• Uncategorized

Analysis of Apollo 13 Incident

Analysisof Apollo 13 Incident

Table of Contents

Analysis of Apollo 13 Incident 3

Abstract 3

Introduction 3

Understanding the Incident 4

The Source of the Problem 5

Events at the Space 5

CCPM Framework 6

Applying CCPM on Apollo 13 Case 7

Analyzing the NSPE Code of Ethics 9

External Efforts 10

Conclusion 12

References 13

Analysisof Apollo 13 IncidentAbstract

Thispaper provides a detailed analysis of one of the NASA missions thatfailed as a result of human error and incompetence in the planningphase. Apollo 13 accident was based on what happened before thelaunch, and it impacts while at space. The analysis below shows thatthe main source of the problem was one of the oxygen tanks which hadearlier on fell resulting in damaging the fill line. Human error isdescribed based on the test procedures which assumed a small detailwhich cost the entire mission being aborted. Further discussion isthe violation of National Society of Professional Engineers (NSPE)code of ethics such as ensuring competence and avoiding actions thatcould put the life and welfare of other people in danger. Theanalysis is based on the critical chain project management (CCPM), aframework that considers project management as a holistic approach byall stakeholders aimed at ensuring effective flow of activities whileavoiding challenges throughout the project implementation. In thisregard, it is found that the failure of Apollo 13 mission was as aresult of poor planning and lack of following the right procedures inthe testing phase. This paper concludes that the incident would havebeen averted if the test team had expressed competence in theiroperations and considered other options such as using a new tank orconducting a further detailed analysis of the damaged tank.


Inevery project or organization, one of the key aspects is to ensure asuccessful accomplishment of the goals and objectives. When theproject entails human lives, there is a need to be more cautious, anaspect characterized by ensuring safety at all time. One of the areaswhere this extreme safety is applicable is engineering. In thisrealm, slight problem is considered a great risk exposing theengineers as well as other people to various effects such as injuriesand death. At the same time, it is important to consider the vastinvestment in these projects. This implies that a slight problemcould result in huge losses. In this regard, engineering projects arecharacterized by perfection and precision. On the other hand, inevery organization or project, there are laws and policies thatgovern the operations of these individuals. Equally, professions areguided by a code of ethics. Various categories exist regarding thecode of ethics which include rules of practice and professionalobligations. Above all is the personal moral and values which assistin the effective achievement of the set objectives.

Understandingthe Incident

TheApollo 13 issues began on the ground. Considering the constructiondesign of the spacecraft, it comprised of three key segments whichincluded astronauts housing, electrical and environmental suppliessection and the gawky lunar module. To power the spacecraft, acombination of three large fuel cells and batteries were used withthe fuel cells being the main sources of electricity during flight(LaViola &amp Cleek, 2012). The working principle of the fuel cellswas to combine hydrogen and oxygen which produced both power andportable water. While the electricity was used to power thespacecraft systems, the portable water was being used for severalpurposes among them cooling the systems, drinking by the crew,rehydration of the food and hygiene. Notably, carrying vastquantities of oxygen and hydrogen is suggested to do it in liquidform. In this regard, the Apollo 13 service module contained twoliquid tanks for both oxygen and hydrogen. The oxygens tanks weresmaller than those of hydrogen. Essential to note is that the Apollo13 challenges were cantered on cylinder two.

TheSource of the Problem

Apollo13 second tank which was spherical shapeed had been manufacturedearlier and was designed for Apollo 10. However, there was someservice, modification, and maintenance required which led to itsremoval. While conducting these procedures, there was an accidentthat involved dropping the tank from an estimated height of twoinches. As noted earlier, engineering projects and machines require ahigh degree of precision which ensures minimum damage. At the sametime, it is important to note that high technological machines andaspects require maximum care. As a result, since the tank was droppedbefore the launch, a new one was fitted on Apollo 10 and the oldertank assigned to Apollo 13 (Chen, 2014). According to those whoinspected it, they ascertained that there was no damage. A crucialfactor to note at this point is that the external inspection missedone red flag the fill line had a small damage. This tank was thenused to fly Apollo 13 service module. In one of the tests before thelaunch, it was noted that there was a challenge in purging of theliquid oxygen. The process involved here was to feed gaseous oxygenin the tank which was then used to purge of the liquid gas. However,the damaged fill line hindered this. The testing team decided tocarry out the emptying process through heating the tank to boil offthe liquid oxygen. One dangerous mistake that occurred here was theuse of 65 volts DC ground instead of 28 volts. This prevented anautomatic shut own with the tanks temperature rising to more than1000 degrees Fahrenheit, something which was not noted since theinternal thermometer could only indicate a maximum of 80 degreesFahrenheit. The emptying process damaged the internal parts of thetank, an aspect that went unnoticed.

Eventsat the Space

Animportant aspect to note is that there is difficulty in measuring thetanks fill level as a result of stratification, a process describedby the oxygen separating to various layers and spreading inside agiven volume. Based on this challenge, the Apollo service modulecomprised a set of internal fans resembling impellers which were usedto stir the tank to achieve uniformity and mass measurements. Throughthis process, it is noted that in every stir, there was current thatraced through the damaged wires and destroying them. Upon a serviceby one of the pilots, Jack Swigert, it is alleged that there was aspark in the damaged wire which resulted in igniting the Tefloninsulation in the damaged tank. As a result of the burning in theoxygen environment, there was pressure build up which overwhelmed thetank’s relief valve resulting in the explosion (LaViola &ampCleek, 2012). Bearing in mind that the oxygen was not only used forbreathing purpose but also a source of power and water, thechallenges of the exploded tank were greater. Since the tanks were inthe same place even in the previous Apollos, it was no doubt that theeffect would extend to tank one. This is actually what happened. Theoxygen in tank one began bleeding in space through the destroyedconnections. Apart from the flight controllers on the spacecraft,those on the ground upon learning the situation were tasked withdeveloping complex but challenging choices aimed at saving the crew.This meant that everything was to be done faster than the normalperception of the public that NASA was a slow bureaucraticorganization. According to Liebergot, the EECOM controller, allpossible decisions were required within the set timeline. Accordingto numerous researches that have been done on the situation, oneaspect that saved the spacecraft was the fact the crew was trained toremain calm while conducting hundreds of simulations to arrive at thebest. Every member was to express their expertise in their fieldwhile working under extreme emotional and physical pressure.


Oneof the key theories in projects is the critical chain projectmanagement (CCPM) which is based on the reduction of waste whileemphasizing on flow. This theory acknowledges routine flow whileenhancing synchronization. According to this theory also, there is aneed to accommodate an environment that is uncertain. CCPM alsoenables effective production while ensuring shorter lead times inprojects. This implies that there will be an enhancement towardswinning criteria which at the same time enhances adherence tospecifications. This is achieved through concentrating on improvingflow. Notably, CCPM takes three main forms in achieving optimum flowin project management. These include planning, execution andimproving the project continuously (Ghaffari &amp Emsley, 2015). Inregards to project planning, CCPM ensures resources are well utilizedwhile depending on the set project duration. This aspect in CCPM isreferred to as critical chain where the critical path that willachieve the objective of the project is taken. Some of the conceptsintroduced by CCPM include feeder time buffer which effectivelymanages the buffer time normally wasted when locally managed at theactivity level. Buffers will, therefore, ensure better control andreduction of lead times. Considering project execution and continuousimprovement, it is based on reporting tasks completed within the settime frame. This is ensured through reporting either weekly ormonthly. Reporting on these tasks allows for visibility on all theupcoming tasks. Providing regular reports is also essential inprioritizing on the upcoming tasks based on urgency. There is also anadvantage of recovering a situation once effective reporting has beenadopted. It is, therefore, the role of senior managers in allprojects to take the necessary actions at any required point. In hisregard, these managers have the flexibility of consideringalternative options while focusing on improvement and averting allchallenges.

ApplyingCCPM on Apollo 13 Case

Indeed,Apollo 13 issues would have been averted if effective procedures werefollowed. The failure of the spacecraft ought to have been discoveredon the ground. While comparing this with Apollo 10, the first issuewas the dropping of the second tank. As noted above, Apollo 10 couldnot risk operating on a damaged tank, yet they were time barred. Thisprompted them to change the entire tank and use a new one. As aresult, Appollo 10 mission was successful. On the other hand, Appollo13 did not resolve to use a new tank. They, however, conducted anevaluation procedure to check on the damage imposed on the fallentank. This, therefore, reflected on effective planning of Apollo 10mission unlike Appollo 13. According to CCPM, there is a need to haveregular reports on projects which will dictate the next course ofaction or consider other options. In Apollo 13, this was noteffectively handled. Despite the extensive evaluation of the secondtank which checked on the damage done on it, there was a need toprovide full reports on all procedures. During the testing procedure,it is indicated that one red flag was ignored. This was the slightdamage in the fill line. Although there was no external challengenoted, there was a need to run the tests repeatedly to ascertain ifthere was any issue. As indicated in the ground analysis above, therewas a challenge during one test where the liquid oxygen could not bepurged of completely. The damaged fill line made this impossible andit was decided that the tank be emptied by heating it and forcing theoxygen to boil off. The issue at this point is whether the managementteam was aware of this procedure and whether it was reported.

Accordingto CCPM, time is critical thus the reason to introduce the buffertime strategy which will ensure continuous flow and synchronizationwithin the set duration. At the same time, there is a need toaccommodate uncertainty which in this case was whether the tank wasfit to complete the mission. According to the test proceduresconducted, there was some violations of the set procedures whichincluded exceeding the power supply which resulted in temperaturesrising exceeding the required and that which would have been noted bythe internal thermometer. Although CCPM advocates for time as thebasis to take certain actions, there is a need also to considerurgency and uncertainty (Strtton &amp Knight, 2009). In this regard,instead of the overnight job done to empty the tank and conductingthe numerous test procedures, it would have been better to fit newtank which would have given ample time to conduct a more extensiveevaluation on the damaged tank. Besides, the Appollo 13 mission wouldhave been a success which would have reduced waste and ensure thesuccessful flow of activities, the main aim of CCPM.

Analyzingthe NSPE Code of Ethics

Inevery profession, there are codes of ethics that govern theiroperation. These codes are developed to mitigate possible issues andchallenges that could emanate from operations affiliated with them.Notably, violation of these codes could result in harmful effects notonly on the project but also to the individual. For engineers, thereare codes of ethics which are described under the National Society ofProfessional Engineers (NSPE, 2007). These codes of ethics are basedon the fact that engineers must express high standards of integrityand honesty. These two aspects are vital in ensuring the quality oflife of the individuals as well as the success of the project. Otheraspects observed by this code include fairness, safety, and equity.The NSPE is categorized into several clauses including Fundamentalcanons, rules of practice and professional obligations. It is certainthat there was a violation of NSPE code of ethics by variousstakeholders in the Apollo 13 mission. Although some of the practiceswere conducted to the best interest of time and profession of thedifferent individuals, there are several aspects that were notaccording to the required competence of these individuals.

Tobegin with, under the rules of practice, it is required that theengineer’s judgment is superseded by circumstances that could putproperty or life in danger. At such a point, this should be notifiedto the employer or client. Considering the mistakes done by thetesting team, this code was violated in several ways. First, uponfalling of the tank, and considering the type of mission beingconducted, the tank would have been more thoroughly evaluated on anydamages. Considering the professional obligations, some of the partsthat were violated included engineers being required to advice theemployer or client accordingly in case there was a possibility offailure in the success of the project. In this regard, it wasexpected that upon the realization that the second tank had thechallenge to purge off the liquid gas, it would have been advisableto either stop the mission or change the tank.

Inengineering, every little detail is critical. In this case, it wouldhave been anticipated that the small damage in the fill line wouldhave adverse effects. As a result, it was required that the missionbe delayed to ensure everything was in place or evaluate furtherwhere the challenge was emanating from. As a result, the damage wouldhave been rectified and another test conducted to ascertain whetherthe issue persisted. Competence in the engineer`s profession was alsochallenged which according to the rules of practice, it exposedpeople to danger. Considering the testing procedure challenge ofpurging of the liquid gas, the test team resolved to use other meansagainst the recommended procedure. Additionally, few aspects in theconnection were changed including the grounding source which was 65volt instead of 28 (Chen, 2014). This resulted in heating the tankstemperature to 1000 degrees Fahrenheit, yet the indicator only showed80. This, according to NASA report damaged the Teflon insulation ifthe internal wiring of the tank. At this point, I believe that ifeverything had been done according to the requirements and the rightprocedure, the accident would have been averted. To mitigate suchfuture challenges, there is need to ensure that all engineers followthe right procedures. I would also question the management for notrequesting a report on the damaged tank. If there was such a reportindicating the challenges during testing, then probably theresponsible individuals would have requested another tank like Apollo10.


Inproject management, averting the effects of a given challenge takes aholistic approach where everyone from the management to the workforceis involved. The impact of this is that a better intervention isdeveloped which is aimed at addressing the situation at that moment.However, it should be ensured that the developed strategies are inline with the professional ethics codes. CCPM principles also governthese interventions in several ways. These include working within thetime limit and ensuring that monitoring and evaluation of the donetasks and those that remain are conducted profoundly. Essential tonote is that there should be collaboration and effectivecommunication between the involved parties to develop bettersolutions. Regarding Apollo 13 case, external efforts included theground controllers whose main aim was not whether the team would landon the moon but coming back home safely (Chen, 2014). Both the pilotsand the ground controllers were working together to develop the bestsolution while the spacecraft looped around the moon. While thecontrollers turned off most of the Lunar Modules systems to minimizethe heat load to conserve water, the ground controllers conductedhundreds of simulations for the best solution.

Accordingto CCPM on the planning phase, there should be readily developedprocedures to address any concerns upon failure. In this regard, NASAhad ensured this by having several simulations which a problem as bigas Apollo 13 explosion would be addressed. In such a situation, theground controllers were tasked with making extremely hard choicesaimed at saving the crew. Changing the course meant aborting themission and developing ways in which the crew got home. This wasachieved through every individual working in their area of competencewhich is according to the NSPE code of ethics (NSPE, 2007). Thereturn to Earth course was now based on developing the necessarypropulsion maneuvers. This involved using the LM to support threecrew members instead of two as initially designed. Arriving at thisdecision entailed some procedures which were working within the settime. At the same time, the ground controllers got ready for the crewin several areas including Indian and Pacific Ocean.


Oneof the key requirements in every project is developing effectivestrategies that will ensure the goals and objectives are attained. Todo this, it is imperative to put into consideration accidents andother uncertain occurrences. While this is plausible, all proceduresin the project should be conducted within the set code of ethics thatgovern the professionals. Developing effective strategies is based oncommunication and interaction within the workforce. Consideringprojects such as engineering, there are several requirements whichaccording to NSPE, are based on integrity and honesty. Essential tonote is that violation of the code of ethics may result in adverseeffects involving loss of lives and money. Various theories andframeworks have been developed to explain effective projectmanagement such as CCPM which is based on ensuring continuous flowand synchronization of activities. Some of the principals involved inCCPM include effective planning, control, and monitoring. CCPMacknowledges effective project management is found on time anddeveloping interventions to avert possible challenges. In thisregard, the above discussion is based on Apollo 13 mission to themoon where an accident occurred as a result of negligence andincompetence during preparation. This included using a tank that hadchallenges which were not recognized earlier. The test crew, in thiscase, ignored some of the procedures being done according to therequirements while considering other actions that were costly to themission. If only the test crew had considered altering their actionsand use a new tank, the mission would have been a success. Despitethe misfortune, the situation was controlled which was attributed tocompetence in the crew and holistic approach to developing the bestsolution.


Chen,J. L. (2014). Apollo 13. In&nbspHowto Find the Apollo Landing Sites&nbsp(pp.71-82). Springer International Publishing.

Ghaffari,M., &amp Emsley, M. W. (2015). Current status and future potentialof the research on Critical Chain Project Management.&nbspSurveysin Operations Research and Management Science,&nbsp20(2),43-54.

LaViola,J., &amp Cleek, M. A. (2012). NASA’s Finest Hour: Decision Makingand Apollo 13.

NSPE(2007), Code of Ethics for Engineers (pp: 1 – 2).King StreetVirginia

Stratton,R., &amp Knight, A. (2009, June). Utilising buffer management tomanage patient flow. In&nbsp16thInternational Annual EurOMA Conference.