The NASA Mishap Board investigating damage to the NOAA-N-Prime
satellite has released its final report.
On September 6, 2003, the National Oceanic and Atmospheric
Administration (NOAA) N-Prime satellite fell to the Lockheed Martin
Space Systems Company factory floor in Sunnyvale, Calif. Technicians
were working on the spacecraft, when the accident happened. The
spacecraft suffered significant damage.
The Board, chaired by the NASA Deputy Associate Administrator of the
Science Mission Directorate, had representatives from NASA research
centers and the Air Force Space Command, as well as advisors from NOAA
and the Federal Aviation Administration.
To view the redacted report on the Internet, visit:
http://www.nasa.gov/pdf/65776main_noaa_np_mishap.pdf
NOAA N-PRIME Mishap Investigation Final Report
September 13, 2004
Download full report (3 MB PDF)
Excerpt
Proximate Cause: The NOAA N-PRIME satellite fell because the LMSSC operations team failed to follow procedures to properly configure the TOC, such that the 24 bolts that were needed to secure the TOC adapter plate to the TOC were not installed.
The root causes are summarized below along the four levels of active or latent failures as ascribed by the HFACS framework.
– The TOC adapter plate was not secured to the TOC because the LMSSC operations team failed to execute their satellite handling procedures.
– The LMSSC operations team’s lack of discipline in following procedures evolved from complacent attitudes toward routine spacecraft handling, poor communication and coordination among operations team, and poorly written or modified procedures.
– The preconditions within integration and test (I&T) operations described above existed because of unsafe supervision practices within the LMSSC project organization, including ad hoc planning of operations, inadequate oversight, failure to correct known problems, and supervisory violations.
– The unsafe supervision practices within the TIROS program had their roots in the LMSSC organization: the inadequate resources and emphasis provided for safety and quality assurance functions; the unhealthy mix of a dynamic I&T climate with a well-established program and routine operations; and the lack of standard, effective process guidelines and safeguards for operations all negatively influenced the project team and activities.
– The in-plant government representation, Defense Contract Management Agency (DCMA), and the GSFC Quality Assurance (QA)/safety function failed to provide adequate oversight to identify and correct deficiencies in LMSSC operational processes, and thus failed to address or prevent the conditions that allowed the mishap to occur.
– The Government’s inability to identify and correct deficiencies in the TIROS operations and LMSSC oversight processes were due to inadequate resource management, an unhealthy organizational climate, and the lack of effective oversight processes.
