More Maintenance Error

NASA ties bolt to training scare

Procedure also blasted for Dec. engine mishap


CAPE CANAVERAL -- A bolt popped loose on an astronaut training plane last December, causing a heavy chunk of one engine to plop into the Banana River as a pilot practiced shuttle landings over Kennedy Space Center.
Ignored repair procedures, skipped inspections, excessively long work days and poorly designed bolts all were listed as possible contributors to the Dec. 2 incident that led to a temporary grounding of NASA's fleet of Shuttle Training Aircraft, space agency investigators found.

The fleet is back in service, and NASA officials pledged greater diligence in maintaining the custom-modified jets used by shuttle commanders and pilots to practice landing the orbiter.

"It scared us all because we don't want things like that to happen," said Ken Bowersox, the former International Space Station commander who recently was promoted to manage NASA's astronaut corps. "It made a lot of people more sensitive. . .There is plenty of life left in those airplanes, but we need to watch them because they are getting old. It's something that needs to be in the forefront of our minds."

The two trainers and astronaut pilot aboard the modified Gulfstream 2 jet were not hurt. Nevertheless, less than a year after the Columbia accident, the incident raised eyebrows. FLORIDA TODAY first reported the incident in January, shortly after the planes were restored to service.

A piece of an engine that dropped off a shuttle training plane is recovered from the Banana River near the NASA Causeway in December. Image 2004, Steven Van Meter, for FLORIDA TODAY
NASA refused to release the statements of the crew or witnesses, providing only a report summarizing the accident and investigators' findings. The severity of the mishap remains unclear.

The pilot, not identified in the investigation report or other documents about the mishap, was making a final approach to the three-mile long Kennedy Space Center landing strip on Dec. 2 as part of a series of simulated shuttle landings.

The plane was flying at 13,000 feet when a light flashed in the cockpit. Something was wrong with one of the thrust reversers, which are metal components that slide into place behind the jet engines to slow the plane and put it into a steep dive toward the runway.

The plane's computers ended the simulation and the training pilot took over to land safely. During a post-landing inspection, technicians noticed the thrust reverser and related parts fell off.

All told, the metal package weighed 585 pounds. It was five feet long and four feet wide. It plopped into the river a couple hundred feet from a highway bridge. Divers found it weeks later.

Investigators found several problems with parts and procedures as they delved into the accident, leaving the training planes grounded until they were sure what had gone wrong.

First, just days before the fateful flight, a repair crew at NASA's Ellington Field near Houston did not follow procedures for installing and inspecting the thrust reverser. And the lack of proper paperwork made it hard for investigators to trace the parts that were used for the repair.

Second, the day before the incident, a support crew that came with the aircraft to Florida worked a 19.5-hour day -- including a series of landing simulations late on the evening of Dec. 1. At the end of the workday, they apparently were too tired to conduct the routine post-flight inspections and did not file paperwork indicating the inspections were not done.

A crane lifts a piece of a heavy engine that dropped off a shuttle training plane and into the Banana River near the NASA Causeway in a December accident. Image 2004, Steven Van Meter, for FLORIDA TODAY
On Dec. 2, the crew preparing the jet for another round of flights was not aware the inspections had not been done the night before. So the plane flew without the engine area being inspected, though investigators noted there is no way to know if inspections would have caught the problem or prevented the accident.

The investigators were not able to determine if the bolt that failed was installed properly. Inspections of other NASA aircraft using similar assemblies found that the bolts might not be long enough to be tightened securely enough to lock in place.

Changes were made to installation procedures to fix the problem, but NASA has not decided whether to redesign the system used to fasten the thrust reverser parts into place.

"It's possible the guys did everything right, but did not document it exactly and that what really happened is the bolts vibrated apart," Bowersox said. "Maybe what we should have done is redesign the bolts six months earlier."

Overall, however, the incident prompted the agency to take a closer look at its fleet of astronaut-flown aircraft. That includes the jets used for landing simulations and the T-38 jets flown by astronauts to maintain piloting skills.

The findings of the Shuttle Training Aircraft incident, however, are strikingly similar to another mishap involving a T-38 in 1999. Ground crews and an astronaut pilot, apparently not following official maintenance and inspection checklists, missed a small part that got stuck in one of the plane's engines. No one was hurt, but safety officials issued a memo imploring everyone who works on and flies astronaut aircraft to follow procedures carefully to avoid accidents.

Contact Kelly at 242-3660 or

from this link


to Safety Menu