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Post by garyplus5 on Jan 13, 2010 17:44:27 GMT -4
It was Thompson himself who characterized the report 275-page report as an expansion of the 58-page report. If it contained "new" third-party info, Thompson didn't mention it in his summary. While the 204 Review Board did consider eyewitness testimony three weeks in February, it dispensed with Baron relatively early. Baron appeared before the board on Feb. 7. And no, his testimony is not included in Appendix B of the review board's report. But then again, there is no summary of interviews with most of the people who appeared before the board. Baron didn't give his report to Rocco Petrone at NASA until Jan. 24 and, as we know, that "short" report is based on Baron's first-hand observations. I think it's more reasonable to conclude that Baron spent the 14 days between submitting his report to NASA and his appearance before the 204 Review Board expanding his original report than it is to conclude he was "interviewing" sources and writing new material. It's more plausible that the 225 pages Baron compiled between Feb. 7 and April 27 was based on information he never shared with Thompson's group. As for the "new", hearsay material, it obviously was considered old news. But whether members of the subcommittee read it, skimmed it, or assumed it was more of the same is a matter of conjecture. No one on the subcommittee claimed to have read it, they just say they received it. I know you think I'm chasing a phantom. You've made that clear from my first post. Maybe I am. But I'm not prepared to dismiss the 500-page report as "old news" without making a concerted effort to find it, or talk to someone who actually read it. Maybe it was a lot of nothing. But it was something to Tom Baron.
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Post by JayUtah on Jan 13, 2010 20:46:44 GMT -4
It was Thompson himself who characterized the report 275-page report as an expansion of the 58-page report.I don't recall: didn't Baron also characterize his 500-page report in April as an expansion of his smaller report? I don't think we can necessarily consider these characterizations to be limits on the nature of Baron's evidence. As I recall, the 58-page report relied on third-party evidence too. You too have speculated that the longer report made many of the same points as the shorter one, but added more concrete documentation and examples. And no, his testimony is not included in Appendix B of the review board's report. But then again, there is no summary of interviews with most of the people who appeared before the board.I agree. I don't suggest anything nefarious by its absence. I just wanted to ascertain what he said to the board and couldn't find it in the report. I haven't read many of these documents since 2002 and my memory may be rusty. Baron didn't give his report to Rocco Petrone at NASA until Jan. 24...But Baron's employment was terminated on Jan. 6, 1967. All the other authors I recall say that this was because he had leaked his report to the media. So now I'm confused about the timeline. Did Baron report his findings first to NAA, to NASA, or to the press, and when? What events prompted NAA to fire him on Jan. 6? I think it's more reasonable to conclude that Baron spent the 14 days between submitting his report to NASA and his appearance before the 204 Review Board expanding his original report than it is to conclude he was "interviewing" sources and writing new material.We know Baron was interested in third-party witnesses at least as early as Feb. 2, 1967. Are you really suggesting that Baron didn't collect any third-party information until after he submitted the 58-page report to NASA? You agree that the 275-page report Thompson spoke of likely grew into the 500-page report that Baron presented to Teague and urged them to publish. I don't think Baron worked exclusively on the 58-page report until Jan. 24, then began working on a new 275-page report the next day, which he delivered to Thompson two weeks thereafter. I think Baron was working on the lengthier report before Jan. 24. It's more plausible that the 225 pages Baron compiled between Feb. 7 and April 27 was based on information he never shared with Thompson's group.That's a no-brainer. Whatever information Baron put into any report between Feb. 7 and April 27 cannot have been known to Thompson's board. The problem is whether that rather arbitrary and artificial milestone (i.e., the delivery of an interim report of 275 pages) marks a significant shift in Baron's research or methods. You seem to be trying to argue that the 500-page report can still carry some significant, undiscovered bombshell even though Thompson didn't think so when it was only 275 pages long. But whether members of the subcommittee read it, skimmed it, or assumed it was more of the same is a matter of conjecture. No one on the subcommittee claimed to have read it, they just say they received it.That doesn't mean they didn't assign some staffer to read it an summarize it, or at least give an assessment of its value. These committees and boards have armies of people working behind those scenes to do just that. Neither Teague nor Thompson read every single word of evidence that was presented. It is defensible to argue that the subcommittee members were unfamiliar with the long report, for whatever reason. It's not as defensible to argue that this is simply because they were lazy and didn't read it. It may simply not have bubbled up to their level of attention, having been squelched lower down. I know you think I'm chasing a phantom. You've made that clear from my first post. Maybe I am. But I'm not prepared to dismiss the 500-page report as "old news" without making a concerted effort to find it...Nobody is suggesting we shouldn't look for it and read it if we find it. I'm quite anxious to discover it, because conspiracy theorists all but assume it contained very damaging material and that's why Baron was murdered by NASA. Nothing would give me greater pleasure than to talk about the long report from a position of knowledge. But you also seem quite convinced that the report must contain something of grave significance, whether or not there's murder attached. You've test-flown a number of frankly absurd propositions that all center around the long report being something so important that people are willing to do questionable things to suppress it. Maybe it was a lot of nothing. But it was something to Tom Baron.There's no question it was something to Thomas Baron. I've never really questioned his passion -- merely his judgment and knowledge. To bring up that same analogy we used before, I'm sure David Percy is very proud of his 500-page book on the hoax theory. That doesn't make it objectively correct or valuable. You're begging the question of the quality of Baron's work.
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Post by garyplus5 on Jan 14, 2010 18:21:49 GMT -4
1) You are correct, Baron did characterize the 500-page report as being an expansion of his smaller report. It was Holmburg who mentioned that Baron gained additional information through late-night phone calls ... Clarification: The 58-page report was almost entirely Baron's first-hand observations. 2) I don't think there is anything nefarious about the omission of Baron's testimony either. And Thompson summarized the 58-page report quite well. In fact there was nothing in his summary that wasn't in the 58-page report, which makes me wonder what was in the 275-page report. You would think Thompson would have mentioned something from the report. Instead, he only says Baron wrote a longer report. As a writer, I don't know how a guy can write 219 additional pages on the same subject without introducing new information, but I guess its possible. Curious. It should be noted that Thompson never said he, or his committee, read the 275-page report. And Baron testified for 5 hours before the Review Board. Yet none of his testimony is included in the board's final report. 3) The timeline has been bungled by other authors. My research shows that Baron took medical leave Nov. 10, but returned to work in December. John Brooks met with Baron in December (not sure of date), and NAA met with him in late December after Mogilevsky went to his superiors with an overview of what Baron told him. According to NASA records, Baron didn't submit a formal report until Jan. 24, after he invited Brooks to his home. The earliest press account I've found of Baron's report was Feb. 7 in the Titusville Star-Advocate. If there was an earlier story, I'd like to know when it was. Baron was terminated on Jan. 5. Boeing won't disclose the reason for his termination. A press report from Feb. 7 said he was fired for missing work. BARON claimed it was because of the report. 4) The portion of Baron's long report that Thompson didn't read COULD have contained a "bombshell"I think its more possible than not since portions of the long report were likely written AFTER the fire and the short report was written BEFORE the fire. Who knows who called him and what they told him. I personally believe Holmburg shared information he had first-hand -- or at the very least, his opinion. I know you disagree. 5) I hope the subcommittee did assign someone to read the long report and summarize it. Then we might one day have documentation of its contents. 6) To clarify my position: I'm not CONVINCED the contents of the 500-page report contained a single sentence of "grave significance". Nor am I convinced it was nothing. I hope to find documentation that will enable me to make an education, unemotional decision. 6) I've flown a "number" of absurd propositions? I only thought the remote-control scenario was the only absurd theory. Outside of that, I haven't thrown out anything more absurd than the "suicide" scenario that was accepted as fact before I found an accident report.
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Post by trebor on Jan 15, 2010 3:13:58 GMT -4
Gary, Paragraphs go a long way towards making a post legible.
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Post by garyplus5 on Jan 15, 2010 17:45:07 GMT -4
Sorry about that. I'm a relatively new poster. How about this --
1) Jay, you are correct, Baron did characterize the 500-page report as being an expansion of his smaller report. It was Holmburg who mentioned that Baron gained additional information through late-night phone calls ... Clarification: The 58-page report was almost entirely Baron's first-hand observations.
2) I don't think there is anything nefarious about the omission of Baron's testimony either. And Thompson summarized the 58-page report quite well. In fact there was nothing in his summary that wasn't in the 58-page report, which makes me wonder what was in the 275-page report. You would think Thompson would have mentioned something from the report. Instead, he only says Baron wrote a longer report. As a writer, I don't know how a guy can write 219 additional pages on the same subject without introducing new information, but I guess its possible. Curious. It should be noted that Thompson never said he, or his committee, read the 275-page report. And Baron testified for 5 hours before the Review Board. Yet none of his testimony is included in the board's final report.
3) The timeline has been bungled by other authors. My research shows that Baron took medical leave Nov. 10, but returned to work in December. John Brooks met with Baron in December (not sure of date), and NAA met with him in late December after Mogilevsky went to his superiors with an overview of what Baron told him. According to NASA records, Baron didn't submit a formal report until Jan. 24, after he invited Brooks to his home. The earliest press account I've found of Baron's report was Feb. 7 in the Titusville Star-Advocate. If there was an earlier story, I'd like to know when it was. Baron was terminated on Jan. 5. Boeing won't disclose the reason for his termination. A press report from Feb. 7 said he was fired for missing work. BARON claimed it was because of the report.
4) The portion of Baron's long report that Thompson didn't read COULD have contained a "bombshell"I think its more possible than not since portions of the long report were likely written AFTER the fire and the short report was written BEFORE the fire. Who knows who called him and what they told him. I personally believe Holmburg shared information he had first-hand -- or at the very least, his opinion. I know you disagree.
5) I hope the subcommittee did assign someone to read the long report and summarize it. Then we might one day have documentation of its contents.
6) To clarify my position: I'm not CONVINCED the contents of the 500-page report contained a single sentence of "grave significance". Nor am I convinced it was nothing. I hope to find documentation that will enable me to make an education, unemotional decision.
7) I've flown a "number" of absurd propositions? I only thought the remote-control scenario was the only absurd theory. Outside of that, I haven't thrown out anything more absurd than the "suicide" scenario that was accepted as fact before I found an accident report.
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Post by JayUtah on Jan 18, 2010 13:43:30 GMT -4
It was Holmburg who mentioned that Baron gained additional information through late-night phone calls...Rather, Holmburg in his testimony stated his belief that Baron got tips anonymously. There is no mention of what time of day these conversations may have occurred. Further, Baron himself names witnesses who appear in his longer report when testifying himself before Teague. We've been over this. The only evidence you have that Baron's informants were largely anonymous comes as hearsay from Holmburg, and the only way you've been able to establish that Holmburg might have known this is your further-unsupported belief that Holmburg and Baron were farther in cahoots than is mentioned in the testimony. You're apparently trying to amplify the mysterious origins and lifetime of the longer report so that it seems a better motive for something having been done to Baron. As a writer, I don't know how a guy can write 219 additional pages on the same subject without introducing new information, ...I can, but it depends on how you define "new information." I routinely write reports that summarize beliefs and findings, and then when necessary add appendices of supporting information. For example, I told you weeks ago about the hydraulic system in Baron's car. I wrote my beliefs in a few sentences. If I were doing this professionally, there would be a reference to a set of appendices in which were given as much information as I could discover about the design and operation of the system, calculations supporting my opinion, and the report of any bench tests that were done to investigate and confirm findings. That one paragraph of findings may require 20 pages of supporting documents. One risk any whistleblower such as Baron runs is having his information downplayed as having come from too small a scope of observation. One could say, "Let's suppose Baron is right, but perhaps NAA was a well-run company on the whole and Baron couldn't see that from where he stood." In Baron's testimony before Teague he's asked to cite the most striking examples from his report -- the longer report. He lists them, and they're not materially different from what he writes about himself, only this time he's willing and able to name names of other witnesses who saw those and similar occurrences. Baron "expands" his shorter report by making the same points, the same arguments he made when writing for himself, but backfilling them with more specific documented examples. That's why it's vital that the tips not be anonymous, despite Holmburg's belief. If Baron's goal is to improve the credibility of his findings, then keeping the informants secret simply will not do. It should be noted that Thompson never said he, or his committee, read the 275-page report.No, but they clearly knew about it and they clearly had the opportunity to quiz Baron on it if they were interested in it. It's reasonable to believe that Thompson's board, like any other such board, will adhere reasonably to the rules of evidence and not accept hearsay testimony. Baron can certainly say that so-and-so told him people were drinking industrial alcohol, but that's not useful evidence until so-and-so appears himself and can be interviewed. Again, Baron's value as the compiler and collator of others' information is limited. And Baron testified for 5 hours before the Review Board. Yet none of his testimony is included in the board's final report.But only a handful of witness reports seem to be in the Appendix. Unless you know specifically what the criteria were for editing the witness statements in the report, you can't insinuate that Baron's testimony was singled out for special treatment. The timeline has been bungled by other authors.Fair enough; I'm sure it has. My research shows that Baron took medical leave Nov. 10, but returned to work in December.So it's fair to say that he worked something like 2 or 3 weeks in December, over which time he spoke to various people at NASA and at NAA about his claims. According to NASA records, Baron didn't submit a formal report until Jan. 24, after he invited Brooks to his home.Nearly three weeks after he was fired. Do you believe Baron began writing his report down after meeting with NAA and Brooks (the first time), or that he had been writing it previously, say even before his medical leave? Baron was terminated on Jan. 5. Boeing won't disclose the reason for his termination.That's fairly common because there are liabilities involved with that. Generally all you're able to find out is whether it was for cause or whether it was a reduction in force. A press report from Feb. 7 said he was fired for missing work. BARON claimed it was because of the report.And if it had been because of the report, Baron could have sued under whistleblower protection statutes. It is unlikely Baron was terminated for calling attention to violations, and it seems clear that he cannot have been fired for having written his report and submitted it to NASA. However, in Baron's testimony before Teague we read, "A case in point is two particular instances when I called in because I was not feeling well and actually not up to par for working, I called in two particular afternoons that I was going to stay home that particular day, because I wasn't feeling well, and I almost was demanded to go to work, and that I would work especially since I was the only one in that particular area that was working. This was in the receiving and inspection area." This tends to support the contention that Baron was fired for missing work. The portion of Baron's long report that Thompson didn't read COULD have contained a "bombshell"Argument from silence. I think its more possible than not since portions of the long report were likely written AFTER the fire and the short report was written BEFORE the fire.No. There was a gag order after the fire, and many companies have strict policies against discussing investigations in progress with third parties. It is less likely Baron's informants would have been more forthcoming after the fire. I hope the subcommittee did assign someone to read the long report and summarize it. Then we might one day have documentation of its contents.Me too. My attempt to discover whether this actually happened has been unsuccessful. I hope to find documentation that will enable me to make an education, unemotional decision.I do too, but in the meantime you seem to lean heavily on the side that makes out Baron's report to be a bombshell, and his untimely death somehow connected to it.
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Post by garyplus5 on Jan 19, 2010 10:43:17 GMT -4
We could debate Baron's 500-page report endlessly. I will, instead, keep looking for answers to questions we all have. And, as previously offered, I would like to submit my findings to you for evaluation when my investigation is complete. Just let me know how to do that.
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Post by JayUtah on Jan 19, 2010 11:40:24 GMT -4
We could debate Baron's 500-page report endlessly.The study of history is, in large measure, debate. The answers are often unclear; debate is one of our tools to improve clarity. Getting "beaten up" by running your ideas past other people keeps us honest, as you said. There is no substitute for the report itself. Let's hope a copy has survived. Or failing that, let's hope we can find someone who read it. I would hate to spend the rest of eternity being able only to speculate what the report may have contained. I will, instead, keep looking for answers to questions we all have.And what you're doing is extremely valuable. I'm very happy that you are able to devote so much more time and effort to this than I've been able to, and that you're so willing to share your interim conclusions. Don't mistake what appears to be hostility here as a lack of gratitude. Just let me know how to do that.webmaster@clavius.org, if it's in digital form. If it isn't, send a message there and I'll give you a physical address.
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Post by ka9q on Jul 17, 2010 0:39:41 GMT -4
Unfortunately that indirection is the problem in this case. An affidavit based substantially on reports provided by others is inadmissible hearsay in a legal context such as testimony before Congress. I know that there are rules that severely limit the use of hearsay in trial courts, but is this true for Congress? Congress has the power to conduct investigations (and issue subpoenas, if they desire) in support of their role to draft and pass legislation. Certain constitutional rules still apply, such as the right of witnesses against compulsory self-incrimination. But all the usual rules of a trial court cannot apply to a Congressional investigation, because they're not a trial court. The Constitution explicitly prohibits Congress from acting as a trial court with the very specific and limited exception of the Senate hearing an impeachment case. And both houses of Congress are explicitly permitted to set their own rules. Now any wise legislature would do well to avoid relying on hearsay and to seek original sources for any material information in an investigation, but few people will accuse Congress of habitual wisdom...
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Post by ka9q on Jul 17, 2010 1:01:58 GMT -4
From my experience as an investigator and as an aerospace engineer, here are my observations on Baron's performance as reported in his testimony. [much fascinating stuff follows...] I'm an engineer, but not a forensic engineer. Nor does the nature of my work (applied research in communications) put me in a position where a mistake would likely cost someone's life or destroy a great deal of property. And I'm pretty grateful for that... But I do have a question for Jay. You said it was a "red flag" that Baron constantly argued with the engineers over his discrepancy reports. And maybe that did reflect poorly on Baron if he frequently cited things that simply weren't significant. But if he cited so many insignificant things, why did they qualify as safety violations in the first place? I assume the engineers and their managers, not the safety inspectors, established those safety policies and Baron accurately cited one or more of them in each of his discrepancy reports. (I.e., he didn't just make up his own rules, or wildly misinterpret the official ones.) I know you can't completely write out personal judgment, but didn't the engineers share some of the blame for writing their policies so broadly? Isn't it their job to figure out exactly what does and doesn't matter to safety? As you said, the engineers are in a far better position to do this than a safety inspector who may not have either an engineering background or an appreciation of the larger issues that drive safety.
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Post by JayUtah on Jul 18, 2010 14:44:47 GMT -4
I'm an engineer, but not a forensic engineer.Now forensic engineering is engineering in a legal or regulatory context, typically with the goal of determining the cause of some undesirable occurrence. In the regulatory context that's often about assigning liability. But private clients are typically interested in the failure-analysis portion of the field; they want to legitimately correct costly errors and improve production performance whether an infraction had been committed or not. In either case a certain rigor in investigative methodology is required. I mention this because human factors such as complacency almost always play a role in engineering failure. The contract I'm working on now involves substantial slippage over time in standards of operator behavior, with several people (operators and engineers) doing what was expedient instead of what had been prescribed, or what best practices should have suggested was prudent. That notion mitigates what I'm about to say. But if he cited so many insignificant things, why did they qualify as safety violations in the first place?Because safety constraints for new or untried technologies are written conservatively to begin with and then broadened as the operators gain experience. Keep in mind that Apollo was development engineering. If you build, say, a naval destroyer, you can rely upon 100 years or more of traditional engineering and operational knowledge to determine what's safe and what isn't about that kind of ship. Your safety constraints are likely to derive from adequate real-world knowledge. However, when you're designing a space ship that has only a sketchy and derivative design lineage, you have to make up a lot of the rules as you go. Naturally when you're making up new rules, you err on the side of caution. You can't foresee everything. You don't know if those rules are reasonable until you see the system in operation. Then, and only then, do you discover that things you once suspected might turn out to be dangerous were really nothing to worry about after all. Conversely you also discover safety issues that didn't occur to you at the start. And often when you discover that when some constraint was far too conservative even though it seemed like a good idea at the time, relaxing it will have other advantages in terms of design, operation, cost, schedule, or even other safety aspects. Hence it's often a good idea to exploit them. Back in 1975, engineers designing the STS orbiter's thermal protection system knew that the tiles and RCC panels they were using were extremely brittle. Hence they wrote handling and operation rules that disallowed any damage to the components. These rules translate into stringent, expensive, time-consuming, and onerous procedures. But over 25 years of STS operations, operators learned that in fact the orbiter's TPS could safely sustain a degree of damage. The cost and hassle of coddling the TPS during prelaunch processing became harder to justify. Now the Columbia accident brought home the danger of taking too lightly the original engineers' estimates. However the physical truth obviously lies somewhere between the 1975 prescription and the Columbia handling protocols. The TSP can sustain some damage safely, but less than what was being allowed operationally at the time. Many safety constraints are written categorically. In assemblies where part counts number in the millions, you can't write specific rules for each item. You categorize the items and write that certain categories of materials or assemblies cannot be subject to certain categories of effects. You may discover along the way that some certain component is subject to some certain effect, and even though the categorical rules forbid it, an engineering analysis of that particular interaction shows no danger. It's appropriate in that case to issue an engineering waiver with an attached rationale. It looks like Baron was arguing against that practice, trying to assert the authority of the categorical constraints. In many cases we have individual occurrences that fail to meet categorical constraints. We see this all the time in mechanical assemblies where tolerance build-up is an issue. Consider a toy example where you intend to lay out ten one-meter components end-to-end, but the final length must be 10 meters plus-or-minus 10 millimeters. Naturally you'll specify that each component is one meter long, +/- a certain amount. In a real-world sense you might suspect that some parts will be cut short and others cut long, and you might relax the per-component tolerance to suit that. But conservatively you want to know what happens when all ten parts are cut long. So you specify a component length of 1 meter +/- 1 millimeter. That way even if all the parts are cut long or all cut short, as long as each part is cut to tolerance you will be okay for the final assembly. Tolerance build-up is the phenomenon of a non-random distribution of error in the parts that compounds to a failure of the whole. Now if the inspector rejects a part that is 1.002 meters long, he is doing his job as written. However, an engineer might come in and measure the other 9 pieces for that assembly and determine that the 1.002 meter part won't fail this assembly. He is within his expertise to waive the inspection in that case. One reason he might not want to do that would be if the contract required all parts to be interchangeable. That's important to some customers. But if that's not an issue, then it's perfectly safe to do so. And as frequently happens, perhaps not having a valid part on hand might delay the assembly and incur a penalty. For want of a nail, and all that. It seems Baron wanted the letter of the law to hold no matter what. In Baron's world, the part could only be between 1.001 and 0.999 meters long no matter what, and if the engineers wanted differently they should have said so in the documents. Baron just didn't understand that it wasn't his place to pound his fist on the manual when discussing matters with those who wrote the manual. Isn't it their job [as engineers] to figure out exactly what does and doesn't matter to safety?Of course it is. And that often means observing the system in operation to confirm or refute what they previously suspected. And that in turn often means employing subordinate inspectors to observe the system for them. It is the inspector's duty to be conservative: i.e., to report everything and not judge for himself without direction that some condition really is safe. It is the engineer's duty in turn to be judicious. It also means occasionally ruling on individual tests. Test procedures tend to employ hard and fast numbers -- an acceptable tire leak rate may be specified in the acceptance test as no greater than 0.50 percent per day. If a tire measures out at 0.51 percent per day, the inspector must fail the tire. And if that's a $75 car tire, then the cost of rejecting it won't be that great. But if it's a $6,000 orbiter tire, and failing it would mean missing a launch window and scrubbing a $500 million launch, then you'd better believe you'll get the engineer in there to determine whether 0.51 percent per day is a real-worldly acceptable leak rate. Tire leak rate is a safety issue because you can't land an orbiter safely on flat tires. Is a 0.01-percent variance in acceptable leak rate a safety issue? That's for the engineer to decide and rule upon. And if the engineer does due diligence and qualifies the tire, the safety inspector simply needs to shut up.
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Post by ka9q on Jul 18, 2010 16:11:50 GMT -4
Gotcha. Thanks, Jay, for an excellent write-up.
Of course, waivers aren't always a good thing, as we saw in both the Challenger and Columbia accidents, which bore some remarkable similarities. In both cases we had engineers (or their managers, to be fair) who seemed to argue that just because an accident hadn't happened already, that things were safe. They didn't understand the basic concepts of probability; that just because you got an empty chamber the first time you played Russian roulette didn't mean that it was safe to continue playing it.
Taking your example, it's as if your components, instead of maintaining their lengths after manufacture, somehow randomized themselves after each mission. So while their overall length might be within specifications most of the time, the law of large numbers gave you a normal distribution with a very long tail that, some of the time, put you outside the specifications.
Although I'm not a forensic engineer, from time to time I do read accident investigation reports. I think I developed the habit when I read the Challenger report. They can be remarkably educational. Accidents rarely happen because of a single cause. They invariably seem to happen after a long series of events, any one of which could have prevented the accident had it not happened. This is especially true for aviation, which has become so mature that serious accidents are a real rarity. (I guess if it weren't true that aviation accidents are the result of a long chain of events, we'd have many more of them.)
You see the same thing in shipping. My favorite shipping accident report was done by the Australian government about a container ship that ran onto the Great Barrier Reef because the bridge officer in charge was talking to his mother-in-law on his mobile phone. He missed the alarm for a turn from the GPS because he and his wife, who was on board for the first time, went out onto one of the bridge wings and closed the door to block the noise from a vacuum cleaner being used by one of the seamen to clean the carpet. The crew was from southern Asia, and the report noted that the culture is such that subordinates in a hierarchy simply don't question their superiors: the guy vacuuming the rug heard the alarm but didn't think it was his place to notify the officer on duty.
You see this kind of thing over and over in accident reports. A long chain of events that would be almost comical (or the plot of a farcical movie) if not for the serious consequences.
I've also learned that there are definite limits to human reliability. It doesn't matter how well trained or experienced you are, sooner or later you're going to do something really stupid. You see this a lot in transportation accidents of all types. Humans just aren't well suited to situations where nothing happens for a very long time, and then suddenly and without warning you have to make a crucial decision.
I really do think we need to revisit the age-old debate of the proper relationship between men and machines. I think there's an unwarranted belief out there that the human is ultimately more reliable than the machine, and that's just not always so. We need human/machine systems that make better use of the best features of both. Humans are best when it comes to making complex reasoned judgements with plenty of time to do so, while machines are best at dealing with relatively simple problems that can appear suddenly after many hours of routine operation, which must be handled very quickly, and which are common enough that they can be thoroughly analyzed in advance and the software written to provide the proper responses. There have been any number of accidents where, had the human simply taken his hands off the controls, the automatic systems would have recovered. Three Mile Island is an example; the operators shut off the core cooling system that was keeping the reactor in a safe state.
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Post by PeterB on Jul 19, 2010 8:48:32 GMT -4
Of course, waivers aren't always a good thing, as we saw in both the Challenger and Columbia accidents, which bore some remarkable similarities. In both cases we had engineers (or their managers, to be fair) who seemed to argue that just because an accident hadn't happened already, that things were safe. They didn't understand the basic concepts of probability; that just because you got an empty chamber the first time you played Russian roulette didn't mean that it was safe to continue playing it. I have a sense that there was a subtle but significant change in culture at NASA between Apollo and the Shuttles. In the Apollo days it seemed to be "Don't launch unless it's proven safe", and yet they seemed to get away with some startlingly courageous decisions (Apollo 12 comes to mind in particular). But with the Shuttles the policy seemed to be "Launch unless proven unsafe". I may be wrong, but that's at least the way it seems to me. I've seen that too. On the one hand it shows just how many things need to happen for something to go wrong, but on the other hand it suggests to me that there are probably many cases where disaster has been averted at that last link in the chain, and potentially no one knew how close things were to complete failure. I was reminded also of the Gare de Lyon railway accident in Paris in 1988 - a remarkably long sequence of events required to cause the accident, and preventing any one of them would have averted or greatly mitigated the severity of the accident.
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Post by ka9q on Jul 19, 2010 15:44:32 GMT -4
and yet they seemed to get away with some startlingly courageous decisions (Apollo 12 comes to mind in particular). But with the Shuttles the policy seemed to be "Launch unless proven unsafe". What about Apollo 12? Do you mean the decision not to abort after the lightning strikes? I attribute that to the MOCR rules "If you don't know what to do, do nothing" and "Never call an abort without two independent indications". I've always thought both rules are good ones that should get wider attention. Minor problems are often made worse by operator overreaction (again, Three Mile Island). The FAA does try to investigate close calls, so sometimes you can study what could have been serious accidents that were averted late in the chain of causes.
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Post by ka9q on Jul 19, 2010 15:59:31 GMT -4
I was reminded also of the Gare de Lyon railway accident in Paris in 1988 - a remarkably long sequence of events required to cause the accident, and preventing any one of them would have averted or greatly mitigated the severity of the accident. I was unaware of that one, so I just read about it. Yes, a very interesting chain of occurrences and unintended consequences. As a communications engineer, I find it interesting that a major contributing cause was a lack of identification of the runaway train. It's not so surprising that an analog radio wouldn't identify him, but he also sounded an alarm of some kind. I definitely would have expected it to identify the specific location. I wonder if the Shuttle or ISS comm systems identify the speaker. Probably not. Even though the over-the-air transmission is digital, the audio system within each spacecraft is probably a simple analog bus, just as they've always been. This feature just might be important in an emergency some day.
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