Cause Mapping is a Root Cause Analysis method that captures basic

cause-and-effect relationships supported with evidence.

Problem

APOLLO 1
Problem(s)

What

Crew
Date

When

Time
Different, unusual, unique
Facility, Site

Where

Equipment
Task being performed

Flash fire, astronauts killed

White, Grissom, Chaffee
January 27, 1967
~6:30 pm EST
1st piloted flight, hatch difficult to open
Cape Canaveral
Apollo 1/Saturn space vehicle
Launch pad test

Impact to the Goals

Safety
Vehicle
Mission
Property, Equip, Mtls
Labor, Time

Three astronauts killed

Rupture of Command Module
Delay in mission
Rupture of Command Module
Rescue efforts

Why?

Why?
Three
astronauts
killed

Safety Goal
Impact

Why?
Lack of oxygen

Fire during launch pad test kills 3 astronauts

Launch pad testing on the Apollo 1 Saturn space vehicle turned
deadly when a fire begin within the command module. Rescue of
the astronauts proved difficult as the hatch had been designed to
prevent accidental opening.

"No single person bears all the responsibility for the

Apollo 204 accident. It happened because many people
made the mistake of failing to recognize a hazardous
situation."
- Senate report on the accident

Step 1. 1

Problem

What's the
Problem?

Step 2.2

Analysis

Why did it
happen?

Step 3.3

Solutions

What will be
done?

Change in
hatch design

Previous
misfiring of
explosive
hatch

More Detailed Cause Map

Add detail as information becomes available.

Labor
Goal
Impacted

Solution:

Effect

Problem Solving Incident Investigation Root Cause Analysis

Apollo 1 Crew, L to R: Edward White,

Gus Grissom, Roger Chaffee

Analysis

Basic Level Cause Map - Start with simple Why questions.

Cause Mapping

Cause Map

Rescue
efforts

Implemented Solutions:
Quick opening hatch

Astronauts
unable to exit
command
module

Cause
Evidence:

Hatch took 5
minutes to
open

Evidence: Incident
on Mercury Liberty
Bell 7 in 1961

Fire in
command
module

Implemented Solutions:
Clarified contractor
expectations,
requirements

No.

Safety Goal
Impacted

Solutions
Action Item
Quick opening hatch

Hatch took 5 minutes to open

Clarified contractor expectations,

requirements
Restriction of flammable material
on-board
Reduced oxygen concentration
for ground operations

Insulation defeated

Extensive combustible
materials in cabin
Use of pure oxygen in
spacecraft

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Lack of
oxygen

AND

Evidence:
Astronauts found to
have asphyxiated

Cause

Three
astronauts
killed

Heat

Electric arcs

Evidence: No single
ignition source
conclusively identified

Evidence: Most
probable (evidence
of several arcs)

AND

Mission Goal
Impacted

Vehicle
Goal
Impacted

Property
Goal
Impacted

Delay in
mission

Fire in
command
module

Fuel

AND

Rupture of
Command
Module
Oxygen

Inadequate
insulation,
installation
Evidence: Numerous
issues with design,
workmanship

Implemented Solutions:
Restriction of flammable
material on-board

Extensive
combustible
materials in
cabin

Discrepancies
between
specifications

Possible Solutions:
Reduced oxygen
concentration for
ground operations

Use of pure
oxygen in
spacecraft

Need for
increased
oxygen in
space