ChrisElyea.com Much analysis brings triumph, little analysis brings disaster

10Sep/090

Part 4: Shuttle Depressurization – Incomplete Training

Crew of the Columbia training in a simulator

Crew of the Columbia training in a simulator

The crew of Columbia had about 40 seconds to close their visors between the time the shuttle went out of control and the Crew Module was breached.  None of them did.  The Crew Module depressurized so quickly that they did not have time after the breach.  One was not even wearing a helmet and two others did not have their gloves on, so their suits would not have been functional anyway.  The crew was rendered unconscious and had no chance of survival.

The crew did not close their visors because they did not recognize their peril.  Their training program was thought to be partly responsible.  Flight training and escape training were separate, even using different Shuttle simulators.  In flight training, every problem scenario has a solution.  The Columbia Crew Survival Investigation Report states, “…in general it is considered nonproductive to train scenarios from which there is no recovery and so those cases are not simulated.”  Evidently NASA doesn’t believe in the Kobayashi Maru Test.  This may encourage the astronauts to persist in troubleshooting instead of starting their escape.  Escape training always began with the assumption that the astronauts were already in an irrecoverable situation.  They never practiced transitioning from normal operations to an emergency.  As a result of the crew survival investigation, training was modified to practice this transition.

7Sep/091

Part 3: Shuttle Depressurization – Manually-Operated Visors and 100% Oxygen

Crew of the Columbia

Crew of the Columbia wearing the Advanced Crew Escape Suit

The spacesuit is the iconic symbol of the astronaut.  Sadly, the suit provided to Shuttle astronauts is not satisfactory.

The first four flights of Columbia were the first four orbital flights of the Shuttle program and were considered tests.  Columbia had a crew of only two, wearing U.S. Air Force SR-71 pressure suits, sitting in ejection seats.  Upon the successful completion of these missions, the ejection seats and pressure suits were no longer considered to be necessary.  Some investigators believed that the crew of the Challenger might have survived until the Crew Module impacted the ocean.  The pressure suits were reintroduced to the Shuttles as a result, though it was not feasible to install ejection seats for seven crewmembers.  Even so, the Shuttles were not designed for pressure suits and the current pressure suit was not really designed for the Shuttles.

1Sep/090

Part 2: Space Shuttle Safety Still Secondary?

Video analysis from the Columbia Accident Investigation

Video analysis from the Columbia Accident Investigation

The seven-member crew of the Space Shuttle Challenger was lost on January 28th, 1986.  NASA’s attitude toward safety was severely criticized by investigators and the federal government.  NASA was directed to make significant improvements.  In 2003, the Columbia Accident Investigation Board found that little had really changed.  The question is:  Has it yet?

The Columbia Crew Survival Investigation Report was released on December 30th, 2008.  That’s one month short of being six years after the accident.  The report’s authors didn’t need to bother stating, “Other Return to Flight activities took priority over the crew survival follow-up investigation.”

1Sep/090

Part 1: Commentary on the Columbia Crew Survival Investigation Report

STS-107 Mission Patch

STS-107 Mission Patch

The seven-member crew of the Space Shuttle Columbia was lost on February 1st, 2003.  The Columbia Crew Survival Investigation Report identified five potentially lethal events that occurred during the accident:

  1. Depressurization – certainly survivable
  2. Dynamic rotating forces – probably survivable
  3. Manually-deployed parachute – certainly survivable
  4. Exiting the Shuttle at high velocity and high altitude – possibly survivable
  5. Breakup of Crew Module – not survivable

One, the breakup of the Crew Module, was not survivable.  Of the other four, two were definitely survivable, one probably was (the immediate effect certainly was, the secondary effect maybe was), and the other might have been.  The report made some astonishing conclusions about the inadequacies of crew safety equipment and procedures.

31Aug/090

Procedures – Who’s Got Time For Them?

The engines on this Boeing MD-80 were NOT started with a pry bar!

The engines on this Boeing MD-80 were NOT started with a pry bar!

Red Forman decried it as ‘the sugar packet solution’ – applying a workaround instead of making a proper repair because it’s quicker. Only I’m not talking about propping up the kitchen table here; this is about operating a plane with 138 passengers!

During regular maintenance, the procedure for cleaning a small component of the automatic engine starter on an MD-80 was not followed. This eventually caused the starter to quit working. Unable to start the engine, the pilots called for assistance. Maintenance personnel then did not follow the procedure for manually starting the engine. Instead of opening the engine cowl and using a specialized wrench, they slid in a pry bar because it was quicker. This further damaged the starter, resulting in an in-flight engine fire.

31Aug/090

My Fascination With Failure Analysis

I was introduced to failure analysis as an engineering student. It fascinated me to take a broken piece of metal into the lab and determine why it had failed. When I returned to do my master’s a few years later, I chose failure analysis as my focus.

I quickly learned that materials failures were almost always a result of a mistake in design, fabrication, or operation. I want to learn how to avoid making those mistakes myself. As Dilbert said, “The goal of every engineer is to retire without getting blamed for a major catastrophe.”

The best way is to learn from the mistakes of others. A proper accident investigation determines the root causes and provides recommendations for preventing future occurrences. The lessons learned are often fundamental enough to be applied across a range of situations. That’s why I search for and study these reports.

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