Root cause of lack of chute deployment has been found. Lack of firm connection between pilot chute and main chute lanyard. That means pilot chute could not pull out main chute. Somewhat hard to inspect this connection prior to use.
— NASA Watch (@NASAWatch) November 7, 2019

What the? Seems like this could apply to all 3 chutes and therefore it was only luck that prevented a total loss of the vehicle.
Also ‘hard to inspect’ doesn’t cut it. A major point of failure and we can’t check it.
Seems like a redesign is in the works.
Cheers
Neil
Nope. In other news, there will be no schedule slip, so it seems like they gave it a pass . I guess they’ll just add more inspections.
Yes, it is just a simple human error. Since you know who to blame if it goes wrong it’s no problem…?
Unfortunately, due to human factors, adding additional inspectors can actually make it less likely that the problem will be found. With multiple inspectors, it’s human nature to not look very closely at every little thing on the checklist because you know X number of other inspectors are going to look at it as well.
I see this often in software when code inspectors are assigned to a change. The inspectors will look at the areas they’re interested in, assuming someone else will take on the role of holistically inspecting the entire set of changes to make sure the overall architecture is a good one.
For a hardware system like this, I would like to see a change where it’s easy to inspect or somehow test the integrity of the connection even if the protective sheath is installed over it.
I agree about having more people involved causing trouble. One of the worst management mistakes I’ve ever made was to look directly at someone, and say “this is what _someone_ needs to do to solve the problem.” Of course, he assumed I meant I’d do it, not that I was politely assigning the job to him.
The obvious solution in this case is, as you say, to make the connecting pin easier to inspect or to allow more time for inspection. But that’s also how things grow. We’re talking about one part of one subsystem. A few more hours or a kilo for a less efficient but more easily inspected system isn’t a big deal. Until you multiply it by the number of subsystems which might warrant similar attention. I’m not sure what the solution is, but there has to be one. Civil aviation has figured this out. (And yes, despite 737 MAX idiocy and similar things, flying is so safe it’s almost unbelievable.)
Arrrgh…this kind of thing can be so frustrating…
https://spacenews.com/missi…
Sounds like a poor excuse to me. They need to make certain the connection is a good one each and every time. If they could not see it this time, then they need to figure out how to see it in the future so this cannot happen again. Otherwise they are saying ‘we guessed we were OK so we took a chance’. Its safety critical. You are not supposed to be guessing or depending on luck.
So, procedural…and something that seems like it could impact all three capsules, and NASA it seems will just add “pull tests” to the preflight inspections and call it good.
Yes it could. But I’d expect that the reality of the situation is that each company will have its own “safety culture”. So even if they’re all following the same sort of checklists, one company might be more likely than the others to have a failure like this.
The good news is that it was a minor problem. The bad news is that this could kill people. Hopefully they are improving their QC.
Aw! If your chute doesn’t work, bring it back and we’ll give you a new one! 🙁