Page 68 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company

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46 Serious Incident Prevention

oxygen creates a highly flammable environment, the problem-free history
of the earlier Mercury and Gemini missions led NASA to become too com-
placent about the possibility of fire. In an effort to meet the flight schedule,
NASA management decided to bypass an oxygen pressure test of the cap-
sule in the unmanned mode. Instead, NASA scheduled a full dress rehearsal
for January 27, 1967, with astronauts Grissom, White, and Chaffee on
board.
With the astronauts on board, pressuring of the capsule was initiated by
discharging pure oxygen into the craft until the desired pressure of 16.7
psig was reached. Somewhere in the cabin, wiring sparked, and flames en-
gulfed the interior of the capsule. All three of the astronauts were killed
within seconds. It would be another 21 months before a manned Apollo
mission would fly.
Following the fire, NASA’s focus shifted from expediting the flight to
identifying the root causes of the catastrophic fire. The Apollo review
board’s investigation concluded that an electric arc from defective wiring
was the most likely source of ignition. Numerous deficiencies related to de-
sign, engineering, manufacturing, and quality control were identified. The
report criticized the NASA management team for poor management, care-
lessness, negligence, and failure to fully consider personnel safety.
Once NASA resources were focused on building an inherently safer
craft, tremendous advances were made. Many design deficiencies of the old
craft were eliminated. The electrical system was redesigned, fire-resistant
materials were extensively utilized, and a new escape hatch capable of being
opened in three seconds was developed. Finally, the pure oxygen was re-
placed with a nitrogen-oxygen mixture.
Twenty-one months were required to develop, implement, and test the
changes needed to improve the craft. The successful ascent of the first
manned Apollo on October 11, 1968, was a milestone date for NASA. The
flight of the redesigned Apollo craft was superb. The intense focus on seri-
ous-incident prevention had been successful.

Commitment and Leadership—
Closing Thoughts

Whenever I speak with safety managers, whether new to the field or
long experienced, I always talk with them about leaving some footprints be-
hind—leaving a personal legacy of accomplishment that will be admired for
decades to come. Such legacies require boldness, leadership, and commit-
ment. Peter Drucker states it well with his rules for establishing priorities: 10