5 ms·

The key question that everyone, especially SpaceX, should be asking is why was it even possible to run the test while Cabada was in an unsafe place? System and

by mabbo 4y ago

The key question that everyone, especially SpaceX, should be asking is why was it even possible to run the test while Cabada was in an unsafe place? System and safety design- a topic that a rocketry company should be deeply familiar with- should lead us to solutions where bad things are exceedingly impossible. Where you have to be trying to cause an accident for it to happen. This should extend beyond the product being built itself, to the factory, to the R&D, to every part of the organization where danger exists. And when failure occurs, it behooves you to shout from the rooftop that you messed up, and show the world how you're making changes so it can't happen again. Being quiet about the failure of your system makes it sound a lot like you aren't planning to make any changes to it. It's a bad culture to start in a rocketry company.

happyopossum 4y ago
The idea that every accident can be prevented by delight is a ridiculous and utopian trope, and to demonize an entire corporate culture and group of 12k employees without any background information is the height of hubris. Nobody would ever design a ladder that cannot be climbed without a safety harness being properly worn, but many people are injured or killed in ladder accidents at workplaces every year. In your world that's a design failure, but out here in reality it's often carelessness or sheer bad luck.
- karlmdavis 4y ago
  To extend that line of argument a bit, what about a more professional tool/system, e.g. cherry pickers? Doesn’t it seem reasonable to you to design and engineer cherry pickers such that the bucket can’t be moved unless a safety harness is attached?
  - happyopossum 4y ago
    > Doesn’t it seem reasonable to you to design and engineer cherry pickers such that the bucket can’t be moved unless a safety harness is attached? No - that seems unreasonable too, as there's no reasonable way for the cherry picker to know if the harness is being worn by anyone, so it's just safety theater.
    - TheCoelacanth 4y ago
      Combine it with immediately firing anyone caught attaching an empty harness to a cherry picker and the cherry picker can be reasonably sure that the harness is worn by someone.
- toss1 4y ago
  Do not make The Perfect an enemy of The Good. Merely because some accidents still happen despite motivated and brilliant people working to prevent them does not mean that the effort should not be made. You don't abandon the endeavor, but nor do you just throw caution to the winds. The article had a great example of a competing space company with an evidently solid safety culture; an accident was reported, and inspection done, and zero issues were found (which is quite difficult to be good enough have an OSHA inspection find nothing of note) >> Relativity has a strong safety record relative to others in the industry, with just one OSHA safety inspection since it was founded in 2015. The inspection, spurred by an accident, did not result in a violation.
  - merely-unlikely 4y ago
    Considering Relativity hasn't actually launched a rocket yet (they are aiming for first launch this year), they are more a prospective competitor.
  - happyopossum 4y ago
    > Do not make The Perfect an enemy of The Good. That's all well and good, but you also can't demonize an entire culture based on unrealistic navel-gazing. It's entirely possible this was a process or design problem that could have been prevented, but it's also possible that it's not - pretending you know based on few details in a one-sided article is pretty silly.
    - krisoft 4y ago
      > pretending you know based on few details in a one-sided article is pretty silly No. It is not. There is one telling detail in the article. SpaceX was fined by OSHA. That pretty much means in itself that there were things SpaceX shoulf have done which they didn’t. We can’t and won’t do each our own investigation. Nobody believes that the article has enough details to decide the case on its merrits. But we know that someone professional did the investigation and found the company violated the safety norms. That is what we have these agencies for.
      - 4y ago
- knome 4y ago
  >but out here in reality This, I expect, is exactly the kind of bad cultural attitude that @mabbo was referring to. You're advocating for accidents as being an unavoidable cost of business while preemptively hand-waving them as being the fault of careless employees or fate. As @P5fRxh5kUvp2th points out, there are established industry safety measures to avoid exactly these kinds of accidents when working around dangerous machinery, in the lockout/tagout system. If tests are locked out while employees are tagged into an area, you can't accidentally smack them into a coma with an over-pressurized part blowing out. By requiring tag ins to access dangerous areas, you don't have to have employees remember someone is out there, or that a test is coming, or worry about anyone getting confused on either front. Blaming the employee for being where they shouldn't be or the other for running tests when someone was nearby is a cop out. It shouldn't even be possible for it to happen at all. Design your systems and processes to expect that humans are fallible.
  - chinabot 4y ago
    Impossible. Humans will find a way to bypass anything.
    - falcor84 4y ago
      As a kid, I remember a lot of people complained about how annoying car seatbelts are, and tried to avoid them, but I haven't heard that sentiment at all in the past 20 years - everyone I know is perfectly happy with them as a safety measure. It seems to me it just required some time for the culture to shift.
  - vkou 4y ago
    > You're advocating for accidents as being an unavoidable cost of business while preemptively hand-waving them as being the fault of careless employees or fate. This needs seconding. It's ridiculous to say that we can't demonize an entire company of 12,000 people, and in the same breath, turn around to demonize the line workers of that company. It's no less ridiculous to instead demonize the line workers that got hurt, which seems to be both post-facto cherrypicking, and victim blaming.
- bombcar 4y ago
  You replace ladders with scaffolding and cherry pickers or similar things, though those too can have their safety issues ( https://www.youtube.com/watch?v=8YBxOA-aQQE https://www.youtube.com/watch?v=8YBxOA-aQQE ) I guarantee you that every job site manager in the WORLD can identify the unsafe employees, even if they're doing 'everything by the book'. Some of it can be designed away (two-hand tools for example) but some of it is basically inherent.
  - metadat 4y ago
    Accepting at face value the claim that "every job site manager on earth" really can identify the "unsafe employees", then these managers are negligent and thus culpable for the failed outcomes. An infinitely better course of action is to ban all known-unsafe employees from operating in the risky path. Workers who unnecessarily put themselves and everyone else in jeopardy have no business being in the path. With that said, I'm highly skeptical about the veracity of this claim. Human behavior is fundamentally unstable, oscillating in the continuity spectrum between stable and erratic. However, the amount of variability for a given individual tends to be stable, which may be what you are saying a good and effective manager should be able to catch. Regardless, humans are wetware and fundamentally error prone. Best to account for this element of our nature in the larger system design.
- deleted 4y ago
  [deleted]
P5fRxh5kUvp2th 4y ago
> The key question that everyone, especially SpaceX, should be asking is why was it even possible to run the test while Cabada was in an unsafe place? absolutely. lockout/tagout may seem unnecessary, but it's specifically to avoid exactly these types of situations. Not is it not possible for someone to be in an unsafe place, it's not possible for miscommunications such that it BECOMES unsafe after the fact because that lockout is with a lock no one else can unlock except the person who did it. It obviously requires humans actually DO the procedures, but I think that's part of the point with the question.
- Jtsummers 4y ago
  > lockout/tagout may seem unnecessary, but it's specifically to avoid exactly these types of situations. Not is it not possible for someone to be in an unsafe place, it's not possible for miscommunications such that it BECOMES unsafe after the fact because that lockout is with a lock no one else can unlock except the person who did it. And despite many comments in this discussion thread asserting that safety reduces progress and speed, lockout/tagout and similar procedures reduce the number of accidents and mishaps. That leads to less downtime spent picking up the body parts or cleaning a corpse out of the equipment. This is one of those "slow is smooth, smooth is fast" things. Get into a good routine with good safety measures and you can get shit done instead of cleaning up shit.
  - ok_dad 4y ago
    You don't even need to slow down, in some cases. I was watching a video[0] about how shinkansen trains are serviced each day, and noticed at one point[2] when the workers are ready to clean the top of the train they do a "point and call"[1] routine at a gate. Now, I am not exactly sure what the purpose is for that, because there isn't much context in the video, but I am logically assuming that they are checking that the train's overhead wires are depowered, and the gate probably only allows itself to be opened when that is the case. Even if that's not the exact reason here, I could imagine a test facility where you had occupancy sensors inside and a lockout gate that operated in this fashion, and wouldn't allow a human to be inside the room while pressure was increased in the test valve. I honestly don't get the cowboy attitude in here, we can progress to space quickly AND safely. [0]: https://www.youtube.com/watch?v=ieRwRS0VUUM https://www.youtube.com/watch?v=ieRwRS0VUUM [1]: https://en.wikipedia.org/wiki/Pointing_and_calling https://en.wikipedia.org/wiki/Pointing_and_calling [2]: https://youtu.be/ieRwRS0VUUM?t=578 https://youtu.be/ieRwRS0VUUM?t=578
AlexandrB 4y ago
Relevant quote from the article: > In the accident involving Cabada, OSHA’s accident investigation summary noted that “the final step in the pressure check operation, venting, was done for the first time using an automated program as opposed to the normal manual method that had been used in previous operations.”
- s1artibartfast 4y ago
  "At 12:44 p.m. on January 18, 2022, an employee, an integration technician, was p erforming pneumatic pressure checks on a Raptor V2 Engine while at the Integrati on Stand. The final step in the pressure check operation, venting, was done for the first time using an automated program as opposed to the normal manual method that had been used in previous operations. Immediately after initiating the aut omated venting, the employee was struck by the fuel controller cover which broke free from the controller module. The controller cover had sheared at the vertic al to horizontal beveled seam, liberating the cover face from the assembly. The employee suffered a skull fracture and head trauma and was hospitalized in a com a for months." https://www.osha.gov/pls/imis/establishment.inspection_detail?id=1579779.015 https://www.osha.gov/pls/imis/establishment.inspection_detai... It sounds like a number of things went wrong: 1) The automated program malfunctioned. 2) The controller cover welds failed. 3) The employee was too close.
jjk166 4y ago
How are you supposed to know ahead of time that a place is unsafe? Cabada should have been perfectly safe where they were, but at least one safety system failed. Ultimately you can never completely eliminate danger, at best you can reduce risk below some rational threshold for failure modes you are already aware of. And self flagellation after an accident does nothing to improve safety. Worse, it feels like you're doing something when you're not. Further, doing so right away leads to kneejerk reactions which might feel like an improvement but which are poorly suited for actually addressing the problem. The proper approach is to methodically investigate the issue, figure out what went wrong, and make appropriate, actionable changes. There is absolutely no reason to make a public announcement at any point in the process - safety is not a PR tactic.
- masklinn 4y ago
  > How are you supposed to know ahead of time that a place is unsafe? Cabada should have been perfectly safe where they were, but at least one safety system failed. Any potentially unsafe location should be behind a LOTO / safety interlock, and you should not be able to access it without locking it.
  - jjk166 4y ago
    All locations are potentially unsafe locations. An interlock prevents people from being in a place they aren't supposed to be, it does nothing for when something goes wrong in a place you are supposed to be. You can take precautions to reduce the odds of something bad happening at the place you are supposed to be, but there's always something else that can go wrong.
    - masklinn 4y ago
      > All locations are potentially unsafe locations. You’re not even going to pretend being honest about this uh? > An interlock prevents people from being in a place they aren't supposed to be, it does nothing for when something goes wrong in a place you are supposed to be. What sort of nonsense is that? The point of an interlock is to keep the place where you’re supposed to be safe for as long as you’re there. And stop you from being there if it’s unsafe. > there's always something else that can go wrong. Yeah sure a volcano could explode from below your desk. Whatever.

by mabbo 4y ago

happyopossum 4y ago

The idea that every accident can be prevented by delight is a ridiculous and utopian trope, and to demonize an entire corporate culture and group of 12k employees without any background information is the height of hubris. Nobody would ever design a ladder that cannot be climbed without a safety harness being properly worn, but many people are injured or killed in ladder accidents at workplaces every year. In your world that's a design failure, but out here in reality it's often carelessness or sheer bad luck.

karlmdavis 4y ago
To extend that line of argument a bit, what about a more professional tool/system, e.g. cherry pickers? Doesn’t it seem reasonable to you to design and engineer cherry pickers such that the bucket can’t be moved unless a safety harness is attached?
- happyopossum 4y ago
  > Doesn’t it seem reasonable to you to design and engineer cherry pickers such that the bucket can’t be moved unless a safety harness is attached? No - that seems unreasonable too, as there's no reasonable way for the cherry picker to know if the harness is being worn by anyone, so it's just safety theater.
  - TheCoelacanth 4y ago
    Combine it with immediately firing anyone caught attaching an empty harness to a cherry picker and the cherry picker can be reasonably sure that the harness is worn by someone.
toss1 4y ago
Do not make The Perfect an enemy of The Good. Merely because some accidents still happen despite motivated and brilliant people working to prevent them does not mean that the effort should not be made. You don't abandon the endeavor, but nor do you just throw caution to the winds. The article had a great example of a competing space company with an evidently solid safety culture; an accident was reported, and inspection done, and zero issues were found (which is quite difficult to be good enough have an OSHA inspection find nothing of note) >> Relativity has a strong safety record relative to others in the industry, with just one OSHA safety inspection since it was founded in 2015. The inspection, spurred by an accident, did not result in a violation.
- merely-unlikely 4y ago
  Considering Relativity hasn't actually launched a rocket yet (they are aiming for first launch this year), they are more a prospective competitor.
- happyopossum 4y ago
  > Do not make The Perfect an enemy of The Good. That's all well and good, but you also can't demonize an entire culture based on unrealistic navel-gazing. It's entirely possible this was a process or design problem that could have been prevented, but it's also possible that it's not - pretending you know based on few details in a one-sided article is pretty silly.
  - krisoft 4y ago
    > pretending you know based on few details in a one-sided article is pretty silly No. It is not. There is one telling detail in the article. SpaceX was fined by OSHA. That pretty much means in itself that there were things SpaceX shoulf have done which they didn’t. We can’t and won’t do each our own investigation. Nobody believes that the article has enough details to decide the case on its merrits. But we know that someone professional did the investigation and found the company violated the safety norms. That is what we have these agencies for.
    - 4y ago
knome 4y ago
>but out here in reality This, I expect, is exactly the kind of bad cultural attitude that @mabbo was referring to. You're advocating for accidents as being an unavoidable cost of business while preemptively hand-waving them as being the fault of careless employees or fate. As @P5fRxh5kUvp2th points out, there are established industry safety measures to avoid exactly these kinds of accidents when working around dangerous machinery, in the lockout/tagout system. If tests are locked out while employees are tagged into an area, you can't accidentally smack them into a coma with an over-pressurized part blowing out. By requiring tag ins to access dangerous areas, you don't have to have employees remember someone is out there, or that a test is coming, or worry about anyone getting confused on either front. Blaming the employee for being where they shouldn't be or the other for running tests when someone was nearby is a cop out. It shouldn't even be possible for it to happen at all. Design your systems and processes to expect that humans are fallible.
- chinabot 4y ago
  Impossible. Humans will find a way to bypass anything.
  - falcor84 4y ago
    As a kid, I remember a lot of people complained about how annoying car seatbelts are, and tried to avoid them, but I haven't heard that sentiment at all in the past 20 years - everyone I know is perfectly happy with them as a safety measure. It seems to me it just required some time for the culture to shift.
- vkou 4y ago
  > You're advocating for accidents as being an unavoidable cost of business while preemptively hand-waving them as being the fault of careless employees or fate. This needs seconding. It's ridiculous to say that we can't demonize an entire company of 12,000 people, and in the same breath, turn around to demonize the line workers of that company. It's no less ridiculous to instead demonize the line workers that got hurt, which seems to be both post-facto cherrypicking, and victim blaming.
bombcar 4y ago
You replace ladders with scaffolding and cherry pickers or similar things, though those too can have their safety issues ( https://www.youtube.com/watch?v=8YBxOA-aQQE https://www.youtube.com/watch?v=8YBxOA-aQQE ) I guarantee you that every job site manager in the WORLD can identify the unsafe employees, even if they're doing 'everything by the book'. Some of it can be designed away (two-hand tools for example) but some of it is basically inherent.
- metadat 4y ago
  Accepting at face value the claim that "every job site manager on earth" really can identify the "unsafe employees", then these managers are negligent and thus culpable for the failed outcomes. An infinitely better course of action is to ban all known-unsafe employees from operating in the risky path. Workers who unnecessarily put themselves and everyone else in jeopardy have no business being in the path. With that said, I'm highly skeptical about the veracity of this claim. Human behavior is fundamentally unstable, oscillating in the continuity spectrum between stable and erratic. However, the amount of variability for a given individual tends to be stable, which may be what you are saying a good and effective manager should be able to catch. Regardless, humans are wetware and fundamentally error prone. Best to account for this element of our nature in the larger system design.
deleted 4y ago
[deleted]

P5fRxh5kUvp2th 4y ago

> The key question that everyone, especially SpaceX, should be asking is why was it even possible to run the test while Cabada was in an unsafe place? absolutely. lockout/tagout may seem unnecessary, but it's specifically to avoid exactly these types of situations. Not is it not possible for someone to be in an unsafe place, it's not possible for miscommunications such that it BECOMES unsafe after the fact because that lockout is with a lock no one else can unlock except the person who did it. It obviously requires humans actually DO the procedures, but I think that's part of the point with the question.

Jtsummers 4y ago
> lockout/tagout may seem unnecessary, but it's specifically to avoid exactly these types of situations. Not is it not possible for someone to be in an unsafe place, it's not possible for miscommunications such that it BECOMES unsafe after the fact because that lockout is with a lock no one else can unlock except the person who did it. And despite many comments in this discussion thread asserting that safety reduces progress and speed, lockout/tagout and similar procedures reduce the number of accidents and mishaps. That leads to less downtime spent picking up the body parts or cleaning a corpse out of the equipment. This is one of those "slow is smooth, smooth is fast" things. Get into a good routine with good safety measures and you can get shit done instead of cleaning up shit.
- ok_dad 4y ago
  You don't even need to slow down, in some cases. I was watching a video[0] about how shinkansen trains are serviced each day, and noticed at one point[2] when the workers are ready to clean the top of the train they do a "point and call"[1] routine at a gate. Now, I am not exactly sure what the purpose is for that, because there isn't much context in the video, but I am logically assuming that they are checking that the train's overhead wires are depowered, and the gate probably only allows itself to be opened when that is the case. Even if that's not the exact reason here, I could imagine a test facility where you had occupancy sensors inside and a lockout gate that operated in this fashion, and wouldn't allow a human to be inside the room while pressure was increased in the test valve. I honestly don't get the cowboy attitude in here, we can progress to space quickly AND safely. [0]: https://www.youtube.com/watch?v=ieRwRS0VUUM https://www.youtube.com/watch?v=ieRwRS0VUUM [1]: https://en.wikipedia.org/wiki/Pointing_and_calling https://en.wikipedia.org/wiki/Pointing_and_calling [2]: https://youtu.be/ieRwRS0VUUM?t=578 https://youtu.be/ieRwRS0VUUM?t=578

AlexandrB 4y ago

Relevant quote from the article: > In the accident involving Cabada, OSHA’s accident investigation summary noted that “the final step in the pressure check operation, venting, was done for the first time using an automated program as opposed to the normal manual method that had been used in previous operations.”

s1artibartfast 4y ago
"At 12:44 p.m. on January 18, 2022, an employee, an integration technician, was p erforming pneumatic pressure checks on a Raptor V2 Engine while at the Integrati on Stand. The final step in the pressure check operation, venting, was done for the first time using an automated program as opposed to the normal manual method that had been used in previous operations. Immediately after initiating the aut omated venting, the employee was struck by the fuel controller cover which broke free from the controller module. The controller cover had sheared at the vertic al to horizontal beveled seam, liberating the cover face from the assembly. The employee suffered a skull fracture and head trauma and was hospitalized in a com a for months." https://www.osha.gov/pls/imis/establishment.inspection_detail?id=1579779.015 https://www.osha.gov/pls/imis/establishment.inspection_detai... It sounds like a number of things went wrong: 1) The automated program malfunctioned. 2) The controller cover welds failed. 3) The employee was too close.

jjk166 4y ago

How are you supposed to know ahead of time that a place is unsafe? Cabada should have been perfectly safe where they were, but at least one safety system failed. Ultimately you can never completely eliminate danger, at best you can reduce risk below some rational threshold for failure modes you are already aware of. And self flagellation after an accident does nothing to improve safety. Worse, it feels like you're doing something when you're not. Further, doing so right away leads to kneejerk reactions which might feel like an improvement but which are poorly suited for actually addressing the problem. The proper approach is to methodically investigate the issue, figure out what went wrong, and make appropriate, actionable changes. There is absolutely no reason to make a public announcement at any point in the process - safety is not a PR tactic.

masklinn 4y ago
> How are you supposed to know ahead of time that a place is unsafe? Cabada should have been perfectly safe where they were, but at least one safety system failed. Any potentially unsafe location should be behind a LOTO / safety interlock, and you should not be able to access it without locking it.
- jjk166 4y ago
  All locations are potentially unsafe locations. An interlock prevents people from being in a place they aren't supposed to be, it does nothing for when something goes wrong in a place you are supposed to be. You can take precautions to reduce the odds of something bad happening at the place you are supposed to be, but there's always something else that can go wrong.
  - masklinn 4y ago
    > All locations are potentially unsafe locations. You’re not even going to pretend being honest about this uh? > An interlock prevents people from being in a place they aren't supposed to be, it does nothing for when something goes wrong in a place you are supposed to be. What sort of nonsense is that? The point of an interlock is to keep the place where you’re supposed to be safe for as long as you’re there. And stop you from being there if it’s unsafe. > there's always something else that can go wrong. Yeah sure a volcano could explode from below your desk. Whatever.