SYSTEMIC FAILURE IN THE VLS-1 LAUNCH ACCIDENT: A CAST PERSPECTIVE

This study applied the Causal Analysis based on System Theory (CAST) methodology to investigate the systemic causes of the 2003 VLS-1 rocket launch pad accident in Brazil. Following the five CAST steps, the analysis models the hierarchical safety control structure, formulates six explicit safety constraints, identifies four unsafe control actions with documentary evidence mapping, and grades each finding by confidence level (High/Medium) based on multi-source triangulation. The findings demonstrate that the tragedy resulted not from a single failure but from a cascade of systemic control flaws distributed across institutional, organizational, and technical layers that reinforce the utility of systems-theoretic methods, such as CAST, in complex environments, including space operations. CAST offers both explanatory and prescriptive value for improving safety culture and resilience in emerging space programs.

Keywords: CAST, space operations, rocket accidents, systems theory, complex systems.