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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.

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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Lessons From Macondo

The Senior Management Walkaround
9-minute read
April 20, 2010, Macondo Prospect, Gulf of Mexico, 7:45 p.m. Central Daylight Time (CDT): Two Transocean executives and two British Petroleum (BP) executives flew aboard the Deepwater Horizon oil rig for a management visibility tour. The purpose of the tour was to meet the 126 rig workers and to check for and discuss key occupational hazards recently found on other Transocean oil rigs in the fleet. The agenda included crediting the crew for their outstanding seven-year safety record with no lost time injuries. During the next seven hours, the executives watched the crew prepare to cap off the well and move to a new site. However, deep beneath their feet, incredible pressure built inside the well casing. Two safety indicators occurred concerning the oil well’s dangerous unsealed state that went undetected. This story, adapted from a 2011 analysis by sociologist Andrew Hopkins, describes how these two precursor events went unnoticed and resulted in the worst oil-well blowout and oil spill in U.S. history.

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All Shook Up

The LADEE Spacecraft Vibration Mishap
10-minute read

May 3, 2012, Bay Area, California: Vibration testing was commencing for the Lunar Atmosphere and Dust Environment Explorer (LADEE) spacecraft Engineering Test Unit (ETU). LADEE’s purpose was to orbit the moon’s equatorial region for approximately one month to collect data on the lunar dust conditions to help guide the possible design for lunar outposts and future robotic missions. The LADEE mission also studied the fragile lunar atmosphere before further human activity contamination occurred. However, during vibration testing, an anomalous sine burst test at a contractor test facility damaged the spacecraft.

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Deadly Exposure

The West Virginia DuPont Phosgene Release
10-minute read

Jan. 23, 2010, Belle, West Virginia: A chemical plant owned and operated by DuPont, an industry safety and health role model, suffered three separate anomalous incidents within 33 hours. The last incident, a phosgene release, proved fatal for one plant employee. The worker, wearing minimal Personal Protective Equipment, was sprayed across the chest and face with 2 pounds of the deadly chemical when it leaked out of a ruptured flex hose. The worker succumbed to the delayed physiological effects of phosgene exposure approximately 32 hours later.

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Down, But Not Out

The Near-Loss and Recovery of America's First Space Station
11-minute read

May 14, 1973, Skylab soared into Low-Earth Orbit from Kennedy Space Center on a modified Saturn V rocket. Whereas the launch of Skylab 1 was unmanned, Skylab 2, planned for launch the following day on May 15, would deliver a three-man crew to the station. However, once Skylab was in orbit and controllers initiated start-up procedures, it became apparent that the vehicle suffered damage during launch. Skylab 2 was postponed for 10 days. During those dire days, Skylab engineers scrambled to understand what went wrong and what they would do to fix it.

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Counterfeit Electronic Parts

Situation Report
1-minute read
This Situation Report looks at the emerging issue of counterfeit electronic components and their impact on agency: project costs, performance and schedules. It includes facts surrounding the counterfeiting of electronic components (i.e., circuit boards and computer chips), the proliferation of illegal offshore production and the international brokerage of non-compliant parts.

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