‘Breaking the Mishap Chain’ is a new NASA ebook that 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.
The book can be downloaded from the NASA website.