Genesis Mishap Investigation Board Report, Volume I
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GENESIS MISHAP INVESTIGATION BOARD REPORT VOLUME I National Aeronautics and Space Administration Trade names or manufacturers’ names are used in this report for identification only. This usage does not constitute an official endorsement, either expressed or implied, by the National Aeronautics and Space Administration. GENESIS MISHAP REPORT VOLUME I G ENES I S M I SHA P R E P O R T PAGE PB PAGE I G ENES I S M I SHA P R E P O R T G ENES I S M I SHA P R E P O R T PAGE ii PAGE iii G ENES I S M I SHA P R E P O R T G ENES I S M I SHA P R E P O R T PAGE ii PAGE iii G ENES I S M I SHA P R E P O R T G ENES I S M I SHA P R E P O R T PAGE iv PAGE V G ENES I S M I SHA P R E P O R T G ENES I S M I SHA P R E P O R T PAGE iv PAGE V G ENES I S M I SHA P R E P O R T G ENES I S M I SHA P R E P O R T PAGE ii PAGE iii G ENES I S M I SHA P R E P O R T VOLUME I CONTENTS Signature Page (Board Members) ........................................................................v Advisors, Consultants, and JPL Failure Review Board Members .................... vii Acknowledgements .............................................................................................ix Executive Summary .............................................................................................1 1. Summary of Genesis Project .........................................................................5 2. Mishap Description -- Sequence of Events and Timeline ...........................16 3. Method of Investigation ..............................................................................18 4. Proximate Cause ..........................................................................................23 5. Root Causes and Contributing Factors ........................................................28 6. Recommendations .......................................................................................41 7. Other Observations and Recommendations ................................................52 8. Stardust Mission Recommendations ...........................................................59 9. Nomenclature and Dictionary .....................................................................65 10. References ...................................................................................................81 Appendices: Appendix A: Letter Establishing the Genesis Mishap Investigation Board ......................................... A-1 Appendix B: Genesis Project Description, narrative ........................................B-5 Appendix C: Fault Tree: Process and Diagram .............................................C-21 Appendix D: Analyses and Studies ............................................................... D-29 Appendix E: Root Cause and Contributing Factor Narrative; Event and Causal Factor Tree .................................................E-209 Appendix F: JPL Failure Review Board Report ........................................... F-259 Appendix G: Contractors Supporting the Genesis MIB .............................. G-261 Appendix H: Meeting Minutes .................................................................... H-263 Appendix I: Press Releases ............................................................................I-323 Appendix J: Bibliography ..............................................................................J-333 G ENES I S M I SHA P R E P O R T PAGE ii PAGE iii G ENES I S M I SHA P R E P O R T G ENES I S M I SHA P R E P O R T PAGE iv PAGE V G ENES I S M I SHA P R E P O R T SIGNATURE PAGE (BOARD MEmbERS) Dr. Michael Ryschkewitsch, Chairman Patricia Jones Director, Applied Engineering & Technology Human Factors Directorate NASA Ames Research Center, Moffett Field, CA NASA Goddard Space Flight Center, Greenbelt, MD Steven Labbe Aerodynamics Peter Spidaliere NASA Johnson Space Center, Houston, TX Executive Secretary NASA Johnson Space Flight Center, Houston, TX Melvin Lucy Senior Engineer, Systems Engineering Directorate Patrick Martin NASA Langley Research Center, Hampton, VA Ex-Officio Office of Safety and Mission Assurance NASA Headquarters, Washington, DC Stacey Nakamura Chief, Safety & Test Operations Division NASA Johnson Space Center, Houston, TX Frank Bauer Systems Engineering NASA Goddard Space Flight Center, Greenbelt, MD John Ormsby Avionics NASA Marshall Space Flight Center, Huntsville, AL Col. Michael Coolidge Air Force Space Command Department of Defense Jenny Stein Parachute Systems Exploration Systems Engineering Division Marlon Enciso NASA Johnson Space Center, Houston, TX Head, Electrical Systems Branch NASA Goddard Space Flight Center, Greenbelt, MD James VanLaak Systems Engineering NASA Langley Research Center, Hampton, VA Thomas Gates Materials/Structures NASA Langley Research Center, Hampton, VA Maj., (USAF Retired) Melba Weatherford Headquarters Air Force Safety Center Department of Defense G ENES I S M I SHA P R E P O R T PAGE iv PAGE V G ENES I S M I SHA P R E P O R T G ENES I S M I SHA P R E P O R T PAGE vi PAGE vii G ENES I S M I SHA P R E P O R T ADviSORS AND CONSULTANTS Mishap Investigation Board Advisors: Clint Crookshanks National Transportation Safety Board Robert Kichak Goddard Space Flight Center, Greenbelt, MD Karen McNamara Johnson Space Center, Houston, TX Catherine White Marshall Space Flight Center, Huntsville, AL Mishap Investigation Board Consultants: Lt. Gen. Edward Berry USAF, Retired Dennis Deel Lockheed Martin Space Systems, Denver, CO Charles Holloway Dynacs MDI Yvonne Kellogg Dryden Flight Research Center, Edwards, CA John Kline Jet Propulsion Laboratory, Pasadena, CA Patrick O’Rear Johnson Space Center, Houston, TX Nicholas Smith Lockheed Martin Space Systems, Denver, CO Donald Sweetnam Jet Propulsion Laboratory, Pasadena, CA Joseph Vellinga Lockheed Martin Space Systems, Denver, CO Ronald Zellar Goddard Space Flight Center, Greenbelt, MD NASA Headquarters, Washington, DC: Debbie Hollebeke Legislative Affairs Don Savage Public Affairs Daniel Thomas Legal Advisor Robert Tucker External Relations G ENES I S M I SHA P R E P O R T PAGE vi PAGE vii G ENES I S M I SHA P R E P O R T JPL Failure Review Board Dr. John Klein Management /Power Systems JPL/Chair Rob Manning Systems JPL/Deputy Chair Arden Acord “System Test, V&V” JPL Kirk Barrow Mission Assurance JPL Ed Barry Project Management USAF Ret. Steven Battel Space Engineering Private Consultant Jerry Dalton Electronics Reliability /Circuit Analysis JPL Jim Donaldson Avionics Systems JPL Wayne Lee Entry Systems JPL Dave Perkins Systems LMSS Tom Rivellini Mechanical Systems JPL Joe Savino Avionics and Power Systems JPL Rao Surampudi Batteries JPL Mark Underwood Battery/Power Systems JPL JPL Failure Review Boad Support Team George Carlisle Navigation JPL Genesis Navigation Prasun Desai Entry Systems LaRC Genesis Ed Hirst Systems Engineering JPL Genesis Mission Manager Bob Kerr Process Engineering JPL George Lewis Navigation JPL Genesis Navigation Nora Mainland Ops/Data Control JPL Genesis MOS Bob Mitcheltree Entry/Descent Systems JPL Tom Spilker Physics JPL Genesis Don Sweetnum JPL Genesis Project Manager Christine Szalai Entry/Descent Systems JPL Tom Wahl Systems Engineering JPL Genesis Bill Wilcockson Entry Systems LMSS Other JPL and LMSS Contacts Robert Berry LMSS Management LMSS Jim Crocker LMSS Management LMSS Gentry Lee Guru JPL David Perkins Genesis Engineering LMSS Mark Underwood Batteries JPL Joe Vellinga Genesis Project LMSS G ENES I S M I SHA P R E P O R T PAGE viii PAGE I X G ENES I S M I SHA P R E P O R T ACKNOWLEDGEMENTS The Mishap Investigation Board would like to acknowledge the support of a num- ber of groups and individuals who contributed to completing the investigation in an effective and timely manner. A special commendation goes to the Genesis Project Team who functioned as an Interim Response Team in performing the initial recovery and securing of the crashed sample return capsule. Their timely and quality response not only pre- served the critical hardware for MIB examination but more importantly, provided the opportunity for the Mission Curation and Science Teams to preserve and pro- cess the scientific samples. Recent reports indicate that most or all of the science goals of the mission will be achieved. In addition, early collection of detailed notes from each member present at the crash site were invaluable in reconstructing the post-recovery timelines. The MIB received exemplary support from many members of the Genesis Project Team from Lockheed Martin Space Systems and from the Jet Propulsion Lab. The personnel from both organizations and their respective line management coop- erated fully and proactively supported the MIB in doing its work. It was clear that everyone on both teams had been strongly personally committed to achieving Genesis mission success and that the crash was a strong personal blow to each one. Each and every team member contacted by the MIB was completely open and tried in every way to help reconstruct events over the life of the Genesis mission. It was clear that people involved felt personally responsible for the failures but, despite significant emotional stress, participated with a high degree of professionalism. Of special mention are Joe Villenga, Nick Smith, Dave Perkins and Al McKinney of LMSS and Don Sweetnam, Tom Wahl and Ed Hirst of JPL. Each of these people did everything possible to help the Board and in every way worked to make sure that the best possible knowledge was gained from the investigation. The Jet Propulsion Laboratory convened an internal Failure Review Board