“From this day forward, Flight Control will be known by two words: ‘Tough’ and ‘Competent.’ Tough means we are forever accountable for what we do or what we fail to do. We will never again compromise our responsibilities. Every time we walk into Mission Control we will know what we stand for. Competent means we will never take anything for granted. We will never be found short in our knowledge and in our skills. Mission Control will be perfect. When you leave this meeting today you will go to your office and the first thing you will do there is to write ‘Tough and Competent’ on your blackboards. It will never be erased. Each day when you enter the room these words will remind you of the price paid by Grissom, White, and Chaffee. These words are the price of admission to the ranks of Mission Control.” Gene Kranz; the Monday morning after the Apollo 1 disaster; flight director for Apollo 13.
Apolo 13 is a catastrophe that could have been. While still a failure as far as the intended mission, Apollo 13 shows both the negative and positive side of cascade events working against each other until the balance ultimately revolved around which side was a hair better.
By all odds, the Apollo 13 mission should have ended with three dead astronauts and the entire space program suspended, if not stopped. Instead it was described, strangely, as “NASA’s finest hour.” The flight’s commander, Lovell, more accurately labeled it: “a successful failure.”
As you will see when we go through the cascade events, NASA actually did make a lot of mistakes, but it also did enough things right to nudge out those negative cascade events.
On 13 April 1970, en route to the moon, Apollo 13 experienced an explosion which crippled the service module and required the three man crew to abandon their moon mission and focus on getting back to Earth alive. Despite the overwhelming odds against them, they made it back to Earth and a successful re-entry.
27 January 1967: A fire in the capsule during a test of Apollo 1 kills Astronauts Virgil I ‘Gus’ Grissom, Edward H. White, and Roger B. Chaffee.
1968: Oxygen tank that will eventually be in Apollo 13 is dropped two inches while being removed.
March 1970: Oxygen tank indicates trouble while being emptied.
11 April 1970: Apollo 13 launches.
13 April 1970: Oxygen tank explodes.
17 April 1970: Successful splashdown of Apollo 13.
Here are the cascade events leading up to the almost catastrophe:
1. A design change wasn’t completely integrated across all equipment.
2. One of the two oxygen tanks was dropped.
3. Unfocused workmanship.
4. Mechanical failure. When the fan was turned on to stir the tanks 55 hours and 54 minutes into the flight toward the moon, the oxygen tank exploded.
5. The catastrophe of Apollo 1 helped save the astronauts on Apollo 13.
6. Innovation, catastrophe planning and leadership helped save Apollo 13.
Leading to a successful landing 45 years ago today. For more, read the short: Apollo 13: Successful Failure.
“There is no danger that Titanic will sink. The boat is unsinkable and nothing but inconvenience will be suffered by the passengers.” Phillip Franklin, White Star Line vice-president, 1912
Titanic is a classic example of systematic cascade events, many unrelated to each other, any of which if corrected, would have averted the final event.
The Titanic sank in the early morning of 15 April 1912 after hitting an iceberg in the North Atlantic. The official death toll is 1,517 making it #5 on the all time fatality list for shipwrecks. What makes this sinking notable is that the Titanic was the largest ship afloat at the time of its maiden voyage and was declared ‘unsinkable’ by its builders.
Hubris is the father of tragedy and catastrophe.
Roughly 1,000 BC: Snow falls on Greenland, which will eventually become the iceberg the Titanic strikes.
31 July 1908: Plans for Number 400 (Olympic) are presented to the White Star Line and approved. Number 401 (Titanic) is also approved.
31 March 1909: Construction begins on Titanic.
1909: The fatal iceberg calves off a glacier on the west coast of Greenland.
31 May 1911: Number 401 slides on 22 tons of soap and tallow into the water. It is not christened or formally named, keeping with White Star tradition.
2 April 1912: First sea trials of Titanic.
10 April 1912: Titanic sets out on her first, and last, voyage.
14 April 1912; 11:40 pm: Titanic strikes an iceberg.
15 April 1912; 2:20 am: Titanic sinks.
The six cascade events that led to the seventh, and fatal, final event:
1. An unusual weather pattern caused more icebergs than usual and forced them further south than normal.
2. Rivets were of inferior material, some put in by inexperienced welders, causing more damage during the collision than should have occurred.
3. Lack of a sufficient number of lifeboats for the crew and passengers.
4. The two lookouts in the crows nest didn’t have binoculars.
5. The ship was going too fast for the conditions.
6. Warnings were ignored and the wireless radio wasn’t used correctly
7. Ship sinks.
BTW, a cook survived in the water for over two hours, constantly swimming, until he was rescued. I empathize with this because one of the first things I did upon taking over my Special Forces A-Team was to go to Denmark where we completed the Royal Danish Navy’s Fromandkorpset School– their combat swim school. We learned great things, like dry suits aren’t. I’ll post more about this experience shortly.
If you want more about Titanic and the cascade events, check out Titanic: Systematic Failure