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  3. NTSB A-15-028
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NTSB · Safety Recommendation

Safety Recommendation A-15-028

Recommendation

TO THE COMMERCIAL SPACEFLIGHT FEDERATION: Work with the Federal Aviation Administration to develop and issue human factors guidance for operators to use throughout the design and operation of a crewed vehicle. The guidance should address, but not be limited to, the human factors issues identified during the SpaceShipTwo accident investigation.

Safety Issue and Context

On October 31, 2014, at 1007:32 Pacific daylight time, the SpaceShipTwo (SS2) reusable suborbital rocket, N339SS, operated by Scaled Composites LLC (Scaled), broke up into multiple pieces during a rocket-powered test flight and impacted terrain over a 5-mile area near Koehn Dry Lake, California. The pilot received serious injuries, and the copilot received fatal injuries. SS2 was destroyed, and no one on the ground was injured as a result of the falling debris. SS2 had been released from its launch vehicle, WhiteKnightTwo (WK2), N348MS, about 13 seconds before the structural breakup. Scaled was operating SS2 under an experimental permit issued by

the Federal Aviation Administration’s (FAA) Office of Commercial Space Transportation (AST) according to the provisions of 14 Code of Federal Regulations (CFR) Part 437.

Response History

July 20, 2021 · NTSB Correspondence · Commercial Spaceflight Federation

We have not received any information from you regarding this recommendation since the October 10, 2016, letter, signed by Mr. Eric Stallmer, then President, CSF, which stated that CSF intended to work with the FAA to develop and issue supplemental human factors guidance for operators to use throughout the design and operation of a crewed vehicle. Pending our review of the human factors guidance developed that addresses the concerns discussed in Safety Recommendation A 15 28, it was classified OPEN-- ACCEPTABLE RESPONSE on February 16, 2017. Copies of previous correspondence are enclosed.

We normally expect actions to address our recommendations to be completed within 3 to 5 years. It has now been 6 years since this recommendation was issued, and we have not received any additional information regarding your actions to implement it. We would appreciate receiving a response from you within 90 days regarding actions that you have completed or planned to address this recommendation. Please update us at ExecutiveSecretariat@ntsb.gov on your progress toward implementing this recommendation, and do not submit both an electronic and a hard copy of the same response.

Thank you in advance for your prompt response and for your commitment to aviation safety.

February 16, 2017 · NTSB Correspondence · Commercial Spaceflight Federation

We note that you intend to work with the FAA to develop and issue supplemental human factors guidance for operators to use throughout the design and operation of a crewed vehicle. We point out, however, that existing human factors guidance for new systems was developed for civilian and military aviation and for government aerospace industries, not for the commercial space flight industry, and because the commercial space flight industry is relatively new, no such guidance exists that is specific to it.

We believe that such guidance could help ensure that human factors issues are fully addressed during a commercial space vehicle’s design, and also during its operation, by acknowledging human factors limitations in written guidance and simulator training. Pending the development of human factors guidance that addresses the concerns discussed above, Safety Recommendation A-15-28 is classified OPEN--ACCEPTABLE RESPONSE.

October 20, 2016 · Recipient Response · Commercial Spaceflight Federation

-From Eric Stallmer, President: The Commercial Spaceflight Federation (CSF) was provided two recommendations from the National Transportation Safety Board (NTSB) following their investigation into the Scaled Composites SpaceShipTwo accident. Our responses can be found on the following page.

We would also like to extend our willingness to participate in and assist with future investigations that may arise. We hope that the NTSB feels comfortable reaching out to us for assistance and expertise from the very earliest stages of future investigations so that we may optimize our contributions.

The Commercial Spaceflight Federation would like to thank the NTSB for the substantial amount of time and effort NTSB dedicated to this investigation. We appreciate the NTSB’s professionalism and patience, as well as its efforts to complete the investigation within nine months. CSF and the NTSB share the common goal of developing a safe and flourishing commercial space industry and appreciate the effort put forth towards achieving that goal.

The CSF will work with the FAA to develop and issue supplemental human factors guidance in addition to those presently in use throughout the design and operation of crewed vehicles, including human factor issues like those identified in the SpaceShipTwo accident investigation. Documentation and knowledge sharing are both integral in developing human factors guidance for commercial space transportation operators.

July 8, 2016 · NTSB Correspondence · Commercial Spaceflight Federation

When we issued these recommendations to you, we asked that you respond within 90 days detailing the actions you had taken or intended to take to implement them. However, in the year since they were issued, we have not received this information. We are interested in knowing whether and how you have implemented our recommendations, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Accordingly, we would appreciate a prompt reply detailing your progress in addressing these recommendations. Pending your timely response, Safety Recommendations A 15 27 and 28 remain classified OPEN—AWAIT RESPONSE.

The background and basis for Safety Recommendation A-15-27 can be found in Section 1.1.3.1, “Analysis of Emergency Response,” on pages 17 through 20 of our report on the October 31, 2014, SpaceShipTwo accident. Similarly, the background and basis for Safety Recommendation A-15-28 can be found in Section 1.4.1.5, “Analysis of Scaled Composites’ Consideration of Human Factors in SpaceShipTwo’s Design and Operation,” on pages 45 through 47 of the report. A copy of the report is available on our website at http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1502.pdf.

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Recommendation Facts

Status
Open - Acceptable Response
Issued
August 4, 2015
Priority
CLASS II
Recipient
Commercial Spaceflight Federation
Adopted
July 28, 2015
Related Investigation
DCA15MA019
Related Report
AAR-15-02