By Lorenda Ward, Chief, NTSB Air Carrier and Space Investigations Division
When I read the Chair’s blog, “A Call to Action from Kennedy,” I asked myself, “Are we ready?” Not for commercial space exploration, but for the next commercial space accident investigation.
One of my responsibilities as the chief of the NTSB’s Air Carrier and Space Investigations Division is to ensure that our senior aviation investigators are prepared to respond to a commercial space accident. As the Chair outlined in her blog post, with the growth of commercial space launches and reentries, it is not a matter of “if,” but a matter of when.
What if we get the call today?
The NTSB has done a lot over the last several decades to prepare, including establishing the Quad-Agency Working Group with the Federal Aviation Administration (FAA), NASA, and the US Space Force, to build those important relationships between the agencies before a bad day happens. We meet regularly to discuss lessons learned and best practices from past investigations to ensure we are ready for the next investigation.
We also have a lot of training opportunities for our investigators that are above and beyond just attending industry conferences. Several years ago, I helped create a spacecraft design and systems engineering training course, as well as a commercial space externship program for our investigators to learn about the different space vehicles. We also take part in mishap tabletop exercises where we discuss the NTSB party process with both government and industry organizations. By far though, our best training opportunities have been the “on-the-job training” investigations that we’ve taken part in over the years. These investigations have provided us a great understanding of multiple launch vehicles and systems.
Responding to the Call
I remember leading the last fatal commercial space accident involving Scaled Composite SpaceShipTwo (SS2). I was actually at the site of another commercial space mishap, examining the recovered ordnance, when the SS2 accident occurred. Because of the possibility that cellphone signals could detonate unexploded munitions, our whole team had left our phones on the bus while we were at the storage location.
An FAA investigator who had stayed back came running into the bunker, saying we need to go now. I didn’t ask any questions and it wasn’t until I got back on the bus that I saw my boss had been repeatedly calling me for half an hour.
When I finally talked with my boss, he told me I would be the investigator-in-charge (IIC) of the go-team to investigate the first fatal commercial space launch accident. All the federal investigators (NTSB and FAA) had to work our way back from Wallops Island, Virginia, to DC. I had to keep pulling over to be patched into conference calls, so the commute took a lot longer than usual. At NTSB, we do not take calls while driving as distracted driving is a serious issue on our roadways. We have an agency-wide policy that prohibits staff from using a cell phone while driving. I remember at one point telling management I would never make it back to DC if I had to keep pulling over.
For the next 9 months, my focus was determining what happened to SpaceShipTwo. The accident occurred on October 31, 2014, when SS2 broke up during its fourth rocket-powered test flight and impacted terrain over a 5-mile area near Koehn Dry Lake, California. One test pilot (the co-pilot) was fatally injured, and the other test pilot was seriously injured. SS2, a reusable suborbital rocket, had released from WhiteKnightTwo, the carrier vehicle, about 13 seconds before the breakup. SS2 was destroyed, no one on the ground was injured by the falling debris, and WhiteKnightTwo made an uneventful landing.
Scaled Composites (“Scaled”) was operating SS2 under an experimental permit issued by the FAA Office of Commercial Space Transportation (AST) according to the provisions of 14 Code of Federal Regulations Part 437. The investigation identified several safety issues, to include the lack of human factors guidance for commercial space operators, missed opportunities during the FAA/AST’s evaluations of Scaled Composite’s hazard analyses, FAA/AST granting waivers from regulatory requirements, and an incomplete commercial space flight database for mishap lessons learned. The full report, safety recommendations and docket material, are available on the NTSB investigation page.
What Went Wrong?
The probable cause of the breakup was Scaled Composite’s failure to consider and protect against the possibility that a single human error could result in a catastrophic hazard to the SS2 vehicle. This failure set the stage for the copilot’s premature unlocking of the feather system which led to uncommanded feather extension and the subsequent overload and in-flight breakup of the vehicle. The accident vehicle had onboard video recording (cockpit image recorder) capability and the recording was obtained from a telemetry ground station located in Scaled’s control room at Mojave Airport, Mojave, California. This video was a key part of the investigation, showing cockpit displays and what actions the crew members took.
The Party System
All of our investigations use a party system, meaning that the operator and the regulator will be part of our investigation, at a minimum. For the SpaceShipTwo investigation, we invited Scaled, Virgin Galactic, Butler Parachute Systems, and the FAA to be parties. Scaled built and tested SS2 and had delivered WhiteKnightTwo to Virgin Galactic before the accident. Scaled had planned on transitioning SS2 to Virgin Galactic toward the end of 2014.
At the end of the investigation, a couple of the party members mentioned that when we first arrived on scene, wearing our blue jackets with giant yellow letters, they had no idea what to expect or what they were in for. They thought they were being invaded. For this reason, and others, we like to meet with commercial space operators before an accident, so we can explain the NTSB investigation process before we show up on their doorstep for an accident investigation. That initial reaction turned to one of trust as the investigation progressed. They said they were glad we led the investigation and had learned a lot from us. We, in turn, also learned a lot from all the parties.
Some party members also mentioned that they felt like full participants in the investigation, and that their voices were heard. To that point, the investigation would not have been completed in 9 months if we did not have the professionalism, openness, responsiveness, and willingness of the parties to trust our process.
To return to the question that I asked myself on reading the Chair’s blog: “Are we ready?”
Yes, we are ready. Nobody is more ready. This is what we do: Investigate. Communicate. Advocate.