PSM in space exploration?
On September 1, 2016 SpaceX attempted to launch a Falcon 9 rocket with payload and "during a standard pre-launch static fire test for the AMOS-6 mission, there was an anomaly at SpaceX’s Cape Canaveral Space Launch Complex 40 resulting in loss of the vehicle." SpaceX has been grounded since then as they have worked to figure out what caused the anomaly.
Initially, they reported that Standard Operating Procedures were followed, which resulted in no personnel injuries. We are able to see from this how important it is to read Operating Procedures when they come across your desk for review. It is illustrated here how procedures play a role in preventing injuries. Imagine if the Operating Procedures did not specify that no personnel were to be in the vicinity of the launch pad during fueling operations. It may have resulted in a very different outcome.
They used Incident Investigation methods to thoroughly look at what happened so they were able to prevent it from happening again. They assembled a team of people from many agencies with a stake in the outcome to get a thorough understanding of the problem. They worked with the FAA, NASA, the US Air Force, and industry experts. They did not work in a bubble. They understood that it would take many eyes with many backgrounds to determine the root cause. They worked methodically through a fault tree analysis, one of many tools available in the Incident Investigation toolbox. Eventually, they concluded "that one of the three composite overwrapped pressure vessels (COPVs) inside the second stage liquid oxygen (LOX) tank failed. Specifically, the investigation team concluded the failure was likely due to the accumulation of oxygen between the COPV liner and overwrap in a void or a buckle in the liner, leading to ignition and the subsequent failure of the COPV."
SpaceX was able to determine the root cause, and made changes in the configuration of the vessel along with modifying its operating procedures for fueling. They were successful in their launch on Saturday, January 14.
How have you used Operating Procedures and Incident Investigation to better your process?