REG NASA-LLIS-0372-1995 Lessons Learned - Loss of Instruments Caused by Balloon-Gondola Incident.pdf

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1、Lessons Learned Entry: 0372Lesson Info:a71 Lesson Number: 0372a71 Lesson Date: 1995-01-25a71 Submitting Organization: JPLa71 Submitted by: P.W. SchaperSubject: Loss of Instruments Caused by Balloon-Gondola Incident Abstract: A JPL built balloon gondola free-fell from an altitude of 102,000 feet, des

2、troying the payload. The gondola attachment fixture was designed to the requirements of the National Scientific Balloon Facility (NSBF), but the requirements were insufficient.The failure showed that FMECA analysis of flight hardware design is necessary to prevent excessive risk to high cost equipme

3、nt. The hardware interface design requirements of a non-JPL organization may not be sufficient to safeguard JPL flight equipment. Description of Driving Event: A JPL built balloon gondola, weighing approximately 4000 pounds and carrying a complement of five scientific instruments, free-fell from an

4、altitude of 102,000 feet. The gondola and all five instruments valued at $10M were totally destroyed upon impact. An accident review board concluded that the free-fall resulted from a structural failure of a “clevis base adapter“ which attached the gondola to the parachute, and that the adapter fail

5、ed because of excessive loads imposed on it by unusual parachute/gondola dynamics during the flight termination sequence. It was found that the design of the adapter met all requirements of the National Scientific Balloon Facility (NSBF), a NASA operated center for high altitude balloon support to s

6、cientific investigators. Investigative efforts subsequent to the accident found the NSBF requirements to be insufficient and also revealed that the flight termination sequence and its dynamics were not understood by NSBF. It is noteworthy that this flight was not the first flight of this type of bal

7、loon-borne payload, and that in several prior flight terminations, heavy stresses had been encountered that resulted in structural damage to gondolas, but not in catastrophic failures. For more details on the event refer to the report of the accident review board, JPL document D-1114.Provided by IHS

8、Not for ResaleNo reproduction or networking permitted without license from IHS-,-,-Lesson(s) Learned: 1. Failure to conduct a Failure Mode Effects and Criticality Analysis (FMECA) of flight hardware design can result in excessive risk to high cost equipment.2. Hardware interface design requirements

9、of a non-JPL organization may not be sufficient to safeguard JPL flight equipment.Recommendation(s): 1. All anomalies or indications of potential failure should be thoroughly investigated, analyzed, and if indicated, corrective action should be taken and the results verified.2. When undertaking rese

10、arch and development experiments with high cost equipment, all modes of possible damage or destruction should be thoroughly analyzed and an assessment made of the risk.3. When interfacing at the working level with a non-JPL organization that is not responsive to JPL needs or concerns, the problem sh

11、ould be escalated up the JPL management chain to the level where resolution is obtained.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Flight Equipmenta71 Safety & Mission AssuranceAdditional Info: Provided by

12、 IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Approval Info: a71 Approval Date: 1986-08-14a71 Approval Name: Carol Dumaina71 Approval Organization: 125-204a71 Approval Phone Number: 818-354-8242Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-