NASA and the "acceptable risk"
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The lack of an independant regulator is a significant conclusion nut not one without its irony. This was considered a key factor after Challenger and these institutions were put in place. The CAIB findings suggest that the regulator did not remain independant and it was NASA's political and commercial proponents who made key go/no go decisions.
More than everything else it was the "we usually lose foam, it often hits the orbiter and damages the tiles but we have never lost a shuttle from it before so we can ignore it" attitude that caused this crash. In fact that is not quite true, they had been working on solutions to the problem and had intended to get the problem resolved within the next couple of flights. This therefore depicts NASA more as a knave than a fool; they had appreciated the danger and had ordered it to be fixed, but did not ground the craft until it had been. This was a soluble problem and you can bet your bottom dollar that no foam leaves the booster on STS-114.
It is hard to imagine an independant regulator allowing the flights to continue under those circumstances.
More than everything else it was the "we usually lose foam, it often hits the orbiter and damages the tiles but we have never lost a shuttle from it before so we can ignore it" attitude that caused this crash. In fact that is not quite true, they had been working on solutions to the problem and had intended to get the problem resolved within the next couple of flights. This therefore depicts NASA more as a knave than a fool; they had appreciated the danger and had ordered it to be fixed, but did not ground the craft until it had been. This was a soluble problem and you can bet your bottom dollar that no foam leaves the booster on STS-114.
It is hard to imagine an independant regulator allowing the flights to continue under those circumstances.
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NASA and the "acceptable risk"
COMMENT: to Bus429
The thread so far seems to be addressing management decision-making as a factor in accidents and incidents, in particular in relation to risk.
Re “Any other suggestions would be welcome.”
OK, along with the excellent Charles Perrow try Scott Sagan whose basic thesis is that it is not ‘risk’ that is the issue, it is power: "The power of elites to impose risks upon the many for the benefit of the few." Scott D. Sagan (1995) The Limits of Safety. Organizational, Accidents, and Nuclear Weapons. Princeton University Press. Princeton New Jersey.
And on the subject of the ‘independent regulator’ there seems to be an implication that regulators can be independent, if so, read Mary Schiavo, Former Inspector General of the US Department of Transportation, Flying Blind, Flying Safe. Her First Chapter, entitled ‘Who does the FAA Work for, Anyway? Not you' draws attention to the lack of independence, indeed to a dual mandate that adds up to an impossibility. This incompatibility is addressed in detail by Professor E Mumford, (1999) Dangerous Decisions. Problem Solving in Tomorrow’s World. Kluwer Academic Plenum.
And when you’ve done that tell us what you think the bottom line answers are. I have one theory but await yours with interest!
The thread so far seems to be addressing management decision-making as a factor in accidents and incidents, in particular in relation to risk.
Re “Any other suggestions would be welcome.”
OK, along with the excellent Charles Perrow try Scott Sagan whose basic thesis is that it is not ‘risk’ that is the issue, it is power: "The power of elites to impose risks upon the many for the benefit of the few." Scott D. Sagan (1995) The Limits of Safety. Organizational, Accidents, and Nuclear Weapons. Princeton University Press. Princeton New Jersey.
And on the subject of the ‘independent regulator’ there seems to be an implication that regulators can be independent, if so, read Mary Schiavo, Former Inspector General of the US Department of Transportation, Flying Blind, Flying Safe. Her First Chapter, entitled ‘Who does the FAA Work for, Anyway? Not you' draws attention to the lack of independence, indeed to a dual mandate that adds up to an impossibility. This incompatibility is addressed in detail by Professor E Mumford, (1999) Dangerous Decisions. Problem Solving in Tomorrow’s World. Kluwer Academic Plenum.
And when you’ve done that tell us what you think the bottom line answers are. I have one theory but await yours with interest!
Iconoclast
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Great thread guys, pprune at it's best.
Lu, post the Challenger accident Richard Feynman ( spelling - I should know better) seemed to be of the opinion that NASA was routinely playing Russian Roulette - the O- ring burn through had never been quite bad enough to ground the Shuttle though it had the potential to cause the losss of a vehicle. It seems that the Columbia accident was similar - impact damage had been going on for a while but it had never been quite bad enough to justify a fundamental review/grounding....what's your opinion.....(sad to hear that Max Faget and Gordon Cooper passed away recently BTW)
Lu, post the Challenger accident Richard Feynman ( spelling - I should know better) seemed to be of the opinion that NASA was routinely playing Russian Roulette - the O- ring burn through had never been quite bad enough to ground the Shuttle though it had the potential to cause the losss of a vehicle. It seems that the Columbia accident was similar - impact damage had been going on for a while but it had never been quite bad enough to justify a fundamental review/grounding....what's your opinion.....(sad to hear that Max Faget and Gordon Cooper passed away recently BTW)
Last edited by wiggy; 22nd Nov 2004 at 10:14.
Iconoclast
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A personal theory which is not supported by NASA.
To: wiggy
Regarding my personal theory I sent it to NASA shortly after it had been determined that the effected “O” ring was the cause of the explosion. I never heard from them.
First a basic lesson in solid rocket motors. Most solid rockets are end burning in that they burn like a cigarette. On this type of rocket motor the combustion chamber volume changes as the propellant is consumed. Upon ignition the combustion chamber is relatively small so that when the propellant is ignited the internal pressure is very high. This accounts for the initial speed. As the propellant is consumed the internal pressure decreases and the rocket slows down but by that time the target has been destroyed. (Hopefully).
On some small rocket motors and larger rocket motors it is different. If you were to cut a segment of one of these motors you would note that the propellant grain has been cast with an internal pattern. This pattern can be cruciform in shape or be in the shape of an asterisk. If you were to measure the surface area of this internal shape it would be very close to the internal circumference of the rocket motor case. In this type of motor upon ignition the burning surface consumes the propellant from the inside out and the internal pressure stays the same so the propulsive force is constant.
On any solid motor there is a possibility of developing cracks in the propellant grain. These cracks provide additional burning surface, which increases the internal pressure and can cause the motor to explode.
The segmented motor on the Shuttle has built in cracks at the segment joints. When attaching the segments the technicians apply putty. I do not know if this putty is applied to the total mating surface or just at the joints. In the case of the Challenger and I believe several other flights a flame was observed emanating from the connecting joint on the motor. As previously stated NASA did not believe this was a serious problem. I disagree. If a flame in the magnitude of that observed on the Challenger was that large there is a possibility that the propellant in the adjacent mating surfaces was also burning increasing the internal combustion pressure resulting in the explosion of the solid rocket motor. If the flame hit the propellant tank the explosion that would result would not be as violent.
That’s my theory and I’m sticking with it.
Regarding my personal theory I sent it to NASA shortly after it had been determined that the effected “O” ring was the cause of the explosion. I never heard from them.
First a basic lesson in solid rocket motors. Most solid rockets are end burning in that they burn like a cigarette. On this type of rocket motor the combustion chamber volume changes as the propellant is consumed. Upon ignition the combustion chamber is relatively small so that when the propellant is ignited the internal pressure is very high. This accounts for the initial speed. As the propellant is consumed the internal pressure decreases and the rocket slows down but by that time the target has been destroyed. (Hopefully).
On some small rocket motors and larger rocket motors it is different. If you were to cut a segment of one of these motors you would note that the propellant grain has been cast with an internal pattern. This pattern can be cruciform in shape or be in the shape of an asterisk. If you were to measure the surface area of this internal shape it would be very close to the internal circumference of the rocket motor case. In this type of motor upon ignition the burning surface consumes the propellant from the inside out and the internal pressure stays the same so the propulsive force is constant.
On any solid motor there is a possibility of developing cracks in the propellant grain. These cracks provide additional burning surface, which increases the internal pressure and can cause the motor to explode.
The segmented motor on the Shuttle has built in cracks at the segment joints. When attaching the segments the technicians apply putty. I do not know if this putty is applied to the total mating surface or just at the joints. In the case of the Challenger and I believe several other flights a flame was observed emanating from the connecting joint on the motor. As previously stated NASA did not believe this was a serious problem. I disagree. If a flame in the magnitude of that observed on the Challenger was that large there is a possibility that the propellant in the adjacent mating surfaces was also burning increasing the internal combustion pressure resulting in the explosion of the solid rocket motor. If the flame hit the propellant tank the explosion that would result would not be as violent.
That’s my theory and I’m sticking with it.
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I remeber reading after the Columbia accident that the crew was not informed of the foam strike and the possibility of wing damage. If this is correct then I find it very disturbing, I am a great believer that the "Pilot in command is the final authority as to the operation of the aircraft", NASA's failure to follow this basic concept shows a clear lack of respect for the lives and skills of the crewmembers. I am left with the impression that NASA views the Astronauts as nothing more than payload.
While the engineers and managers could argue that they had made assesments of the situation and deemed that there was no significant risk (About which they were 100% wrong). I have to ask myself, how much trouble would it have been to make a quick transmission to the commander, "By the way we noticed on launch that....."
I know that space travel involves a high degree of risk but it seems to me, after 3 tragic accidents over 35 years, that NASA's idea of risk management is, like that of most large buraucracies, to generate large quantities of memos and reports, when the real solution to the problem is to listen to the people doing the everday work. Nine times out of ten it is the little guy who has the solution, someone in management just needs to start paying attention.
The more I think about this topic, it just makes me p
d, everyone of these tragic accidents could have been avoided if someone in the chain of command had just stopped writing reports for 10 minutes, paid attention and spoke up. Instead what we have is more reports and policies with catchy titles. It is about time that someone in charge started listening to the engineers that build these craft and the pilots that fly them.
While the engineers and managers could argue that they had made assesments of the situation and deemed that there was no significant risk (About which they were 100% wrong). I have to ask myself, how much trouble would it have been to make a quick transmission to the commander, "By the way we noticed on launch that....."
I know that space travel involves a high degree of risk but it seems to me, after 3 tragic accidents over 35 years, that NASA's idea of risk management is, like that of most large buraucracies, to generate large quantities of memos and reports, when the real solution to the problem is to listen to the people doing the everday work. Nine times out of ten it is the little guy who has the solution, someone in management just needs to start paying attention.
The more I think about this topic, it just makes me p
d, everyone of these tragic accidents could have been avoided if someone in the chain of command had just stopped writing reports for 10 minutes, paid attention and spoke up. Instead what we have is more reports and policies with catchy titles. It is about time that someone in charge started listening to the engineers that build these craft and the pilots that fly them.
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Somewhere there must be proper risk assessments that were made on the mathematical probability of losing spacecraft. The outcome, with the Shuttle, has been two total, fatal losses, in 120 or so launches. Any aircraft, even military, that crashed with that kind of regularity would be instantly grounded.
Werner Von Braun, when shown the Shuttle designs, was appalled, because they decided to dispense with an escape rocket, which, as on the Apollo and Gemini craft, could remove the crew to safety if something bad happened between launch and a viable separation altitude.
Add up the other fatal incidents to Russian and American space programmes and you have a statistically high risk. If these were military personnel on military missions, perhaps the risk would be acceptable, but NASA is a civilian agency and, I think, had been fooling itself that space flight was safe enough.
Astronauts may be pioneers, but the Shuttle fatals really pinpointed the big question. Do humans need to do this stuff? On a strictly technical level they don't. NASA got into manned spaceflight and believes, as do its political backers, that it cannot get more public funds without the glamour of manned space flight. Even a moment's thought about the technicalities of maintaining survival of humans in space shows what science is sacrificing to put humans up there.
If astronauts are fully aware of the dangers and still want to do it, fine. But please let's stop kidding ourselves that manned space flight is necessary from a scientific point of view.
What for?
Werner Von Braun, when shown the Shuttle designs, was appalled, because they decided to dispense with an escape rocket, which, as on the Apollo and Gemini craft, could remove the crew to safety if something bad happened between launch and a viable separation altitude.
Add up the other fatal incidents to Russian and American space programmes and you have a statistically high risk. If these were military personnel on military missions, perhaps the risk would be acceptable, but NASA is a civilian agency and, I think, had been fooling itself that space flight was safe enough.
Astronauts may be pioneers, but the Shuttle fatals really pinpointed the big question. Do humans need to do this stuff? On a strictly technical level they don't. NASA got into manned spaceflight and believes, as do its political backers, that it cannot get more public funds without the glamour of manned space flight. Even a moment's thought about the technicalities of maintaining survival of humans in space shows what science is sacrificing to put humans up there.
If astronauts are fully aware of the dangers and still want to do it, fine. But please let's stop kidding ourselves that manned space flight is necessary from a scientific point of view.
What for?
Iconoclast
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Dead men in space. Live men on the ground.
To: Frangible
More men on the moon. Men on Mars and beyond.
This inspires the average person and it ensures that the NASA engineers and the engineers at the companies producing the transportation systems job security to the point that they can retire on the respective programs. When I worked on the manned space programs and several satellite programs they were referred to as WPA programs. The WPA for those not initiated in the acronym is the Works Progress Administration a program initiated by Roosevelt to keep people working during the depression.
George Bush has proposed that men return to the moon and that he intends to put men on Mars. The men on the moon would build a base camp and extract “water”? from the moons sub surface and create hydrogen and oxygen for the propellants necessary to carry the Mars rocket to its’ destination.
First of all, the machinery necessary to fraction the hydrogen and oxygen from the water (assuming it is there) is very large and heavy and would require a rocket larger than the Saturn 5 to get it on the moon. There would also be a means of powering the cryogenic and pumping systems that would function in an airless environment. And this does not account for the housing of the crew and all of their support systems.
As far as the Mars rocket is concerned it would have to be 100% reliable and so far man has not been able to construct a system that is 100% reliable. An anvil is not 100% reliable, as it would eventually rust.
George W proposes these programs because it makes him look like a man of vision. NASA supports him as it ensures job security. If these programs are put into effect they will be paid for with money that is not there and if it is there it will put the United States into financial stress.
If it keeps on this way the Canadian dollar will be worth more than the US dollar and that will place me in financial stress.
More men on the moon. Men on Mars and beyond.
This inspires the average person and it ensures that the NASA engineers and the engineers at the companies producing the transportation systems job security to the point that they can retire on the respective programs. When I worked on the manned space programs and several satellite programs they were referred to as WPA programs. The WPA for those not initiated in the acronym is the Works Progress Administration a program initiated by Roosevelt to keep people working during the depression.
George Bush has proposed that men return to the moon and that he intends to put men on Mars. The men on the moon would build a base camp and extract “water”? from the moons sub surface and create hydrogen and oxygen for the propellants necessary to carry the Mars rocket to its’ destination.
First of all, the machinery necessary to fraction the hydrogen and oxygen from the water (assuming it is there) is very large and heavy and would require a rocket larger than the Saturn 5 to get it on the moon. There would also be a means of powering the cryogenic and pumping systems that would function in an airless environment. And this does not account for the housing of the crew and all of their support systems.
As far as the Mars rocket is concerned it would have to be 100% reliable and so far man has not been able to construct a system that is 100% reliable. An anvil is not 100% reliable, as it would eventually rust.
George W proposes these programs because it makes him look like a man of vision. NASA supports him as it ensures job security. If these programs are put into effect they will be paid for with money that is not there and if it is there it will put the United States into financial stress.
If it keeps on this way the Canadian dollar will be worth more than the US dollar and that will place me in financial stress.
Enigmatologist
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In Feynman's Book "What Do You Care What Other People Think?", it comes to light that Nasa knew they had a problem with the "O" rings and Thiokol kept fiddleing with the installation to rectify the situation. Infact the Parker Seal Company told Morton Thiokol that the rings were not designed to be used that way an there could not offer any solution.
However, the only mention of the "Problem" in all the NASA post flight data was a mention in a summary at the end of some flight readyness reviews, " The lack of a good secondary seal in the field joint is the most critical and ways to reduce joint rotation should be incorporated as soon as possible to reduce criticality"
Then near the bottom it said "Analysis of existing data indicates that it is safe to continue flying the existing design as long as the joints are leak checked with a 200 psig stabilization....."
Feynman said he was "Struck by the contradiction": "If it is most critical how could it be safe to keep flying?"
Later in the investigation they found that the 200 psig leak check was the most likely cause for the dangerous bubbles in the chromate putty also used in the seal joint.
Mr Feynman later wrote a design proposal to overhaul the faulty decision making process at NASA which was apparently adopted in part and then forgotten. A bloody shame if not manslaughter.
In my opinion: Until NASA comes up with a suitable pre re-entry inspection plan and some "SPACE BONDO" the shuttle needs to stay on the ground.
Have a look at any of the books on Richard P. Feynman if you want to meet a wonderful brilliant man.
However, the only mention of the "Problem" in all the NASA post flight data was a mention in a summary at the end of some flight readyness reviews, " The lack of a good secondary seal in the field joint is the most critical and ways to reduce joint rotation should be incorporated as soon as possible to reduce criticality"
Then near the bottom it said "Analysis of existing data indicates that it is safe to continue flying the existing design as long as the joints are leak checked with a 200 psig stabilization....."
Feynman said he was "Struck by the contradiction": "If it is most critical how could it be safe to keep flying?"
Later in the investigation they found that the 200 psig leak check was the most likely cause for the dangerous bubbles in the chromate putty also used in the seal joint.
Mr Feynman later wrote a design proposal to overhaul the faulty decision making process at NASA which was apparently adopted in part and then forgotten. A bloody shame if not manslaughter.
In my opinion: Until NASA comes up with a suitable pre re-entry inspection plan and some "SPACE BONDO" the shuttle needs to stay on the ground.
Have a look at any of the books on Richard P. Feynman if you want to meet a wonderful brilliant man.
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Suggestions from the Public - CAIB
Some of you may recall the CAIB's website inviting (even soliciting) suggestions from the public for ways in which to avoid a Columbia repeat. Well I went to all the trouble of sending them a snail-mail letter, but before doing so, checked out my facts with Dow Corning.
A bureaucrat intercepted my letter and returned it unopened. Just for the record here, this is what I had to offer:
A bureaucrat intercepted my letter and returned it unopened. Just for the record here, this is what I had to offer:
Please pass to Shuttle Program Manager Bill Parsons
NASA’s RCC Leading Edge Tile Repair Plans Fizzle Out
See AW&ST article extract below. NASA is practicing their blinkered vision again. Read the article carefully and you'll see that they're trying all but the one measure that would afford real protection......and avoid the necessity for in-orbit repair, ISS shack-up and rescue (which measure(s) could remain as a last-ditch fall-back position -only).
Perhaps someone should suggest to NASA/CAIB yet again the concept of a sacrificial glove coating over the vulnerable inboard leading edge RCC panels. It would protect RCC tiles during extended on-pad time (against weather and corrosive gantry leaching contaminants), most importantly would effectively shield the brittle RCC tiles against direct debris impact during launch and burns away early (ablatively and completely) during re-entry interface super-heating. During launch, because of the low Mach numbers attained, it’s non-critical – and doesn't even have to be 100% conformal.
I sent a couple of explicit emails to their publicized email address way back (at www.caib.us) - but received no acknowledgement and I'm betting that they'd not have been read. I did receive an acknowledgement from Dow Corning that they had a suitable silastic material that would fit the bill (about a 1.5" thick conformal coating out to two-thirds span for the wings' and vertical stabilizer's leading edges). That was also forwarded on to NASA (same email address) and to a few Space Industry Journo hacks - but nothing further was heard from them on that either. Search for “sacrificial” on www.pprune.org and you’ll see where the idea came up some 18 months ago. It would appear that NASA isn't interested in event avoidance but is fixated on heroic recovery. A risk-prone Cart before horse mentality methinks.
________________________________________
NASA Abandons Rigid Overwrap For Patching RCC Holes
After encountering "significant technical challenges," NASA is abandoning attempts to develop a rigid overwrap to patch large holes in the space shuttle's reinforced carbon-carbon (RCC) panels in the event of damage during flight, and instead is pursuing other methods that probably won't be ready in time for the shuttle's return to flight, according to agency officials.
The shuttle program plans to fly again in March or April of next year. The Columbia Accident Investigation Board (CAIB) specified that NASA must develop methods of on-orbit thermal protection system (TPS) inspection and repair for the shuttle before that flight. Columbia was lost after foam debris from its external tank punched a large hole in one of the orbiter's RCC leading edge panels.
"The biggest problem with any of the TPS repair techniques [is preserving the] outer mold line," Shuttle Program Manager Bill Parsons said during a teleconference Aug. 3. "The second [problem] is how do we connect something like that to the wing?"
Another problem is the variable geometry of the 22 RCC panels that run along the leading edge of each wing, no two of which are the same. "You'd have to make a wrap that would fit with that geometry, because that outer mold line is so important," Parsons said. "So you end up having to build a number of these panels that would be able to fit in the exact right place on the wing."
Instead, NASA is trying to develop a flexible overwrap with new materials, but this solution will not be ready in time for first flight. Other concepts such as sealing the hole with a ceramic filling also are being considered.
NASA’s RCC Leading Edge Tile Repair Plans Fizzle Out
See AW&ST article extract below. NASA is practicing their blinkered vision again. Read the article carefully and you'll see that they're trying all but the one measure that would afford real protection......and avoid the necessity for in-orbit repair, ISS shack-up and rescue (which measure(s) could remain as a last-ditch fall-back position -only).
Perhaps someone should suggest to NASA/CAIB yet again the concept of a sacrificial glove coating over the vulnerable inboard leading edge RCC panels. It would protect RCC tiles during extended on-pad time (against weather and corrosive gantry leaching contaminants), most importantly would effectively shield the brittle RCC tiles against direct debris impact during launch and burns away early (ablatively and completely) during re-entry interface super-heating. During launch, because of the low Mach numbers attained, it’s non-critical – and doesn't even have to be 100% conformal.
I sent a couple of explicit emails to their publicized email address way back (at www.caib.us) - but received no acknowledgement and I'm betting that they'd not have been read. I did receive an acknowledgement from Dow Corning that they had a suitable silastic material that would fit the bill (about a 1.5" thick conformal coating out to two-thirds span for the wings' and vertical stabilizer's leading edges). That was also forwarded on to NASA (same email address) and to a few Space Industry Journo hacks - but nothing further was heard from them on that either. Search for “sacrificial” on www.pprune.org and you’ll see where the idea came up some 18 months ago. It would appear that NASA isn't interested in event avoidance but is fixated on heroic recovery. A risk-prone Cart before horse mentality methinks.
________________________________________
NASA Abandons Rigid Overwrap For Patching RCC Holes
After encountering "significant technical challenges," NASA is abandoning attempts to develop a rigid overwrap to patch large holes in the space shuttle's reinforced carbon-carbon (RCC) panels in the event of damage during flight, and instead is pursuing other methods that probably won't be ready in time for the shuttle's return to flight, according to agency officials.
The shuttle program plans to fly again in March or April of next year. The Columbia Accident Investigation Board (CAIB) specified that NASA must develop methods of on-orbit thermal protection system (TPS) inspection and repair for the shuttle before that flight. Columbia was lost after foam debris from its external tank punched a large hole in one of the orbiter's RCC leading edge panels.
"The biggest problem with any of the TPS repair techniques [is preserving the] outer mold line," Shuttle Program Manager Bill Parsons said during a teleconference Aug. 3. "The second [problem] is how do we connect something like that to the wing?"
Another problem is the variable geometry of the 22 RCC panels that run along the leading edge of each wing, no two of which are the same. "You'd have to make a wrap that would fit with that geometry, because that outer mold line is so important," Parsons said. "So you end up having to build a number of these panels that would be able to fit in the exact right place on the wing."
Instead, NASA is trying to develop a flexible overwrap with new materials, but this solution will not be ready in time for first flight. Other concepts such as sealing the hole with a ceramic filling also are being considered.
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Feynman
I second the positive comments on Richard Feynman. He was the man who exposed the management culture of NASA and stopped the Challenger disaster enquiry from just being a "rubber stamp" for the shuttle.
As I recall, he was the only scientist on the Challenger investigation panel which was otherwise made up of generals and bureaucrats.
You MUST read his minority report on the Challenger disaster.
As I recall, he was the only scientist on the Challenger investigation panel which was otherwise made up of generals and bureaucrats.
You MUST read his minority report on the Challenger disaster.
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As to that SRB design...
Didn't I read somewhere that the reason the SRB was designed with these inherently risky joints was to enable the segments to be fabricated elsewhere and then transported to the launch site? In other words, it was a political decision to design it that way, meant to spread the work around.
A one-piece booster could have been fabricated on site, thus eliminating the o-rings and the associated risk of leakage. It would have been too large to build elsewhere and then transport to the launch site.
Is that correct or was it really necessary to design a segmented SRB?
A one-piece booster could have been fabricated on site, thus eliminating the o-rings and the associated risk of leakage. It would have been too large to build elsewhere and then transport to the launch site.
Is that correct or was it really necessary to design a segmented SRB?
