Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-15-024
Details
Synopsis: On October 31, 2014, at 1007:32 Pacific daylight time, the SpaceShipTwo (SS2) reusable suborbital rocket, N339SS, operated by Scaled Composites LLC (Scaled), broke up into multiple pieces during a rocket-powered test flight and impacted terrain over a 5-mile area near Koehn Dry Lake, California. The pilot received serious injuries, and the copilot received fatal injuries. SS2 was destroyed, and no one on the ground was injured as a result of the falling debris. SS2 had been released from its launch vehicle, WhiteKnightTwo (WK2), N348MS, about 13 seconds before the structural breakup. Scaled was operating SS2 under an experimental permit issued by the Federal Aviation Administration’s (FAA) Office of Commercial Space Transportation (AST) according to the provisions of 14 Code of Federal Regulations (CFR) Part 437.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Develop and implement a program for Office of Commercial Space Transportation inspectors that aligns them with individual operators applying for an experimental permit or a launch license to ensure that the inspectors have adequate time to become familiar with the technical, operational, training, and management controls that they will inspect.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Koehn Dry Lake, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA15MA019
Accident Reports: In-Flight Breakup During Test Flight Scaled Composites SpaceShipTwo, N339SS Near Koehn Dry Lake, California October 31, 2014
Report #: AAR-15-02
Accident Date: 10/31/2014
Issue Date: 8/4/2015
Date Closed: 2/10/2017
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/10/2017
Response: Our previous letter restated our findings from the SpaceShipTwo accident investigation that were the basis for this recommendation. In our investigation, we found that AST inspectors had limited time in which to understand a permittee’s or licensee’s training, procedures, and operations before conducting the inspections specified in the safety inspection plan (SIP). Because the AST inspectors for the accident flight did not have any significant experience with Scaled, they lacked ongoing knowledge of Scaled’s operations and procedures. Consequently, they overlooked the simulator software change and the inconsistencies between the flight test data card and SpaceShipTwo’s pilot operating handbook. In addition, although the SIPs were designed to ensure compliance with federal regulations and the representations made in the experimental permit application, none of the AST inspectors for the accident flight, or for the two preceding test flights, verified whether Scaled was performing the mitigations involving the simulator and chase planes that were identified in the waiver of two federal regulations issued by AST. On January 11, 2016, we replied that, although you believed that you had effectively addressed this recommendation, the system that you described in your October 30, 2015, letter was similar to the one that did not prevent the SpaceShipTwo accident. Therefore, we concluded that you had not addressed the recommendation. Before we closed Safety Recommendation A-15-24, we asked what actions you had taken to address the problems that we found in our investigation. In your most recent letter, you described the actions completed in response to Safety Recommendation A-15-22 that improved the linkage between your license and permit evaluation outcomes and the safety inspection procedures in P-008. You believe that the procedures used with the revised P-008 ensure that information related to waivers and processes is incorporated into SIPs. In addition to the procedural steps described in P-008 and in your previous letter, you continue to strengthen your inspector workforce and align it with the areas of highest activity. You have taken these steps as AST’s workload continues to significantly increase. You indicated that during the past year, the number of unique applicants seeking FAA authorization has grown by roughly one-third, and you are working projects with approximately 45–50 unique companies at any given time. In 2016, you added four additional safety inspectors to the previous staff of 14 credentialed inspectors. The improvements that you have made to P-008 address Safety Recommendation A 15 22, but do not address Safety Recommendation A 15 24. Increasing the number of inspectors was needed, particularly considering the inspectors’ workload and the rate at which it is increasing. However, Safety Recommendation A-15-24 asks that there be a single inspector throughout the life of an experimental permit or launch application, and the actions you have taken are not an acceptable alternative. Because you consider your actions complete and do not plan to take any further action, Safety Recommendation A-15-24 is classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 12/6/2016
Response: -From Michael P. Huerta, Administrator: In our initial response to A-15-22, we outlined improvements in the linkage between our license and permit evaluation outcomes and our safety inspection procedures (P-008) to ensure that information related to waivers and processes that are critical for public safety are fully incorporated in our safety inspection plans. As noted earlier in this letter, the FAA has completed its implementation of actions related to A-15-22. In addition to the procedural steps discussed above and in our previous letter, the FAA continues to strengthen our inspector workforce and align them to the areas of highest activity. This is crucial as we work to keep abreast of a rapidly growing commercial space industry. For example, during the past year, the number of unique applicants seeking FAA authorization has grown roughly by one-third. The FAA is working projects with approximately 45-50 unique companies at any given time. To further demonstrate our commitment to addressing this area of concern, in 2016, we added four additional safety inspectors to our previous staff of 14 credentialed inspectors, increasing our inspector workforce by 29 percent. One inspector has been assigned to Vandenberg Air Force Base to support west coast operations. The remaining inspectors are all assigned to our Florida field office due to the sustained growth of current (77 percent of all inspection activity) and future operations that we expect in that region of the country. This arrangement allows each of the inspectors to gain in-depth familiarity with the specific public safety characteristics, features, and operational practices associated with the launch sites, vehicles, and the specific operators, while ensuring we meet our broader public safety mission.

From: NTSB
To: FAA
Date: 1/11/2016
Response: We issued this recommendation because we found in the SpaceShipTwo accident investigation that AST inspectors had limited time (even with a pre-inspection meeting to prepare for a launch inspection) to understand a permittee’s or licensee’s training, procedures, and operations before conducting the inspections specified in the SIP. Because the AST inspectors for the accident flight did not have any significant experience with Scaled, they lacked ongoing knowledge of Scaled’s operations and procedures and missed the change to the simulator software and the inconsistencies between the flight test data card and the SpaceShipTwo’s pilot operating handbook. In addition, even though the SIPs were designed to ensure compliance with federal regulations and the representations made in the experimental permit application, none of the AST inspectors for the accident flight, or for the two preceding test flights, verified whether Scaled was performing the mitigations involving the simulator and chase planes that were identified in the waiver that was issued by AST of two federal regulations. Your letter described that, in 2012 (long before the SpaceShipTwo accident), you had initiated an approach that assigns a dedicated safety inspector (SI) to support each individual program at the inception of each license and permit application, beginning in the pre-application process phase. That same SI continues through the completion of the application evaluation in order to provide appropriate input and feedback to both the operator and the FAA evaluation team, while the SI is also learning all pertinent inspectable operational items, mitigations, and special terms and conditions associated with a specific operator’s planned activities and processes. The SI assigned to each evaluation program incorporates all applicable inspectable items into a comprehensive SIP, which SIs other than the one assigned to the operator use to verify compliance once inspections begin for that operator. In this approach, any SI may monitor any licensed or permitted operation to verify operator compliance and ensure public safety. Thus, the SI may not be the one who is most familiar with the operation. In your letter, you indicated that, although assigning specific SIs to each operator’s program works over the course of an extensive pre-application coordination and evaluation review, you do not believe it is either feasible or desirable in an operational environment. You described three specific concerns: (1) the size of the credentialed AST SI workforce, (2) the dynamic nature of launch operations scheduling, and (3) the central role of launch sites in the public safety aspects of commercial space flight operations. You believe that you have effectively addressed this recommendation and consider your actions complete. You believe that you have effectively addressed this recommendation, but you described a system similar to the one that did not prevent the SpaceShipTwo accident. We therefore conclude that you have not addressed the recommendation. Before we close it, however, we ask that you describe what actions you have taken that address the problems that we found in our investigation. Pending an acceptable answer to that question, Safety Recommendation A 15 24 is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/30/2015
Response: -From Michael P. Huerta, Administrator: We understand the Board's intent and expectation of benefits, such as improved knowledge of individual operators and their vehicles, by aligning a dedicated SI to a specific launch operator and all of their subsequent operations. Because of these potential benefits, AST initiated an approach in 2012 to assign a dedicated SI to support each individual program at the inception of each license and permit application, beginning in the pre-application process phase. That same SI continues engagement through the completion of the application evaluation in order to provide appropriate input and feedback to both the operator and the FAA's evaluation team, while they are also learning and capturing all pertinent inspectable operational items, mitigations, and special terms and conditions associated with a specific operator's planned activities and processes. This approach is now institutionalized in our respective internal procedures documents: P-0 11, which governs pre-application coordination, and P-002, for license and permit application review and issuance. The SI assigned to each evaluation program incorporates all applicable inspectable items into a comprehensive safety inspection plan, which other Sis employ to verify compliance once inspections begin for that operator. We also review these safety inspection plans following the completion of each launch or reentry inspection campaign to discuss and identify lessons learned and modify the safety inspection plan where needed. This approach allows any SI to monitor any licensed or permitted operation, verify operator compliance, and ensure public safety consistent with authorizing statutes and the CST regulations. While assigning specific Sis to each operators' program(s) works over the course of an extensive pre-application coordination and evaluation review, the FAA does not believe it is feasible in an operational environment, nor is it necessarily desirable given the public safety aspects of space launch operations and the dynamic nature of the CST industry. Specifically, our concerns are in three primary areas: the size of the credentialed SI workforce, the dynamic nature of launch operations scheduling, and the central role of launch sites in the public safety aspects of CST operations. AST's SI Workforce AST is a small organization (81 full time positions in FY 20 15), with only 14 credentialed SIs distributed across three field offices and headquarters. The FAA believes that we must ensure that all Sis have familiarity with a number of different launch/reentry vehicle systems and operators. Each launch/reentry system has different configurations and processes and many operators employ more than one launch vehicle system. However, the overall engineering aspects, propulsion concepts, flight safety systems, and inspection approaches among launch operators (suborbital, expendable, reusable, etc.) remain similar while presenting unique countdown challenges related to public safety. Issues that occur in one program often may have implications to another (e.g., a flight safety system issue), and therefore are more easily identifiable through inspection for those Sis who have monitored different operators and different launch vehicles. We have found that in our unique industry, exposing Sis to different operators, and launch and reentry vehicle systems, allows them to become better, more well-rounded in their inspection duties, and capable of responding to a number of real-time safety challenges during critical launch countdown operations. Inspection Scheduling Challenges In FY 2014, AST conducted 223 safety inspections in 12 different locations for 19licensed and permitted flights/reentries. However, only three of these locations had a permanent, dedicated inspection field office, which allowed for rapid response to dynamic rescheduling of operational procedures which required safety inspection monitoring. The Sis are assigned as needed to conduct inspection activities for all programs under FAA oversight. The nature of today's CST industry often requires different inspections for various programs to be conducted simultaneously in areas around the country. In fact, it is not unusual for CST operations to now be planned or conducted nearly simultaneously at different sites around the country. Also, the exact nature of CST safety inspection activities varies significantly from the historical FAA's aviation safety inspection model in authority, activity type, and frequency. All regulated launch and reentry activities that can affect public safety require safety inspection and occur at all phases of operation (preflight, flight, and post flight). All safety inspections correspond to components, systems, and procedures which are safety critical due to their impact on public safety. A majority of the inspection activities are extremely dynamic in nature with quick call-ups and sudden reschedules based on a launch/reentry operator's schedule. A majority of these activities may also slip over extended periods of time, further requiring a flexible distribution of manpower resources. In addition, duty time and crew rest concerns must also be addressed if we are to ensure that Sis can safely conduct their mission. For example, a specific expendable launch vehicle operation at Cape Canaveral Air Force Station may comprise 20 or more safety inspections that occur over all phases of a launch campaign. The preflight activities associated with that given launch campaign often occur simultaneously or back to back on consecutive shifts and consecutive days. No single SI aligned to a specific operator can observe all of these activities without violating crew rest requirements and impacting the SI's personal safety and ability to properly monitor. In addition, that same operator may be planning or conducting operations simultaneously at another site in an entirely different region of the country. Fundamentally, limiting AST's ability to schedule only certain Sis assigned to specific operators and their flight vehicles would create a logistical impossibility for the FAA to conduct all of its necessary inspections. Launch Site Aspects of Public Safety The specific features of launch sites and their surroundings are central to the safety of the public and their property. These considerations are integral to the FAA' s licensing and experimental permitting evaluations, determinations, and safety oversight. The FAA believes that the most effective way to distribute its SI workforce is to base them in the vicinity where operations will occur. Since the majority ofF AA licensed operations sti ll continue to occur at or near the major federal launch ranges, SI field offices are located at Patrick Air Force Base, Florida (1 Field Manager and 3 Sis); Vandenberg Air Force Base, California (1 SI); and Wallops Flight Facility, Virginia (1 SI). In addition, the FAA maintains an SI workforce in its headquarters in Washington, DC (1 Division Manager and 7 Sis). We have found a number of benefits occur by basing our Sis in field locations. First, the scheduling and response benefits, which were discussed earlier, are clear. However, the benefits extend to other areas. Both the FAA and our Federal partners benefit by the closer coordination, information flow and sharing of knowledge that is enabled. Also, and perhaps more significantly, our Sis are able to understand the unique aspects of operations in and around these operational sites. As a result they are more tuned to specific issues that could arise for operations at these sites, regardless of the operator. Because of these benefits the FAA expects to continue to align our geographic field offices and Sis to high-activity launch sites, and we will consider adding new field office locations as warranted by CST developments. I believe the FAA has effectively addressed Safety Recommendation A-15-24 and consider our actions complete.