Line with about 380 passengers on board, stopped on the tracks after encountering smoke in the tunnel between the L'Enfant Plaza station and the Potomac River Bridge in Washington, D.C. Some passengers started to self-evacuate to escape the smoke, causing the train control center to shut off third rail power until emergency services could evacuate the victims. In total, the accident resulted in one death, 91 injured people and $120,000 in estimated damages.

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The Human Interface

Human Factors and Redundancy on Apollo 10 and Skylab 4
7-minute read
The Apollo and Skylab Programs each suffered major setbacks and losses. These events, such as the Apollo 1 fire, the Apollo 13 oxygen tank explosion, and the Skylab 1 micrometeoroid shield loss, continue to serve as lessons and reminders to engineers and managers at NASA and in the expanding private spaceflight industry. As the major incidents of these heritage Programs linger in memory, multiple lesser known crises were averted during the 21 missions that utilized the Apollo spacecraft. During Apollo 10 and Skylab 4, crews suffered from human factors related incidents that were remedied by engineered redundancies and excellent operational knowledge of the spacecraft.

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The Near Loss of the Apollo-Soyuz Test Project Crew
10-minute read
In an extraordinary display of international cooperation during the height of the Cold War between the United States and former Soviet Union, television viewers around the globe tuned in July 17, 1975 to witness Apollo-Soyuz Test Project (ASTP) astronauts and cosmonauts shaking hands between their docked, orbiting spacecraft. Following two days of joint experiments, shared meals and press conferences, the Soyuz crew undocked their spacecraft and landed in Russia on July 21. The Apollo crew continued on-board experiments until their July 24 re-entry. During descent, the crew did not activate the Apollo’s Earth Landing System (ELS) at the correct altitude. As a result, toxic propellant fumes entered the Command Module (CM) through open cabin pressurization valves before splashdown, threatening the lives of America’s first orbital ambassadors.

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No Guarantees

The Gulfstream G650 Test Crash
10-minute read
April 2, 2011, 9:34 a.m. mountain daylight time (MDT), Roswell International Air Center, Roswell, New Mexico: An experimental Gulfstream Aerospace Corporation GVI (G650), N652GD, took off on a planned one-engine-inoperative (idle) (OEI), heavy take-off weight test flight. Test scheduling had been aggressive in order for Gulfstream to obtain Federal Aviation Administration (FAA) type certification for the G650 by the third fiscal quarter of 2011. During the takeoff, the G650 crashed and the four crewmembers aboard died.

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The Great Wave of Reform

The Prophetic Fallacy of the Fukushima Daiichi Meltdown
10-minute read

March 11, 2011, off the Pacific coast of Tohoku, Japan: At 14:46 (2:46 p.m.) Japan Standard Time a magnitude 9.0 earthquake occurred 43 miles east of the Oshika Peninsula. The undersea megathrust earthquake shifted the mainland of Japan an estimated 8 feet east and deviated Earth’s axis by estimates between 4 to 10 inches. The Great East Japan Earthquake generated massive tsunami waves that peaked at heights of 133 feet and traveled up to 6 miles into areas of mainland Japan. According to the latest accessible Japanese National Police Agency police reports, the earthquake and tsunami are responsible for 15,891 dead, 6,152 injured and 2,584 missing peoples. In addition to the horrific loss of life, 129,290 buildings have been reported collapsed, with another 1,020,777 structures sustaining varying degrees of damage. The disaster also triggered the second Level 7 International Nuclear Event (after Chernobyl) in history: the Fukushima Daiichi nuclear disaster.

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Six Degrees of Freedom

The Valuable Failures of the Lunar Landing Research and Training Vehicles
15-minute read
May 21, 1961: President John F. Kennedy challenged the United States to send humans to the moon. With unprecedented funding and the support of the nation, NASA’s Apollo team committed to unravelling the program’s numerous design challenges. Many of their solutions left them asking more questions. In 1962, NASA selected Grumman Aircraft Corporation to design and build a vehicle that could land in the airless lunar environment with a gravitational pull one-sixth that of the Earth. Grumman’s bug-like, four-legged Apollo lunar modules (LMs) utilized a complex rocket propulsion system that controlled pitch, yaw, roll, descent, and ascent. Apollo astronauts realized they needed new piloting skills that no electronic simulator could fully develop. Beyond that, the limited fuel supply of Grumman’s LM precluded multiple landing attempts that would allow the astronauts to master their skills during the mission. And although an autopilot would be available as a backup, true lunar surface conditions were almost unknown and could not be left to automation. So, in 1963, Bell Aerosystems was chosen to create one of the most bizarre flying machines ever built: the Lunar Landing Research Vehicle.

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Escape to Failure

The Qantas Flight 32 Uncontained Engine Failure
10-minute read
Nov. 4, 2010, over Batam Island, Indonesia: Qantas Flight 32, an Airbus A380-842, departed from Singapore Changi International Airport (SIN) for Sydney Kingsford Smith Airport (SYD), Australia. But, as the 500-ton airliner climbed past 7,000 feet, two loud bangs reverberated throughout the aircraft, startling passengers and crew. An uncontained turbine failure blew shrapnel through the aircraft’s port wing, severing wiring harnesses. The crew was unable to shut down the huge, damaged engine and prepared for an emergency landing.

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