A bad day at work. The NOAA 19 satellite drop.

[EEVblog]

For want of a bolt......

Not just one bolt, but all of them!
That jig has only two operations, to rotate and tilt the satellite for working on. The only thing that holds it down is 24 bolts.
How on earth do you press a button to tilt a $220M satellite without multiple people checking it's bolted in place?
And not just checking, but probably being paranoid about having all 24 in place and torqued correctly etc.

[rolycat]

Rules are made for the guidance of the wise and the blind obedience of fools.

Sir Douglas Bader.

I've met a lot of people that think they are in the "wise" category but aren't.

Problem is we are all fools at one time or another.

[John Coloccia]

For want of a bolt......

Not just one bolt, but all of them!
That jig has only two operations, to rotate and tilt the satellite for working on. The only thing that holds it down is 24 bolts.
How on earth do you press a button to tilt a $220M satellite without multiple people checking it's bolted in place?
And not just checking, but probably being paranoid about having all 24 in place and torqued correctly etc.

Because of where I worked at the time, this incident made the rounds almost instantly and somehow I ended up with grainy, photocopied pictures of it.  I also heard a good deal about how the incident occurred, right after it occurred.  I don't know what the report says, but I remember reading and hearing an awful lot of BS in the months following.  It's been a while, but my fuzzy recollection is that the accident was as simple as dope #1 "borrowing" the bolts for another project, and dope #2 not checking that the thing was actually bolted down.  I guess it HAD been bolted down at one point.  That's what I remember about it, anyway.

I have to say that in my career, I've been involved with a number of expensive accidents like this (not this particular one, but ones like it).  The thing that the final reports never seem to address is WHY so many things could go wrong...how does the environment get to that point.  I'll tell you a story how:

I remember one incident, and I won't get into details, but there was some big thing that moved, and any time it was powered up and could potentially move there was a guy holding "the pickle"...essentially an E-STOP.  Any time motion was expected, someone would clearly indicate that, and the guys running the software had supposedly tight coordination with the guy manning the pickle.  Well, things being what they are we fall behind schedule...shit, what am I saying...we were always behind schedule.  We were falling DANGEROUSLY behind schedule on just about everything, and there was tremendous pressure to produce produce produce.  Also, someone decided, "Well, I'll show these assholes...they'd better get on the ball and do everything right, and incidentally, anytime someone E-STOPS this thing, we're going to have a big meeting, and a root cause analysis, and someone's going to answer for what happened and why!!".

That'll show'em, right?  See where this is going?  One day, they're running a test, and NO motion was supposed to occur.  Things start moving...."Uhm, are we expecting motion?"     AHHHHH!!!  "NO NO NO!!!!!!!".  Oh well, too late.  Pickle man hesitated because he knew his ass would be on the hot seat if he made a boo boo.  End result?  Some damage to a very expensive piece of equipment.

Investigative finding?  The software was at fault.  It did not adequately warn the operator that running the command could potentially make something move that wasn't in the right configuration to move.  Solution?  Put a warning on any command that could potentially cause damage.  That goes down to the lead engineer for that part of the project.  He asks for the list of commands that they feel could damage the system.  No one can decide on which commands can cause damage, so they put it on the software lead's shoulders to figure out every possible interaction on this tremendously huge and complex system being built by multiple vendors and multiple teams.

HIS solution?  Well, he's not putting HIS ass on the line, so he makes EVERY command in the system pop up this message...some nonsense like, "Grave Damage May Occur!!!!".  Not exactly that, but close.  End result?  Well, it conditioned everyone to completely IGNORE that message because it was absolutely meaningless.

But lost somewhere in the mix was the real root cause:  CRAPPY management punishing their employees just for doing their job the best they could, and employees making the very rationale decision that it's better to avoid getting in trouble than actually doing their job.  THAT part never seems to make it into any of the fish bones or final reports.

[vk6zgo]

Back in the very late '80s,TVW7 moved the Studio Earth Station from over the road to the Station
property,& did an excellent job of it.
A huge crane lifted the dish off the pedestal assembly & gently placed it out of harm's way,then picked up the (huge) pedestal assy & set it down on a pre-prepared concrete base.

No disasters,no nothing,but there were a couple of guys from the original manufacturer who came over to help out.
They told an interesting story of how in an anonymous city in the USA,they had been approached about moving the hut containing the Earth Station Electronics (Uplink Tx ,Downlink Rx.etc)  from one side of a bulding roof to another.

The inquirer ,on seeing the quote,decided they could do it themselves much cheaper.

On the day,all went well,until the Uplink Tx PA,which was mounted on rollers in its cabinet came flying out of the hut door & went crashing to the pavement,many floors below.
Luckily,no one was injured,but it all cost a lot more than the original quote,by the time all the lawyers were finished with it.

As it is all hearsay,I don't know any other details.