Breaking the Mishap Chain

Download or read book Breaking the Mishap Chain written by Peter W. Merlin and published by Government Printing Office. This book was released on 2012 with total page 248 pages. Available in PDF, EPUB and Kindle. Book excerpt: This volume contains a collection of case studies of mishaps involving experimental aircraft, aerospace vehicles, and spacecraft in which human factors played a significant role. In all cases the engineers involved, the leaders and managers, and the operators (i.e., pilots and astronauts) were supremely qualified and by all accounts superior performers. Such accidents and incidents rarely resulted from a single cause but were the outcome of a chain of events in which altering at least one element might have prevented disaster. As such, this work is most certainly not an anthology of blame. It is offered as a learning tool so that future organizations, programs, and projects may not be destined to repeat the mistakes of the past. These lessons were learned at high material and personal costs and should not be lost to the pages of history.