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Angry Alligators and Workflow Processes
While attending the funeral last week of American icon Gene Cernan, the last astronaut to walk on the moon, I was reminded of how a gloriously successful career can be peppered occasionally with failed efforts.
Gene was a veteran of three space flights, Gemini 9A, Apollo 10, and Apollo 17, and a man I was honored to call a friend. While the Apollo missions were greatly successful, the Gemini mission in 1966 was not. It had two major objectives – to rendezvous and dock with an unmanned rocket that had been launched into Earth orbit two days earlier, and to perform a spacewalk using a new “rocket pack” that would allow Cernan to fly independently of his spacecraft. The rendezvous objectives were achieved, but neither the docking nor the spacewalk objectives was met.
When Gemini commander Tom Stafford and pilot Gene Cernan arrived in space at the unmanned rocket, they noticed the two pieces of its nose cone had not detached properly, and was dangling by a band that had not released. Lanyard wires that were supposed to activate explosive bolts on the band had not been properly attached before launch, and the unreleased band was now holding the cone halves together. Stafford described the sight as looking “like an angry alligator.” There would be no docking with the unmanned rocket.
The second major objective, to navigate a spacewalk using the “rocket pack”, was called off when Cernan’s visor began to fog up from the exertion of getting to and into the pack located at the back of their spacecraft. An insufficient number of handrails had been placed on the vehicle, and the struggle in weightlessness to maneuver to the back had worn him out.
So what happened with the improperly attached lanyards? According to later investigations, an engineer from the Douglas Aircraft Company (who had manufactured the nose cone) had supervised a practice run to prepare the unmanned rocket for launch. For safety’s sake, though, the lanyards that armed the explosive bolts were not hooked up. They were instead taped to the side of the rocket. Sometime between this practice run and the final launch preparations, the Douglas engineer was forced to return home to attend to his pregnant wife*. So this portion of the final launch activities were conducted by employees from the McDonnel Aircraft Corporation, manufacturer of the unmanned rocket. Unclear written instructions left the employees unsure what to do with the lanyards, so they left them taped to the side of the rocket. The rest is history.
Although checklists were used at the time to ensure proper execution of steps, they were clearly fallible. Only years later were automated workflows made possible with the availability of advanced information technologies. Imagine how the Gemini 9A mission might have turned out if they had had the advantage of this technology to ensure all crucial steps were properly taken. The process could have prevented close-out of launch preparations until the lanyard-attachment step had been completed. Have you ever had one of those projects where a missed activity prevented the achievement of project objectives? Imagine how you might avoid costly failure with the controls enabled by automated work flows.
*Years ago I was told a story, possibly apocryphal, by an engineer who had worked on the Gemini 9A mission. He gave a different version of the events, an alternative to the pregnant wife narrative, saying “This will never be documented in any official accounts, but I was there.” If you are interested in hearing this alternative version, call me at (713) 554-7572.