The panel found that an improperly installed sensor prevented the capsule's software from determining its rate of descent into Earth's atmosphere, and consequently it failed to deploy the drogue parachute system properly during re-entry.

Launched on Aug. 8, 2001 and designed to collect solar wind particles and return them to Earth - thereby providing scientists with new data to help them understand the formation and evolution of the solar system - the Genesis capsule seemed to achieve its mission objectives properly, but landed violently in the military's Utah Test Range Sept. 8, 2004.

The 15-member board concluded that capsule components called G-switch sensors had been installed in an inverted position because of an erroneous design. They were unable to sense the capsule's deceleration accurately during atmospheric entry and initiate the parachute deployment.

The board also found deficiencies in four pre-launch processes that contributed to 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 project review process did not uncover the failure in the verification process.

The board faulted what it called a "lack of involvement by (Jet Propulsion Laboratory) Project Management and Systems Engineer¬ing," which led to insuf¬ficient critical oversight that might have identified the key process errors that occurred at Lockheed Martin Space Systems (the spacecraft's builder) during the spacecraft's design, review and testing phases.

In addition, the board found other mission problems, including:

- Multiple weaknesses within the Genesis systems engineering organization. This resulted in requirements and verification process issues that led to the failure.

The board recommends adding a thorough review of all systems engineering progress, plans and processes as part of existing major milestone reviews. This review is necessary to "enforce discipline and critical assessment in the systems engineering organizations of future projects."

- Inadequate review process. "All levels of review, including the Genesis Red Team review, failed to detect the design or verification errors," the board wrote, adding that NASA's technical reviews have become too superficial and perfunctory to serve the needs of the agency's Science Mis¬sion Directorate.

- Unfounded confidence in heritage designs. The Genesis management, systems engineering and "Red" teams made a number of errors because of their belief that the G-switch sensor circuitry was a heritage, or standard, design.

Apparently, engineers commonly held the view that heritage designs require less scrutiny and are inherently more reliable than new designs - a misperception that led to the mishap.

The board recommends review and verification of heritage designs to the same level expected of new hardware and 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. The board recommends strengthening the review process within the Science Mission Directorate, and requiring a "test as you fly" plan and a "phasing test plan" for all future SMD projects.

- Flaws in NASA's "Faster, Better, Cheaper" philosophy. As demonstrated by several mission failures, NASA's use of the philosophy apparently has encouraged increased risk-taking 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," the board wrote.

This approach precluded JPL from ensuring that the mission was executed within the range of previously successful practices - thereby adding additional risk. Similar approaches contributed to the failures of the Mars Climate Orbiter and Mars Polar Lander missions, the board noted.

"Instead of creating more reviews, the Board recommends establish¬ing more effective reviews that identify requirements, design, verification, and process issues early to avoid costly overruns or tragic failures," the panel report said.

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