Blame it on Oliver Cromwell

NASA is keen on training its personnel.  I kept a list of all the training classes they sent me to take through the years. Single spaced, the list of just the titles of the classes takes a page and a half.  Seems like I should have learned something!   There were classes in software development and testing, classes in engineering topics such as stress corrosion prevention, classes in management and supervision.  But the best class was in Washington, DC in a conference room in one of the Capitol’s office buildings.  Legislative Operations was the name.  There were lectures and featured speakers including congressional staffers and lobbyists, political science professors, and various NASA officials.  We got to observe some committee hearings, discuss our observations, and we got to make the rounds on Capitol Hill visiting congressional offices.  All of this in the name of helping us understand how things really get done in Washington and how it affects our agency.

But the best and most memorable part of the class was a lecture by history/poli sci professor from GWU who explained to us how all this mess was really Oliver Cromwell’s fault.

I have told you before that I was forced to take a history course in college.  I picked “History of the Modern World” thinking it would be a current events class.  Turns out the ‘modern world’ in the classification of professional historians is anything that happened from the Renaissance to well, maybe a hundred years ago.  But we didn’t even make it to the American Civil War, too recent! We studied the English Civil War – something I had no idea existed.  In case you missed the class, there was war between the English factions who wanted either more power for the Parliament (by extension, the common people) and those who wanted more power for the King (and the nobility).  Over a decade of fighting between the Roundheads and Cavaliers (you can look it up) resulted in the triumph of the New Model Army, the Puritans, andthe Parliamentarian faction.  The King lost his head over that one.  When we later studied the French Revolution, some of the similarities were striking.  Professional historians will critique my two sentence summary of a pivotal period in English history, but that is the gist of what I remember.

This turbulent period ended with a fellow named Oliver Cromwell being proclaimed the “Lord Protector” – which is another way of saying he became absolute dictator.  Times were grim with the Puritan Major Generals enforcing all kinds of social restrictions on the people.  After about a decade, Oliver Cromwell died, and quietly the people threw off the Puritan restrictions and invited the King in exile back.

All this happened in the second half of the 1600’s.  Just about a hundred years later a group of Englishmen who colonized British North America tried to write a constitution that would organize a new government.  The example of what happened a century earlier was recent memory for them.  Firmest of the principles for the new government was that there should be no Oliver Cromwells.  No one should be able to exercise absolute power in the new government.  Instead there would be a system of checks and balances on power, and an ingenious way of guaranteeing that nothing would get done unless there was compromise between the factions.  No simple majority could ride roughshod over a numerically inferior group.  Consensus, compromise, and limits were to be the hallmark of the new government.

So when we complain about nothing getting done in Washington, the professor concluded, we should all blame Oliver Cromwell.  After all, if he had not set the example of how an absolute dictator establishes power, our forefathers might not have built a government which protects against it.  Seems they thought that efficiency in government should take back seat to more important principles. It appears they succeeded.

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King for a Day

“Arm chair generals study tactics; real generals study logistics” – attributed to General Norman Schwwarzkopf

Many of my old friends and colleagues are asking me a question these days:  “If you were NASA Administrator, what would you have the agency do?”  I know what they want to hear:  Moon, Mars, or Asteroid – what is the next destination for human spaceflight?  But that is not the answer I would give. Whatever ‘horizon goal’ is established, without significant organizational and cultural changes at NASA, the chance for success is in doubt.

To make NASA into the extraordinarily effective organization it once was and could be again will require significant work to transform it.  NASA is filled with extremely smart, highly motivated individuals who are the experts in their fields.  They can do amazing things.  Measured against any other organization – government or commercial – the NASA civil service and contractor work force is outstanding in terms of inherent capabilities and the desire to make their projects successful.

But success in NASA’s endeavors is hobbled by three structural and cultural problems:  (1) inter-center rivalry, (2) mind numbing bureaucracy, and (3) a paralyzing cultural requirement for perfection in all things.

These are the problems I would propose must be improved for any large scale program to be effective.  And frankly, resolving these issues exceeds the NASA Administrator’s authority.  Solutions will require not just concurrence from the President, but action by the Congress would be required.  And given that somebody somewhere would probably file a lawsuit regarding some of the directions, the Judicial branch would have to concur as well.  Rapid, coordinated concurrence from all three branches of government?  What are the odds of that?  So my title:  King for a Day.

So in the Libyan fable it is told
That once an eagle, stricken with a dart,
Said, when he saw the fashion of the shaft,
“With our own feathers, not by others’ hands,
Are we now smitten.”    – Aeschylus, Choephoroe 59

Topic 1:  break down inter-center rivalry.  NASA was established in 1958 as a collection of 10 loosely federated fiefdoms and it has never broken out of that paradigm.  If you ask a typical NASA employee who they work for, the response will be their center, not the agency.  Can’t blame them; they are hired through a center, promotions and career advancements come through their center, the very culture of the organization enforces loyalty to a center.  Every center has its local politicians and politics centered on local interests, every center has its own history and area of expertise, and every employee is inculcated with the beliefs and norms.  Centers sometimes seem united only in their disdain for NASA Headquarters.  Not that anybody openly works to sabotage direction from Headquarters, they just bend the direction toward what their individual project and center would like to do.  Competition for scarce resources drives rivalries between centers.  In addition, there is a huge ‘not invented here’ problem everywhere.  Not just with any idea from an organization outside NASA but also with any idea from another center.  It makes the workforce ready to find fault, slow to see the advantages of any new thing not born from within their own organization.  Secretive, competitive, and ultimately destructive of the larger purpose, these behaviors have been worse in the past but are still present.  My solution:  make people move.  Many organizations both government and industry do this as a matter of course.  Move not just the senior leaders, but the journeyman workers.  Take the center name off the badges.  Develop a ‘Bureau of Personnel” to centralize promotions, bonuses, and career advancement.  No small tasks these.

“A system under which it takes three men to check what one is doing is not control; it is systematic strangulation.” – Admiral Hyman G. Rickover

Topic 2:  mind numbing bureaucracy.  The organization has evolved, as all bureaucracies do, to the point where too many people can say ‘no’ to any action.  In the early days of NASA, this was not so.  It is good to have checks and balances and oversight, but the pendulum has swung too far in the direction of (electronic) paperwork, diffuse responsibility, and inaction.  The system now has watchers watching watchers watching doers – and always with criticism for the doer.  Corrective action will take serious attention from any leader.  Achieving the proper balance may well be impossible and the best we can hope for is to swing decision making back to the lowest level possible.  Gibbs Rule #13 applies here:  Never involve the Lawyers.

 “The desire for safety stands against every great and noble enterprise.” – Gaius Cornelius Tacitus

Topic 3:  the cultural imperative to make everything perfect.  This is a very sensitive topic for me.  I have personal been involved with decisions that were made with too little information, riding roughshod over the experts in the field.  But these days, after Columbia, the agency is paralyzed by requiring too much:  too much data, too many tests, too much analysis.  In the Apollo days, this was not so.  We – and I am a guilty party in this – have trained the work force to make everything perfect before any project can proceed.  In this business, nothing is ever perfect.  Space flight involves risk, it can never be completely eliminated.  But real space flight is actual flight, not studies and ground tests.  It is difficult to find the balance of having done enough to be reasonably sure of success and safety and to get on with a project and actually fly.  I hate the term ‘risk averse,’ but as much as it makes my teeth grate, the effect of wanting to make every detail perfect has the same outcome as cowardice: never flying.

So when folks ask me that question:  “If you were NASA Administrator, what would you have the agency do?”  I have a rueful look on my face and tell them any destination – or all three – are good; the tougher job is what we must do to ensure that we get there.

 

            “Come, my friends,

‘Tis not too late to seek a newer world.

Push off, and sitting well in order smite

The sounding furrows, for my purpose holds

To sail beyond the sunset, and the baths

Of all the western stars, until I die.

It may be that the gulfs will wash us down;

It may be we shall touch the Happy Isles,

And see the great Achilles, whom we knew.”

  • Tennyson’s Ulysses
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Flying with the Window Shades Down

Second only to space, I have always been very interested in aviation.  To this day I am thrilled to get to fly on any type of airplane – well, maybe not about the security lines, but I am thrilled about the actual flying.

I grew up in a time and place where people actually went to the local airport just to watch the airplanes land and take off.  Seems silly now, but aviation is like magic in many ways.

I always search out a window seat and curse my luck when I can’t get one.  I like to watch them marshal the planes around the gates and I study the taxiway patterns.  I always check to see if the flaps are set properly (at least on my side of the airplane) and am mentally prepared to ring the flight attendant call button to send a message to the pilot if it doesn’t look right.  During the takeoff or landing roll I count the distance remaining boards on the runway to see how fast we are accelerating or stopping.  I find it all so very interesting and entertaining.

In flight I am fascinated by what I can see out the window.  I love those flight tracking programs that keep me updated on where we are; watching the geography unfold below me is endlessly fascinating.  And especially out west, where the vegetation is sparse, contemplating the geology and land forms is intriguing.

But best of all is watching the weather.  Back when I was a Shuttle Ascent/Entry Flight Director we hung on every word that the airborne weather observers would radio down to us.  On every airline flight I would study the clouds and imagine how I would describe them to Mission Control – good practice in understanding what the weather pilots would report to me later.  Thin high cirrus clouds – are they translucent or opaque?  Not an easy call some times, but the difference would have a dramatic effect on a shuttle deorbit call.  Lower puffy clouds –are they building and showing precipitation forming?  Or are they just fair weather cumulus?  How high are the bases?  Is the coverage more or less than 50% – the difference between scattered and broken – the difference between go and no-go? Watching the gravity waves in stratus clouds, lightning erupting from towering cumulus, uncanny demarcation lines between a cloud street and clear skies; all endless fodder for study.

And beautiful as well.  Pastels that cannot be captured by any camera.  Endlessly changing.

So, I love to fly in a window seat, with the window shades open.

Lately however, I’ve been getting a lot of dirty looks from people sitting near me.  The light coming in from the window is making it hard to see their little electronic screens where they are watching some fiction or sending some emails.  They want me to close the window shade so they can live in their virtual world unimpeded by light from the real world.

Nobody yet has been bold enough to request a lowered shade, but I expect that any time now.

What does it say that we are more interested in the virtual than the real?  When did the real world –with all its beauty and imperfections become less interesting than a manufactured flickering ephemeral images of vapors and imagination?

Not that imagination is bad, far from it.  But whose imagination?  Yours or somebody else’s?  And what fuels that imagination? Is it rooted in the real world?

Some profound message may be hiding here, but in my simple way it makes me worry.  We can hope to improve the world, but it is not a good thing, I think, to believe the world is different than it is.  We all have to live in the real world and deal with it – good and bad, beautiful and ugly, joyful and painful.  Hiding in the dark doesn’t seem to me to be the way to have a full, successful, and happy life.

So I won’t be flying with the window shades down, but I will be looking out there, studying.

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The Triumph of the Flexible Path

These days I frequently travel to the Denver area for personal and work reasons.  Driving in from the south, just at the edge of town, I always think when I pass the big Marriott at the I-25 Lincoln street exit:  “That’s where the space program changed.”  Let me explain.

Just as my year of ‘education’ was ending in 2009; poof! – a new administration came in.  Everything changed, subtly at first but nevertheless significantly.  While we were waiting for a new Administrator to be nominated, the OMB and OSTP commissioned a blue ribbon study group: “The Review of Human Spaceflight Plans Committee” more popularly known by its chairman’s name as The Augustine Commission.

Several of us NASA HQ types were assigned to provide assistance to the commission:  Phil McAlister was chosen to be the ‘Secretary’, Tricia Mack was his assistant.  Tom Cremins and I were assigned to provide support along with a few others.  We soon found out that the committee members did not want the opinions of this support staff, we were responsible to ensure only that the experts they wanted to hear were provided to them.

Many of the meetings were public, but the pivotal meeting that I recall most clearly was not.  The west coast members started complaining that all the meetings were held on the east coast causing the westerners to bear the biggest travel burden.  An arrangement was made for a meeting in late July in Denver, near the Lockheed-Martin facility building the Orion spacecraft.

As the meeting evolved, no side trip to visit to the LM plant happened. Various experts were called to the Marriott to be interrogated by the committee.  It was at this closed meeting in late July that I recall hearing Dr. Ed Crawly first mention ‘the flexible path’ as a possible plan for human space flight.

It was clear that there was just not enough money in the out-year budget plan to fly the shuttle, fly the space station, build the big rocket that everybody felt was required for deep space missions, and develop the landing vehicles as well.  Even with the shuttle retired, the committee felt that at least $3B a year would be required to continue the existing plan.  As Norm Augustine put it in one of the public sessions later on ‘It appears you can’t have a very interesting space program without an additional $3B per year.”

Since OMB was implacably opposed to additional money for NASA’s budget, ‘The Flexible Path\ plan evolved as a way to allow development of the early parts of any human deep space plan until more money would be available under a future administration.

After the report was published, the ‘Flexible Path’ option quickly became nicknamed ‘The Path to Nowhere’.  Not really accurate, but right up there with the assertion that NASA had spent the last 30 years ‘going around in circles.’  Various factions have always been ready to apply disparaging labels to any plan they oppose.

The new administration liked a hodgepodge of the ideas in the Augustine commission.  Particularly they seemed to like a policy which would return NASA to its predecessor agency NACA’s status as a research and development organization while providing financial encouragement to private industry to develop new, more affordable space vehicles.  This would be a complete break with the previous goals and policies that NASA had been instructed to accomplish.

After the administration announced the cancellation of Constellation on February 1, 2010, there was a huge disconnect between the administration and the congress.  After months of contentious wrangling, a compromise (there is that magic word!) or more accurately a tense détente resulted.  The money which was proposed to go to R&D was largely moved to build a big rocket – no longer called Ares V but SLS.  There was continuation of development of a deep space capsule – Orion – and increased support to commercial space development for transportation to LEO.  And there we stand to this day.

Bill Gerstenmaier has masterfully orchestrated the political and financial resources available for human space flight.  He has sought to maximize progress toward both commercial crew and cargo to LEO but also develop the big rocket and deep space capsule.  But in the near future, the wherewithal to build a landing vehicle (think of it like the descendant of the Apollo LM) must come.  Lander design depends on where we would land:  a design that would work on the Moon would not work at Mars and vice versa.

And where is the money to come from?  When the shuttle retired, one might have expected NASA to keep all that money to apply to future projects; sadly that was not the case, funds have eroded.

So everybody is anxious to see what the incoming administration will direct.  The crystal ball is cloudy.  Will it be the Moon?  Will it be Mars?  Probably not the Asteroid Retrieval Mission.  Or will it be stasis:  giving NASA just enough budget to continue development of the vehicles and systems in work today and waiting for some future time when the money will become more readily available?   The clock starts ticking at noon on January 20.

Meanwhile, of all the options that the Augustine commission offered, the Flexible Path is the one we have chosen, whether we wanted it or not.

And when I see that Marriott in Denver again, I will still think:  that is where America’s space program changed.

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The Road Not Taken

I always knew what I wanted to do:  anything in the space program.  Getting a job offer to come to work at NASA Mission Control in Houston was beyond my wildest dream.  To tell the truth, I would have paid them to let me come and sweep out the floors.  But it worked out much better than that.

The very best job I ever had was that of Flight Director.  Each flight was different, but we put together the teams, decided how we would approach the challenges, and trained like the devil.  Every shuttle flight was an exercise in pure adrenaline rush.  Whether it was two days or three weeks, nothing else in life mattered while the shuttle was in flight – every waking moment spent reviewing, planning, preparing, and then executing the most difficult and riskiest work I know.  After the flight was over, well, sometimes I needed to sleep for a week.

One short illustration; as the Entry Flight director (26 times!) I had to go over to the press room after the landing and sit with the Program Manager for the press conference.  Generally, there were only a handful of reporters present, but there were many more watching the video and tied in by phone to ask questions.  I was always exhausted; running on fumes as they say by that point.  I learned that the Entry Flight Director got to make a little opening statement, how great the landing was, how challenging the weather was, so forth.  Then the Program Manager made a statement about the flight just over and the challenges upcoming.  Then the media questions started.  I quickly learned that there were never any questions for the Entry Flight Director.  After all, the landing went fine; it was over, what more could I have been asked?  All the questions went to the Program Manager.  And the Program Manager could drone on with long and involved answers as to what might or might not be next.  There were two cameras in the media room, a wide shot that captured both the PM and me, and a narrow shot that was focused on whichever of us was speaking.  The red light indicated which camera was active.  When the narrow shot was on the PM, I could nod off – for just a short while – close my eyes, rest my brain.  But I had to be awake enough to know when the PM was winding up his long answer and the wide shot was going to be selected.  Time to look alive!  I practiced this trick many times.

Getting to be Deputy Program Manager, and later PM, I got to practice the other end of the media role – a lot less fun, I must say.  In fact, I never enjoyed the Shuttle PM job as much as being a Flight Director.  To this day if the Chief of the Flight Director Office were to call me up and ask for my help, I would be there in an instant.  Unfortunately, being a Flight Director is a young person’s job – quick reflexes, quick study of the issues, and indefatigable alertness even in the wee hours of the morning when all is going boringly well because the next moment may not be boring at all.

After five years in the Shuttle Program Office as deputy and chief, Mike Griffin asked me to take a role that would let me learn about ‘the whole agency’ as he put it.  It was really time for me to have a change, so I went on HQ staff – but they allowed me to work and live in Houston.  It was an eye opening year as I learned a lot about Washington, and about the various parts of NASA beyond human space flight.  Sitting with the Administrator in the Heads of Agencies meeting in Paris gave me a glimpse at how hard it is to hold together the fragile international coalition that keeps the ISS going.  Sitting in on Congressional hearings gave me the strong sense that, in spite of the theater involved, the real work at HQ was earning the respect and support of the legislators who ultimate decided what resources the agency would get.

Just as my year of ‘education’ was ending, poof – a new administration came in.  Everything changed, subtly but nevertheless significantly.  I was pleased to help support the Augustine Commission during the summer months; another intensively educational experience.  Following that, Bill Gerstenmaier assigned Frank Bauer and I to develop plans for the proposed Commercial Crew program since that was clearly one of the common themes from Augustine Commission likely to be approved by the new administration.  Meanwhile, Charlie and Lori were nominated and confirmed as the new heads of NASA.

I made it known that I would be happy to have to more substantive role, feeling that my ‘sabbatical’ was over.  But, despite repeated inquiries at NASA HQ, JSC, KSC, and MSFC, there appeared to be nothing for me other than to continue in my support role.  As the shuttle program wound down, most of the other senior leaders in that program found themselves in the same situation; no place to put that talent to good use inside the agency.  With the cancellation of the Constellation program, NASA was awash in senior leaders without jobs.

Being well past the age and years of service to take my retirement, I turned in my paperwork and thought about what would be next.  Bill Gerstenmaier offered to bring me to Washington to be of closer assistance to him, more about that later, but by the time of that offer I had made my decision.

I found a small, family owned specialty engineering firm run by ex-NASA folks which was a good fit for me.  It was a place where I could bring my experience and lessons learned to the aid of the new companies building the new vehicles on a commercial basis.  This continues to be very exciting work and I like to think that I have provided critical help to several organizations.  It has been a new component to my education to closely observe how private industry makes decisions.  Certainly different from the government.  And it has been extremely interesting to deal with some of my old colleagues and organizations from the vantage point of the outside.  Makes it much more clear how the government could be more effective.  Finally, I have been asked to volunteer my time (that’s right – unpaid volunteer) to advise both NASA and the FAA Office of Commercial Space.  Additionally we are working with Johns Hopkins University Energetics Department to document lessons learned from reusable space vehicles.  Hopefully this will help future programs be more successful, especially in the financial sense.

Still, my heart is with NASA, and I wake up about once a week wishing that I were back in the agency, back in the trenches fighting the good fight to advance human space flight.  Maybe back in mission control making sure that we get the most research possible accomplished.  Maybe back in Washington haggling with the OMB about funding levels.  I don’t know, back there somewhere substantive.

I wonder about that last minute job that Bill G offered me, to come to DC and help him directly.  Would I have made a difference?  Would plans and goals have evolved differently?  Could I have made a difference in the budget wars?   Or would an old Flight Director just have mucked things up? But one thing is for certain, that was the road not taken.  And you can’t change the past.

I believe I am making a contribution in a different way right now.  And, oh-my-goodness, I don’t miss the sheer bureaucratic nonsense that my still-working colleagues remind me about on a regular basis.  Changing an Agency is very hard.  I think that there may be a number of folks in the new administration who will try to change various agencies in their goals and internal culture.  I wonder how likely that is to succeed.

When I was having a particularly hard time with some of the bureaucrats at NASA HQ, I encountered a group of retired senior JSC leaders one day and asked them how they dealt with HQ in their day.  They just laughed at me.  And then one of them said: “Just remember, they won’t be there very long.”

You can take that several ways.  And for the record; I really don’t want to work in Washington.

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Auld Lang Syne

The last day of 2016 is appropriately dreary here with rain and a damp chill.  Just the thing to reinforce a melancholy mood or at least induce a good nap.  All around it seems every media outlet has complied their list of notables that we have lost in 2016.  This is as it should be.  These shared lists run to actors and singers and other entertainers.  Too seldom do they list the heroes whose names are not written on stars in the sidewalk but who made a real difference in someone’s life.  Pity, that.  We need to be reminded of heroes more.

Many of us take a cup of kindness yet to remember those who have departed that will never show up a list of ‘notables’ except in our hearts.  Family and friends no longer with us who shared themselves in uncountable ways.  Faces no longer to be seen except in old photographs or their digital cousins.  Voices ditto no longer shared fresh daily but sometimes played back from a recording.  Quiet stillness everywhere but always alive in our hearts.

It is now commonplace to remind one another that no one ever ‘gets over’ a loss, but that time can fade the pain somewhat.  For those who have lost a loved one this year, that anesthetic has scarce effect.

So at the end of the year, in melancholy fashion, it is right and proper to remember those departed so dear to us.  Tomorrow will dawn a new and bright new year full of promise and fears; how that will turn out depends on us.  Tomorrow resolve to hug those dear to you a little tighter; to make on new occasions memories that will remain fragrant through the years no matter what else may come.

“Will the circle be unbroken,

by and by Lord, by and by?

One by one their seats were emptied.

One by one they went away.

Now the family is parted.

Will it be complete one day?”

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Accident Investigations

This week’s crash of a commuter train in New Jersey plus other recent events got me thinking about the lessons I have learned the hard way through several accident investigations.

One of the toughest parts of investigating an accident is that everyone wants to know the answer, the cause, right away.  Folks, it simply does not happen quickly.  Accidents involving complex high energy systems are tough to figure out.  Even little incidents can be hard:  as we used to say in the shuttle program:  “The first story is always wrong”.  It takes time to get an accurate picture and compile the evidence.  It will be long after the news cycle has moved on to other things before the true cause becomes apparent in these complex systems failures.  The boss and the media want answers right away and sometimes will make something up – or at least grasp on the first theory – to get a quick answer.  Real accident investigators know it takes time.  Typically the NTSB takes a year to finalize their reports; I’d have to say that is about right in most cases.

So I’d offer this explanation about why it takes so long.  And I would offer a few tips and rules from my experience.  This is not what they teach in accident investigation school where the emphasis is typically on preserving the data, making sure the evidence is uncontaminated, gathering witness statements, collecting the maintenance records, examining training records, and the other mechanics of the process – which are important.  These rules are in addition to those good practices which should be followed at all times.  Sort of ‘Gibbs Rules’ here:

Rule #1 for accident investigators:  keep an open mind.  Do not start making theories too early. Stay away from quick conclusions and let the facts lead to the conclusion, not the other way around.  This is very hard to do, not to start spinning theories right away.  Don’t speculate and don’t let others lead you into conversations that speculate on the cause. It is amazing how biased thinking becomes and how easy it is to overlook evidence once your mind (consciously or subconsciously) believes it has a conclusion.  Keep an open mind as long as you can.  When we had shuttle ‘anomalies’ the first analysis was almost invariably wrong and sometimes it would take months before we got to the correct conclusion.  Fixing the wrong thing is never helpful.

Rule #2 for accident investigators:  make a good, comprehensive timeline of all the information around the time of the accident.  This is not as easy as it sounds.  In the rocket business we always have a stream of telemetry of pressures, temperatures, valve positions, operating speeds, etc., recorded in a central place.  But sometimes the telemetry is built up from different sources on the rocket or on the ground.  It is important to dig into the time sources and make sure every event is put on a master time line with the correct and cross correlated time.  When milliseconds count, as they often do in these investigations, make sure that time lags and adjustments in the system are fully understood and accounted for.  For other evidence, video from external cameras for instance, be certain about the timing source, make sure the frame rate of the video is accounted for.  It is vitally important that video or still photos give their evidence in the right time frame.  Knowing what happened when, in the right order is the most powerful tool in the investigator’s toolbox.  Getting all the evidence and timing right can take weeks.  Be patient and adjust the timeline as the evidence comes in.  Continue to keep an open mind at this stage.

Rule #3 for accident investigators:  make sure the physical evidence is examined by a dis-interested third party that is well qualified to evaluate it.  To avoid the appearance of impropriety that may cloud a final report, using a well-qualified lab that is not associated with the manufacturer or operator of the equipment is vital.  Well qualified labs and experts are hard to find and often expensive, but it is worth the time and cost to come to a final conclusion that is as free of controversy as possible.

Rule #4 for accident investigators:  make a fault tree.  This helps the accident investigator build up knowledge about the system and makes sure that all possible causes are investigated.  Fault trees typically are of less use than the outside world may think.  The most important result from building the fault tree is that it makes the accident investigators aware of all the items that need to be examined.

Rule #5 for accident investigators:  ask ‘why’ seven times.  It is much too easy to come to a first level conclusion and leave the investigation.  That is guaranteed to result in future accidents.

I have no idea why the train crash occurred, but let’s take an imaginary trip through the kind of questions that an accident investigator should ask later in the investigation when a proximate cause is identified.  Here is that strictly hypothetical example: Q1: Why did the train not stop? A1:  The brakes failed to apply when commanded by the operator.  Q2: Why did the brakes fail?  A2:  part X in the braking system failed.  Q3: Why did part X in the braking system fail?  A3 It was installed improperly at the last maintenance period. Q4:  Why was part X installed improperly? A4:  The maintenance installation procedure was incorrect.  Q5:  Why was the maintenance procedure incorrect? A5:  The procedure was not updated when a new part manufacturer was selected to build part X.  Q6: Why was the procedure not updated?  A6:  The process for updating maintenance procedures did not allow for a change in part manufacturer.  Q7:  Why did the process not allow for a new manufacturer:  A7:  It was not foreseen that a new part manufacturer would make a part that needed new installation procedures.  Following this hypothetical case – and just note that I know nothing about the train crash, I am just making this up as a teaching tool – an accident investigator would find that the proximate cause of the accident was a braking failure, but the root cause was an inadequate process to account for new part manufacturers and the corrective action is to update the maintenance procedure change process to ensure that when a new part is introduced, the maintenance procedures are updated properly.

It is easy to see that if one quit with the part failure, a band aid fix would probably ensure that that particular part never failed again, but other failures could occur.  Similarly if at step 3, the investigation were to blame the maintenance person who installed the part, not only would an injustice occur, but the way for other failures in the system would be left open.  It is important to get to root cause – which is almost always a process problem – and address that as well as the more simple corrective action for proximate cause.

All of this takes time and discipline.  Months may pass before the real cause of the accident can be established.  That is true for rocket ships and airplanes and I’m sure it’s true for trains.

Don’t expect the media to get this right, or even care about it when the final report comes out.  Short attention span there.  The important thing is that the source of future accidents has been cut off.

Rule #6 for accident investigators:  there will always be conflicting and confusing information.  It is very rare in these failures of complex systems to come to a one and final guaranteed 100% conclusion.  There are always counter indications and other possibilities.  A good accident report will always give the most likely cause and list other causes which are less likely but cannot be completely ruled out.  Absolute certainty is not something that engineers or accident investigators deal in.

So be patient and let the investigators do their job.

Oh, and follow Gibbs rule #13.  Look it up.

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