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New NASA Book Tells Why Aerospace Accidents Happen
June 5, 2012



Understanding what causes an accident often is like looking at an iceberg. We see the accident as the tip of the iceberg, but all the missteps, poor decisions and coincidences that led up to it often are missed, hidden just beneath the surface.

In NASA's newest book, "Breaking the Mishap Chain," that oversight is corrected as some of the most well-known accidents in aviation and space history are remembered with details that reveal the non-technical, human-related events that led to each incident.

For example, in 1967 an X-15 rocketplane crashed, killing the pilot, Mike Adams. In detailing the events surrounding the mishap, the authors explain how the pilot's history with spatial disorientation – what was generally called vertigo back then – and confusion about what one of his instruments was telling him contributed to the accident.

"Anybody involved in flying needs to learn the lessons of the past," said Dr. Gregg Bendrick, NASA's chief medical officer at the Dryden Flight Research Center in California. Bendrick is one of the book's three authors.

The other authors include Peter Merlin, a NASA aerospace historian at Dryden; and Dr. Dwight Holland, a principal partner in Human Factors Associates who has served as president of the International Association of Military Flight Surgeon Pilots and the Space Medicine Association.

"This book is unique because it integrates aerospace history, medicine, human factors, and system design issues in a compelling multi-level examination of some truly fascinating stories of aerospace exploration," Holland added.

Altogether, nine cases are detailed, not all of them resulting in fatalities. Some of the others include:

  • The infamous "touch and go" double landing of the prototype space shuttle Enterprise at Edwards Air Force Base in California during the Approach and Landing Test program in 1977.
  • The 1967 crash of the M2-F2 lifting body on the dry lakebed at Edwards, in which film footage of the accident later was used in the opening credits of the television series "The Six Million Dollar Man."
  • The mid-air collision in 1966 of NASA's XB-70A Valkyrie supersonic test aircraft with an F-104 Starfighter chase plane while flying in formation with other aircraft during a photo opportunity over the California high desert.
  • The low Earth orbit collision in 1997 of the Russian Progress 234 cargo spaceship with the Russian space station Mir while NASA astronaut Michael Foale was on board the orbiting outpost.

The book offers rich details of the people, machines and history of each case that is easy for the average person to begin to understand why each event occurred.

"Hopefully, by identifying the underlying causes and lessons learned from past incidents, we will prevent future mishaps," Bendrick said.

Each case also includes a surgically precise analysis of what happened that is intended for aerospace medicine and air safety professionals to consider – such as understanding how the difference between somatogravic and oculoagravic illusion was important in fully understanding the X-15 accident.

Read the book to find out what those words mean.

"This book is designed for anyone interested in aerospace safety issues but, with some of the more complicated topics included, may be of particular interest to aeromedical professionals and those responsible for managing aviation safety programs," Merlin said. "In fact it would make an excellent textbook for related classes."

Publication of "Breaking the Mishap Chain" was sponsored and funded by the communications and education department of NASA's Aeronautics Research Mission Directorate.

›  Download Breaking the Mishap Chain e-Book


Jim Banke
NASA Aeronautics Research Mission Directorate

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Breaking the Mishap Chain Book Cover.
It's never one thing that leads to an accident, but a chain of events that can include things never expected. "Breaking the Mishap Chain" walks readers through well-known aviation and space mishaps and notes the lessons learned.
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Accident investigators learned that the enormous and confusing array of dials and gauges in older aircraft cockpits were sometimes a link in the mishap chain.
Accident investigators learned that the enormous and confusing array of dials and gauges in older aircraft cockpits were sometimes a link in the mishap chain.
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