Normal accident theory and learning from major accidents at the National Aeronautics and Space Administration (NASA)

Abstract

A review of NASA's accident history through the lens of Normal Accident Theory (NAT) offers insights into the prospects for safety during the Artemis Program. NAT is applied to NASA's four major human spaceflight accidents: the Apollo launch pad fire, Apollo 13, Challenger and Columbia. NAT predicts that in the complex and tightly coupled systems used for human spaceflight, an accident type known as the “normal accident”, is inevitable. These accidents are attributable to hidden system interactions that overwhelm the cognitive abilities of human operators and, thereby, escape detection. A review of the four official accident reports and supporting secondary analyses suggests NASA has had one such accident: Apollo 13. It was also the only major accident without injury and a successful recovery effort. NAT would categorize the other three as component failure accidents. Unlike normal accidents, component failure accidents are not inevitable. They stem from an organization's failure to appropriately monitor, assess and mitigate the risk associated with a faulty component. In such cases, NAT would ask if production pressures, often rooted in scheduling and resource constraints, were a factor.

Production pressures are ultimately imposed on organizations through the exercise of power. These pressures impede an organization's ability to adequately assess risk and increase the likelihood of component failure accidents. The substantial organizational literature on NASA's human spaceflight accidents has yielded potential remedies to help mitigate the risks associated with production pressure. This paper discusses these remedies and their potential safety benefits. It also proposes a modification to a safety governance mechanism recommended by the Columbia Accident Investigation Board (CAIB). The resulting changes could help NASA, and other organizations administering high risk technologies, further improve safety.