Everyone else seems to be commenting on this story today, so I’ll add another voice to the chorus of “what the #$%# were they thinking?”
No, this kind of accident doesn’t “just happen” — judging from the facts presented in the brief report, it was due to at least two unpardonable failures on the part of the technicians: first, those who removed the bolts without notifying anyone that they had done so, and second, those who attempted to turn over the satellite without first doing a check on the fixture as per procedure.
Had even one person in either group been doing their job properly, the incident never would have happened.
Beyond the parties immediately involved, however, there are two other players who should answer for this: the transportation and handling crew (who task it ought to have been to turn over the satellite, and thus check the fixture over before doing so — why were techs moving it?), and the production operations personnel in that area (who should have been aware that there were insufficient bolts for two satellites, and requisitioned a sufficient number — and who should also have picked up on the techs not following instructions).
I’m not at all surprised that such a thing could happen, though, as the first thing that came to mind when I first saw a turn over cart was that it was an accident waiting to happen.
Ahh, but the real question, since this was LockMar, is: Were the missing bolts English or Metric??? 🙂
Yeah, sure, you laugh…
Today a “lessons learned” bulletin was forwarded around the company regarding proper rounding of converted dimensions in dual-dimensioned (english and metric) hardware drawings. No mention was made, however, of the most obvious fix for the problem: mandating one unit system for all elements of the program. Duh.