Oops

By Alan M. Marcum

I wasn't sure if you were aware of this incident that occurred in Sunnyvale CA. (Lockheed Martin). See photo attachment. It appears that some bolts were removed from the rotation fixture without the proper documentation, then the configuration was not verified prior to lifting critical flight hardware. The result speaks for itself.

ANOMALY REPORT  
 
TO:    
FROM:          
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 approximately7:15 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. 

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.

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