NEWS: Under-construction satellite topples to floor in mishap

Lift with the legs, boys, not the back.......


as to the bolt shortage, I would not be surprised to find there was a budget
issue and a shortage resulted. Maybe they weren't expecting to be working on
more than one bird at a time, so no need for two sets of bolts...

I'm curious now about the other bird that needed bolts, what was THAT one...
defense or recon oriented, perhaps?

"stmx3" wrote in message
...
Ralph Nesbitt wrote:
[snip]
Usually NASA has a detailed written "Job Scenario" detailing each step
of
what/when/where/how a given operation is to be accomplished. Odds are
checking for the "Bolts" that were missing is/was not part of the
detailed
"Job Scenario" for the "Incident Operation". Wonder where the
"Quality/Inspector Types" were, to say nothing of "Safety Oversight"?
Ralph Nesbitt


I'm fairly certain there was a procedure with a MIP step to verify the
pins were
in place. The QA stamp probably occurred the day before the accident.
Somewhere in the night, the pins were removed (lack of communications
between the 2 separate ops requiring pins). Safety was probably
required to sign off on the procedure but didn't have to be present.

The problem was
1) PINS were removed by another crew (w/o procedure, apparently)
2) The original crew did not reverify their setup when
they arrived in the morning.

The fix will be
1) Safety standdown
2) Training on effective communications
3) Training on following procedures and reverifying lineups
4) Reprimand, possibly firing, of a few individuals, including the
unwitting QA individual
5) Facility wide review of all load lifting operations
6) Review of Lessons learned following investigation

Did I miss anything?

-stmx3

Summed up nicely IMHO.
Ralph Nesbitt

(Rusty B) wrote in message . com...

Excerpt from the Columbia Orbiter CAIB accident report:


"Kennedy Quality Assurance management has recently focused its efforts
on implementing the International Organization for Standardization
(ISO) 9000/9001, a process-driven program originally intended for
manufacturing plants. Board observations and interviews underscore
areas where Kennedy has diverged from its Apollo-era reputation of
setting the standard for quality. With the implementation of
International Standardization, it could devolve further. While ISO
9000/ 9001 expresses strong principles, they are more applicable to
manufacturing and repetitive-procedure industries, such as running a
major airline, than to a research-and-development, non-operational
flight test environment like that of the Space Shuttle. NASA
technicians may perform a specific procedure only three or four times
a year, in contrast with their airline counterparts, who perform
procedures dozens of times each week. In NASA's own words regarding
standardization, "ISO 9001 is not a management panacea, and is never a
replacement for management taking responsibility for sound decision
making." Indeed, many perceive International Standardization as
emphasizing process over product."

Al Jackson wrote:
Indeed, many perceive International Standardization as
emphasizing process over product."

What do you mean, "perceive"? It's explicitly and unequivocally
(and unapologetically) about process. That's one reason it's so moronic
to apply it to the space biz - no matter what anyone might claim, space
is about semi- to totally- custom design work. Maybe the only space
project I know about that really wasn't that way was Iridium, where
there was indeed a legitimate production line that could reasonably be
treated with nearly standard industrial process controls.

Brett

In article ,
stmx3 wrote:
The fix will be
1) Safety standdown
2) Training on effective communications
3) Training on following procedures and reverifying lineups
4) Reprimand, possibly firing, of a few individuals, including the
unwitting QA individual
5) Facility wide review of all load lifting operations
6) Review of Lessons learned following investigation

Sounds about right. The one thing missing will be any fundamental
changes. This accident won't recur, because people will be alert for it.
The next boneheaded slip-up will be something different.
--
MOST launched 1015 EDT 30 June, separated 1046, | Henry Spencer
first ground-station pass 1651, all nominal! |

(Henry Spencer) wrote:

In article ,
stmx3 wrote:
The fix will be
1) Safety standdown
2) Training on effective communications
3) Training on following procedures and reverifying lineups
4) Reprimand, possibly firing, of a few individuals, including the
unwitting QA individual
5) Facility wide review of all load lifting operations
6) Review of Lessons learned following investigation

Sounds about right. The one thing missing will be any fundamental
changes.

Like what for example?

This accident won't recur, because people will be alert for it.
The next boneheaded slip-up will be something different.

There will never be freedom from bone-headed slips.

D.
--
The STS-107 Columbia Loss FAQ can be found
at the following URLs:

Text-Only Version:
http://www.io.com/~o_m/columbia_loss_faq.html

Enhanced HTML Version:
http://www.io.com/~o_m/columbia_loss_faq_x.html

Corrections, comments, and additions should be
e-mailed to , as well as posted to
sci.space.history and sci.space.shuttle for
discussion.

Brett Buck wrote in message ...
Al Jackson wrote:
Indeed, many perceive International Standardization as
emphasizing process over product."

What do you mean, "perceive"? It's explicitly and unequivocally
(and unapologetically) about process. That's one reason it's so moronic
to apply it to the space biz - no matter what anyone might claim, space
is about semi- to totally- custom design work. Maybe the only space
project I know about that really wasn't that way was Iridium, where
there was indeed a legitimate production line that could reasonably be
treated with nearly standard industrial process controls.

Brett

That was not me, that was the CAIB report.

jeff findley wrote:

(Henry Spencer) writes:
Modern practice is to admit that people will always make mistakes, and to
pursue *engineering* methods of eliminating accidents -- reorganizing the
hardware or the procedures to prevent mistakes or reliably (mechanically)
detect them. Eliminating whole classes of problems is far more effective
than exhorting people to make fewer mistakes. If people are making
mistakes in some operation, that means the operation is error-prone, and
*it* (not the people) needs fixing.

Examples of this type of thinking are abundant in automotive design.
If people make the mistake of throwing the car in reverse with their
foot off the brake, install a safety interlock to prevent the shifter
from moving out of "Park" unless the brake is depressed. If people
try to start their manual transmission equipped car with their foot
off the clutch and the car in gear, install a safety interlock that
prevents the starter from cranking unless the clutch is completely
depressed. If people don't always remember to "pump the brakes" when
they lock up, install an ABS system to do it for them. If people
don't remember to pump the gas once to set the choke on a cold start,
install a computer controlled fuel injected system. ;-)

Which results in an ever more complex system with additional failure
modes and problems of their own.

D.
--
The STS-107 Columbia Loss FAQ can be found
at the following URLs:

Text-Only Version:
http://www.io.com/~o_m/columbia_loss_faq.html

Enhanced HTML Version:
http://www.io.com/~o_m/columbia_loss_faq_x.html

Corrections, comments, and additions should be
e-mailed to , as well as posted to
sci.space.history and sci.space.shuttle for
discussion.

(Derek Lyons) writes:

Examples of this type of thinking are abundant in automotive design.
If people make the mistake of throwing the car in reverse with their
foot off the brake, install a safety interlock to prevent the shifter
from moving out of "Park" unless the brake is depressed. If people
try to start their manual transmission equipped car with their foot
off the clutch and the car in gear, install a safety interlock that
prevents the starter from cranking unless the clutch is completely
depressed. If people don't always remember to "pump the brakes" when
they lock up, install an ABS system to do it for them. If people
don't remember to pump the gas once to set the choke on a cold start,
install a computer controlled fuel injected system. ;-)

Which results in an ever more complex system with additional failure
modes and problems of their own.

This is a moot comparison from the start. In automotive design most of
these "security" thingies just don't work. Cars with ABS have more and
harder crashes than those without (this is statistically true at least
for some countries in Europe, I don't know for the US). Not because they
don't work but because the drivers rely on them to work even when this
does not help at all.

Some people think the best safety regulation for cars would be to
disallow all safety equipment except a spike protuding from the stearing
wheel and pointing directly at the drivers chest.

In space crafts the best safety regulation might be to allow only manned
crafts and let those who will fly the thing also build it. Impractical,
sadly.



Jochem

--
"A designer knows he has arrived at perfection not when there is no
longer anything to add, but when there is no longer anything to take
away." - Antoine de Saint-Exupery

Derek Lyons wrote:
[...]. If people don't always remember to "pump the brakes" when
they lock up, install an ABS system to do it for them. If people
don't remember to pump the gas once to set the choke on a cold start,
install a computer controlled fuel injected system. ;-)

Which results in an ever more complex system with additional failure
modes and problems of their own.

While naively true, the actual evidence is that properly designed
ABS systems and computer controlled fuel injection systems have
many fewer failures per operating hour or vehicle than older mechanisms
tended to. It's like fly-by-wire in aviation; as implimented,
the rate of control system failure crashes in aviation dropped by
roughly a factor of 3 after FBW was introduced.

I have nothing against well designed mechanical systems,
but if the statistics tell you the newfangled things need
less maintenance and break less often and kill fewer people...


-george william herbert