APOLLO 1 - ThinkReliability

1 Problem

What

Problem(s) Crew

When

Date Time

Different, unusual, unique

Where

Facility, Site Equipment

Task being performed

Impact to the Goals

Safety

Vehicle

Mission Property, Equip, Mtls

Labor, Time

Flash fire, astronauts killed White, Grissom, Chaffee January 27, 1967 ~6:30 pm EST 1st piloted flight, hatch difficult to open Cape Canaveral Apollo 1/Saturn space vehicle Launch pad test

Three astronauts killed Rupture of Command Module Delay in mission Rupture of Command Module Rescue efforts

APOLLO 1 Cause Map

Fire during launch pad test kills 3 astronauts

Launch pad testing on the Apollo 1 Saturn space vehicle turned deadly when a fire begin within the command module. Rescue of the astronauts proved difficult as the hatch had been designed to prevent accidental opening.

"No single person bears all the responsibility for the

Apollo 204 accident. It happened because many people

made the mistake of failing to recognize a hazardous

situation."

- Senate report on the accident

Cause Mapping is a Root Cause Analysis method that captures basic cause-and-effect relationships supported with evidence.

Cause Mapping

Problem Solving ? Incident Investigation ? Root Cause Analysis

Step 1.1 Problem

W hat's the Problem?

Step 2.2

Analysis

W hy did it happen?

Step 3.3 Solutions

What will be done?

Apollo 1 Crew, L to R: Edward White, Gus Grissom, Roger Chaffee

More Detailed Cause Map Add detail as information becomes available.

2 Analysis

Basic Level Cause Map - Start with simple Why questions.

W hy?

W hy?

W hy?

Effect

Solution: Cause Evidence:

Safety Goal Impact

Three astronauts

killed

Lack of oxygen

Fire in command

module

3 Solutions

No.

Action Item

Cause

1 Quick opening hatch

Hatch took 5 minutes to open

2 Clarified contractor expectations, Insulation defeated requirements

3 Restriction of flammable material Extensive combustible

on-board

materials in cabin

4 Reduced oxygen concentration Use of pure oxygen in

for ground operations

spacecraft

Safety Goal Impacted

Labor Goal Impacted

Three astronauts

killed

Mission Goal Impacted

Rescue efforts

Astronauts unable to exit

command module

Lack of

AND

oxygen

Evidence: Astronauts found to have asphyxiated

Delay in mission

Fire in command

module

Implemented Solutions: Quick opening hatch

Hatch took 5 minutes to open

Change in hatch design

Previous misfiring of explosive

hatch

Evidence: Incident on Mercury Liberty Bell 7 in 1961

Heat Evidence: No single ignition source conclusively identified

AND

Fuel

Electric arcs

Evidence: Most probable (evidence of several arcs)

Implemented Solutions: Clarified contractor expectations, requirements

Inadequate insulation, installation

Evidence: Numerous issues with design, workmanship

Implemented Solutions: Restriction of flammable material on-board

Extensive combustible materials in

cabin

Discrepancies between

specifications

For a free copy of our Root Cause Analysis Template in Microsoft Excel, used to create this page, visit our web site.

Investigate Problems. Prevent Problems.

Houston, Texas 281-412-7766 Copyright ThinkReliability 2013

Vehicle Goal

Impacted

Property Goal

Impacted

Rupture of Command

Module

AND

Oxygen

Possible Solutions: Reduced oxygen concentration for ground operations

Use of pure oxygen in spacecraft

Need for increased oxygen in

space

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