JF Mezei wrote on Sun, 28 Oct 2018
16:31:01 -0400:

On 2018-10-28 15:13, Fred J. McCall wrote:

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).

How do you know that lubrication wasn't permitted by the higher ups as
standard practice?

How do you know that a certain amount of bending wasn't considered
tolerable?


How do you know that it was? My answer is much more likely than yours
given the culture of the organization, but you go ahead and engage in
all the bootless speculation you care to. Just don't be surprised
when you get no answers or are told you're full of ****.


Where the 'guideline' is 0% bent.

Your perfectionist guideline.


God, I hope you never wind up in a safety critical job!


The actual guideline may have been
different, allowing a certain play as long as merely applying lubricant
was enough.


Yes, and monkeys might fly out your butt.


And if that guideline has worked for a long time, it
becaomes established as safe. This incident will obviously cause them to
rethink this.

ex-post safety instead of ex-ante safety.


And how do you decide it's 'safe' the first time you do it? Or the
second? How many times do you need to bend parts of the rocket before
you decide it's 'safe' and how the **** did you get to that point?


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

But which human being? If the mating people were told a certain bend is
normal, then they accept vehicles with a certain bend and mate them and
launch them. The real problem might be with the design of the cradle
that is use to hold the equipment during transport or even during
manufacturing. Going back to the source is important.

And if the equipment the mating peopole use is inadequate and causes the
bending, then that equipment need to be improved to prevent the problem.
How do you know that the employees haven't been complaining for years
but uppoer management unwilling to soend the money on new mating
equipment to perfectly align the 2 items to avoid the problem ?


I know because complaining by low level workers just isn't part of the
culture. Why do you think the guy who drilled the hole in the Soyuz
spacecraft didn't report it?


If management has been told this has been a long standing problem and
need X$ to fix, but this never actually caused a crash, then prioority
to fix it is less. Now, that priority has just gone up because they
know it causes a problem.


And the way you 'fix it' is to direct that they must NEVER BEND THE
ROCKET PARTS.


NASA allowed faulty foam on the ET until it caused a problem. So the
Russians aren't the only ones whose safety practices aren't perfect.
The difference is that with each accident, NASA improved their quality
assurance significantly, whereas for the Russians, it appears to be on a
downward curve.


No, they're nothing alike.


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.


How do you know that the folks assembling it don't often receive the
equipment with pin already bent and have been told this is normal, just
add lubricant? In such a scenario, the quality assurance problem isn't
located there, it's located elsewhere.


How would the pin get bent?


yes, in hindsight, it is a problem. But if bent pins were common in the
past and lubricant fixed the problem every time, can you really blame
the folks doing the mating ?


These things don't bend themselves, you know.


You seem to draw conclusions too early to assign fault.


You seem to flap your arms and squawk and think you are flying.


IF the specs allow a bend of x degrees that can be fixed with lubricant,
then you can't blame the crews for doubting the specs. Go back to
whoever drew the specs to accept such bends. If those specs never caused
a problem in the past, they would become accepted practice with everyone
thinking they are safe.


And perhaps the whole thing was caused by a unicorn ****ting magic
pixie dust on the pin.


NASA engineers didn't think the foam from the ET could cause problems
and didn't prioritize its fixing until an accident happened.


You know that foam shedding was never 'fixed', right?


Once they conclude that bent pins are unacceptable (which is likely
happening now) then it becomes easier to document this such athat if the
mating people receive equipment with pins already bent, they can signal
this up the chain. (think about a pin being bent during transport where
railway workers aren't trained to detect bent pins, so it isn't really
their fault, but if transport causes it, then the cradle holding the
parts might need an upgrade).


You're an idiot. Perhaps the pin was bent by a bunch of monkeys
flying out of your butt?


A top-down safety culture would spread to all parts. But if the specs
accepted a certain amount of bending, then the safety culture wouldn't
stop this because it is part of the specs.


If monkeys flew out your butt your asshole would be THIS big.


So while you quickly reach conclusions, I don't because I see many ways
in which this problem can occur.


That's because you're an ignorant git.


No. The initial "if it don't fit, force it"

Applying lubricant isn't "forcing it".


You're an idiot. If it's going to slide on without forcing it you
wouldn't need to lubricate it.


Your attitude is not constructiuve because you seek to assign blame
(lack of safety culture) instead of trying to find out why this happened.


You're an idiot.


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.

Drilling a hole in the wrong place in the capsule is a clear error by
the worker and it is very unlikely that the specs call for a worker who
drills a hole in the wrong place to just plug it with chewing gum.


And yet he didn't report it when it happened. THAT tells you what the
culture among lower level workers is like and puts paid to all your
arm waving and squawking.


But what if the specs document how to handle a hole drilled in wrong
place and document how to plug the whole with what compound and it was
those specs that were faulty since evidently that coumpound didn't hold ?


I'm pretty sure the specs say not to drill holes in random locations.
Then you don't need to plug them up.


The fact that you and I know about a hole having been drilled in wrong
place on a Soyuz seems to point to it having been documented at some
point.


It was 'documented' by going back and interrogating the workers.


What if "how to handle a leak/hole" was documented in the safety
procedures and the staff performed te procedure as documented and used
the documented compound to plug the hole ?


What if the hole was made by a monkey that flew out your butt?


It may simply turn out that years before some engineer didn't test that
compound well enough and now we know it doesn't last the 6 month mission
in space. The falt would not be on the worker if he followed procedure
properly.


It may simply turn out that a magic unicorn gored the spacecraft.


(We can however study the workflow and masks used that resulted in him
drilling in the wrong place to begin with).


It is very easy to just blame lax quality assurance with Russians, and
"big picture" this is what transpires. But when you dig deeper, you may
find a different story, especially if each faulure points to procedures
that were followed and it was the procedures that were wrong.


Yes, it IS very easy to blame lax quality assurance and a poor safety
culture BECAUSE THAT IS THE ROOT CAUSE.


I don't claim to know whether handling of a bend pin with liubrican is
documented as a procedure or whether it was pure initiative of the
workers on that day. I don't claim to know whether this was common or if
this was first time it happened.

But neither can you.


Flap ... flap ... flap ...


--
"Ignorance is preferable to error, and he is less remote from the
truth who believes nothing than he who believes what is wrong."
-- Thomas Jefferson