Theories are nice. Having a way of explaining an event or failure, or both is a nice comfort blanket. It can give us a way of trying to look ahead. The common notion that; if it has happened once, it can happen again, is part of our mental hard wiring. We store up memories and are constantly ordering and re-ordering them in our minds. Looking for patterns.
What cuts across is a simple factual recollection of an event. Examples can be illustrative of a theory. Also, they can stand alone as evidence that anyone of us can fall foul of the unthinkable. One of my favourite events, which has the ingredients of the unthinkable happened in the 1990s. It’s about exploration and the space industry. That said, a story on this theme could be written about any part of the aerospace world.
Safety assessments are scoped to consider about anything that’s not extremely improbable. Let’s be clear that’s an approach that consciously asks people to discount some events as absurd or never going to happen, just beyond what we would ever do. The lesson is that when considering how things go wrong it’s as well to be open minded.
Let’s go back to December 1998. A spacecraft called the Mars Climate Orbiter (MCO) was intended to skim the upper atmosphere of the planet and return data to Earth. It had taken over 9 months to get to Mars. A journey like that one come with costs mounting in the tens of millions.
The spacecraft was about to go into orbit, it disappeared behind Mars but failed to re-emerge. Efforts to communicate with it were continued for a long-time but nothing came back. An investigation into the MCO’s loss concluded that it had crashed into the surface of the red planet. This was not the crux of the matter. Such projects have risks that can be unknown.
Investigation concluded that the MCO had been obliterated[1]. It was off course by 60 miles, so it plunged to destruction rather than entering orbit around Mars.
Now, I said that anyone of us can fall foul of the unthinkable. In this situation, that’s what happened. The managing organisation for spacecraft thruster data had been using imperial units. Thruster performance data was in “English” units. NASA’s navigation team had assumed the units used were metric. The trajectory modelers assumed the data was provided in metric units as per their requirements. Thus, the difference between miles and kilometres sealed the fate of the MCO.
Discovering that cause of the loss must have been excruciatingly embarrassing. One of the published recommendations; take steps to improve communication, seems modest. In addition to taking on-board all the investigations findings, my take on this event is two-fold.
- Think the unthinkable. Not all the time, but every so often it pays dividends and
- Question assumptions. Even the most cherished simple assumptions can be wrong.
These two are universally applicable.
[1] https://llis.nasa.gov/llis_lib/pdf/1009464main1_0641-mr.pdf
John Vincent 