Escolar Documentos
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Cultura Documentos
Problem
APOLLO 1
Problem(s)
What
Crew
Date
When
Time
Different, unusual, unique
Facility, Site
Where
Equipment
Task being performed
Why?
Why?
Three
astronauts
killed
Safety Goal
Impact
Why?
Lack of oxygen
Step 1. 1
Problem
What's the
Problem?
Step 2.2
Analysis
Why did it
happen?
Step 3.3
Solutions
What will be
done?
Change in
hatch design
Previous
misfiring of
explosive
hatch
Labor
Goal
Impacted
Solution:
Effect
Analysis
Cause Mapping
Cause Map
Rescue
efforts
Implemented Solutions:
Quick opening hatch
Astronauts
unable to exit
command
module
Cause
Evidence:
Hatch took 5
minutes to
open
Evidence: Incident
on Mercury Liberty
Bell 7 in 1961
Fire in
command
module
Implemented Solutions:
Clarified contractor
expectations,
requirements
No.
Safety Goal
Impacted
Solutions
Action Item
Quick opening hatch
Insulation defeated
Extensive combustible
materials in cabin
Use of pure oxygen in
spacecraft
281-412-7766
ThinkReliability.com
Lack of
oxygen
AND
Evidence:
Astronauts found to
have asphyxiated
Cause
Three
astronauts
killed
Heat
Electric arcs
Evidence: No single
ignition source
conclusively identified
Evidence: Most
probable (evidence
of several arcs)
AND
Mission Goal
Impacted
Vehicle
Goal
Impacted
Property
Goal
Impacted
Delay in
mission
Fire in
command
module
Fuel
AND
Rupture of
Command
Module
Oxygen
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
Possible Solutions:
Reduced oxygen
concentration for
ground operations
Use of pure
oxygen in
spacecraft
Need for
increased
oxygen in
space