Satellite mishap blamed on human error
Wednesday, October 6, 2004
SAN JOSE, California (AP) -- A $239 million satellite toppled to a factory floor last year because nobody bothered to check that it was secure before moving it, according to a NASA investigation board's report on the mishap.
The 113-page document criticized both Lockheed Martin Space Systems Co., which was assembling the weather satellite, and NASA, which was overseeing the project on behalf of the National Oceanic and Atmospheric Administration.
The NOAA N-Prime satellite fell about 3 feet as it was being moved from a vertical to a horizontal position on September 6, 2003, to remove an instrument at a facility in Sunnyvale, Calif. Nobody noticed that the 24 bolts that should have secured the spacecraft were missing.
Investigators were especially critical of the Lockheed Martin operations team for its "lack of discipline in following procedures," a problem that evolved from "complacent attitudes toward routine spacecraft handling, poor communication and coordination."
Buddy Nelson, a Lockheed Martin spokesman, said NASA's final report was consistent with the findings of the company's internal investigators.
"Lockheed Martin has implemented improvements to company policies, procedures and practices that ensure such an incident will not occur again," he said Tuesday.
It will cost an estimated $135 million to rebuild the spacecraft's main section and two damaged instruments. No one was injured in the incident.
The NASA board, which was led by Christopher Scolese of the agency's Science Mission Directorate, faulted an unidentified engineer who didn't look at the cart's configuration but instead relied on paperwork from a prior operation.
"Had he followed procedures, the unbolted (cart) adapter plate would have been discovered and the mishap averted," the report said. "Errors were also made by other team members, who were narrowly focused on their individual tasks and did not notice or consider the state of the hardware or the operation outside those tasks."
NASA investigators also said planning for the maneuver was "hurried" and the operations team was "hastily formed." Overall, the contractor's system safety program was found to be "very ineffective."
Nelson said appropriate disciplinary action has been taken, though he declined to say whether anyone has been fired.
Government checks also were lacking, according to the report. An onsite representative waived a mandatory inspection during the maneuver -- something investigators said might not have caught problem but was indicative of a failed oversight process.
The in-house representative also knew of problems at Lockheed but did not pass them along to NASA, the report said.
On Monday, NOAA announced that it has reached an agreement with Lockheed Martin to finish the satellite. In addition, the company will contribute all profits it earned from the contract to rebuild the spacecraft and will complete the work on a cost-only basis, Nelson said.
Before the accident, the spacecraft was supposed to be placed into storage until launch in 2008. It's now scheduled to be launched in December 2007.
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