Accession Number:

ADA588095

Title:

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

Descriptive Note:

Conference paper

Corporate Author:

ARMY AVIATION AND MISSILE COMMAND REDSTONE ARSENAL AL

Personal Author(s):

Report Date:

2010-11-01

Pagination or Media Count:

25.0

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 Agencys 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

Subject Categories:

  • Operations Research
  • Safety Engineering

Distribution Statement:

APPROVED FOR PUBLIC RELEASE