NASA: Workers Caused NOAA N-Prime Accident

By | October 11, 2004 | Feature

In a scathing report dated Sept. 13 but only made public last week, the National Aeronautics and Space Administration (NASA) and the National Oceanic and Atmospheric Administration (NOAA) N-Prime Mishap Investigation Board (MIB) pointed the finger at Lockheed Martin Space System Co. (LMSSC) factory workers in its Sunnyvale, Calif., plant for causing an accident involving the N-Prime satellite on Sept. 6, 2003.

The satellite sustained heavy damage after slipping off a turnover cart (TOC) and, according to the report, the exact extent of any harm to the hardware still is being assessed. The MIB reported that the satellite fell because “the TOC adapter plate was not secured to the TOC with the required 24 bolts.”

But what led to the satellite not being bolted properly is perhaps more telling, The MIB reported that the “TOC adapter plate was not secured to the TOC because the LMSSC operations team failed to execute their satellite handling procedures.”

Additionally, the report identified a variety of other issues related to the lack of attention to detail by LMSSC employees. The MIB said in its report that the operations team’s “lack of discipline in following procedures evolved from complacent attitudes toward routine spacecraft handling, poor communications and coordination among operations team, and poorly written or modified procedures.” MIB added that the “preconditions within the integration and test (I&T) operations…existed because of unsafe supervision practices within the LMSSC project organization, including ad hoc planning of operations, inadequate oversight, failure to correct known problems and supervisory violations.”

The MIB also identified certain organizational issues that contributed to creating the environment that led to the accident. The report noted that the unsafe supervision practices “had their roots in the LMSSC organization: the inadequate resources and emphasis provided for safety and quality assurance functions; the unhealthy mix of dynamic I&T climate with a well-established program and routine operations; and the lack of standard, effective process guidelines and safeguards for operations all negatively influenced the project team and activities.”

Inadequate government oversight also was to blame, the MIB said. “[The] Defense Contract Management Agency (DCMA) and the [Goddard Space Flight Center] Quality Assurance (QA)/safety function failed to provide adequate oversight to identify and correct deficiencies in LMSSC operational processes, and thus failed to address or prevent the conditions that allowed the mishap to occur,” the report noted. In addition, the government’s inability to identify and correct deficiencies “was due to inadequate resource management, an unhealthy organizational climate, and the lack of effective oversight processes.”

Problems Corrected, Says LMSSC

LMSSC spokesman Buddy Nelson told Satellite News the incident was investigated by an internal Accident Investigation Team (AIT), which came to similar conclusions with regards to what caused the NOAA N-Prime accident.

In a carefully scripted response to questions, Nelson told us, “The AIT found that the accident was caused by the failure of spacecraft integration and test workers to follow Lockheed Martin written procedures.”

Nelson added LMSSC has implemented operational changed recommended by the AIT and MIB and “audits conducted by Lockheed Martin’s customer as well as internal reviews have verified that the company has corrected the cause of the accident.”

But all is not lost professionally for LMSSC. As evidence of its confidence that procedural changes have been made, Nelson told us NOAA has asked LMSSC to rebuild the satellite in question. As for who will finance the rebuild, Nelson said, “Lockheed Martin has voluntarily contributed to the rebuild effort all profit previously earned and paid on the contract. The company will undertake the completion of the N-Prime satellite bus on a cost-only basis, forgoing all profits that otherwise might have been accrued to Lockheed Martin for this spacecraft bus.” Nelson could not supply us with any dollar amount related to company losses stemming from this incident.

Long Term Effects Minimal

While the financial effects of the accident certainly can be calculated, its long- term impacts may not be as severe.

Timothy Logue, a space and telecom analyst with Washington, D.C.-based law firm Coudert Brothers, told Satellite News there is a certain expectation that LMSSC had to correct the kinds of problems that led to the accident. He characterized the mishap as a “one-off type of catastrophe that may symbolize some procedure that needs to be corrected” but a recurrence is most unlikely due to the safeguards put in place. “In other words, it’s such a slap in the face that you expect the company to respond to it,” he said.

In the near term, Logue said the issues might have customers asking for proof that things have changed to prevent the recurrence of an incident similar to the NOAA N-Prime accident, and it could lead to additional due diligence on the part of commercial and government contractors. Logue harkened back to a time when satellite customers had a more involved oversight of the manufacturing process.

“It used to be that some of the original [satellite] customers, like Intelsat, used to be all over contractors,” Logue said. “They had their own people and they had contractors that watched the contractors. [However] in the rush-to-market 1990s, [that level of oversight got] slimmed back quite a bit. But I think there has been a swing back in the pendulum toward a bit more monitoring and a bit more due diligence before and after the contract [is signed].”

(Timothy Logue, Coudert Brothers, 202/736-1816; Buddy Nelson, LMSSC, 510/ 797-0349)

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