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NASA NTRS2014

Loss of Signal, Aeromedical Lessons Learned from the STS-107 Columbia Space Shuttle Mishap

Loss of Signal, a NASA publication to be available in May 2014 presents the aeromedical lessons learned from the Columbia accident that will enhance crew safety and survival on human space flight missions. These lessons were presented to limited audiences at three separate Aerospace Medical Association (AsMA) conferences: in 2004 in Anchorage, Alaska, on the causes of the accident; in 2005 in Kansas City, Missouri, on the response, recovery, and identification aspects of the investigation; and in 2011, again in Anchorage, Alaska, on future implications for human space flight. As we embark on the development of new spacefaring vehicles through both government and commercial efforts, the NASA Johnson Space Center Human Health and Performance Directorate is continuing to make this information available to a wider audience engaged in the design and development of future space vehicles. Loss of Signal summarizes and consolidates the aeromedical impacts of the Columbia mishap process-the response, recovery, identification, investigative studies, medical and legal forensic analysis, and future preparation that are needed to respond to spacecraft mishaps. The goal of this book is to provide an account of the aeromedical aspects of the Columbia accident and the investigation that followed, and to encourage aerospace medical specialists to continue to capture information, learn from it, and improve procedures and spacecraft designs for the safety of future crews. This poster presents an outline of Loss of Signal contents and highlights from each of five sections - the mission and mishap, the response, the investigation, the analysis and the future.

Stepaniak, Phillip C.↗
NASA NTRS2020

Recurring Causes of Human Spaceflight Mishaps during Flight Tests and Early Operations

n analysis of recurring causes underlying human spaceflight mishaps that occurred during flight tests and early operations was performed. Eight mishaps from the Apollo, Soyuz, Skylab, Space Shuttle, and Constellation Programs (i.e., the Ares-1X test flight) and commercial suborbital systems were included in the study. Detailed event analyses were performed for the historical mishaps and aggregate data analyses conducted to identify recurring issues. The nine most frequent issues were inadequate technical controls or risk management practices, incomplete procedures, system design and development issues, inadequate inspection or secondary verification requirements, failures of organizations to learn from previous incidents, inadequate schedule controls, inadequate task analyses or design processes, flaws in the design of organizations, and issues with organizational safety cultures.

Timothy S Barth↗
NASA NTRSDate not supplied

Incorporation of Human Risk Directed Acyclic Graphs (DAG) With Mishap Investigations to Un-Silo Knowledge

NASA’s Human System Risk Board (HSRB) has been a central driver in efforts to understand, mitigate, and communicate the 29 human systems risks monitored by the board. As a result of the collaboration between research, operations, and technical authorities, large bodies of knowledge have been collected and digested to represent the current understanding of the risks. As a part of these bodies of knowledge, directed acyclic graphs (DAGs) have been developed to communicate the current understanding of the causal relationship of the hazards, contributing factors, countermeasures, other risks, and outcomes that contribute to the overall risk. This risk knowledge is applied in a theoretical sense for potential incidents during exploration even while informed by surveillance data. However, there have been mishaps and close calls during past space exploration that intersect with one or more of the Human System Risks DAGs and knowledge bases. The purpose of this exercise was to un-silo this risk knowledge and connect it to the close call of EVA 23 through the development of a DAG representing the intersection of the HSRB Risks and the events of the close call. The development of the DAG occurred through an iterative process, with each iteration expanding and/or refining the nodes and connections described by the source materials. In addition to the risk documentation developed by the HSRB, lessons learned and other mishap investigation documents were utilized to understand the events that led to water entering the helmet of a crewmember on the EVA. New nodes specific to the events of EVA 23 were interconnected with existing HSRB DAG nodes and edges. Nodes within the DAG were defined within a “DAG-tionary” with any updates to a definition that may have previously existed from the HSRB DAGs, and edges were recorded in a matrix. Both the DAG-tionary and matrix describe where nodes and edges are present across the Risk and Mishap DAG. This DAG will then be reviewed by experts outside of HSRB and HRP to confirm that interpretations of the non-health related events (such as the engineering nodes) are represented accurately. DISCUSSION This process highlighted a method by which the knowledge generated among the contributing members of the HSRB Risks can be effectively adapted and utilized through the tools employed by the Risk Custodian teams. By leveraging these tools, new context and insights to the information at hand can be brought forward to address current spaceflight challenges. Moreover, un-siloing this knowledge through future DAGs and other efforts can drive interprofessional collaboration and foster communication. This will enable teams to work together more effectively, leveraging their diverse expertise to tackle the complex challenges of space exploration and human research. Ultimately, this collaboration will bring NASA closer to achieve agency goals and contribute to the overall shared mission and vision.

Samuel Jacobs↗
NASA NTRS2000

Results of the HESSI Test Mishap Investigation

On March 21, 2000, the High-Energy Solar Spectroscopic Imager (HESSI) spacecraft was subjected to a series of vibration tests at the Jet Propulsion Laboratory (JPL) as a part of its flight certification program. The structural qualification test, denoted as the sineburst test, subjected the spacecraft to a major overtest that resulted in significant structural damage to the spacecraft. The HESSI Test Mishap Investigation Board (MIB) was formed on March 24, 2000, in response to a NASA headquarters request. Board membership included experts from NASA and the University of California at Berkeley. This paper will present the investigation methods, findings, and lessons learned from the HESSI mishap.

Worth, Daniel B.↗
NASA NTRS2009

Helios High Altitude Long Endurance Mission Mishap

This slide presentation reviews the failure of the Helios solar aircraft failure. Included are pictures of the aircraft, inflight, and after the mishap, analysis of the root causes of the mishap, contributing factors, recommendations and lessons learned in respect to crew training, and assessing the level of risk.

Henwood, Barton E.↗
NASA NTRS2013

Lessons of History: Organizational Factors in Three Aviation Mishaps

This presentation examines organizational factors that contributed to three aircraft mishaps and provides analysis of lessons learned. Three historical aviation mishaps were studied from a human factors perspective, and organizational factors identified and analyzed. These case studies provide valuable lessons for understanding the interaction of people with aircraft systems and with each other during flight operations.

Merlin, Peter William↗
NASA NTRS2014

Loss of Signal, Aeromedical Lessons Learned for the STS-I07 Columbia Space Shuttle Mishap

Loss of Signal, a NASA publication to be available in May 2014, presents the aeromedical lessons learned from the Columbia accident that will enhance crew safety and survival on human space flight missions. These lessons were presented to limited audiences at three separate Aerospace Medical Association (AsMA) conferences: in 2004 in Anchorage, Alaska, on the causes of the accident; in 2005 in Kansas City, Missouri, on the response, recovery, and identification aspects of the investigation; and in 2011, again in Anchorage, Alaska, on future implications for human space flight. As we embark on the development of new spacefaring vehicles through both government and commercial efforts, the NASA Johnson Space Center Human Health and Performance Directorate is continuing to make this information available to a wider audience engaged in the design and development of future space vehicles. Loss of Signal summarizes and consolidates the aeromedical impacts of the Columbia mishap process-the response, recovery, identification, investigative studies, medical and legal forensic analysis, and future preparation that are needed to respond to spacecraft mishaps. The goals of this book are to provide an account of the aeromedical aspects of the Columbia accident and the investigation that followed, and to encourage aerospace medical specialists to continue to capture information, learn from it, and improve procedures and spacecraft designs for the safety of future crews.

Patlach, Robert↗
NASA NTRS2014

A Historical Analysis of Crane Mishaps at Kennedy Space Center

Cranes and hoists are widely used in many areas. Crane accidents and handling mishaps are responsible for injuries, costly equipment damage, and program delays. Most crane accidents are caused by preventable factors. Understanding these factors is critical when designing cranes and preparing lift plans. Analysis of previous accidents provides insight into current recommendations for crane safety. Cranes and hoists are used throughout Kennedy Space Center to lift everything from machine components to critical flight hardware. Unless they are trained crane operators, most NASA employees and contractors do not need to undergo specialized crane training and may not understand the safety issues surrounding the use of cranes and hoists. A single accident with a crane or hoist can injure or kill people, cause severe equipment damage, and delay or terminate a program. Handling mishaps can also have a significant impact on the program. Simple mistakes like bouncing or jarring a load, or moving the crane down when it should go up, can damage fragile flight hardware and cause major delays in processing. Hazardous commodities (high pressure gas, hypergolic propellants, and solid rocket motors) can cause life safety concerns for the workers performing the lifting operations. Most crane accidents are preventable with the correct training and understanding of potential hazards. Designing the crane with human factors taken into account can prevent many accidents. Engineers are also responsible for preparing lift plans where understanding the safety issues can prevent or mitigate potential accidents. Cranes are widely used across many areas of KSC. Failure of these cranes often leads to injury, high damage costs, and significant delays in program objectives. Following a basic set of principles and procedures during design, fabrication, testing, regular use, and maintenance can significantly minimize many of these failures. As the accident analysis shows, load drops are often caused or influenced by human factors. Therefore, proper training and understanding of crane safety throughout the workforce is critical. It is important that the engineers designing the cranes, lift planners preparing the lift plans, operators performing the lifts, and training officers conducting the operator training all understand the problems that can happen with cranes and how to ensure the safety of the workforce and equipment being lifted.

Materials Handling↗
NASA NTRSDate not supplied

NASA Mishap Investigation and Resources

NASA does everything possible to reach success. But we must also prepare for failure in an effort to limit the impact of our bad days. To continue our mission, we must plan the moves ahead after loss. Kristie French, NASA Mishap Investigator will present the preparations, analysis and resources of the NASA mishap investigation process to ensure we understand and learn from our history.

Kristie French↗
NASA NTRSDate not supplied

High Pressure Vent Line Mishap: Investigation Summary

During testing on the E-1 Test Stand, the High Pressure (HP) Liquid Hydrogen (LH) vent line was displaced off its supports, damaging the expansion joints (EJ), piping, and pipe supports of the line. The damage to the vent line is believed to have occurred during Cell 3 testing on Thursday, September 21, during the first test of the day. The fuel systems being used for Cell 3 testing are connected to the LP and HP LH Vent systems and are being used in Liquid Natural Gas (LNG) service. The Cell 3 interface bleed valve that discharges to the HP LH Vent system was inadvertently left at 100% open during the chill-in process for longer than the typical amount of time. Since this valve is usually at a lower set point or intermittently closed during the chill-in process, more than the typical amount of LNG flowed into the vent line as pre-test procedures continued as normal. The open bleed valve was noticed before test preparations were completed and prior to refilling of the HP LH Tank before test. The test sequence was started, run, and shutdown normally. Video of the flare stack showed an atypical discharge of liquid at the flare stack exit. Pressure downstream of the Cell 3 interface bleed valve (a valve connected to the southernmost part of the vent system) spiked to a higher-than-normal level. No evidence of damage was captured at the time of the event. The system was used in a typical fashion after the event and for 4 subsequent tests on Thursday and Friday, before the damage was observed. A drive-by inspection of the flare stack was performed on Friday (September 22nd) morning before sunrise and before test activities began, but no damage of the vent line was observed at that time. No abnormal system behavior was observed during testing on Friday. The damage was discovered and reported to NASA Test Operations on Monday, initiating the Incident Response Team. The Mishap appointment letter was issued September 27th to formally initiate the Mishap Investigation.

LNG↗
NASA NTRS1971

The practical application of mishap data in Army aircraft system safety programs

The means are discussed by which the the United States Army Board for Aviation Accident Research (USABAAR) now utilizes the vast store of historical accident data in the application of the system safety concept for developmental aircraft. USABAAR serves as the central agency for the Army Accident Prevention Program which includes the receipt, processing, and analysis of all data and information related to Army aircraft accident experience. It is pointed out that methods which served the cause of accident prevention so well in the past are no longer adequate and that traditional parameters used to measure mishap experience have become obsolete. USABAAR has developed, and recently put into use, completely revised accident reporting forms which greatly expand the scope and detail of information provided as a result of investigation. This and other factors which have resulted in an improved data system are discussed in detail.

James T. Darrah, Jr↗
NASA NTRS1988

Chronic stress as a factor in aircraft mishaps

Naval aviation is an unusually stressful career because of the inherent demands of the work. Stress is recognized as a cause of mishaps which involve pilot error. A questionnaire was adapted from Rahe and Homes' list of stressful life events in order to determine the relationship between pilot behavioral, personality, and life change factors on the one hand and responsibility for accidents on the other. A number of factors regarding interpersonal relationships, changes in personal behavior, personality factors, and life changes were found to discriminate between pilots who were and were not at fault in accidents.

Alkov, Robert A.↗
NASA NTRS1990

Analysis of the National Transonic Facility mishap

The nonlinear dynamic finite element code DYnamic Crash Analysis of STructures (DYCAST) was used to model an accident scenario that occurred at the National Transonic Facility (NTF) wind tunnel. A post mishap investigation revealed that a total of five upstream bulkhead fairing plates were missing, three in one location and two in another. These plates were drawn into the wind tunnel's composite fan blades causing extensive damage. A DYCAST model was developed to determine if one-half of a small thermal shield flange clamp, weighing approximately 2.7 lbs., could have spun off the NTF drive shaft and impacted the bulkhead fairing plates with sufficient energy to cause failure of the attachment bolts. The clamp was presumed to have spun off at a tangent from the NTF drive shaft at a velocity of 1624 in/sec (drive shaft rotating at 580 rpm). The DYCAST analytical model predicts that impact of the 2.7 lbs projectile failed all of the bolts in two of the fairing plates allowing them to escape from the bulkhead ring with a low velocity of a few in/sec.

Fasanella, Edwin L.↗
NASA NTRS2007

Technical Findings, Lessons Learned, and Recommendations Resulting from the Helios Prototype Vehicle Mishap

The Helios Prototype was originally planned to be two separate vehicles, but because of resource limitations only one vehicle was developed to demonstrate two missions. The vehicle consisted of two configurations, one for each mission. One configuration, designated HP01, was designed to operate at extremely high altitudes using batteries and high-efficiency solar cells spread across the upper surface of its 247-foot wingspan. On August 13, 2001, the HP01 configuration reached an altitude of 96,863 feet, a world record for sustained horizontal flight by a winged aircraft. The other configuration, designated HP03, was designed for long-duration flight. The plan was to use the solar cells to power the vehicle's electric motors and subsystems during the day and to use a modified commercial hydrogen-air fuel cell system for use during the night. The aircraft design used wing dihedral, engine power, elevator control surfaces, and a stability augmentation and control system to provide aerodynamic stability and control. At about 30 minutes into the second flight of HP03, the aircraft encountered a disturbance in the way of turbulence and morphed into an unexpected, persistent, high dihedral configuration. As a result of the persistent high dihedral, the aircraft became unstable in a very divergent pitch mode in which the airspeed excursions from the nominal flight speed about doubled every cycle of the oscillation. The aircraft s design airspeed was subsequently exceeded and the resulting high dynamic pressures caused the wing leading edge secondary structure on the outer wing panels to fail and the solar cells and skin on the upper surface of the wing to rip away. As a result, the vehicle lost its ability to maintain lift, fell into the Pacific Ocean within the confines of the U.S. Navy's Pacific Missile Range Facility, and was destroyed. This paper describes the mishap and its causes, and presents the technical recommendations and lessons learned for improving the design, analysis, and testing methods and techniques required for this class of vehicle.

Noll, Thomas E.↗
NASA NTRS2005

Mishap Investigation Team (MIT) - Barksdale AFB, Louisiana

The Shuttle Program is organized to support a Shuttle mishap using the resources of the MIT. The afternoon of Feb. 1, 2003, the MIT deployed to Barksdale AFB. This location became the investigative center and interim storage location for crewmembers received from the Lufkin Disaster Field Office (DFO). Working under the leadership of the MIT Lead, the medical team executed a short-term plan that included search, recovery, and identification including coordination with the Armed Forces Institute of Pathology Temporary operations was set up at Barksdale Air Force Base for two weeks. During this time, coordination with the DFO field recovery teams, AFIP personnel, and the crew surgeons was on going. In addition, the crewmember families and NASA management were updated daily. The medical team also dealt with public reports and questions concerning biological and chemical hazards, which were coordinated with SPACEHAB, Inc., Kennedy Space Center (KSC) Medical Operations and the Johnson Space Center (JSC) Space Medicine office. After operations at Barksdale were concluded the medical team transitioned back to Houston and a long-term search, recovery and identification plan was developed.

Stepaniak, Philip↗
NASA NTRS2015

Failure Analysis Results and Corrective Actions Implemented for the EMU 3011 Water in the Helmet Mishap

During EVA (Extravehicular Activity) No. 23 aboard the ISS (International Space Station) on 07/16/2013 water entered the EMU (Extravehicular Mobility Unit) helmet resulting in the termination of the EVA (Extravehicular Activity) approximately 1-hour after it began. It was estimated that 1.5-L of water had migrated up the ventilation loop into the helmet, adversely impacting the astronauts hearing, vision and verbal communication. Subsequent on-board testing and ground-based TT and E (Test, Tear-down and Evaluation) of the affected EMU hardware components led to the determination that the proximate cause of the mishap was blockage of all water separator drum holes with a mixture of silica and silicates. The blockages caused a failure of the water separator function which resulted in EMU cooling water spilling into the ventilation loop, around the circulating fan, and ultimately pushing into the helmet. The root cause of the failure was determined to be ground-processing short-comings of the ALCLR (Airlock Cooling Loop Recovery) Ion Filter Beds which led to various levels of contaminants being introduced into the Filters before they left the ground. Those contaminants were thereafter introduced into the EMU hardware on-orbit during ALCLR scrubbing operations. This paper summarizes the failure analysis results along with identified process, hardware and operational corrective actions that were implemented as a result of findings from this investigation.

Steele, John↗
NASA NTRS2015

Failure Analysis Results and Corrective Actions Implemented for the Extravehicular Mobility Unit 3011 Water in the Helmet Mishap

Water entered the Extravehicular Mobility Unit (EMU) helmet during extravehicular activity (EVA) no. 23 aboard the International Space Station on July 16, 2013, resulting in the termination of the EVA approximately 1 hour after it began. It was estimated that 1.5 liters of water had migrated up the ventilation loop into the helmet, adversely impacting the astronaut's hearing, vision, and verbal communication. Subsequent on-board testing and ground-based test, tear-down, and evaluation of the affected EMU hardware components determined that the proximate cause of the mishap was blockage of all water separator drum holes with a mixture of silica and silicates. The blockages caused a failure of the water separator degassing function, which resulted in EMU cooling water spilling into the ventilation loop, migrating around the circulating fan, and ultimately pushing into the helmet. The root cause of the failure was determined to be ground-processing shortcomings of the Airlock Cooling Loop Recovery (ALCLR) Ion Filter Beds, which led to various levels of contaminants being introduced into the filters before they left the ground. Those contaminants were thereafter introduced into the EMU hardware on-orbit during ALCLR scrubbing operations. This paper summarizes the failure analysis results along with identified process, hardware, and operational corrective actions that were implemented as a result of findings from this investigation.

Steele, John↗