JF Mezei wrote on Sun, 28 Oct 2018
13:43:54 -0400:

On 2018-10-26 06:36, Jeff Findley wrote:

connecting pin on the top connection point. Instead of fixing the
issue, they used lubricant on it and forced the booster onto the launch
vehicle. If this proves to be the cause, it's looking like the Russian
"safety culture" is horribly flawed.


On the surface, one couldn't disagree with above. But digging deeper you
could find that this wasn't "safety culture" problem.


No, you cannot find that. Something like this would ALWAYS be a
safety culture problem, whether or not 'it always worked before'.


What if this "fix" had been done countless of times and worked
flawlessly and was thus considered safe?


That's not how you determine whether something is 'safe'; try it and
see if anything blows up.


Now that they have seen that it isn't, will they use statistics to say
"ok, we can continue as before, just be more careful", or would they
change the mechanics of assembly to ensure that pin can't get bent?


I doubt anyone but individual workers knows when or how often this
occurred, so they can't do 'statistics' on anything. Your other
possibility is probably not possible. So they'll do the third thing
that you never think of. They will absolutely prohibit the
'lubrication' procedure and if things don't fit you back up and start
over (with new hardware if necessary).


Or would they just issue guidelines on how bent the pin can get before
something must be done to rectify ?


Where the 'guideline' is 0% bent.


Ideally, the hardware that is used to mate the booster to the core would
ensure that the pins cannot get damaged/bent. (for instance, add laser
alignment or something similar to increase precision and not let it down
to some worker who had a few too many vodkas at lunch do the alignment
by eyesight)


No such thing and it ALWAYS eventually comes down to a human being.


This issue doesn't appear to be too different from the foam issue that
brought down Columbia: they knew of an issue but didn't think it would
cause problems.


I suspect this is nothing like the foam issue. For that engineering
and management were aware. I doubt anyone but the local assembly
worker knew anything about the "if it don't fit, force it" approach to
R-7 assembly.


Having said this, if this bent pin was common but hadn't caused problems
before, the "safety culture" should have resulted n changed practices or
improved mating hardware because they would have know that despite
being "acceptable", bending pins during mating shouldn't happen so they
should have found ways to mate without the risk of bending pins.


No. The initial "if it don't fit, force it" was a "Zen of Motorcycle
Repair culture" and I doubt anyone knew about it other than the local
assembler. A "safety culture" approach is "if it don't fit, back
everything up, inspect it all, then try to reassemble".


This si especially true considering the longevity fo the program and the
fact that they have been assembling these rockets for decades, so you'd
think that by now, they would have experienced problems and found ways
to prevent them from happening.


Yes, and we know that the lower level workers who are working out all
these 'work arounds' are poorly paid and treated and thus are unlikely
to report anything to the higher ups.


--
"Insisting on perfect safety is for people who don't have the balls to
live in the real world."
-- Mary Shafer, NASA Dryden