Cause Mapping is a Root Cause Analysis method that captures basic

cause-and-effect relationships supported with evidence.

1 Problem
APOLLO 1 Cause Map Cause Mapping
Problem Solving • Incident Investigation • Root Cause Analysis
What Problem(s) Flash fire, astronauts killed
Crew White, Grissom, Chaffee Fire during launch pad test kills 3 astronauts Problem What's the
Step 1. 1 Problem?
When Date January 27, 1967 Launch pad testing on the Apollo 1 Saturn space vehicle turned
deadly when a fire begin within the command module. Rescue of Why did it
Time ~6:30 pm EST the astronauts proved difficult as the hatch had been designed to Step 2.2 Analysis happen?
Different, unusual, unique 1st piloted flight, hatch difficult to open prevent accidental opening.

Where Facility, Site Cape Canaveral Solutions What will be

"No single person bears all the responsibility for the Step 3.3 done?
Equipment Apollo 1/Saturn space vehicle Apollo 204 accident. It happened because many people
Task being performed Launch pad test made the mistake of failing to recognize a hazardous
situation." - Senate report on the accident
Impact to the Goals
Safety Three astronauts killed
Apollo 1 Crew, L to R: Edward White,
Vehicle Rupture of Command Module Gus Grissom, Roger Chaffee
Mission Delay in mission More Detailed Cause Map
Property, Equip, Mtls Rupture of Command Module Add detail as information becomes available.
Labor, Time Rescue efforts
2 Analysis Labor
Rescue Implemented Solutions:
Goal
efforts Quick opening hatch
Basic Level Cause Map - Start with simple Why questions. Solution: Impacted
Astronauts Previous
Effect Cause Hatch took 5
unable to exit Change in misfiring of
minutes to
Why? Why? Why? Evidence: command hatch design explosive
open
module hatch
Evidence: Incident
Three Fire in on Mercury Liberty
Safety Goal
astronauts Lack of oxygen command Bell 7 in 1961
Impact
killed module
Implemented Solutions:
Clarified contractor
expectations,
requirements
Three Inadequate
Safety Goal Lack of AND
astronauts insulation,
3 Impacted oxygen Heat Electric arcs
Solutions killed installation
Evidence:
No. Action Item Cause Evidence: No single Evidence: Most Evidence: Numerous
Astronauts found to
ignition source probable (evidence issues with design,
have asphyxiated
1 Quick opening hatch Hatch took 5 minutes to open conclusively identified of several arcs) workmanship

2 Clarified contractor expectations, Insulation defeated AND

Implemented Solutions:
requirements Restriction of flammable
3 Restriction of flammable material Extensive combustible material on-board

on-board materials in cabin Extensive

Fire in Discrepancies
4 Reduced oxygen concentration Use of pure oxygen in Mission Goal Delay in combustible
command Fuel between
Impacted mission materials in
for ground operations spacecraft module specifications
cabin

Vehicle
For a free copy of our Root Cause Analysis Template in AND Possible Solutions:
Microsoft Excel, used to create this page, visit our web site. Goal
Impacted Reduced oxygen
Rupture of concentration for
Command ground operations
Module Need for
Property Use of pure
Investigate Problems. Prevent Problems. increased
Goal Oxygen oxygen in
Houston, Texas 281-412-7766 ThinkReliability.com oxygen in
Impacted spacecraft
space
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