Repeated Failures: What We Haven't Learned About Complex Systems

Abstract

Several large-scale, high-risk programs have suffered catastrophic failures. Investigations have revealed numerous contributing factors. Starting with the Apollo 1 fire and the loss of the orbiters Challenger and Columbia, NASA has seen the greatest scrutiny due to the loss of life. The loss of the unmanned European Space Agency's Ariane 5 on its maiden voyage was a serious blow to the hitherto successful Ariane family of launch vehicles. The findings of the failure investigations can be grouped into general categories, some of which are common (e.g. process control) or unique to a particular accident (e.g. software design). Tabulating these causes has enabled assessing several large-scale weapons programs (either fielded or in development) as to commonality. Most of the weapons programs have experienced incidents of the general type, but without catastrophic results as yet. The question is raised: "Can this array of findings serve as a useful indicator for the weapons programs?"

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Document Details

Document Type
Technical Report
Publication Date
Nov 01, 2010
Accession Number
ADA588095

Entities

People

  • Patricia S. Vittitow

Tags

Communities of Interest

  • Biomedical
  • Human Systems
  • Weapons Technologies

DTIC Thesaurus Topics

  • Accidents
  • Acquisition
  • Army Aviation
  • Booster Rocket Engines
  • Complex Systems
  • Control Systems
  • Department Of Defense
  • Engineering
  • Explosives
  • Failure Mode And Effect Analysis
  • Insensitive Explosives
  • Launch Vehicles
  • Lessons Learned
  • Materials
  • Munitions
  • Software Design
  • Space Shuttles

Readers

  • Aerospace Engineering.
  • Aviation Safety Risk Assessment.
  • Educational Psychology

Technology Areas

  • Autonomy
  • Space