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NASA Releases Failure Report On Outback Crash 72

Posted by timothy
from the failure-analysis-is-not-an-option dept.
cybrpnk2 writes "In a Friday news release, NASA Goddard Space Flight Center has issued Part 1 and Part 2 of an excellent and very interesting failure review on the April 28 failed balloon launch of the Nuclear Compton Telescope at Alice Springs, Australia. Bottom line: make sure you don't need a gorilla to pull the payload release handle at balloon launch; if the release mechanism does fail then make sure your safety cables are sized for lift loads and a swinging payload, not just static hanging payload weight; and oh yeah — keep people and vehicles out of the downwind flight path. One spectator was nearly crushed while running from his SUV that was hit and flipped (Figure 29, Vol I). At least nobody ordered video evidence destroyed."
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NASA Releases Failure Report On Outback Crash

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  • In Sum (Score:5, Insightful)

    by Mikkeles (698461) on Sunday October 24, 2010 @11:49AM (#34004384)

    Hire a competent engineer to design your balloon!

    • Re:In Sum (Score:5, Insightful)

      by Kell Bengal (711123) on Sunday October 24, 2010 @12:26PM (#34004612)
      Well, in fact, it's not that simple. I worked for a time with an engineer who did exactly that - balloons and apparatus for radio astronomy. He often told me of how complex and dangerous this process is. This is hardly the first launch mishap of a radio astronomy balloon, and it won't be the last.

      Even with the very best balloon design, the very best tethers and the very best launch protocol, if the wind turns on you unexpectedly, everything can be lost in an instant. This crash wasn't negligence or even direct human error in design or execution, it's just a confluence of things (some foreseeable, some not) that lead to a failure. It happens, especially in experimental work.

      I don't know why TFS is contrasting the accident report to a soldier being ordered to delete footage - what does this have to do with the story?. After all, it's not like NASA has a history of erasing important footage or data [wikipedia.org].
      • Re:In Sum (Score:5, Insightful)

        by Chuckstar (799005) on Sunday October 24, 2010 @12:39PM (#34004680)

        The report may not use the word "negligence", but if you read it, you'll see they come down pretty hard on the balloon program for not taking the proper precautions to avoid an accident. How that differs from negligence, I have no idea. Here are just a few of the findings that led to that conclusion:

        - Suggestions developed from the investigation of a crash in 2002 were ignored.

        - NASA's requirement to have a range safety officer independent of the program were ignored.

        - A variety of other safety guidelines were ignored.

        - Culture in the balloon program was that balloon launches are straightforward and nothing could go wrong, in spite of a history of mishaps.

      • Re: (Score:3, Funny)

        by mhelander (1307061)

        Even with the very best balloon design, the very best tethers and the very best launch protocol...

        ...and the very best gorilla at the payload release handle.

        • Even with the very best balloon design, the very best tethers and the very best launch protocol...

          ...and the very best gorilla at the payload release handle.

          None of those "lowland" gorillas: Mountain or better.

        • by StikyPad (445176)

          And the very best boy hiding in your attic.

      • by Macrat (638047)

        Even with the very best balloon design, the very best tethers and the very best launch protocol, if the wind turns on you unexpectedly, everything can be lost in an instant.

        Launch from a silo?

      • If the launch protocol includes "some dude will chase after the balloon with an ungainly hacked-up truck" then something is fucked up. The report never even comments on this!

        For extra badness: instead of putting the launch dude in the driver seat and giving him a launch button, you have him standing on a platform that blocks the driver's view. He tries to control the truck by shouting orders to the driver while the truck drives over rough ground. Assuming he doesn't fall out and get run over, he is supposed

  • by bcmm (768152)
    So, is the video on the net?
  • A few quibbles (Score:5, Insightful)

    by Gadget_Guy (627405) * on Sunday October 24, 2010 @12:03PM (#34004462)

    First, an Australian wouldn't call the car involved an SUV, but rather a 4WD (4 wheel drive).

    Secondly, it doesn't seem like an amazing story. They saw some spectators were in the way, so they tried to quickly move it all and they had problems doing this. The only real concerns that I had with the operation was lack of direction given to the spectators as to where they should go to stay out of harm's way and the campaign manager not being organised enough to know the emergency services number in Australia. No, it is not 911. It is also not what they said it was in the NASA report "0". It is in fact 000 or 112 if you are using a mobile (cell) phone.

    Finally, what is with the trolling in the summary about video evidence being destroyed. That has nothing to do with this story.

    • Wasn't this the incident where the apparatus landed on two old age pensioner's 4WD?
      • It landed on the 4WD in front of theirs, so they just missed being clobbered by the telescope. But they were a bit shaken by the whole thing. I guess they didn't realize that parking downwind of a balloon launch might be an unwise thing to do.
        • Re: (Score:3, Interesting)

          by sumdumass (711423)

          I guess they didn't realize that parking downwind of a balloon launch might be an unwise thing to do

          Maybe they though since it was a balloon filled with helium and launched by NASA, it would go up and not sideways so it didn't cross their mind?.

    • by Raenex (947668)

      First, an Australian wouldn't call the car involved an SUV, but rather a 4WD (4 wheel drive).

      Slashdot primarily writes for an American audience.

      Secondly, it doesn't seem like an amazing story.

      The footage is pretty spectacular, and three people were almost killed.

      Finally, what is with the trolling in the summary about video evidence being destroyed. That has nothing to do with this story.

      Agreed.

      • by Smauler (915644)

        Slashdot primarily writes for an American audience.

        Slashdot may write primarily for an American audience, but that audience has the intelligence to understand complicated foreign terms like 4WD, right?

        Anyway... the 4WD term is ambiguous... there are cars like the Lancer and Impreza that have been 4wd 4-door quick cars for years (Audi started it). Here in the UK we just call any car way too big for it's purpose Chelsea tractors.

        • I am an Australian and I have no problems with the term SUV. Yes, you would normally hear "4WD" here but its not worth the argument really.

          • The appropriate terminology is "Toorak Tractor". [wikipedia.org]

          • by forebees (1641541) *

            I think it is worth arguing :)

            SUV is such a strange and ambiguous term which doesn't really describe what the vehicles are.

            4WD is much clearer and a better description.

            This is also a separate issue to the culturally imperialist language...don't even start on 'cookies' to describe ANZAC biscuits.

            • by Raenex (947668)

              4WD is much clearer and a better description.

              No it isn't, because some cars have 4-wheel drive.

              This is also a separate issue to the culturally imperialist language...

              If the same automobile called a 4WD in Australia would be called an SUV in the United States, then it's not "cultural imperialism" to use the US term when reporting on a US-centric site. By the way, there really were two countries involved in this story. NASA is a United States organization, while the launch took place in Australia.

            • by Coren22 (1625475)

              4WD is a technology. SUV is sport utility vehicle, a class of vehicle which has two or more rows of seats and is roughly boxlike in the back. 4WD is used on many classes of vehicles, so the more precise term in this instance is SUV.

  • by jshackney (99735) on Sunday October 24, 2010 @12:08PM (#34004490) Homepage

    Am I the only one who expected the final link of the summary to take me to video of the mishap and not some crap about the Ft. Hood shooting?

    • by cybrpnk2 (579066)
      The point of the final link is that destruction of video evidence critical to an mahor incident investigation DOES happen and as long as we are all learning lessons here from a failure mode report, that's a very timely and important one to add. Concern about "gee, it would be too tough to see on TV and against America's best interest" is totally misplaced IMHO. The guy that took the Ft. Hood video stood up and fought back with the only weapon he had, a cellphone that could record the truth about what real
  • and oh yeah — keep people and vehicles out of the downwind flight path

    Thankfully no one was seriously injured or killed. It's been fifty years today [physorg.com] since the infamous Nedelin Disaster [wikipedia.org] happened at the Baikonur cosmodrome. It shocks me that as recently as 15 years ago [cnn.com] these sort of catastrophes happened [youtube.com].

    At least nobody ordered video evidence destroyed.

    Given the above incidents and their cover-ups, I'd agree. We must study these mistakes, own up to them and learn from them.

  • by DNS-and-BIND (461968) on Sunday October 24, 2010 @12:40PM (#34004692) Homepage
    Excuse me, but can anyone tell me the significance of the link to the soldier who was ordered to erase the video of Major Hasan's murders? This has what do with NASA now? The video was erased because it wouldn't look good on the evening news to show him shouting 'Allahu akbar' as he killed American soldiers. Or is this just some sort of post-ironic offhand hipster comment that nobody can understand, including the story submitter?
    • It seems that this is part of the "government can't do anything right" narrative at Slashdot, so the submitter and/or the editor were saying "well, this is a refreshing surprise".

      Of course, poor or misleading analysis is nothing new here, sad to say.

    • Re: (Score:3, Funny)

      by whoop (194)

      Look here sonny, let me tell ya something bout this here gubmint. They control everything you think, everything you do, everything you think you might do. Everything the gubmint does is to keep this control over the peoples. So, they lie, cheat, hide, and distort the real truth from ya. It's our job here on Slashdot to stick it to the man and make sure the peoples know how things really are. So, when some low-level ossifer in the militry tells some kid to delete a video off his cell phone, it's because

    • by cybrpnk2 (579066)
      My point in including the final link is that destruction of video evidence critical to a major incident investigation DOES happen and as long as we are all learning lessons here from a failure mode report, that's a very timely and important one to add. Concern about "gee, it would be too tough to see on TV and against America's best interest" is totally misplaced IMHO. The guy that took the Ft. Hood video stood up and fought back with the only weapon he had, a cellphone that could record the truth about wh
      • Look guy, "The Narrative" is not that he was a self-radicalized jihadi who decided to kill as many Americans as possible. No, "The Narrative" is that he suffered so much discrimination in the Army that he just HAD to act out somehow.

        Stop being ironic and putting throwaway shitty comments in what you write. Just stop.

        • by cybrpnk2 (579066)
          I don't give a flying frack about "The Narrative" as you obviously do. I care about having the facts available to get to The Truth. I still remember that ten seconds of footage from an actual event is more important that ten hours of crap spewed from talking heads on Fox News. It's people that listen to the latter that issue orders to destroy the former. Their priorities (and yours) are mixed up, not mine.
      • by khallow (566160)

        My point in including the final link is that destruction of video evidence critical to a major incident investigation DOES happen and as long as we are all learning lessons here from a failure mode report, that's a very timely and important one to add.

        There's a one word rebuttal for this sentiment. "Irrelevant." The launch contractor couldn't suppress such information because there were a bunch of spectators taking pictures (and it'd probably be a felony, if they tried). NASA had no real interest in suppressing the tape. So the moral equivalency with suppressing murder evidence isn't there.

  • from the failure-analysis-is-not-an-option dept.

    I've got to say, lots of times the "from the ____ dept." things are stupid but this one is actually pretty good.

  • by Animats (122034) on Sunday October 24, 2010 @01:29PM (#34005008) Homepage

    After reading through the whole report, the most surprising thing is the design of the launch mechanism. The basic setup was that the launch was done from a moving crane truck. The truck was equipped with special outrigger wheels, so it could handle some side load without rolling over, and a platform for the "launch director", who was supposed to release the payload by yanking on a strap attached to a cable, pulley, and pin. The launch setup is that the balloon is inflated, allowed to rise, and then the crane truck. which is carrying the payload, tries to get under the balloon, chasing the balloon if necessary. When the payload is in position, the launch director yanks the strap and releases the payload.

    This is obviously a setup which is highly dependent on what the wind does during the launch process. Some of the time, the wind is not going to cooperate, and an abort will be required. That's to be expected. But this time, they didn't abort until it was far too late.

    During the process of chasing the balloon, the stresses on the restraint system were about 3x higher than at rest. It would have taken a 300 pound pull to release the pin; this was tested after the event. The guy who was supposed to pull the strap, while standing on a moving platform atop the crane truck, wasn't even wearing gloves. There was no backup system for releasing the payload. The payload eventually released when the crane truck reached the airport perimeter fence and had to stop. The wind forces from the balloon were then great enough to tear off a mounting plate on the truck, releasing the payload, which plowed through the fence and wiped out an SUV.

    They didn't have an explosive bolt system to release the payload. The launch system used remote controlled pyrotechnics for releasing the balloon's restraining ring, and for the balloon-release abort system, so they already had all the systems and procedures in place for using pyrotechnics. But the main launch function was a guy pulling a strap.

    There's clear video of the incident. [youtube.com] This is useful to watch. When the payload tears loose from the crane, the crane truck is facing 90 degrees from the wind direction and stuck at the fence line. The crane boom is under high sideways stress. The abort system should have been triggered when the truck got into that situation, but it wasn't. (An abort prior to release loses the balloon and saves the expensive payload.) But the person with the abort button (the "campaign manager") and the guy trying to pull the release strap (the "launch director") were in different places and not coordinated, so when things went wrong, the abort didn't happen until after the payload had come loose and wiped out the perimeter fence and an SUV.

    • by Animats (122034) on Sunday October 24, 2010 @05:20PM (#34006554) Homepage

      A video that shows a second or two before the payload broke loose [youtube.com] yields more information. It looks like the crane truck was starting a left turn, pulling against the balloon, when the pull from the balloon broke the attachment to the truck. The previous video made it look like the balloon was pulling the crane boom sideways, and the boom snapped back after release. But no. The truck was doing a left turn (they had to do something, they'd reached the perimeter fence) while the balloon pulled it to the right. That's where the big stress came from.

      If the plate on the crane holding the cable to the balloon (safety factor 1.3, far too small, as later computed by NASA) hadn't failed, the launch team would have been able to hold the balloon and save the payload. They'd had failed launches before, and knew the truck was heavy enough to hold the balloon. So one can see why they held off on an abort. They might have been able to back the truck out and try the launch again. But their crane rigging wasn't built for sizable side loads.

      In retrospect, they should have aborted sooner. The payload is the valuable part; it's normally recovered by parachute. An abort would have saved the payload and lost the balloon. The balloon is a consumable. But, as NASA's critique points out, they didn't have formal abort criteria, and tried an ad-hoc fix to get out of the mess they were in. If the bolts on the crane's attachment plate had been stronger, it would have worked.

    • by khallow (566160)
      From Appendix H of the report, I read this:

      The NCT payload balloon mission launch took place on 4/28/10. Layout and balloon inflation was nominal. Civilians who were located outside the airport security fense on the public road were instructed to move to another location prior to launch. Launch was nominal, winds (11-13kts) do not at this time appear to have been an issue. Balloon release from the spool was nominal. In the process of releasing the payload from the launch vehicle, the crew chief was unable to release the payload due to friction between the pin and truck plate pressing up against the safety cables. The Crew Chief attempted to catch up with the balloon to relieve the friction, but the launch vehicle became stuck in the dirt. When free, the launch vehicle was unable to catch the balloon for proper release. In an attempt to abort launch, the crew chief noticed personnel outside the fence, and for safety reasons, decided the safest way to abort was by pulling the balloon down to te [sic] ground. During this attempt to abort, the safety cables failed and the NCT payload self released, and then was dragged across the airfield and through the safety fence, impacting an SUV. The payload was substantially damaged.

      The first bit that I bolded shows the already mentioned ad hoc nature of the launch process after the failure to release. They had a failure that dumped them outside their comfort zone and an untested way to try to keep going with the launch. The second bolding was, as I see it, a key problem that the safety report misses (it should have been a "proximate cause" for starters). Namely, if you decide to abort a balloon flight, first thing you do is disconnect the pay

      • by Spikeles (972972)

        I couldn't tell from the parts I read or the photos provided with the report, that the crane had driven all the way to the fence in question, those people weren't "in the flight path", the danger was brought to them

        Vol 1 [nasa.gov]
        Page 40 - "Key Event 39: At about PET=105 sec, the launch vehicle arrived at the perimeter fence and stopped. The LD realized that the mission would have to be aborted, but because spectators were in the flight path, did not order an abort. After several seconds at the fence, the LD orde

        • by khallow (566160)
          The key two words there? "Page 40" I appreciate you spending the time to find this, but it remains that the report was poorly designed.
          • by Spikeles (972972)

            Executive Summary. Page 5

            "Subsequently, the launch vehicle was accelerated in an attempt to catch up with the balloon for a second release effort. Upon reaching the airport fence the CSBF team recognized that the mission would have to be terminated and the LD attempted to maneuver the launch vehicle to a safe position after observing that spectators were in harm’s way"

            • by khallow (566160)
              Oh well, failed my reading comprehension check. Odd thing was that I was trying to figure out how close the spectators were even to the point of going through all those photographs in the second volume. I read that section (even remember the next sentence), but missed the meat I was looking for.
      • You've got that right about the small budget affecting the way they do the launch. I work in radio astronomy and some of our people are building a balloon-borne telescope much like the one reported on here. They cobble together bits of this and that that they have lying around, rather than build a completely new instrument. They can't afford to do it the big NASA way, as is done for the billion-dollar space launches. So an occasional failure is going to happen.
      • by Animats (122034)

        Seeing your comment, Animats, that the the person who makes the decision to abort, and the person who actually makes the abort are in different places, it makes sense to me now how that failure occurred.

        That's part of it. One guy was frantically trying to release the payload and launch, trying to yank on a strap. Coordination was by walkie-talkies, so, since he had his hands full, he probably wasn't on the air. So the guy with the abort button didn't act until it was too late. The range safety mistak

  • by FudRucker (866063) on Sunday October 24, 2010 @01:42PM (#34005094)
  • Is it just me, or does this accident report seem to point out that NASA is a hugely bloated organization? Pages and pages just of signatures of guys in the chain of command. One Hundred Twenty Seven pages analyzing something about as complicated as a swing set. Seems about ten times as long as it should be.

     

  • by Anonymous Coward

    MIT professor shows how it should be done [archive.org] (relevant bit begins around 12m45sec).

    If you watch a bit more of the video, he does talk a bit about the delicacy of the operation, including the danger posed by the wind.

  • The excellent (Australian) ABC science program "Catalyst" shot the story of the crash [abc.net.au] as part of the article on the launch. I remember seeing this a few months ago. Very sad to watch but also awe inspiring just how much payload these huge balloons can hoist into the sky. The SUV get walloped pretty badly!
  • That ballon really wrecked things up.

    Straight out of Compton indeed.

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