Satellite Tip-Over Mishap Due to Missing Bolts
cradle writes "On September 6th, the $239 Million Dollar NOAA N-Prime Satellite toppled over and crashed to the floor of Lockheed Martin Space Systems' factory in Sunnyvale, CA, as it was being repositioned to replace an instrument. Today NASA released their report on the cause of the accident. It seems somebody forgot to check whether it was bolted down: '... during an operation that required repositioning (rotating) the
TIROS NOAA N-PRIME spacecraft from a vertical to a horizontal position, the spacecraft
slipped from the Turn-Over Cart (TOC) and fell to the floor. The spacecraft fell because the
TIROS adapter plate to which it was mounted was not bolted to the TOC adapter plate with the
required 24 bolts. The bolts were removed from the TOC by another project while the cart was
in a common staging area, an activity which was not communicated to the NOAA project team.'"
"I didn't feel like it."
And, another Simpsons quote:
"Haw-haw!"
What happened is easy: the bolts weren't put in. Why took some looking into: People were sloppy in following procedures.
Yeah that sucks but these things happen. Whether you're working on a 100K toy or a $300 million dollar one, every once and awhile there's going to be a mishap. Still, it sounds like there's a management problem here if people are going around removing bolts and the project team isn't even aware of it. If there's literally so few nuts and bolts handy for the various projects going on that they feel the need to cannabalize other projects, that's a disaster waiting to happen. I hope my neighbour doesn't decide to remove my brakes without letting me know.
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Science -- Sealed, Delivered.
If I was "repositioning" a $239,000,000.00 piece of hardware, I would visually check the bolts before starting the rotation. I would also check every other piece of safety equipment... twice. If the bolts were there, I would probably check the torque on them, if I hadn't tightened them myself.
Jeeeez, people, this isn't rocket science. Well actually it is rocket science, but that's the difference between rocket science and stuff that blows up on the pad.
Some mornings it's hardly worth chewing through the restraints to get out of bed.
I agree with you, but good process doesn't bore me at all. But I know I'm the exception. The truth is Managagment just wants to get the job done with the least resources, so they pressure the techs with increasing workload and tend to look the other way when people cut corners to get the job done. Techs know they are supposed to do process 100%, but they don't want to be the guy who takes twice as long to do stuff because of following procss. So whenever I see major screw ups like this, I blame management and ops equally.
Engineers, BTW, write processes but never follow their own process. Thus, they leave messes for the techs to sort out.