- The lack of standing orders from the commanding officer of the Death Star. Despite the importance of clear, unambiguous orders to proper mission safety, when the commanding officer entered the field in a personal fighter craft, he did not leave any standing orders to protect the vulnerable trenches of the Death Star. This may have contributed to the inadequate defense of the trenches which ultimately allowed rebel forces to fire upon an exposed exhaust vent. The CSB recommends that the Imperial Star Fleet amend operating procedures to require commanding officers to give clear standing orders identifying priority objectives before personally engaging enemy forces.
- The absence of defensive screens, grills, or other protective shielding around the reactor exhaust port. Despite being critical to the proper functioning of the reactor, the absence of protective shielding allowed a missile to enter into the exhaust port. The CSB urgently recommends that all stations and vessels be retrofitted so that all critical exhaust ports have adequate shielding to prevent any hazardous objects from entering the port.
- The absence of any automated detection systems within the exhaust vent itself. Without an automated detection system, workers remained unaware that there was an obstruction within the exhaust vent until it was too late. While not directly contributing to the disaster, a system to automatically detect and warn workers of an obstruction within the exhaust vent could prevent similar disasters caused by catastrophic failure of the reactor thermal regulation systems. The CSB recommends that automated detection systems be installed in all thermal exhaust vents to alert workers in the event of an obstruction.
- Finally, the absence of blast shielding in the reaction chamber. The reactor is the most critical part of any orbital weapons platform, and it is also the most vulnerable to enemy fire. Retractable emergency blast shielding may have prevented the missile from colliding with the reactor, causing the catastrophic meltdown that ultimately took the lives of every crewman on board. The CSB recommends that retractable emergency blast shielding be required in thermal exhaust vents for all reactors to prevent enemy fire or other hazardous objects from damaging the reactor. The CSB further recommends that this shielding be designed to deploy automatically should the thermal exhaust vent detection system described earlier detect an obstruction in the vent which could indicate a hazardous object.
While combat is always a hazardous environment, with properly functioning safety features on critical equipment the unnecessary loss of life of Imperial soldiers can be prevented. Critical safety features and safe operating procedures are an essential part of the Galactic Empire's mission to bring Peace, Order, and Stability to the Galaxy.
