NTSB · Safety Recommendation
Safety Recommendation A-93-092
Recommendation
THE NTSB RECOMMENDS THAT THE DEPARTMENT OF TRANSPORTATION: REQUIRE THAT, AS A CONDITION FOR LICENSE FOR COMMERCIAL SPACE LAUNCHES, AS A MINIMUM, THE COMPANY APPLYING FOR THE LICENSE INCLUDE IN ITS LICENSE APPLICATION: A PLAN FOR APPROVAL OF A SAFETY DIRECTIVE OR SAFETY NOTEBOOK FOR THE LAUNCH TO EMPHASIZE THE SAFETY ASPECTS OF THE LAUNCH OPERATION AND TO CLEARLY LIST AND CONSOLIDATE MISSION CONSTRAINTS, RULES AND SPECIAL LAUNCH RULES, AS WELL AS ABORT PROCEDURES.
Safety Issue and Context
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS CARRIER AIRCRAFT. THE IGNITION AND STAGING OF THE PEGASUS AND ITS SUBSEQUENT DEPLOYMENT OF TWO SATELLITES INTO LOW EARTH ORBIT WERE ALSO UNEVENTFUL. THERE WERE NO INJURIES TO PERSONNEL INVOLVED IN THE MISSION AND NO DAMAGE TO MISSION ASSETS.
Response History
August 26, 1999 · NTSB Correspondence · DOT
THE SAFETY BOARD NOTES THAT THE FAA'S FINAL RULE MEETS THE INTENT OF OUR RECOMMENDATIONS. THEREFORE, A-93-87, -88, -89, -91 AND -92 ARE CLASSIFIED "CLOSED--ACCEPTABLE ACTION."
May 25, 1999 · Recipient Response · DOT
THE FAA RESPONSE LETTER DOES NOT ADDRESS THIS RECOMMENDATION, RATHER THE INCLUDED FEDERAL REGISTER FINAL RULE (14 CFR PARTS 401 ET AL. FINAL RULE) PART 415 (LAUNCH LICENSE) SUBPART C SAFETY REVIEW,,,SECTION 37 (2) PROCEDURES THAT ENSURE MISSION CONSTRAINTS, RULES, AND ABORT PROCEDURES ARE LISTED AND CONSOLIDATED IN A SAFETY DIRECTIVE OR NOTEBOOK APPROVED BY LICENSEE FLIGHT SAFETY AND FEDERAL LAUNCH RANGE PERSONNEL.
September 4, 1997 · Recipient Response · DOT
It was previously reported to the Board that changes were incorporated into the launch applications guidelines. The FAA has now published a notice of proposed rulemaking (NPRM) in the Federal Register proposing to clarify license application procedures and requirements for conducting space launches. This NPRM addresses the requirements for launch operations at federally operated launch ranges. I have enclosed a copy of the NPRM for the Board's information. Additionally, the FAA is initiating a separate rulemaking action proposing similar requirements to address launches from non-Federal sites.
I will provide the Board with a copy of the final regulatory document as soon as it is issued.
April 22, 1994 · NTSB Correspondence · DOT
THE BOARD NOTES THAT THE OCST, AS A PART OF ITS LICENSING PROCESS, REQUIRES APPLICANTS TO SUBMIT A DESCRIPTION OF THEIR SAFETY ORGANIZATION & PERSONNEL REQUIREMENTS. THE OCST IS ALSO STUDYING THE NEED TO EXPLICITLY REQUIRE THAT APPLICANTS PROVIDE CLEARLY DELINEATED STATEMENTS OF AUTHORITY FOR ALL PARTIES & KEY INDIVIDUALS INVOLVED IN THE LAUNCH. THE BOARD NOTES THAT THE OCST REQUIRES, THROUGH THE LICENSING PROCESS, ALL APPLICANTS TO DEMONSTRATE THEIR CAPABILITY TO CONDUCT SAFE LAUNCH OPERATIONS.
DUE TO THE APPARENT DEFICIENCIES IN PRELAUNCH OPERATIONS FOR THE PEGASUS/SCD-1 LAUNCH, THE OCST IS EVALUATING WHETHER TO REQUIRE THAT LAUNCH LICENSE APPLICANTS PROVIDE MORE SPECIFIC DETAILS & CRITERIA FOR LAUNCH READINESS REVIEWS & DRESS REHEARSALS, & THAT THOSE CRITERIA BE INCORPORATED AS CONDITIONS OF LICENSING. THE BOARD NOTES THAT ALTHOUGH THE OCST'S LICENSING PROCESS INCLUDES A REVIEW OF CRITERIA FOR DETERMINING READINESS TO LAUNCH, THE OCST IS STUDYING THE NEED TO REQUIRE THAT APPLICANTS EXPLICITLY DESCRIBE THEIR PROCESS FOR APPROVING CHECKLISTS FOR A LAUNCH, & TO INCLUDE A PROVISION FOR ENSURING THE CURRENCY & CONSISTENCY OF EACH PARTICIPANT'S CHECKLIST DURING DRESS REHEARSALS.
THE BOARD NOTES THAT THE OCST IS STUDYING THE NEED TO EXPLICITLY REQUIRE, AS A CONDITION FOR A LICENSE, THE MANDATORY REST PERIODS DESCRIBED ABOVE. ADDITIONALLY, IF THE OCST DETERMINES THAT SUCH A CONDITION IS NECESSARY, IT WILL USE HUMAN PERFORMANCE EXPERTS TO DEVELOP QUANTITATIVE CRITERIA FOR SUCH REST PERIODS TO ENSURE APPLICABILITY TO THE ASSIGNED TASKS. THE BOARD NOTES THAT THE OCST IS STUDYING THOSE LAUNCH SCENARIOS & TECHNOLOGIES WHERE IT WOULD BE APPROPRIATE TO REQUIRE FROM APPLICANTS, AS A CONDITION FOR A LICENSE, A COMMUNICATION PLAN INCLUDING THE TWO PROVISIONS IDENTIFIED IN A-93-091.
THE BOARD NOTES THE AT THE OCST IS INCORPORATING INTO ITS LICENSING REVIEW PROCESS THE REQUIREMENT FOR SAFETY DIRECTIVE HAVING STRICT CONFIGURATION CONTROL REQUIREMENTS THAT CLEARLY LISTS AND CONSOLIDATES ALL OPERATIONS INVOLVING THE SAFETY OF THE LAUNCH. THE BOARD NOTES THE OCST IS RESEARCHING THE COMMUNICATION ISSUE IN GENERAL & IS ALSO ASSESSING OPERATIONAL ISSUES IN THE CONTEXT OF AN ORBITAL SCIENCES CORPORATION PROPOSAL TO LAUNCH THE PEGASUS FROM COMMERCIAL L-1011 AIRCRAFT.
THE BOARD APPRECIATES YOUR RESPONSE TO RECOMMENDATIONS A-93-87 THROUGH -93 & HAS PLACED THE RECOMMENDATIONS IN AN "OPEN--ACCEPTABLE RESPONE" STATUS PENDING COMPLETION OF THE ACTIONS INITIATED BY THE OCST AS DESCRIBED IN YOUR JANUARY 11, 1994, LETTER.
January 11, 1994 · Recipient Response · DOT
OCST AGREES THAT IT IS BENEFICIAL FOR LICENSEES TO MAINTAIN, FOR USE BY ALL SAFETY PERSONNEL, A SAFETY DIRECTIVE HAVING STRICT CONFIGURATION CONTROL REQUIREMENTS THAT CLEARLY LISTS & CONSOLIDATES ALL OPERATIONS INVOLVING THE SAFETY OF THE LAUNCH. THIS CONCEPT IS GRADUALLY BEING INCORPORATED INTO OCST'S LICENSING REVIEW PROCCESS, BUT WAS NOT IN PLACE IN TIME FOR THIS LAUNCH. OCST WILL CONTINUE TO INCORPORATE & FURTHER DEVELOP THIS CONCEPT OF REQUIRING AN APPLICANT'S PLAN FOR APPROVAL OF A SAFETY DIRECTIVE, INCLUDING LESSONS LEARNED FROM THE NTSB INVESTIGATION.