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

[Homer J Simpson]

This happened back in 2004 but it is interesting if you have not heard about it before.

Basically the accident happened because the bolts to the adaptor used to rotate the satellite were left out and know one noticed.

Satellite cost was $220 million.

Repairs cost $130 million.

"The Responsible Test Engineer (RTE) did not "assure" the turnover cart configuration through physical and visual verification as required by the procedures but rather through an examination of paperwork from a prior operation."








NASA accident report.   http://www.nasa.gov/pdf/65776main_noaa_np_mishap.pdf

KT

[Jon86]

Oops. Expensive mistake...

[SeanB]

For want of a bolt......

[pickle9000]

Man there must have been a great deal of upset stomachs that day, no matter who did it.

[mdszy]

Oh man. I would've hated to be the guy responsible for that mishap!

[SeanB]

I knew a guy who had something similar happen to him. Somebody neglected to unlock the nosewheel steering, and when the tractor turned the drawbar did so, but the nose gear did not. Shear bolts did as designed, and snapped off.  Aircraft rolled down the gentle slope and 5m further stopped. No brakes as no hydraulics and pump was still being pumped for braking on impact. Nose cone left a 5cm hole in the 6mm steel wall bands, and in the rammed earth behind them. Too bad the nose cone is not the front most  projection, that is a pitot static probe. That sheared the 16 rivets mounting it to the frame and went backwards, snapping off the 2 air lines and the 2 heater wires. Then it went through the main relay box about half way, at the level of the internal mounting plate, tearing it and all the wiring to pieces. not a cheap repair that one. Relay box was not repairable, and had to be remade. Quick fix was a new nose borrowed from another plane in for overhaul, it was not going anywhere in any case for the next year. Did lead to some fast retraining and testing for all flight line personnel.

[Bored@Work]

And next time when you hear people here in the forum or at work bragging how cool they are for not following procedures or processes, that safety regulations are for wimps, that doing it the ghetto way is what real men do, that they don't need all that crap that is just slowing them down and limiting their creativity, and the establishment is just trying to deny them their freedom of expression ...


... thats why they are wrong.

[Maxlor]

I see you like procedure. But my first gut reaction when reading the accident report was, there's such a whole lot of procedure that people have stopped thinking about what they're doing. What in the report is described narrowing of focus (or similar.)

I've experienced that attitude during my stint in the army; if procedure dictates everything I do, I stop thinking about what I'm doing. If I did otherwise, I might annoy someone, which usually has negative consequences. If I just concentrate on my tasks, I'll be fine, even if the guy next to me makes a mistake that I might have noticed... but hey, it's his problem and responsibility, not mine.

I'm very glad that the work climate these days is a lot different. There's some overlap between us developers, and it happens every so often that I see something that seems odd to me, that I don't understand. So I question it. Most of the time, it's really nothing, and I might even learn something. Sometimes though issues are discovered (and promptly fixed.)

People aren't robots. If you treat them like robots by giving them rigid instructions, you'll usually find a boat load of procedure violations after a while. It seems to me that instead of fighting against the negative aspects of being human (like us all being lazy to a degree), we should make use of the positive aspects, like giving people a reason to be there (as opposed to a robot), which makes them feel needed and important. And finally, let's give people training and schooling (which creates understanding) instead of just instructions (which is just procedure again, no understanding required.)

[KJDS]

And next time when you hear people here in the forum or at work bragging how cool they are for not following procedures or processes, that safety regulations are for wimps, that doing it the ghetto way is what real men do, that they don't need all that crap that is just slowing them down and limiting their creativity, and the establishment is just trying to deny them their freedom of expression ...


... thats why they are wrong.

Rules are made for the guidance of the wise and the blind obedience of fools. I've met a lot of people that think they are in the "wise" category but aren't.

[nctnico]

One of my personal experiences on my first job: the senior design engineer put 2 electrolytics in series to get a capacitor with a higher voltage rating. I wanted to put the proper capacitors in it but he insisted it would be OK. A couple of months later I went to install the equipment (worth an amount with 7 digits) at a major bank. So there I was in the equipment room of a bank (those are huge!) and doing some tests. Just as the bank's project manager walks in to see how things where going the capacitors blew... I don't think I ever looked unhappier. Fortunately the bank's manager made a joke from the situation.

[vk6zgo]

If the Electros are the same capacitance & voltage rating,it should work,& has worked on countless occasions.
Of course,it will double the ESR,which may be critical in a particular application.

What very few people do,however is to say,use two 25vwkg caps in series hoping to get 50vwkg.
It is far more common to put two 40vwkg caps in series to give a bit more lee-way.

[HackedFridgeMagnet]

"The Responsible Test Engineer (RTE) did not "assure" the turnover cart configuration through physical and visual verification as required by the procedures but rather through an examination of paperwork from a prior operation."

I wonder how the QA manual got updated to make sure that did not happen again.

Maybe an RTE overseer.

[GEuser]

Like Bored@Work mentions , these pictures in the OP also reminds me of those people that post @ new beginners or others just inquiring , those special people promoting their "intelligence" and opinion but without actually adding anything to the inquiries , like>

Study before you ask questions!                                                                               (recent)

Try something easier in the hobby your too ahead of yourself , read books and study!  (recent)

Don't ask questions without studying first !                                                                (recent)

They are obviously sitting there in front of the computer all knowledgeable and superior in their perfect world with supposedly excellent advice yet seem to exist to post only that , the rant is nearly over btw , these "experts" are the one reason that I could get banned from this forum as there is quite a few here imo and instead of enlightening (not feeding with spoon btw) or imparting a road to stay on or track they seem to actually deride those trying to learn like smartarse effing nitwits , I'd like to smack em one in real life but all I could say or type in this isolated relative one way communication is drivel like this < .

And look at those pictures nerds!
 

 

[vk6zgo]

Like Bored@Work mentions , these pictures in the OP also reminds me of those people that post @ new beginners or others just inquiring , those special people promoting their "intelligence" and opinion but without actually adding anything to the inquiries , like>

Study before you ask questions!                                                                               (recent)

Try something easier in the hobby your too ahead of yourself , read books and study!  (recent)

Don't ask questions without studying first !                                                                (recent)

They are obviously sitting there in front of the computer all knowledgeable and superior in their perfect world with supposedly excellent advice yet seem to exist to post only that , the rant is nearly over btw , these "experts" are the one reason that I could get banned from this forum as there is quite a few here imo and instead of enlightening (not feeding with spoon btw) or imparting a road to stay on or track they seem to actually deride those trying to learn like smartarse effing nitwits , I'd like to smack em one in real life but all I could say or type in this isolated relative one way communication is drivel like this < .

And look at those pictures nerds!
 

All quite fair answers!
We get a few people who seem to think this forum is a free school.---well,sorry,it isn't!

The knowledgeable people who volunteer part of their time to answer beginner's questions spent substantial parts of their life to acquire that knowledge,& know from bitter experience that shortcuts to proficiency in Electronics do not exist.

For that reason,they fairly understandably,expect a little bit of effort from the questioner.

[amyk]

I see you like procedure. But my first gut reaction when reading the accident report was, there's such a whole lot of procedure that people have stopped thinking about what they're doing. What in the report is described narrowing of focus (or similar.)

I gave up trying to decipher all the bureaucracy in the report and just skimmed over it. IMHO it's saying a whole lot of nothing... 100+ pages around something so simple? No wonder it cost $130 million to fix...

The Technician Supervisor even commented that there were empty bolt holes, the rest of the team and the RTE in particular dismissed the comment and did not pursue the issue further.

Apparently "this is a bloody expensive piece of kit, let's make damn sure it's not going to come off the mount when we turn it" was not in the minds of anyone working on it.

[Kjelt]

One of my personal experiences on my first job: the senior design engineer put 2 electrolytics in series to get a capacitor with a higher voltage rating.

If the Electros are the same capacitance & voltage rating,it should work,& has worked on countless occasions.
Of course,it will double the ESR,which may be critical in a particular application.

This needs an extra voltage devider across the caps (two high ohms resistors) to make sure the common connection in the middle has exactly half the voltage otherwise it could be that one elco gets to endure an higher voltage (higher then it is speced).

[TMM]

One of my personal experiences on my first job: the senior design engineer put 2 electrolytics in series to get a capacitor with a higher voltage rating. I wanted to put the proper capacitors in it but he insisted it would be OK.

It would have been ok... if he added balance resistors appropriately

[nctnico]

Or just ordered the right capacitors. It was only 200V or so not needing low-ESR or anything special. It was a slip up from an otherwise very competent engineer.

[grumpydoc]

It would have been ok... if he added balance resistors appropriately

Hadn't heard of that but I suppose it makes sense - more at http://www.illinoiscapacitor.com/pdf/Papers/voltage_balancing_resistors.pdf for anyone who, like me, didn't know this was necessary.

Or just ordered the right capacitors

Quite but when you've something around that "will do" but is not ideal there is a high temptation to bodge it and get the lid back on there and then rather than leave the job around waiting for a delivery.

[SeanB]

Even the OHL power supplies have the resistors in, if they were not needed you know they would be cost cutted out. Of course they use a 0.25W unit there which fails after a short period as open and then the supply goes bang.

[peter.mitchell]

Even the OHL power supplies have the resistors in, if they were not needed you know they would be cost cutted out. Of course they use a 0.25W unit there which fails after a short period as open and then the supply goes bang.

Only if it makes it past the "plug it in and make sure it does pop" test, so if it does pop, it pops with the customer some time later and its their problem.

[Kjelt]

Of course they use a 0.25W unit there which fails after a short period as open and then the supply goes bang.

Saw applications that used for the balancing resistors two times three SMD 0603 in series which are even lower power, but the resistance is so high it should withstand mains 24/7 without problem, don't see the problem. Maybe a different topic, a schematic would help.

[London Lad]

I see you like procedure. But my first gut reaction when reading the accident report was, there's such a whole lot of procedure that people have stopped thinking about what they're doing. What in the report is described narrowing of focus (or similar.)

I gave up trying to decipher all the bureaucracy in the report and just skimmed over it. IMHO it's saying a whole lot of nothing... 100+ pages around something so simple? No wonder it cost $130 million to fix...

The Technician Supervisor even commented that there were empty bolt holes, the rest of the team and the RTE in particular dismissed the comment and did not pursue the issue further.

Apparently "this is a bloody expensive piece of kit, let's make damn sure it's not going to come off the mount when we turn it" was not in the minds of anyone working on it.

^ This

[TerraHertz]

Urrgh! I'd seen the first image but not the others or the NASA 'incident report'.
Sigh. 90 pages of avoiding saying it straight up - "we forgot to put any bolts at all in, dammit". Every time they mention bolts they first go on about how they put in every second bolt on one adapter, and that's normal. But only in Fig 5-20 (page 37) is it perfectly clear that the 'turnover cart adapter plate' requires 24 bolts to the baseplate, and NONE were installed. So the thing was just sitting there like a paperweight.

I like how one guy noticed, and pointed it out to the others, and everyone ignored him. Ha ha ha...  So typical.

Also, what a wimp. Didn't have the guts to start yelling "Hey you f*cks, STOP! There are NO BOLTS! Just LOOK you jerks!"
Or words to that effect.

How ironic, that in a 'how we screwed up and smashed a multi-million dollar satellite, many pages are 'export restricted' and 'proprietary'.

The whole thing is an allegory of why centrally planned economies have never worked and can never work. Because they condition everyone to think like those guys working on the satellite that Saturday.

Oh well. I suppose I'm just feeling extra cynical, having in the last week witnessed yet another instance of some great old Australian technological history trashed, via institutional incompetence bordering on criminal negligence. Or maybe even deliberate bloodymindednes for all I know. I'm not privy to the reasoning behind it. Nor can I talk about it. Very frustrating.

(Edit: typo)

[GEuser]

Urrgh! I'd seen the first image but not the others or the NASA 'incident report'.
Sigh. 90 pages of avoiding saying it straight up - "we forgot to put any bolts at all in, dammit". Every time they mention bolts they first go on about how they put in every second bolt on one adapter, and that's normal. But only in Fig 5-20 (page 37) is it perfectly clear that the 'turnover cart adapter plate' requires 24 bolts to the baseplate, and NONE were installed. So the thing was just sitting there like a paperweight.

I like how one guy noticed, and pointed it out to the others, and everyone ignored him. Ha ha ha...  So typical.

Also, what a wimp. Didn't have the guts to start yelling "Hey you f*cks, STOP! There are NO BOLTS! Just LOOK you jerks!"
Or words to that effect.

How ironic, that in a 'how we screwed up and smashed a multi-million dollar satellite, many pages are 'export restricted' and 'proprietary'.

The whole thing is an allegory of why centrally planned economies have never worked and can never work. Because they condition everyone to think like those guys working on the satellite that Saturday.

Oh well. I suppose I'm just feeling extra cynical, having in the last week witnessed jet another instance of some great old Australian technological history trashed, via institutional incompetence bordering on criminal negligence. Or maybe even deliberate bloodymindednes for all I know. I'm not privy to the reasoning behind it. Nor can I talk about it. Very frustrating.

In bold above , WHAT! you mean that they have got rid of the short drop AND long drop now 

btw , I don't believe one word that one is overly cynical , its really going on , really really stooooopid stuff and it'll be getting worse as it has too imo .

The analogy I use for the op's picture is nerdburglerizm at its best , and that is all the upperclass sat builders who are of course superior  got rid of the nut and bolt guy as who needs a nut and bolt guy , anyone can do that even a monkey the monkeys say , so we'll do the nuts and bolts too as its sooooo easy and we can save $40 thou by getting rid of that pesky low intelligence nut and bolt guy , its easy ...

btw , I have a bias in the above story real or not real as I'm a nut and bolt guy also and over the years have really screwed some nuts , ya see the nuts I gather think they are also superior to the bolts so have tried to rid themselves of the bolts but forgetting as they be nuts they'll have no existence in existence just being a Nut , so I say screw em! Ha Ha Ha Ha ...