Posted on 09/19/2003 2:23:21 PM PDT by beckett
Earth Science Missions Anomaly Report: GOES/POES Program/POES Project: 6 Sep 2003
EARTH SCIENCE MISSIONS ANOMALY REPORT
TO: GSFC: 100/A. Diaz, 100/W. Townsend, 100/ 400/D Perkins, NASA HQ: Y/G. Asrar, Y/M. Luther, Q/B OConnor
FROM: GSFC/POES Project/480/K. Halterman
DATE: September 6, 2003
PROGRAM/PROJECT: GOES/POES Program/POES Project
DATE OF ANOMALY: September 6, 2003
LOCATION OF ANOMALY: Lockheed Martin, Sunnyvale CA
DESCRIPTION OF EVENT:
As the NOAA-N Prime spacecraft was being repositioned from vertical to horizontal on the "turn over cart" at approximately 7:15 PDT today, it slipped off the fixture, causing severe damage. (See attached photo). The 18' long spacecraft was about 3' off the ground when it fell.
The mishap was caused because 24 bolts were missing from a fixture in the turn over cart. Two errors occurred. First, technicians from another satellite program that uses the same type of turn over cart removed the 24 bolts from the NOAA cart on September 4 without proper documentation. Second, the NOAA team working today failed to follow the procedure to verify the configuration of the NOAA turn over cart since they had used it a few days earlier.
IMPACT ON PROGRAM/PROJECT AND SCHEDULE:
The shock and vibration of the fall undoubtedly caused tremendous damage. Significant rework and retest will be required. NOAA-N Prime is planned for launch in 2008.
CORRECTIVE ACTION:
Lockheed Martin formed an Accident Review Team in which GSFC is participating. The immediate actions concern safety (preventing the spacecraft from rolling, discharging the batteries, and depressurizing the propulsion system). NOAA-N Prime is under guard, all records have been impounded, and the personnel interviewed. After the safety issues are addressed, attention will focus on assessing the damage to NOAA-N Prime.
But it was so difficult to change them, that everybody just winked at each other and did what needed to be done. If you complained about the procedure, you were labeled a troublemaker. This ISO 9000 crap has only compounded the problem.
It was the same in the nuclear power industry - even worse.
When I was in the Activation group at KSC working on MLP-3, I was responsible for all the T-0 cables. The LES Cable Shop was overwhelmed, and so we had to contract out the fabrication to Olsen Electric out of Daytona Beach.
So we gave Olsen the official specifications which were (allegedly) used to fabricate the cables. It turned out that these were twenty years out of date, and the LES Cable Shop did it their own way. They had their own QC who would sign off on the work even though it was contrary to the specifications. It wasn't wrong, technically, it just wasn't per written specifications.
But Olsen had no such leeway - they HAD to use the official procedure if they wanted to get paid. So I had to go back and try and change all the Apollo cable specs and bring them up to the way it was really supposed to be done in the 90's. What a treat it was getting all the NASA DE weenies to put their signatures on the change.
It will be interesting to hear the results of this investigation, if we ever do.
I know that good people are not treated well in today's space program where diversity and sycophancy rules.
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