"Breaking the Mishap Chain: 
Human Factors Lessons Learned from Aerospace Accidents and Incidents in 
Research, 
Flight Test, and Development"
By Peter W. Merlin, Gregg A. Bendrick, and Dwight A. Holland 

This volume contains a collection of case studies of mishaps involving 
experimental 
aircraft, aerospace vehicles, and spacecraft in which human factors played a 
significant role. In all cases the engineers involved, the leaders and 
managers, 
and the operators (i.e., pilots and astronauts) were supremely qualified and by 
all accounts superior performers. Such accidents and incidents rarely resulted 
from a single cause but were the outcome of a chain of events in which altering 
at least one element might have prevented disaster. As such, this work is most 
certainly not an anthology of blame. It is offered as a learning tool so that 
future organizations, programs, and projects may not be destined to repeat the 
mistakes of the past. These lessons were learned at high material and personal 
costs and should not be lost to the pages of history. 

http://www.nasa.gov/connect/ebooks/break_mishap_chain_detail.html



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