SCALED COMPOSITES 339Scaled Composites LLC
Koehn Dry Lake, CA, USA · 2014-10-31·N339SS
What happened
NTSB summary, verbatimNTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aerospace accident report. The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aerospace Accident Report number is NTSB/AAR-15/02. 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.
Photographs
32the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationScaled Composites' failure to consider and protect against the possibility that a single human error could result in a catastrophic hazard to the SpaceShipTwo vehicle. This failure set the stage for the copilot's premature unlocking of the feather system as a result of time pressure and vibration and loads that he had not recently experienced, which led to uncommanded feather extension and the subsequent aerodynamic overload and in-flight breakup of the vehicle.
Occurrence sequence
1 stepsNTSB coding · CICTT taxonomy- 1 · OtherLoss of control in flightdefining event
Findings
3 causal · 4 contributing- CAUSEOrganizational issues › Development › Design › Equipment design — Manufacturer
- CAUSEPersonnel issues › Action/decision › Action › Incorrect action selection — Copilot
- CAUSEEnvironmental issues › Task environment › Pressures/demands › Time/schedule pressure — Effect on personnel
- FACTOROrganizational issues › Support/oversight/monitoring › Oversight › Oversight of reg compliance — FAA/Regulator
- FACTORPersonnel issues › Experience/knowledge › Training › Training with equipment — Flight crew
- FACTOROrganizational issues › Management › Resources — Manufacturer
- FACTOROrganizational issues › Management › Resources — Emergency services
Safety recommendations
10 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: In collaboration with the Commercial Spaceflight Federation, develop and issue human factors guidance for operators to use throughout the design and operation of a crewed vehicle. The guidance should address, but not be limited to, the human factors issues identified during the SpaceShipTwo accident investigation.
TO THE FEDERAL AVIATION ADMINISTRATION: Implement steps in your evaluation of experimental permit applications to ensure that applicants have (1) identified single flight crew tasks that, if performed incorrectly or at the wrong time, could result in a catastrophic hazard, (2) assessed the reasonableness, including human factor considerations, of the proposed mitigations to prevent errors that could result from performing those tasks, and (3) fully documented the rationale used to justify related assumptions in the hazard analysis required by 14 Code of Federal Regulations 437.55.
TO THE FEDERAL AVIATION ADMINISTRATION: Develop a process to determine whether an experimental permit applicant has demonstrated the adequacy of existing mitigations to ensure public health and safety as well as safety of property before granting a waiver from the human error hazard analysis requirements of 14 Code of Federal Regulations 437.55.
TO THE FEDERAL AVIATION ADMINISTRATION: Develop and implement procedures and guidance for confirming that commercial space operators are implementing the mitigations identified in a safety-related waiver of federal regulations and work with the operators to determine the effectiveness of those mitigations that correspond to hazards contributing to catastrophic outcomes.
TO THE FEDERAL AVIATION ADMINISTRATION: Develop and issue guidance for experimental permit applicants that (1) includes the information in Advisory Circular 413-1, “License Application Procedures,” and (2) encourages commercial space vehicle manufacturers to begin the consultation process with the Office of Commercial Space Transportation during a vehicle’s design phase.
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.
TO THE FEDERAL AVIATION ADMINISTRATION: Direct Office of Commercial Space Transportation (AST) management to work with AST technical staff to (1) develop clearer policies, practices, and procedures that allow direct communications between staff and applicants, (2) provide clearer guidance on evaluating commercial space transportation permits, waivers, and licenses, and (3) better define the line between the information needed to ensure public safety and the information pertaining more broadly to ensuring mission success.
TO THE FEDERAL AVIATION ADMINISTRATION: In collaboration with the commercial space flight industry, continue work to implement a database of lessons learned from commercial space mishap investigations and encourage commercial space industry members to voluntarily submit lessons learned.
TO THE COMMERCIAL SPACEFLIGHT FEDERATION: Advise commercial space operators to work with local emergency response partners to revise emergency response procedures and planning to ensure that helicopter and other resources are appropriately deployed during flights.
TO THE COMMERCIAL SPACEFLIGHT FEDERATION: Work with the Federal Aviation Administration to develop and issue human factors guidance for operators to use throughout the design and operation of a crewed vehicle. The guidance should address, but not be limited to, the human factors issues identified during the SpaceShipTwo accident investigation.
NTSB analysis
from the final reportNTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aerospace accident report. The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aerospace Accident Report number is NTSB/AAR-15/02. 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.