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.'"

Re:So... what they said originally?

[CheshireCatCO]

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 -------------

Re:Wow!!!

[TykeClone]

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

It's about organizational problems

[cradle]

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.