Full Report (11 MB PDF)
Genesis was one of NASA's Discovery missions, and its purpose was to collect samples of solar wind and return them to Earth. The Jet Propulsion Laboratory was the managing Center; the California Institute of Technology was designated the principal investigator and project team leader. Los Alamos National Laboratory provided the science instruments, and Lockheed Martin Corporation (acting through its Lockheed Martin Space Systems company) was the industrial partner and provided the spacecraft and sample return capsule. The Jet Propulsion Laboratory and Lockheed Martin Astronautics conducted mission operations.
Launched on August 8, 2001, Genesis was to provide fundamental data to help scientists understand the formation of our solar system. Analysis of solar materials collected and returned to Earth will give precise data on the chemical and isotopic composition of the solar wind.
On September 8, 2004 the Genesis sample return capsule drogue parachute did not deploy during entry, descent, and landing operations over the Utah Test and Training Range. The drogue parachute was intended to slow the capsule and provide stability during transonic flight. After the point of expected drogue deployment, the sample return capsule began to tumble and impacted the Test Range at 9:58:52 MDT, at which point vehicle safing and recovery operations began. Section 2.0 provides a description of the mishap.
On September 10, 2004, the Associate Administrator for the Science Mission Directorate established a Type A Mishap Investigation Board as defined by NASA Procedural Requirements 8621.1A, NASA Procedural Requirements for Mishap Reporting, Investigating, and Recordkeeping, to determine the cause and potential lessons from the incident. The Board was chartered to determine the proximate cause of the failure, identify the root causes, and develop recommendations to strengthen processes within NASA's Science Mission Directorate to avoid similar incidents in the future. Section 3.0 describes the method of investigation used by the Board.
Additionally, the Board was to determine the adequacy of contingency response planning and the appropriateness of the actual contingency response, to include the safing and securing of the spacecraft and the science payload, and the protection of response personnel. The results of this second inquiry are documented in Volume II of this report. The Board determined the proximate (or direct) cause of the mishap to be that the G-switch sensors were in an inverted orientation, per an erroneous design, and were unable to sense sample return capsule deceleration during atmospheric entry and initiate parachute deployments. Section 4.0 describes the proximate cause and lists other candidates that the Board investigated.
The Board found that deficiencies in the following four pre-launch processes resulted in the mishap:
- the design process inverted the G-switch sensor design;
- the design review process did not detect the design error;
- the verification process did not detect the design error; and
- the Red Team review process did not uncover the failure in the verification process.
The Board identified several root causes and major contributing factors that resulted in the design inversion of the G-switch sensors and the failures to detect it. The root causes and contributing factors fall into six categories, some of which contributed to more than one of the above process errors. Each category is briefly explained below and in more detail in Section 5.0. Recommendations to avoid future reoccurrences are provided in Section 6.0.
Inadequate Project and Systems Engineering Management.
A lack of involvement by JPL Project Management and Systems Engineering in Lockheed Martin Space Systems spacecraft activities led to insufficient critical oversight that might have identified the key process errors that occurred at Lockheed Martin Space Systems during the design, review, and test of the spacecraft. This process was consistent with the Faster, Better, Cheaper philosophy of the time and approved of by the Discovery Program.
Inadequate Systems Engineering Processes.
Multiple weaknesses within the Genesis Systems Engineering organization resulted in requirements and verification process issues that led to the failure. The Board recommends adding a thorough review of all project Systems Engineering progress, plans, and processes as part of existing major milestone reviews. This recommendation was written to enforce discipline and critical assessment in the Systems Engineering organizations of future projects. Recommendations regarding Systems Engineering also address the issues raised by the Inadequate Project and Systems Engineering Management root causes by compelling a commitment by Project Management to support an adequate Systems Engineering function.
Inadequate Review Process.
All levels of review, including the Genesis Red Team review, failed to detect the design or verification errors. It is the Board's position that technical reviews have become too superficial and perfunctory to serve the needs of the Science Mission Directorate. The technical review recommendations in this mishap report are targeted at significantly strengthening the Science Mission Directorate review process beyond its current state.
Unfounded Confidence in Heritage Designs.
Genesis Management and Systems Engineering and the Genesis Red Team made a number of errors because of their belief that the G-switch sensor circuitry was a heritage design. Further, the prevalent view that heritage designs required less scrutiny and were inherently more reliable than new designs led to the mishap. The Board addresses the systemic problem of inappropriate faith in heritage designs in the Science Mission Directorate by recommending review and verification of heritage designs to the same level expected of new hardware/software.
Failure to 'Test as You Fly.'
Several issues led to the lack of proper testing of the G-switch sensors, including a failure to treat the G-switches as sensors, which ultimately led to the mishap. The Board's recommendations to strengthen the review process within the Science Mission Directorate will partially address this issue, as well as a recommendation to require a "test as you fly" plan and a "phasing test plan" for all Science Mission Directorate projects.
Faster, Better, Cheaper Philosophy.
As demonstrated by several failures, NASA's use of the Faster, Better, Cheaper philosophy encouraged increased risk taking by the Projects to reduce costs. Although NASA Headquarters had solicited and selected Genesis under the Faster, Better, Cheaper paradigm, the way JPL chose to implement the Genesis Mission substantially reduced their insight of the technical progress of the project. This precluded them from ensuring that the Project was executed within the range of previously successful mission implementation practices, thereby adding additional risk. The Discovery Program Office accepted these arrangements implicitly by way of the selection and subsequent management review processes.
The potential pitfalls of this approach became clear when the Mars Climate Orbiter and Mars Polar Lander missions failed. Although much has been done within Science Mission Directorate to correct Faster, Better, Cheaper issues, the Board recommends that when establishing appropriate levels of budgetary and schedule reserve that the Science Mission Directorate gives greater consideration to the overall maturity; launch constraints (e.g., short window planetary vs. others), and complexity. Board members based several of the recommendations on their experience with on-going Science Mission Directorate Systems Engineering and technical review issues. The Board also considered previous failure investigations when generating several of the recommendations. Most of the recommendations center on improving the technical review process of new designs, heritage designs, and Systems Engineering. Instead of creating more reviews, the Board recommends establishing more effective reviews that identify requirements, design, verification, and process issues early to avoid costly overruns or tragic failures.
It appears highly likely to the Board that due to the dedicated efforts of the Genesis Recovery and Curation Teams and the nature of the sample collection materials most of the Genesis science goals will be met. However, the Board believes that this fortunate outcome should not reduce the importance of the lessons learned from the Genesis mishap to future missions.
Other significant observations and recommendations not directly related to root causes or contributing factors are provided in Section 7.0. Recommendations of the Board regarding actions the Stardust Project should consider are provided in Section 8.0.
