LOC investigations, DOD way, NASA way, major inconsistencies

read link

Subject: Investigations of LOC, DoD way, NASA way, —major inconsistencies

Cv22 report below
CAIB summary link provided

If you review a number of the DOD accident investigations with LOC(CV22, an example) and the CAIB , you come away with night and day differences in the manner the different organizations are treated.
Both NASA and DOD the primary cause is determined in a straight forward manner.
However, the DOD rarely mentions organizational /culture issues.  With NASA pages were written on leadership, communications, etc.  In both cases, lives were lost which is unfortunate.
With Columbia and challenger, extreme emphasis was placed on crew loss, heavy media coverage, boards which last many months whereas with DOD the opposite was the case.
The shuttle system, NASA working level personnel were not treated
fairly by CAIB. Personnel preformed well, but errors were made. This occurs in DOD but not made public. NASA being an open organization is at a disadvantage in these situations.
If DOD would have been operating the shuttle it would still be in service.

The shuttle system received unfair treatment which in the end cost the USA big money.  Congress and NASA leadership along with the
boards contributed to the tragic shuttle retirement. This would not
have occurred in DOD, since excessive media and public board coverage would not have been permitted

The shuttle would remain in service if under DOD.  Congress, adm, and NASA leadership with their actions have cost the USA in space leadership, and large amounts of money.  These impact the space effort up to 50 years. Maybe longer, since we are headed in the
wrong direction, back to expendables with less capability than what we have in shuttle. Aldrin is correct — evolve and use shuttle.
Although, not fair to NASA, for sake of USA security, DOD should take over and return shuttle to flight.
   
CV22 accident report—
Air Force Special Operations Command officials released the results of their investigation into the CV-22 Osprey accident that occurred April 9, 2010, near Qalat, Afghanistan. Four people were killed and 16 of the 20 people onboard were injured in the accident. The CV-22, like the one shown here, is a tilt-rotor vertical takeoff and landing aircraft. (Courtesy photo)
Download HiRes
 
Related Factsheets
• CV-22 Osprey
CV-22 accident investigation board results released

Posted 12/17/2010  Email story   Print story 

 
12/17/2010 - HURLBURT FIELD, Fla. (AFNS) – Air Force Special Operations Command officials released the results of their investigation into the CV-22 Osprey accident April 9, near Qalat, Afghanistan, that killed four people and injured 16 of the 20 onboard. 

The pilot, flight engineer, an Army Ranger, and a civilian contract employee were killed in the crash. 

Under the authority delegated to him by the AFSOC commander, the AFSOC vice-commander convened an Accident Investigation Board to investigate the matter, and designated Brig. Gen. Donald Harvel, the Air National Guard assistant to the commander, AFSOC, Hurlburt Field, Fla., as the board president.

Concluding the investigation, the board president could not determine the cause of the mishap by the standard of “clear and convincing evidence,” in part because the flight incident recorder, the Vibration Structural Life and Engine Diagnostics control unit, and the right engine were destroyed and therefore not available for analysis. After an exhaustive investigation of the available evidence, the board president ruled out multiple possible causes. Items ruled out included loss due to enemy action, environmental brownout conditions and vortex ring state. In addition, a design problem that led to the replacement of the Central De-ice Distributor support bracket found in all Marine Corps and Air Force Ospreys, was not a factor. 

The board president determined 10 factors substantially contributed to the mishap. These included inadequate weather planning, a poorly executed, low-visibility approach, a tailwind, a challenging visual environment, the mishap crew’s task saturation, the mishap copilot’s distraction, the mishap copilot’s negative transfer of a behavior learned in a previous aircraft, the mishap crew’s pressing to accomplish their first combat mission of the deployment, an unanticipated high rate of descent and engine power loss. Substantially contributing factors play an important role in the mishap sequence of events and are supported by the greater weight of credible evidence. 

The convening authority approved the board president’s report, with comments. While legally sufficient, he assessed the evidence in the AIB report did not support a determination of engine power loss as one of the 10 substantially contributing factors. The convening authority made this decision based upon the evidence in the AIB report and additional analysis of the evidence in the report. The convening authority concluded the preponderance of credible evidence did not indicate engine power loss as a substantially contributing factor of the mishap. 

After a review of the original AIB report, the convening authority’s statement of opinion and additional material obtained after the completion of the AIB report, the chief of staff of the Air Force reopened the investigation and directed the AIB board president to analyze the additional information. 

The board president conducted a follow-on investigation to analyze two Naval Air Systems Command reports and the convening authority’s analysis of video data. After consideration of the new material the only fact the AIB president changed from his original report was the ground speed of the aircraft at impact from what was believed to be 75 knots to 80 knots at the time of impact. The remainder of the findings was unchanged.

The primary purpose of the board was to provide a publicly releasable report of the facts and circumstances surrounding the accident. An executive summary of the report is available at http://usaf.aib.law.af.mil/index.html. 

The entire report is available at http://www.afsoc.af.mil/accidentinvestigationboard/index.asp or by contacting the AFSOC Public Affairs Office at 850-884-5515.

Sent from my iPad
read