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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.'"

21 of 76 comments (clear)

  1. I bet that wise guy is bolting now by Johnny+Doughnuts · · Score: 4, Funny

    I bet the wise guy who decided to do that is 'bolting' right now. ;D

  2. So... what they said originally? by CheshireCatCO · · Score: 4, Interesting

    That's exactly what they said had happened right after the accident. A detailed study of the cause is always in order, but I'm surprised that it took a year to verify what they apparently knew at that outset.

    1. Re:So... what they said originally? by JVert · · Score: 4, Funny

      http://images.spaceref.com/news/2003/9.6.2003_01.l rg.jpg
      This time we are pretty sure it was the guy on the left. What do you think he's got behind his back?

    2. Re:So... what they said originally? by CheshireCatCO · · Score: 4, Funny

      I keep expecting to see little ruby slippers sticking out from under the spacecraft, but I have a weird mind.

    3. Re:So... what they said originally? by CheshireCatCO · · Score: 2, Informative

      Ah, here's the origins forwarded message I got 13 months ago just after the mishap. I knew I had a copy somewhere.

      ------------- Begin Forwarded Message-------------

      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 O?Connor
      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.

      ------------- End Forwarded Message -------------

    4. Re:So... what they said originally? by Gogo+Dodo · · Score: 2, Insightful
      The Mishap Investigation Board doesn't just figure out what happened, but why it happened and also writes recommendations on what to do about the problems they find.

      What happened is easy: the bolts weren't put in. Why took some looking into: People were sloppy in following procedures.

  3. I'm sorry. by JVert · · Score: 3, Funny

    I can't be expected to show up for school every day. So I get the flu and miss one day.

    Who knew "Lug nut day" would be soo important?

  4. (Expletive here) happerns! by going_the_2Rpi_way · · Score: 3, Insightful

    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.

    1. Re:(Expletive here) happerns! by Ayaress · · Score: 2, Insightful

      If this was something like a burned out computer, a bolt shearing off, or the machine it was supposed to be bolted to failing and dumping the satellite on the ground, I'd agree with you. There are some things that just happen, even though every reasonable analysis says they won't.

      However, there are still some things that shouldn't go wrong, ever, and there's not an excuse for it after the fact. This is one of them. You don't pull parts off something that's supposed to work without replacing them. This is almost akin to a mechanic servicing your engine and having "extra" parts left over when he closes the hood again. They were there for a reason, and they need to go back on before you finish whatever you're doing.

  5. Re:A year? by torpor · · Score: 2

    Its a multi-million dollar project.

    Of course they're going to take their time to publish the full results of the mis-hap. Since its millions of dollars of tax-payer money, the report must be complete, accurate, and fully account for the entire mis-hap.

    Would you want to have to do such a report in a day? A week? I think a year is fine for this sort of event; assuming, of course, that in the meantime repair work was being done ... anyone know what sort of repair is required, and what state the project is now in, a year later?

    --
    ; -- the corruption of government starts with its secrets. a truly free people keep no secrets. --
  6. Personally... by Kozar_The_Malignant · · Score: 4, Insightful

    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.
    1. Re:Personally... by boredMDer · · Score: 4, Interesting

      You say that now, but once you start working with that type of equipment every day, you get lazy.

      They had used the TOC a few days prior, and there was no documentation that the bolts had been removed, so they assumed that it was fine. If some that other project team hadn't forgotten the documentation this wouldnt've happened.

    2. Re:Personally... by BurritoJ · · Score: 2, Insightful

      So, do you visually check the lug nuts on your car everyday before you drive off? How about after leaving it unattended in an airport parking lot for a couple of days? No? Well, that's the difference between being a driver and being an oozing pile of red goo on the highway...

      I think the transition for sentient being to red goo is much more motivating than the loss of a few dollars in hardware. That's just me though... YMMV

    3. Re:Personally... by Kozar_The_Malignant · · Score: 2, Insightful

      >You say that now, but once you start working with that type of equipment every day, you get lazy.

      Familiar -> Complacent -> Lazy -> Dead

      >They had used the TOC a few days prior, and there was no documentation that the bolts had been removed, so they assumed that it was fine. If some that other project team hadn't forgotten the documentation this wouldnt've happened.

      [Fred] OK Bob, let's run through the checklist and fire this 747 up.

      [Bob] Don't bother with the checklist. Some guys flew it back from Tokyo a couple of days ago. Everything should still work, and I don't see any trouble tickets. They probably fueled it up, too.
      --
      Some mornings it's hardly worth chewing through the restraints to get out of bed.
    4. Re:Personally... by JVert · · Score: 2, Interesting

      At first I thought it was the CV joint but this car has like 30k miles! The car had a definate knock when we made a turn and had a slower knock as we drove straight. We looked under for any damage and everything look ok. While calling for a tow truck I stared at the car in disgust and noticed a few lug nuts missing... Curious I reached down and unscrewed another one with my fingers. Then I renember I did brakes a month ago... I thanked the operater for their time and said we wouldn't be needing any more help.

      The wife doesn't let me do brakes alone now.

      But no, I look out for tire pressure more then nuts. But thats another story...

    5. Re:Personally... by zcat_NZ · · Score: 2, Insightful

      Well yeah, but I also don't expect the guy in the next parking space to 'borrow' the lug nuts for any reason and I sure as hell hope that if he did, he'd leave a note on the windshield so I know about it before I drive away!

      --
      455fe10422ca29c4933f95052b792ab2
  7. What mama learnt ya... by Picass0 · · Score: 4, Funny

    You're inside or outside. Stop running through the door. We're not trying to air condition the whole street.

    Rinse off your dishes when you're done eating.

    Don't sass back to your teacher.

    Brush your teeth before bed.

    Put things back where you found them.

    JUMPIN' JESUS, PUT THE FUCKING BOLTS BACK IN THE 230 MILLION DOLLAR SATELLITE!!!

  8. Ouch by Pinkoir · · Score: 5, Interesting

    As somebody who has personally watched stuff fall off of test tables as they rotate to vertical I can definitively say that that the sinking feeling in your stomache as the equipment slowly topples off the stand is exceeded only by the sinking feeling in your bowels when it shatters on the ground.

    I can only imagine the multiplicative factor involved when it's a $240M satellite instead of a $20K prototype.

    As for why they took a year to report out on the cause...the thing cost 240 million frickin' dollars! I'm sure the managers wanted more of an answer as to why it's in pieces on the ground than "Uh...we dropped it". Maybe they wanted to know "why it was dropped" and "how it was dropped" and "what is the likelyhood that a thing will be dropped again" and "where does that tech who dropped it live?"

    -Pinkoir

  9. Re:Wow!!! by TykeClone · · Score: 2, Informative

    Not breaking a quarter billion dollar piece of equipment make your day?

    --
    A fine is a tax you pay for doing wrong and a tax is a fine you pay for doing all right.
  10. Re:Summary article by Euler · · Score: 2, Insightful

    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.

  11. It's about organizational problems by cradle · · Score: 2, Informative

    The report covers much more than just the proximate cause of the accident. It focuses on the organizational and procedural failures that led to a situation where nobody checked the bolts. Whoever posted this story should have mentioned, that, too.