Apollo 1 redux: the inevitability of disaster

By Phil Plait | January 28, 2007 1:30 pm

My friend Jim Oberg has written an article about the Apollo 1 tragedy. He is a space historian, and he knows his stuff. His angle on this was 1) the loss of these people and the missions were due to preventable mistakes, including arrogance at key places in NASA administration, and 2) we need to learn from these mistakes; not about hardware or safety, but about the roles of human beings in decision-making when it comes to spaceflight.

This is very different that the way I wrote my own Apollo 1 article. But I think we both have a point.

When I wrote the essay, I did not mean to exonerate the people of mistakes made. Jim is right; the disasters of Apollo 1, Challenger, and Columbia are the more tragic because they were preventable. I think all disasters are preventable, and that in every case it is probable that if only someone hadn’t been careless, forgetful, greedy, ambitious, foolish, then lives would have been saved. In these three cases, I agree with Jim, especially with the Shuttles. People in positions to prevent these disasters were told what the problems were, and forged ahead anyway.

Complacency kills just as much as a holed Shuttle wing, or a frozen O-ring.

As Jim wrote about current NASA workers:

They need the consequent inescapable ache of fear and the gnawing of doubt that keeps asking, over and over, if they’ve covered all angles and done all they can. And if their stomachs do not knot up, and mouths go dry, as they confront such decisions — perhaps they need new jobs.

Again, people will die as we explore space. Sometimes these deaths will be due to human error, human stupidity, human weakness. Sometimes things will just happen — Nature is just that way.

We must learn from these mistakes and do what we can to minimize them. No human, or even team of humans, can possibly avoid every potential mistake. What we need, and what Jim advocates, is a system to prevent the preventable mistakes. That may sound like a tautology, but it isn’t. If a disaster happens, and people have done all they can to prevent it, that is what it’s like to explore. But we also need to make sure that human fallacy is not at the root of the problem.


Comments (26)

  1. jbCharleston

    While I can’t add more to the eloquent posts, I can share a personal anecdote about the tradegy. I was a kid right out of high school helping an older gentleman take his 25′ boat down the Intracoastal Waterway from NY to FL. Going through the marshy FL areas on a beautiful summer day, we slowed for an oncoming tug pulling a barge. As it approached, we saw armed soldiers posted around the barge. And as it went by, we could see that it was the remains of the Apollo 1 capsule – larger than I thought, more than just singed, a death trap for those 3 men. The entire encounter lasted no more than 2 or 3 minutes, but the memory is burned in forever.

  2. As an aviator for over 40 years (and also a friend of jim Oberg’s) my opinion is that ache of fear, that gnawing doubt doesn’t come from a system as much as from an attitude.

    A system becomes a convenient scapegoat that depersonalizes the problem. Sure, you could wire every seat in the control room to give a killer shock to each butt there in the event of another disaster—that would make it real personal. But a more realistic solution is one where each individual personally feels responsibility for the outcome, and knows their opinion is valued, even crucial, to the success of the mission.

    If you’re a soloist you have no one to blame but yourself if the concert goes badly. Make it a duet and you already have someone to blame. Make it an orchestra and it’s the rare performer that will stand up and tell the conductor when things are going badly. NASA is a very big band.

  3. kedaver

    I think on these annaversariy dates the thing to remember is the sacrifice that these men (and women where appropriate) made in the pursuit of science and knowledge. It is these heros that have allowed us to progress and reach for the stars. It is their dedication that has made dreams reality. Their sacrifices were not in vain.

  4. bassmanpete

    BA, I think you meant human fallibility in your last sentence, a fallacy is a false or deceptive argument (Pedantic Pete strikes again!) However, I agree entirely with your post. It brought to mind the first Ariane V that was launched – it went haywire & had to be destroyed by ground control. Turned out (or so I read) it had been loaded with Ariane IV software!

  5. Tim G

    In his book, Failure is not an Option Gene Kranz writes about that day and the speech he gave to the engineers. I cannot remember all of the details of the speech, but he cited “go fever” as the root cause. Supposedly, everyone pressed forward with the program so quickly, that no one said to slow down or stop. Of course, they were under a lot of time pressure to reach the moon by the end of the decade and before the Soviets.

  6. Mark Schindler

    It is good on these anniversaries to stop and ask, “Is there anything we can do to make space travel safer?” However, life in general, and transportation in particular, always involves risk. Does anyone know how many NASA employees have died in car (or airplane) accidents traveling to or from work? I have no idea, but I expect it is more than the number of astronauts.

  7. Ed Davies

    “It brought to mind the first Ariane V that was launched – it went haywire & had to be destroyed by ground control. Turned out (or so I read) it had been loaded with Ariane IV software!”

    That’s literally true but saying like that is very misleading. It was not by any means a simple case of “opps, wrong file”.

    As understand and remember it, the Ariane V reused a lot of the software from the IV. There was one routine which only had an active role in the period before launch (something to do with aligning the gyro reference platform) which was kept running for a short while after launch but with its output not being used so that if the launch was aborted on the pad the whole system could be recycled for another launch attempt quickly.

    The problem was that the Ariane V had a different trajectory so this routine overflowed one of its internal values (something to do with the horizontal velocity). This was interpretted as a hardware failure resulting in the main guidance computer shutting down and passing control to the backup. The backup, running the same software, had the same problem a few milliseconds later and also gave up, dumping its memory in a way which resulted in the main engines flailing around randomly.

    A twist to the story was that the routine in question had had a check for that overflow but this was taken out for performance reasons – so the processor could do its job quickly enough. This was carefully reviewed for the Ariane IV but somehow the implications of the trajectory change were not taken into account for the Ariane V.

    In some ways this is like the Challenger accident. With that, MTI knew about the o-ring problem and were working on it but it was not regarded as terribly urgent because it was only really likely to be a problem in the cold. What I think is the root cause of the accident was that that limitation wasn’t documented well in advance, in a calmer meeting not immediately before a launch. Perhaps if NASA had been fully aware of the problem well in advance they could have put heating blankets round the booster field joints – doing this was discussed in the pre-launch meeting.

    The common theme to these two accidents is, in my opinion, an assumption being made (trajectory for the Arianes, likely launch temperatures for the Shuttle) but not formally documented or reviewed properly in the light of changing circumstances.

  8. I wonder why the Russian space program has turned out to be so much less costly in terms of human lives than the American one? Have they simply had fewer people in space? Do they perhaps use simpler technologies, that have less that can go wrong? Can NASA learn any lessons in safety from the Russians, or have the Russians simply been luckier?

  9. Ed Davies

    “I wonder why the Russian space program has turned out to be so much less costly in terms of human lives than the American one?”

    The US has had two fatal accidents actually in spaceflight (Challenger and Columbia). So has the Soviet/Russian program (Soyuz 1 and 11). The Soyuz has a much smaller crew than the Shuttle (Komarov was solo in Soyuz 1, 11 had a crew of three) resulting in fewer deaths. Apollo 1 was also a spacecraft accident, of course, but both programs have had astro/cosmonaut deaths in training, particularly in jet flying (Bassett, See, Freeman, Gagarin, ?).

    Apollo 13 could easily have been much worse but then so could some Russian incidents such as the Progress/Mir collision.

    Apart from the smaller crews I don’t think there’s a significant difference between the accident rates of the two programs – the samples are (thankfully) small enough for the results to not be statistically significant. The use of the words “so much” here is pushing things a bit.

  10. Carolyn

    In one of his books (“What do you care what other people think?”), Richard Feynman discusses his experience and investigation as part of the Challenger accident investigation committee. It’s a very illuminating look into what it takes to avoid or cause an accident like Challenger.

    The discussion of “Powerpoint” and the briefing slides included in the Columbia accident report also gives some insight into how communication can go so very wrong.

  11. If I recall there were more deaths in the soviet programme, but they were on the ground. There was the incident when they tried to test the N9, a replacement of the current Russian launch platform. It managed to blow up on the launch platform killing several on the ground. (They went into this in detail on the BBC / National Geographic series Space Race just incase I got details wrong)

  12. Gary Ansorge

    Gee, maybe what the space programe needs is a Sylvia Browne to keep ahead of the disasters??? Might work if SHE had to go up in the capsule, either that or she’d have to admit she don’t know diddly,,,

    My brother Jerry, was a rocket scientist with Rockwell. He sometimes went into all the check lists they had to ensure the darned things got off the ground and he wasn’t talking about a single sheet of paper. It involved BIG books of all those things that needed to be verified before any launch.
    These systems are the most complex we’ve ever built and therein lies the problem. What we really need is to simplify the system and as long as we’re constrained by launch weight versus payload that ain’t gonna happen. If we ever get to magnetic launch catapaults THAT could do the trick. Less launch weight for onboard fuel leaves more payload and greater redundentcy in the launch vehicle. That should provide for more reliability.

    Well, technology marches on,,,

    Gary 7

  13. myronwls

    Here is a link to an updated version of Holst the Planets It includes a tribute to the fallen Cosmonaut Kamorov

  14. Gary Curtis

    As a structural engineer with a specialty in tall (say1500′) guyed towers I have investigated maybe 10 collapses. Because there is no redundancy in these structures any loss of a single member results in total collapse. Every collapse was caused by someone doing something really stupid either in the design or in the construction. It was never a result of flawed material.

  15. DennyMo

    Gary, fifteen hundred foot guyed towers? I didn’t know such critters existed, much less that 10 of them had collapsed. Where are these monsters located?

    I live about 10 miles from Gus Grissom’s home town. Our local paper ran a few articles on the recent anniversary, including this interesting quote from Gus himself: “If we die, we want people to accept it,” he was quoted as saying in March 1965 after the Gemini 3 mission. “We are in a risky business, and we hope that if anything happens to us, it will not delay the program. The conquest of space is worth the risk of life.”

  16. I am now informed that it was the N1, not the N9 that caused the problems in the Soviet space programme

  17. Rosemary

    As I remember from a book I read as a teenager the Soviet program lost a great many cosmonauts on the ground or in training and early development. Many of them were eliminated from records so that it appeared they had never been in the program in the first place.

    As I read this as a teenager I didn’t investigate this as fully as I would now. I’m not sure about the accuracy of the information. However, my understanding is that the Soviet loss of Cosmonauts would equal the loss of the NASA program, if not outweigh it.

  18. bassmanpete

    Thanks for clarifying that Ed. The article I read just said it was loaded with Ariane IV software and didn’t elaborate. Plus I didn’t dig any deeper myself – my fault for relying on just one media report!

  19. JustAl


    The very same James Oberg mentioned in the original post did most of the investigation into missing cosmonauts, well before the Soviet Union collapsed. During this time, most of the Soviet space program was kept strictly private, so this was no small feat. In post-Glasnost years, records of the program were released and, I believe, confirmed nearly all of Oberg’s findings. The main book of these investigations is “Red Star In Orbit,” published before the collapse, but I believe there are others.

    I have personally found Oberg to be a bit too egotistical in his writings for my tastes, but there’s no denying the work involved and the accuracy thereof.

    As a slightly-related aside, the secrecy of the Soviet program is another point against the moon hoax believers. The US program couldn’t have been any more open and accessible to the public than it was (and is), and there was ample reason to keep things much more secretive – in NASA’s case, it would actually have involved much less effort. The idea that this was necessary for funding is ludicrous – money for NASA has never been decided by the public, and public funding is an infinitesimal fraction of their budget.

    Meanwhile, programs like the Corona satellite were kept from the public eye, but the funding government knew all about them.

  20. JustAl

    I am in hesitant agreement with Oberg over this one. Most accidents are “avoidable,” but in most cases (and we’re not just talking the space programs here) there’s a tradeoff between the risks and the implementation of greater safety precautions. In other words, while the space program (and even passenger cars) could be safer, it most likely would not have progressed at the pace it has, and certainly would have cost far more.

    This is not intended to excuse the accidents. It is instead intended to point out that “blame” or “responsibility” need to be assessed realistically and objectively.

    For instance, no one ever discovered what actually ignited the Apollo 1 (204) fire. Guesses led to some capsule redesign and outright paranoia on the part of the NASA workers, but whether it was a case of inadequate safety features or simply a freak accident has never been determined.

    Challenger suffered a confluence of factors that led to the accident, some of which were unprecedented (temperatures at the Cape, wind shear at altitude). The infamous O-Rings had been observed, several times previously, to seal themselves against leaks, and let’s not forget that the lack of expansion at colder temperatures would cease to be a factor once the heat of the SRB exhaust gases reached them.

    And Challenger was carrying a still-unspecified military payload – there are strong indications of serious pressures to launch regardless of the misgivings. Then-President Reagan was present at the Cape for the launch.

    Potential damage to Columbia’s leading-edge surfaces was known before re-entry. But what could have been done about it? There were no EVA suits for inspection, and it wouldn’t have mattered if there had been – ceramic tile replacement is not a procedure that can be done in space. Funding for the X-35/38 CRV hadn’t been forthcoming, and no other launch vehicles were available to retrieve the astronauts, nor could be made available in an effective amount of time. The standby Soyuz capsule attached to the ISS can hold only 3 people, leaving four of the shuttle crew stranded in space.

    And finally, the ultimate decision (most especially for the Columbia) is usually left to the crew. They know the risks on all sides and it’s their own lives they’re deciding upon. Given the factors involved, I know I would have made the same decision.

    Could the Apollo 1 fire have been prevented? Quite possibly, we don’t know for sure. Challenger? Sure, with very significant delays and cost increases within the program. Columbia? Yes, to a point – care is now taken to help prevent foam from breaking free, and I believe there is an emergency patch procedure for missing tiles in place for shuttle crews. But the issue itself is not “solved” by any stretch and the accident can easily repeat. Attempts to secure the foam tighter stand the chance of also increasing the risk, should they themselves break free and strike the shuttle with even greater force.

    (Anyone with greater knowledge of the programs should feel free to correct anything I’ve said above as needed).

    There will always be risks. We can minimize them, but the extent of this depends on many other factors, including funding and time. It’s a balancing act, and everyone in the program knows this. The fatalities that took place were of people who knew the risks. Safer programs are always available, but require a distinct commitment on all levels.

    The moon by 2020? Great! How about, “A moon program that progresses at a safe and effective schedule, and let us know what you need to do this. And don’t take away from other programs to accomplish it.” I’d like that one better.

  21. Rachel

    Hello. I am participating in a NASA space school camp, and was wondering if any one could help me with a Question I am stuck on.
    Q: After the Challenger accident, new safety precautions included the crew:
    a. doing survival training
    b. using ejection seats
    c. practising egress procedures
    d. wearing launch and entry suits

    I would really appreciate any help from anyone if possible.


  22. Kaya

    same as the girl above!!
    could anyone could help us with that question, it seems that there is no where online that knows!
    the question is

    Q: After the Challenger accident, new safety precautions included the crew:

    a. doing survival training
    b. using ejection seats
    c. practising egress procedures
    d. wearing launch and entry suits

    any help would be much appreciated!

    thank you for your time.xx

  23. Kaya

    Rachel if you come back onto this site ever i found the answer in the text we’re supposed to read!the answer is d- launch and entry suits!

  24. Rachel

    kaya you are AMAZING!

  25. tm

    Ladies and gentlemen, your future NASA administrators: Rachel and Kaya. You can be sure they’ll remember the legacy of NASA’s darkest days during their tenure, and be able to demonstrate the proper respect for the dead.

    Joking aside, but we know that future NASA PHBs are still going to be driven by the pressure to launch, and that will inevitably override safety objections. The Rachels and Kayas of NASA will hunt around and come to the same fantastically unrealistic “safe” ratio that Feynman observed NASA managers citing during the Rogers Commission.


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