Quality Communication: Do It Early and Often!

Transcription

1 Quality Communication: Do It Early and Often! Conference on Quality in the Space and Defense Industries March 18-19, 2013 Joe Nieberding

2 Factors Affecting Quality* Quality can be lost due to many factors, such as: Bad design Weak testing Poor procedures Outdated or incomplete documentation Ineffective system engineering Flawed processes Missed advance warnings Misunderstandings etc. *Based on material from two day class titled Mission Success First: Lessons Learned 2

3 Factors Affecting Quality (cont d) Many of these have a common cause: Ineffective Communications Person to person Generation to generation Discipline to discipline Group to group Company to company Agency to agency 3

4 The Milano Cathedral: Prominent Historic Communication Failure : Italian Master Masons learned how to build Gothic structures via practical skill : Master masons moved on to other parts of Europe This skill in practice decayed as rules of practice were transferred to apprentices 1399: A wall collapsed in the Milano Cathedral Cardinal-Archbishop in Milano called in the masons Pope convened a board of Master Masons from throughout Europe This Cathedral Accident Investigation Board identified the problem Milano Cathedral historical commentary and photograph courtesy of Dr. Joseph R. Fragola Critical knowledge and quality lost through lack of generational communication! 4

5 Skylab Underlying Issue: As-built flight hardware deviated from the design analyzed - changes not communicated Problem: Multiple structural failures (5/14/73) during ascent Impact: Loss of significant Skylab functionality Why: Meteoroid shield separated from S-IVB workshop Faulty presumption that the meteoroid shield would remain tight to the tank Unexplained discrepancy between as-built hardware and assumption used in venting analysis Failure to treat a structure as a complex mechanism Source: NASA Investigation Board Report on Initial Flight Anomalies of Skylab, May 14,1973; 5

6 Skylab Orbital Work Shop 6

7 Skylab Micrometeoroid Shield General Arrangement 7

8 Skylab Micrometeoroid Shield Vent Areas 8

9 Skylab Micrometeoroid Shield Separation DESIGN INTENT AS DESIGNED 9

10 Damaged Skylab On Orbit Temporary Parasol Installed by SKYLAB 2 Crew Covered by Sun Shield Installed by SKYLAB 3 Crew 10

11 Skylab (concluded) LESSONS: Systems engineering must provide the means to verify hardware is built consistent with analytical (e.g. venting) assumptions Routinely verify that these systems are effective Be attentive to hardware deviation dispositions (e.g. MRB s) to ensure compatibility with original analysis Mission compromised due to faulty interdisciplinary communications! 11

12 B-2A Crash VIDEO Video Underlying Issue: Critical maintenance information not communicated Problem: Loss of control following takeoff rotation (2/23/2008) Impact: Loss of B-2A aircraft ($1.4B) Why: Improper maintenance of aircraft s air data system Source: Summary of Facts, B-2A S/N KSZL501A, Floyd L. Carpenter, Maj General, USAF, President, Accident Investigation Board 12

13 B-2A Crash (cont d) Background: The B-2A Flight Control System Computes altitude, airspeed, Angle of Attack (AOA), and Angle of Slide-slip 24 Port Transducer Units (PTU s) provide input data Upon power-up, each PTU output compared with the average for all 24 Calibration required if deviation is out of specification, Calibration biases any deviating PTU into specification Guam deployments entailed unusual number of deviations Found to be caused by high humidity Corrective action was to activate PTU heaters during the PTU check Corrective action never communicated or added to Lessons Learned log 13

14 B-2A Crash (cont d) Pre-Flight of the Spirit of Kansas Air Data Calibration Required message appears as Flight Control System (FCS) powered up Output of 3 PTU s deviate from specification (due to moisture) Responding technician unaware of the undocumented PTU heaterson procedure Performs calibration procedure without PTU heaters on 3 PTU s are biased to null out the moisture induced deviations 14

15 B-2A Crash (cont d) Flight of the Spirit of Kansas Pilot activates PTU heaters (normal pre-flight procedure) and begins takeoff 3 moist PTU s dry out Still biased outputs now deviate significantly from corrected value causing: Airspeed indication 12 knots greater than actual Angle of Attack indication of -8 deg Pilot rotates at 12 knots below correct rotation speed FCS reacts to false -8 deg AOA by commanding full nose up Aircraft AOA goes to 30 degrees nose up Low airspeed and high AOA cause stall and loss of control 15

16 B-2A Crash (concluded) LESSONS: Accurate, timely, and proactive flow of information within organizations, and across organizational interfaces is essential to maintain safety Procedure revisions must be formalized and documented The qualification of operations personnel needs to include a thorough knowledge of how their systems function Here key personnel believed that the FCS calibration merely corrected the aircraft altimeter They were unaware of the potential to cause catastrophic errors! System designers need to flag those procedures that do have the potential for catastrophic errors and create appropriate controls and safeguards Tragic breakdown in maintenance communications! 16

17 The Balloon Structure of Atlas (until Atlas V) and Centaur Video Video A Convair innovation - design concept for the original Atlas ICBM Subsequently extended to Centaur (to the present) Propellant tanks are thin walled pressure vessels Strength and stability derived from internal pressure Advantage is very light structure (and corresponding attractive mass fraction) Disadvantage is handling complexity the need to insure tanks are always pressurized or stretched Dramatic consequence of procedural communication breakdown! Source: Atlas The Ultimate Weapon, Chuck Walker, Apogee Space Books 17

18 The Balloon Structure of Atlas (until Atlas V) and Centaur Video A Convair innovation - design concept for the original Atlas ICBM Subsequently extended to Centaur (to the present) Propellant tanks are thin walled pressure vessels Strength and stability derived from internal pressure Advantage is very light structure (and corresponding attractive mass fraction) Disadvantage is handling complexity the need to insure tanks are always pressurized or stretched Dramatic consequence of procedural communication breakdown! Source: Atlas The Ultimate Weapon, Chuck Walker, Apogee Space Books 18

19 Embarrassing Failure To Communicate With Range Safety The One That Got Away! 19

20 Conclusions Quality can be compromised so easily The proper culture must be created and nurtured to emphasize quality in all areas, not just traditional areas such as quality parts A major contributor to loss of quality is a breakdown in communications at many levels It is critical that effective communications become part of the bedrock culture of a project early-on and be reinforced on a continuing basis 20

21 Conclusions (cont d) It is often said that: Successful, high performing organizations are pre-occupied with the prospect of failure Such preoccupation is always marked by an extraordinary obsession with effective communication! 21

22 Joe Nieberding, President Cell: P. O. Box Bay Village OH MISSION AEA s mission is to leverage the vital lessons learned by NASA s spacefaring pioneers to strengthen the skills of today s aerospace explorers. Larry Ross, CEO ljross1@att.net Cell: Excellence Through Experience