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Description of the Accident

Discuss about the Production Management and Industrial Economics.

Quality issues in Systems Engineering often bring disastrous results if not addressed properly. There have been thousands of major accidents around the world that have occurred due to the quality issues persisting in the technical systems. Most of the major accidents like aircraft crash, train derailment, building fires, bridge collapse and other accidents occur due to the same reasons and in most of these accidents, a large number of lives are lost. Quality issues occur when the qualities of the systems are either not adequately checked or ignored for some reasons. These issues can also occur if the quality standards are not met or the qualities of materials are not good enough to support large technical structures (Chapman 2018). Very often, in addition to these factors discussed, certain other factors also play a major role in the loss of lives in the accidents. These factors include lack of proper safety equipments, evacuation systems, lack of sufficient training regarding evacuation techniques and others.

The Apollo 1 accident is one such accident that was caused due to the quality issues in the system engineering of the Apollo 1 rocket that was poised to carry the first men to the moon. However, coincidentally, during quality checking of the internal parts of the rocket, a massive fire broke out that also caused the loss of three astronauts who were inside the rocket at that time. In this report, this particular incident has been specifically focused on in order to analyze the quality issues of system engineering that caused the deaths of the astronauts.

In 1967, just few days before the launch, three astronauts, who were to travel to the moon in the Apollo 1 rocket, went in to make some quality inspections and internal testing. In addition, they also needed to test the emergency and evacuation systems inside the rockets that were too be used in cases of emergency. They had to go inside in full space environment with pure oxygen environment and high pressure and hence, they needed to wear space suits inside the rocket during the testing process (Allday 2018). After five hours of intense testing process, suddenly the communication system with the astronauts started malfunctioning. At that time, fire broke out inside the pilot’s cabin as heard from the astronauts’ unclear screams in the microphones. Due to the pure oxygen environment inside the rocket as well as intense pressure, the fire spread quickly inside the different chambers. The astronauts did not have much time to escape and the rapidly spreading fire quickly engulfed the cabin in which the astronauts were located. In addition to the fire, due to the pure oxygen environment, very heavy smoke was also produced and this smoke killed the astronauts via suffocation and heart attack (Barth et al. 2016). The nylon materials also played a major part in the spreading of the fire and the scientists also determined that there were not sufficient emergency evacuation trainings provided to the astronauts and hence, they were not able to escape the moment they saw the fire. They were also not able to open the emergency escape hatch during the spreading of the fire. This particular incident was a major setback for the Apollo missions although two years later, another mission happened and took men to the moon.

Quality Issues Leading to the Accident

On January 27, 1967, a few days before the launch, the three astronauts were sent inside the rocket in full space suits to undertake plugs test and some other quality checks to ensure the rocket was safe to travel. Inside the rocket, the space environment was created with high pressure and pure oxygen air and hence, the astronauts entered the rocket with full pressure resistant space suits and strapped themselves inside the command module seats. First the communication testing was done and then they started the hatch installation inside the chamber (Beeson 2017). Till then, there was no hint of any fire or even short circuit although one of the astronauts did express regarding some unusual smell inside the chamber. After five hours of intense checked, there was a sudden flickering in the bus voltage inside the spacecraft and one of the astronaut’s indistinct shouting that was interpreted to be “fire” was heard. Most possibly, due to short circuit issue or voltage overload on a certain bus, there was a small explosion or may be a spark that lit the fire in the oxygen environment inside the rocket. The rocket had an external heat shield on the outer body but there was no fire resistant internal walls and instead has materials that catch and spread fire easily.

Later on during the investigation of incident, several quality problems and issues were raised that were blamed to the reasons of the accident. One of the main points that were raised was the choice of pure oxygen inside the rocket. An investigator raised a question regarding why pure oxygen environment was used instead of normal proportionate air with the mixture of nitrogen and oxygen. NASA revealed that there were plans to use nitrogen-oxygen mixed air inside but the presence of high amount of nitrogen in the air caused decompression sickness in the astronauts and hence, pure oxygen was deemed to be the safest oxygen (Buede and Miller 2016). It is to be noted here that the major concern that pure oxygen can increase any fire instantly was completely ignored during this consideration. Another major question that was raised regarding the issue was that the contractors did not build and install electrical connections properly while working in the rocket and even in cases of noted shortfalls or issues, they did not report to the authority at any point of the rocket development project. This later resulted to the ignoring of the electrical safety issues that ultimately became the main villain of the incident and claimed the lives of three astronauts.

Factors Contributing to the Deaths of the Astronauts

In the context of systems engineering, it can be said that the incident was not simply an “accident”; it happened because there were a lot of quality issues that were not properly addressed before the astronauts were sent inside for testing and checking. Some of the main quality issues that led to the accident are explained as follows.

Improper Electrical Connections – In most of the fire incidents, the main culprit is the improper electrical connection from which, sparks emerge and light fire in the surroundings. In this incident also, there were faults in the electrical connections inside the rocket that caused the fire. During the installation of the electrical connections inside the rocket, the electricians failed to notice the problems and issues that resulted in short circuit and sparking (Campbell 2017). Another probable cause was the lack of sufficient insulation in the connections that resulted in the sparking and lighting of fire in the environment. Furthermore, presence of pure oxygen in the air led to the immediate spreading of the fire inside the rocket.

Internal Insulations – Another main cause of the accident was the lack of sufficient insulation inside the rocket itself. Inside the rocket, there were many nylon materials that easily catch fire. There were no precautions taken earlier to use insulations on the nylon materials that could have resulted in avoiding the incident. Hence, the oxygen environment and the nylon materials quickly contributed to the growth and spreading of the fire inside the rocket chambers.

No Proper Evacuation System – One main reason regarding why the astronauts could not escape in time was the lack of proper evacuation system inside the rocket. The emergency evacuation system only worked after taking care of several mechanisms that resulted in the loss of time within which, the fire engulfed the astronauts (Carayon 2014). Furthermore, proper training was not provided to the astronauts regarding how to open the evacuation hatch quickly during emergency conditions and hence, they failed to escape. They got suffocated in the heavy smoke and also had third degree burns on their bodies.

No Smoke Resistant Equipments – Another major quality issue that led to the death of the astronauts was the absence of any smoke resistant equipment inside the rocket. The astronauts were provided with gas masks but they were only suitable for preventing poisonous gases and not heavy smoke. As a result, in spite of wearing the masks, they quickly suffocated and encountered heart attack.

Causes of Unnoticed Quality Issues

Non-Insulating Space Suits – The astronauts went inside the rocket in full space suits in order to encounter space like environment inside the rocket. However, the suits were only designed to provide protection against low gravity and non-oxygenated air but not against fire. Instead of insulating material, they were provided with space suits made of plastic materials that melt quickly in even low grade fire (Dawson 2017). It was found that the space suits of all the astronauts almost entirely melted and then joined with the cabin walls against which the astronauts were stuck. Furthermore, the melting of the space suits exposed the astronauts to the heat of the fire that engulfed them resulting in third degree burns.

In the previous sections, the technical details of the accident as well as the main quality issues associated with the accident have been explained. Now the main causes that led to the unnoticed quality issues that in turn led to the accidents have been discussed.

Insufficient Follow Up – During the development phase of the rocket, several contractors were assigned for various duties including construction of the body, design of the internal part of the rocket body, installation of electrical connections and wirings, installation of the motors and electrical devices and others. However, it was important to take regular follow up on the progress of the project that NASA failed to do. They relied on the contractors themselves to take follow ups and make necessary changes required for the rocket (Hartley 2017). However, the contractors also did not take follow ups and proceeded with their works instead of checking for existing problems and issues. Furthermore, there was no reporting from the contractors’ side regarding the persisting issues faced or encountered during performing their work. As a result, NASA never knew about the shortfalls that ultimately resulted in the accident.

No Quality Audit before Testing – During any large scale project, quality audit is required in order to ensure the project is running on track and is within the scope set during the project. Furthermore, quality audit includes checking and ensuring that right quality standards are met during the project. However, it was later found that there were no quality audits done during the project. Both the lack of follow up and audit resulted in major technical errors and issues persisting inside the rocket body that all eventually led to the accident without even anyone’s notice.


Lack of Quality Standards – In any project, there are certain quality standards that are set in order to ensure the project follows a benchmark quality. The contractors need to follow these quality standards while working on the project (Heizer 2016). However, in this project, it was found that there were no prior quality standards set before the initiation of the project. When the contractors were hired, they were simply handed with the requirements specifications that they needed to follow. Hence, they did not have any idea regarding the necessary quality for the project.

From these points, it has been seen that a lot of quality issues and problems were more or less neglected that ultimately led to such a large scale accident. Furthermore, general project management procedures like setting quality standards, undertaking quality audits and other factors were completely ignored while the project was being worked on (Hitomi 2017). It was also the fault on the contractors’ side that they did not ensure the safety standards were met and all the developed systems were error free before they handed over the project. Later on, NASA took initiatives to learn from the mistakes in this accident and ensured all the required procedures were followed before the rocket was tested and sent to the moon with astronauts.


From the analysis presented in the report, it is clear that several quality issues and problems led to the unfortunate incident of Apollo 1. Judging by the causes of the accident and the spread of the fire, it is more or less clear that such problems could have been avoided if sufficient quality checks and audits were done during the project itself. It was the fault of both the contractors and NASA who did not take much care for ensuring the quality of engineering inside the rocket. Moreover, that was the first realistically proposed man mission to the moon and hence, extra care should have been taken to ensure no technical issues and problems arise. However, the positive side of the event is that such mistakes were not repeated in the future missions as within 2 years time, NASA successfully sent manned spacecraft to the moon. In this context, not only NASA but all the people and entities involved in engineering field works should take important lesson regarding safety and quality of the structure to be built. It must be noted that quality is an aspect that should never be compromised with even if it incurs additional costs and time, especially a structure or object that will be used by some people as it will only mean risking the lives of the people. Any chances of risks that may cost the lives of people must be avoided at all costs.

Based on the overall analysis and conclusive points, some recommendations have been provided that will help to avoid quality issues in the field of engineering in the future as follows.

No Compromise on Quality – The main recommendation to be made is that there should never be any compromise made with the quality especially if it is risks the lives of people. There are some projects where due to insufficient funding and budget, project managers often compromise with the quality of work in order to complete the project within the budget limits. In small scale projects, this may not be an issue but in large scale projects like construction of large structures, building of vehicles and others, quality is not the thing to be compromised. During the planning phase of the project, when budget estimation is done, the best quality materials are to be considered for calculating possible expenses. Further, suitable contractors should also be hired who will not compromise with quality for personal profits.

Quality Check and Audits – In spite of ensuring procurement of best quality materials and hiring of reliable contractors, the project manager / authority should conduct regular audits or field checks in order to ensure quality is not compromised. Even with quality materials and support, it has been seen, as evident in the case of Apollo 1, the field works often do not meet quality standards. Without regular checks and audits, these faults cannot be detected later on and hence, may cause major accidents at the slightest of the stimulus. Furthermore, setting quality standards before the start of the project is another important thing to do and failure to meet such standards should incur strong penalty.


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