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Case Studies Archive

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.

Apollo 1-Challenger-Columbia

Lessons Learned
Wayne Hale’s Ten Rules for Engineering for Space is the focus of Remembrance Day 2014. As former NASA Flight Director and Space Shuttle Program Manager, Hale has compiled a list of lessons learned based on the Apollo 1, Challenger and Columbia disasters.

A Loaded Magazine

The Honolulu Fireworks Disposal Explosion
1-minute read
April 8, 2011, Waipahu, Oahu, Hawaii: Six workers were disassembling imported fireworks seized by federal law enforcement personnel during the previous summer. Without specific safety standards or contract stipulations to guide disposal efforts, the workers used unsafe practices and amassed large quantities of explosive material near tools and in containers that were capable of producing sparks, friction and static electricity. The explosive material detonated in a mass explosion, killing five workers and injuring one other.

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The Case for Safety

The North Sea Piper Alpha Disaster
1-minute read
July 6, 1988, Piper Oilfield, North Sea: As shifts changed and the night crew aboard Piper Alpha assumed duties for the evening, one of the platform’s two condensate pumps failed. The crew worked to resolve the issue before platform production was affected. But unknown to the night shift, the failure occurred just hours after a critical pressure safety valve had just been removed from the other condensate pump system and was temporarily replaced with a hand-tightened blind flange. As the night crew turned on the alternate condensate pump system, the blind flange failed under the high pressure, resulting in a chain reaction of explosions and failures across Piper Alpha that killed 167 workers in the deadliest offshore oil industry disaster to date.

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Through a New Lens

Apollo, Challenger and Columbia through the Lens of NASA's Safety Culture Five-Factor Model
1-minute read
Ten years after the inflight breakup of Space Shuttle Columbia Space Transportation System Mission (STS-107), the memory of those astronauts -- and of Apollo 204 in 1967 and Challenger in 1986 -- who died in the line of service continues to serve as a reminder to the agency.

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Survival and the United States’ Most Advanced Fighter Jet
1-minute read
Nov.16, 2010, Joint Base Elmendorf-Richardson (JBER), Alaska: On a clear and quiet night, six United States Air Force (USAF) F-22A Raptor fighter jets departed from base to intercept and skirmish against four USAF F-16 fighter jets for an opposed air-to-ground attack training mission. The training mission went according to plan, but during the return-to-base (RTB) phase of the flight, one F-22A crashed. The pilot did not attempt an ejection and was killed in the crash.

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Kiloton Killer

The Collision of the SS Mont-Blanc and the Halifax Explosion
1-minute read
Dec. 6, 1917, Halifax, Nova Scotia, Canada: The Great War reached across the Atlantic to transform one of North America’s natural deepwater ports into a teeming logistics hub. In a new tactic, the Allies formed shipping convoys against lurking German U-boats to deliver tons of supplies. To join one such convoy, the French freighter SS Mont-Blanc entered Halifax Harbour that bright, sunny afternoon. Known only to the crew and a few port officials, the ship was packed with munitions. Steaming outbound, the SS Imo collided with the Mont-Blanc. Sparks set the French ship on fire beyond the crew’s ability to extinguish the flames; they escaped and the ship erupted into the largest explosion yet created by man. Blast pressure leveled every structure within a mile and blew wreckage for tens of miles. Approximately 2,000 people were killed and over 9,000 injured. The unprecedented recovery effort that followed was the genesis of modern disaster relief programs.

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Vapor Trap

The Xcel Energy Confined Space Penstock Fire
1-minute read

Oct. 2, 2007, Cabin Creek, Georgetown, Colo.: Nine industrial painters were recoating a portion of penstock tunnel that runs 1,530 feet deep into the remote mountainous area surrounding the Xcel Energy Cabin Creek hydroelectric station. Inside the confined area, the workers used a highly flammable solvent to clean their equipment, which filled the tunnel with flammable vapor. The vapor ignited and the resulting explosion separated the nine workers -- blocking five of them from the only egress point by a wall of fire. Despite lengthy rescue attempts, the five workers were asphyxiated as smoke slowly filled the tunnel.

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From Rockets to Ruins

The PEPCON Ammonium Perchlorate Plant Explosion
1-minute read
May 4, 1988, Clark County, Nev.: What began as a normal repair procedure at the Pacific Engineering Production Company of Nevada (PEPCON), a chemical plant specializing in the manufacture of a major component in solid propellant, ended in the worst way imaginable. While many workers were leaving for lunch, sparks from a repair crew welding torch set ablaze fiberglass infrastructure. The flames, which grew out of control, soon engulfed PEPCON’s massive stock of oxidizer, creating the largest domestic, non-nuclear explosion in recorded history. The explosion affected structures in a 10-mile radius, accrued damages estimated at $100 million, injured approximately 372 people, and ended the lives of two plant employees.

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A Set-Up for Failure

USS Iwo Jima
Oct. 1990: The USS Iwo Jima amphibious assault ship was deployed to the Persian Gulf for Operation Desert Shield. The USS Iwo Jima docked at a Bahrain shipyard for emergent repairs. As the ship was leaving port, just one hour after the propulsion plant was brought online, bonnet fasteners for a 4-inch valve supplying steam to the ship's service turbine generator failed catastrophically and 850 degree superheated steam at 600 psi escaped into manned compartment. Nine sailors were killed instantly, one more was fatally injured.

A Gift

Lessons from the STS-3 Close Call
Touchdown was 25 knots too fast, 220 knots instead of 195 knots equivalent airspeed (EAS). The commander (CDR) started to nose down prematurely, then, realizing his error, immediately applied aft stick to stop nose down pitch. CDR needed excessive aft stick to stop nose, and then was surprised by pitch-rate reversal (pitch gain glitch). A second pitch reversal resulted in higher-than-desired nose gear slap down. It was a close call; nothing was broken and no one was injured, but STS-3 came close to being two flights.
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