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MEDS Created "Window of Vulnerability" Safety Risk

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Stuf4 - 24 Sep 2003 18:50 GMT
In exposure of further weakness to the argument that MEDS can be
justified as a safety upgrade, the NASA Mixed Fleet Study of May 2001
stands as clear recognition that transition to MEDS created a safety
risk:

"The purpose of the Mixed Fleet Study was to develop an option to
reduce the time the fleet is flying in a mixed configuration [incl.
old "steam gauge" cockpits mixed with new MEDS cockpits]...  The
purpose of reducing the mixed fleet operating time was to...reduce the
strain associated with limited resources working multiple
configurations, minimize the need for maintaining and operating
multiple manuals and processes, reduce the window of
vulnerability/risk of errors with multiple processes and procedures,
and reduce training requirements for operations and support."

(One source- p13of32,
http://news.findlaw.com/hdocs/docs/nasa/ig70102shttlsftyaud.pdf)

The conclusion is that key safety upgrades got cut while an extremely
costly upgrade got funded producing a safety risk.  Alternate MEDS
acronym:

Multimillion
Ex-orbit-ant
Dollars
Squandered

It is sad irony that MEDS equipped STS-107 was flown in the middle of
this "window of vulnerability".

Regarding current events...

Resignation without admission of error does not constitute
accountability.  Bob, Sid and Bryan were at least three members who
were fully cognizant of the WLE Russian Roulette.  I can imagine the
hot debates within NASA, within ASAP and within Congress.  I am
certain that strong objection was voiced against funding MEDS in lieu
of WLE MMOD (etc).  For those individuals who did argue for safety
over glitz, the honorable time to resign was -before- fatalities
occur.

~ CT
stmx3 - 24 Sep 2003 19:34 GMT
[snip complaint]
> Regarding current events...
>
[quoted text clipped - 6 lines]
> over glitz, the honorable time to resign was -before- fatalities
> occur.

As I understand it, many of the ASAP members were drawn from NASA
employees/managers.  Did they resign from the board or actually resign
from NASA civil service?

The ASAP board was required by congress and appointed by NASA, if I'm
not mistaken.  Their problem, as has been pointed out, was that they
weren't being heard.  They were even turned down a request for more
"authority".  I guess after some point, they should have all stepped
down from the board en masse to emphasize their predicament.  I don't
think they should necessarily resign from NASA, unless they are
disgusted with upper management and unhappy in their jobs.

Too bad NASA didn't give them a voice, but even so, the foam problem
wouldn't have been caught.  It'll be interesting to see if NASA heeds
their outgoing warnings about ISS and how it's an accident waiting to
happen.

> ~ CT
Stuf4 - 24 Sep 2003 23:47 GMT
From stmx3:
> [snip complaint]

?

(If NASA can recognize the safety threat, I'd like to think that this
forum can see validity in that as well.)

> > Regarding current events...
> >
[quoted text clipped - 23 lines]
> their outgoing warnings about ISS and how it's an accident waiting to
> happen.

I've been repeatedly pointing out that the foam problem *was* caught.
THIS is my best guess as to why all panel members "resigned".
Reporters have plenty of information available to them to press key
officials as to why the known problem was neglected.  Consider the
info in this one webpage:

http://quest.arc.nasa.gov/people/journals/space/katnik/sts87-12-23.html

Excerpt:
------
STS-87 is Home! The Post-Flight Inspection Begins
by Greg Katnik
December 23, l997

STS-87 rolled to a stop...the extent of damage at the conclusion of
this mission was not "normal." ... During the STS-87 mission, there
was a
change made on the external tank. ... Foam cause damage to a ceramic
tile?! That seems unlikely, however when that foam is combined with a
flight velocity between speeds of MACH two to MACH four, it becomes a
projectile with incredible damage potential. The big question? At what
phase of the flight did it happen and what changes need to be made to
correct this for future missions?  ...  It was determined that during
the
ascent, the foam separation from the external tank was carried by the
aerodynamic flow and pelted the nose of the orbiter and cascaded aft
from
that point. Once again, this foam was carried in a relative air-stream
between MACH two and MACH 4!   ...  As this investigation continues, I
am very comfortable that the questions will be answered and the
solutions applied.
------

There are lots more people directly involved who could answer
questions to give an accounting for horrible mistakes that were made.

~ CT

Full article:
----------------------
FIELD JOURNAL

STS-87 is Home! The Post-Flight Inspection Begins

by Greg Katnik
December 23, l997

STS-87 rolled to a stop; the mission was complete! That statement
would
be true for the flight of the Columbia, however a new mission began
when the wheels of the Columbia came to a stop -- the post flight
inspections. My division is responsible for the overall analysis of
these
inspections and we insure that all changes made, due to these
inspections,
do not affect other areas that may jeopardize the flight-worthiness of
the shuttle. This division does not focus on one specific area, but
analyzes all information and ensures that all aspects are kept in
balance.

Immediately after the Columbia rolled to a stop, the inspection crews
began the process of the post flight inspection. As soon as the
orbiter
was approached, light spots in the tiles were observed indicating that
there had been significant damage to the tiles. The tiles do a
fantastic job of repelling heat, however they are very fragile and
susceptible
to impact damage. Damage numbering up to forty tiles is considered
normal on each mission due to ice dropping off of the external tank
(ET)
and plume re-circulation causing this debris to impact with the tiles.
But the extent of damage at the conclusion of this mission was not
"normal."

The pattern of hits did not follow aerodynamic expectations, and the
number, size and severity of hits were abnormal. Three hundred and
eight
hits were counted during the inspection, one-hundred and thirty two
(132) were greater than one inch. Some of the hits measured fifteen
(15)
inches long with depths measuring up to one and one-half (1 1/2)
inches.
Considering that the depth of the tile is two (2) inches, a 75%
penetration depth had been reached. Over one hundred (100) tiles have
been
removed from the Columbia because they were irreparable. The
inspection
revealed the damage, now the "detective process" began.

During the STS-87 mission, there was a change made on the external
tank. Because of NASA's goal to use environmentally friendly products,
a
new method of "foaming" the external tank had been used for this
mission
and the STS-86 mission. It is suspected that large amounts of foam
separated from the external tank and impacted the orbiter. This caused
significant damage to the protective tiles of the orbiter. Foam cause
damage to a ceramic tile?! That seems unlikely, however when that foam
is
combined with a flight velocity between speeds of MACH two to MACH
four,
it becomes a projectile with incredible damage potential. The big
question? At what phase of the flight did it happen and what changes
need to
be made to correct this for future missions? I will explain the entire
process.

The questions that needed to be answered were:

* what happened?

* what phase of flight did it happen in?

* why did it happen?

* what corrective action is required?

At this point, virtually every inch of the orbiter was inspected and
all hits were documented and mapped to aid in visualizing the damage.
Maps were constructed of the lower surface, the left and right
surfaces
and the top surface of the orbiter. At this point, a "fault tree" was
created. The fault tree provides a systematic approach in considering
all
possibilities of what may have happened. Everything that is on the
fault tree is considered to be legitimate until it is totally ruled
out.
Some of the considerations were where the damage occurred -- in the
OPF,
in the VAB, or on the pad before launch. These were quickly eliminated
because an inspection at T-3 ("t minus three") hours takes place on
each mission and everything was normal.

After these and many other considerations were eliminated, the focus
was placed on the ascent, orbit and re-entry phase of the mission.
Because of the fore and aft flow characteristics of the damage sites,
and the
angle of penetration, the ascent phase seemed most likely. The orbit
phase of flight was eliminated because the characteristics of these
types
of hits (most likely meteorites or space debris) occur in a random
pattern and direction. Re-entry was eliminated because the "glazing
and
re-glassifying" of the tiles due to heat upon re-entry (a normal
process)
indicated that the damage had occurred prior to this phase. The
fault-tree was now pointing to the ascent phase.

The pictures that were taken by cameras mounted in the orbiter
umbilical began to give the first clues. These cameras are designed to
turn on
during the solid rocket booster (SRB) separation, and turn off after
the separation is complete, thereby recording the event. This process
occurs once again when the external tank separates from the orbiter.
The
initial review of these photographs did not reveal any obvious damage
to
the external tank. No foam missing, no "divots" (holes) and no
material
loss. Everything appeared normal.

The SRBs were then focused on for the answers. After inspection of the
SRBs, no clues were found. In fact, the solid rocket boosters looked
to
be in great condition. Where to now? The external tank photographs
were
magnified and reviewed once again. This time some material loss was
noted, but not in a significant degree. The attention was now focused
on
the crew cabin cameras. These cameras gave more of a side view of the
external tank as it tumbled back to Earth. These photographs revealed
massive material loss on a side of the external tank that could not be
viewed by the umbilical cameras!

Where are we now? One of the questions had now been answered. The
ascent phase of flight was when the damage occurred. With the
information
provided by the photography and the mapped flow of damage, a logical
reason could be established as to "what" happened. It was determined
that
during the ascent, the foam separation from the external tank was
carried by the aerodynamic flow and pelted the nose of the orbiter and
cascaded aft from that point. Once again, this foam was carried in a
relative
air-stream between MACH two and MACH 4!

Now the big question -- why? The evidence of this conclusion has now
been forwarded to Marshall Space Flight Center (MSFC) because this is
the
design center for the external tank. MSFC will pursue the cause of
damage. Here are some descriptions of some of the considerations:

* The primer that bonds the tank foam to the metal sub-stream was
defective and did not set properly. This was eliminated as a cause
because
the photography indicated that the areas of foam loss (divots) did not
protrude all the way down to the primer.

* The aerodynamics of the roll to "heads up." The STS-87 mission was
the first time this maneuver had ever been completed.

* The STS-86 mission revealed a similar damage pattern but to a much
lesser degree than STS-87. The STS-86 tile damage was accepted ruled
as
an unexplained anomaly because it was a night launch and did not
provide
the opportunity for the photographic evidence the STS-87 mission did.
A
review of the records of the STS-86 records revealed that a change to
the type of foam was used on the external tank. This event is
significant because the pattern of damage on this flight was similar
to STS-87
but to a much lesser degree. The reason for the change in the type of
foam is due to the desire of NASA to use "environmentally friendly"
materials in the space program. Freon was used in the production of
the
previous foam. This method was eliminated in favor of foam that did
not
require freon for its production. MSFC is investigating the
consideration
that some characteristics of the new foam may not be known for the
ascent environment.

* Another consideration is cryogenic loading, specifically hydrogen
(-423 degrees Fahrenheit) and oxygen (-297 degrees Fahrenheit). These
extreme temperatures cause the external tank to shrink up to six (6)
linear
inches while it is on the pad prior to launch. Even though this may
not
seem much when compared to the circumference of the external tank, six
inches of shrinkage is significant.

This is where the investigation stands at this point in time. As you
can imagine, this investigative process has required many hours and
the
skills of many men and women dedicated to the safety of the shuttle
program. The key point I want to emphasize is the process of
investigation,
which is coordinated amongst many people and considers all
possibilities. This investigation has used photography, telemetry,
radar coverage
during the launch, aerodynamic modeling, laboratory analysis and many
more technical areas of expertise.

As this investigation continues, I am very comfortable that the
questions will be answered and the solutions applied. In fact, some of
the
solutions are already in progress. At present the foam on the sides of
the
tank is being sanded down to the nominal minimum thickness. This
removes the outer surface, which is tougher than the foam core, and
lessens
the amount of foam that can separate and hit the orbiter.

---------
stmx3 - 25 Sep 2003 15:00 GMT
> From stmx3:
>
[quoted text clipped - 4 lines]
> (If NASA can recognize the safety threat, I'd like to think that this
> forum can see validity in that as well.)

IMO, your obsession with MEDS as being the root cause of the loss of
Columbia is far on the fringe and I relegate it merely as a particular
complaint of yours.  Certain issues brought up in this topic elucidate
the overall problem at NASA, but your insistence on a direct link
between MEDS and Loss of Columbia is not sensible.

[snip]
> I've been repeatedly pointing out that the foam problem *was* caught.
> THIS is my best guess as to why all panel members "resigned".
[quoted text clipped - 3 lines]
>
> http://quest.arc.nasa.gov/people/journals/space/katnik/sts87-12-23.html

My comments are derived from the statements of an outgoing team member.
 See http://www.chron.com/cs/CDA/ssistory.mpl/space/2116366
and the quote

"It was very frustrating to us," he said. "The Senate committee, in
effect, said I was culpable for the deaths of seven people and yet we
had been working hard and trying to warn NASA about many safety issues.

"Yes, we did miss the foam, but there were other things we pointed out
that could be the next foam, the next big issue," he said.

[snip all after]
Stuf4 - 26 Sep 2003 03:27 GMT
From stmx3:

> >>[snip complaint]
> >
[quoted text clipped - 28 lines]
> "Yes, we did miss the foam, but there were other things we pointed out
> that could be the next foam, the next big issue," he said.

I don't see how this fits with your statement:

"Too bad NASA didn't give them a voice, but even so, the foam problem
wouldn't have been caught."

It takes an active decision to cancel an upgrade that was designed to
fix a very specific problem.  When the decision was made to not fund
WLE MMOD, their job was to thoroughly examine the case *for funding*
stronger WLEs.

ASAP's job is to police NASA.  Imagine a person running away from a
bank and gets stopped by a police officer.  The police officer
questions the person about all of the $100 bills hanging out of
bulging stuffed pockets...

The police officer, after due examination tells this person, "you're
free to continue running to wherever you were going."

What do you know!  A bank had gotten robbed earlier that day.  Six
tellers and one customer were shot dead.  Who could have done such a
heinous act?

Eight months later, the police officer is questioned by a Senate
committee after it has been brought to light that the officer had
stopped and questioned the person who was later identified as the bank
robber.

The police officer "voluntarily resigns" and issues the public
comment, "The Senate committee, in effect, said I was culpable for the
deaths of seven people and yet we had been working hard..."

*

No, the ASAP resignations are a far cry from accountability.  I would
like to see all eleven of them, and many others, account for key
mistakes that they made.

~ CT
Stuf4 - 26 Sep 2003 06:12 GMT
> From stmx3:

> > "It was very frustrating to us," he said. "The Senate committee, in
> > effect, said I was culpable for the deaths of seven people and yet we
> > had been working hard and trying to warn NASA about many safety issues.

[...perhaps a more fitting analogy would be a security guard at the
entrance of the bank (*preventative*) who responds to a metal detector
going off, searches the person, finds weapons, let's them through
anyway...and a bank robbery occurs...]

~ CT
stmx3 - 26 Sep 2003 13:38 GMT
>>From stmx3:
>
[quoted text clipped - 8 lines]
>
> ~ CT

You ignore the guard's history of warning about lapses in security in
the past, the guard's continual recommendations for improvement and
his/her being told to go sit in the corner and be quiet like a good
little guard.
Stuf4 - 27 Sep 2003 01:47 GMT
From stmx3:
> >>From stmx3:
> >
[quoted text clipped - 13 lines]
> his/her being told to go sit in the corner and be quiet like a good
> little guard.

The point made elsewhere is that the honorable action for the vigilant
guard would be to >resign<.  By that, I mean >before< the bank gets
robbed and people get shot.

After having been told to sit in the corner and be quiet, the guard
who subsequently proceeds to the corner in silence is an incompetent
guard.

Irregardless of however many kudos for obedience anyone may want to
give that guard, the guard's job is to ensure the security of the bank
and its customers.

~ CT
stmx3 - 26 Sep 2003 13:35 GMT
> From stmx3:
>
[quoted text clipped - 41 lines]
> WLE MMOD, their job was to thoroughly examine the case *for funding*
> stronger WLEs.

The problem was with the foam.  There was no upgrade for the foam.
There was no upgrade to the bipod ramp.  There was no intent to upgrade
WLE MMOD to protect against large chunks of foam of the size the
Columbia experienced.  ASAP didn't think to put foam on their priority
list.  Rather, I believe ASAP concurred with NASA that funding the
Cockpit Aviation Upgrade (CAU) (especially Increment II), achieved the
largest safety benefit for the buck.

Please recognize that ASAP realized they were ineffectual, complained
that they were ineffectual, requested that they be positioned to exert
greater influence...and were always shutdown and ignored by NASA
management.  I'm not sure what more you would have them do, short of
chaining themselves to the shuttle on launch day.  Have *you* ever
worked in an organization where your opinions don't align themselves
with management?

[snip all after]
Stuf4 - 27 Sep 2003 02:08 GMT
From stmx3:
> The problem was with the foam.  There was no upgrade for the foam.
> There was no upgrade to the bipod ramp.  There was no intent to upgrade
[quoted text clipped - 3 lines]
> Cockpit Aviation Upgrade (CAU) (especially Increment II), achieved the
> largest safety benefit for the buck.

Foam shedding in and of itself poses no problem.  The problem occurs
when the shed foam *hits* something.  Therefore it is incomplete to
see the problem only as a foam problem, because it does not
acknowledge possible solutions of strengthening vulnerable foam strike
areas.

It is a foam impact problem, not a foam shedding problem.  And this
brings to light another approach to find a solution that Craig is
advocating on another thread:

Modify the flight profile to change the vehicle AOA so that the
likelihood of foam impact decreases.

Regarding the CAU rationale you are offering, a review of the
justification in terms of SAFETY will expose how miminal the gain is.
And then, when you factor in cost, the dismal safety efficiency gets
exposed.

*

If anyone can construct a sound safety justification for funding MEDS,
I would be extremely interested to see it.

*

> Please recognize that ASAP realized they were ineffectual, complained
> that they were ineffectual, requested that they be positioned to exert
[quoted text clipped - 3 lines]
> worked in an organization where your opinions don't align themselves
> with management?

I'd say *every* organization.

What more would I have them do?  They can, and did, make their own
choices.  Now if I were in such a position of frustration that my
warnings were not heeded, and I wanted to influence change for the
purpose of protecting lives, then my course of action would be clear:

Resign in protest.

If my voice isn't heard as I go out the door, then at least I am
absolved of the obligations of that position.

*

ASAP did not submit resignations until the aftermath.  They seem to be
OK with public perception that their unanimous resignations were
self-initiated.  I see no acknowledgement that they were culpable for
-107.  I see no answers from them nor from any other leaders as to the
cancellation of the WLE MMOD upgrade.  What is perhaps more disturbing
is that...

I have yet to hear any of them being *asked the question*.

~ CT
 
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