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All sourcesNASA NTRSDOE OSTI
NASA NTRS2015

Common Cause Failure Modeling in Space Launch Vehicles

Common Cause Failures (CCFs) are a known and documented phenomenon that defeats system redundancy. CCFs are a set of dependent type of failures that can be caused for example by system environments, manufacturing, transportation, storage, maintenance, and assembly. Since there are many factors that contribute to CCFs, they can be reduced, but are difficult to eliminate entirely. Furthermore, failure databases sometimes fail to differentiate between independent and dependent CCF. Because common cause failure data is limited in the aerospace industry, the Probabilistic Risk Assessment (PRA) Team at Bastion Technology Inc. is estimating CCF risk using generic data collected by the Nuclear Regulatory Commission (NRC). Consequently, common cause risk estimates based on this database, when applied to other industry applications, are highly uncertain. Therefore, it is important to account for a range of values for independent and CCF risk and to communicate the uncertainty to decision makers. There is an existing methodology for reducing CCF risk during design, which includes a checklist of 40+ factors grouped into eight categories. Using this checklist, an approach to produce a beta factor estimate is being investigated that quantitatively relates these factors. In this example, the checklist will be tailored to space launch vehicles, a quantitative approach will be described, and an example of the method will be presented.

Hark, Frank↗
NASA NTRS2017

And the Humans Save the Day or Maybe They Ruin It: The Importance of Humans in the Loop

Flying a mission in space requires a massive commitment of resources, and without the talent and commitment of the people involved in this effort we would never leave the atmosphere of Earth. When we use the phrase "humans in the loop", it could apply to almost any endeavor since everything starts with humans developing a concept, completing the design process, building or implementing a product and using the product to achieve a goal or purpose. Narrowing the focus to spaceflights, there are a variety of individuals involved throughout the preparations for flight and the flight itself. All of the humans involved add value and support for program success. The purpose of this paper focuses on how a Probabilistic Risk Assessment (PRA) accounts for the human in the loop for potential missions using a technique called Human Reliability Analysis (HRA). Human actions can increase or decrease the overall risk via initiating events or mitigating them, thus removing the human from the loop doesn't always lower the risk.

DeMott, Diana↗
NASA NTRS2016

Estimating Orion Heat Shield Failure Due To Ablator Cracking During The EFT-1 Mission

The Orion EFT-1 heatshield suffered from two major certification challenges: First, the mechanical properties used in design were not evident in the flight hardware and second, the flight article itself cracked during fabrication. The combination of these events motivated the Orion Program to pursue an engineering-level Probabilistic Risk Assessment (PRA) as part of heatshield certification rationale. The PRA provided loss of Mission (LOM) likelihoods considering the probability of a crack occurring during the mission and the likelihood of subsequent structure over-temperature. The methods and input data for the PRA are presented along with a discussion of the test data used to anchor the results. The Orion program accepted an EFT-1 Loss of Vehicle (LOV) risk of 1-in-160,000 due to in-mission Avcoat cracking based on the results of this analysis. Conservatisms in the result, along with future considerations for Exploration Missions (EM) are also addressed.

Avcoat↗
NASA NTRS2016

Human Reliability Assessments: Using the Past (Shuttle) to Predict the Future (Orion)

NASA (National Aeronautics and Space Administration) Johnson Space Center (JSC) Safety and Mission Assurance (S&MA) uses two human reliability analysis (HRA) methodologies. The first is a simplified method which is based on how much time is available to complete the action, with consideration included for environmental and personal factors that could influence the human's reliability. This method is expected to provide a conservative value or placeholder as a preliminary estimate. This preliminary estimate or screening value is used to determine which placeholder needs a more detailed assessment. The second methodology is used to develop a more detailed human reliability assessment on the performance of critical human actions. This assessment needs to consider more than the time available, this would include factors such as: the importance of the action, the context, environmental factors, potential human stresses, previous experience, training, physical design interfaces, available procedures/checklists and internal human stresses. The more detailed assessment is expected to be more realistic than that based primarily on time available. When performing an HRA on a system or process that has an operational history, we have information specific to the task based on this history and experience. In the case of a Probabilistic Risk Assessment (PRA) that is based on a new design and has no operational history, providing a "reasonable" assessment of potential crew actions becomes more challenging. In order to determine what is expected of future operational parameters, the experience from individuals who had relevant experience and were familiar with the system and process previously implemented by NASA was used to provide the "best" available data. Personnel from Flight Operations, Flight Directors, Launch Test Directors, Control Room Console Operators and Astronauts were all interviewed to provide a comprehensive picture of previous NASA operations. Verification of the assumptions and expectations expressed in the assessments will be needed when the procedures, flight rules and operational requirements are developed and then finalized.

DeMott, Diana↗
NASA NTRS2017

Human Reliability Assessments: Using the Past (Shuttle) to Predict the Future (Orion)

NASA (National Aeronautics and Space Administration) Johnson Space Center (JSC) Safety and Mission Assurance (S&MA) uses two human reliability analysis (HRA) methodologies. The first is a simplified method which is based on how much time is available to complete the action, with consideration included for environmental and personal factors that could influence the human's reliability. This method is expected to provide a conservative value or placeholder as a preliminary estimate. This preliminary estimate or screening value is used to determine which placeholder needs a more detailed assessment. The second methodology is used to develop a more detailed human reliability assessment on the performance of critical human actions. This assessment needs to consider more than the time available, this would include factors such as: the importance of the action, the context, environmental factors, potential human stresses, previous experience, training, physical design interfaces, available procedures/checklists and internal human stresses. The more detailed assessment is expected to be more realistic than that based primarily on time available. When performing an HRA on a system or process that has an operational history, we have information specific to the task based on this history and experience. In the case of a Probabilistic Risk Assessment (PRA) that is based on a new design and has no operational history, providing a "reasonable" assessment of potential crew actions becomes more challenging. To determine what is expected of future operational parameters, the experience from individuals who had relevant experience and were familiar with the system and process previously implemented by NASA was used to provide the "best" available data. Personnel from Flight Operations, Flight Directors, Launch Test Directors, Control Room Console Operators, and Astronauts were all interviewed to provide a comprehensive picture of previous NASA operations. Verification of the assumptions and expectations expressed in the assessments will be needed when the procedures, flight rules, and operational requirements are developed and then finalized.

DeMott, Diana L.↗
NASA NTRS2017

And the Human Saves the Day or Maybe They Ruin It, The Importance of Humans in the Loop

Flying a mission in space requires a massive commitment of resources, and without the talent and commitment of the people involved in this effort we would never leave the atmosphere of Earth as safely as we have. When we use the phrase "humans in the loop", it could apply to almost any endeavor since everything starts with humans developing a concept, completing the design process, building or implementing a product and using the product to achieve a goal or purpose. Narrowing the focus to spaceflight, there are a variety of individuals involved throughout the preparations for flight and the flight itself. All of the humans involved add value and support for program success. The paper discusses the concepts of human involvement in technological programs, how a Probabilistic Risk Assessment (PRA) accounts for the human in the loop for potential missions using a technique called Human Reliability Analysis (HRA) and the tradeoffs between having a human in the loop or not. Human actions can increase or decrease the overall risk via initiating events or mitigating them, thus removing the human from the loop doesn't always lowers the risk.

DeMott, Diana L.↗
NASA NTRS2018

Synthesizing a New Launch Vehicle Failure Probability Based on Historical Flight Data

New launch vehicles have historically had significantly higher failure rates in early flights than what has been predicted using Probabilistic Risk Assessment - PRA. This is because PRAs typically model a mature vehicle where a significant portion of the early failure probability contributors have been eliminated due to testing and improvements after actual field operation. To capture a more accurate early flight failure probability estimate, this paper develops a method that estimates ascent failure probability starting with the first flight based on historical launch vehicle records. With new launch vehicles being developed, such as the Space Launch System - SLS, a PRA model must be extended to cover early flight failure probability contributions that are either not covered in the mature-vehicle PRA or are underestimated. These failure probability contributions include design errors, quality control deficiencies, installation errors, and environmental impacts. There are also failure dependencies due to systemic errors that still exist due to limited entire-system testing.

Cross, Robert B.↗
NASA NTRS2018

Synthesizing a New Launch Vehicle Failure Probability Based on Historical Flight Data

New launch vehicles have historically had significantly higher failure probabilities in early flights than what has been predicted using Probabilistic Risk Assessment. Work on a new methodology originally started with ARES I-X and the Common Standards Working Group (CSWG) for range safety applications. CSWG consists of the Federal Aviation Administration (FAA), Air Force, and NASA. Historical launch vehicle data was viewed as the best predictor of success/failure for launches of new vehicles. A launch vehicle database was developed that includes all launches from 1980-2017 (both US and foreign). Entries to the database include: Vehicle by model type; Launch dates; Failure description; Failure Result (Loss Of Vehicle (LOV)/Loss Of Mission (LOM); Failure cause (when available); Vehicle designs (stages/engines/etc.)

Early flight risk↗
NASA NTRS2018

A Prognostic Launch Vehicle Probability of Failure Assessment Methodology for Conceptual Systems Predicated on Human Causal Factors

Lessons learned from past failures of launch vehicle developments and operations were used to create a new method to predict the probability of failure of conceptual systems. Existing methods such as Probabilistic Risk Assessments and Human Risk Assessments were considered but found to be too cumbersome for this type of system-wide application for yet-to-be-flown vehicles. The basis for this methodology were historic databases of past failures, where it was determined that various faulty human-interactions were the predominant root causes of failure rather than deficient component reliabilities evaluated through statistical analysis. This methodology contains an expert scoring part which can be used in either a qualitative or a quantitative mode. The method produces two products: a numerical score of the probability of failure and guidance to program management on critical areas in need of increased focus to improve the probability of success. In order to evaluate the effectiveness of this new method, data from a concluded vehicle program (USAF's Titan IV with the Centaur G-Prime upper stage) was used as a test case. The theoretical vs. actual probability of failure was found to be 4.46% vs. 6.67% respectively. Recommendations are made for future applications of this method to ongoing launch vehicle development programs.

Launch Vehicle↗
NASA NTRS2018

A Prognostic Launch Vehicle Probability of Failure Assessment Methodology for Conceptual Systems Predicated on Human Causal Factors

Create an improved method to calculate reliability of a conceptual launch vehicle system prior to fabrication by using historic data of actual root causes of failures. While failures have unique "proximate causes", there are typically a finite amount of common "root causes". Heretofore launch vehicle reliability evaluation typically hardware-centric statistical analyses, while most root causes of failures are been shown to be human-centric. A method based on human-centric root causes can be used to quantify reliability assessments and focus proposed actions to mitigate problems. Existing methods have been optimistic in their projections of launch vehicle reliability compared to actuals. Hypothesis: reliability of a conceptual launch vehicle can be more accurately evaluated based on a rational, probabilistic approach using past failure assessment teams' findings predicated on human-centric causes."Human Reliability Analysis Methods Selection Guidance for NASA"Chandler F.T., et al., NASA HQ/OSMA study group, July 2006. Outside HRA experts from academia, other federal labs, and the private sector. 50 system reliability methods considered, fourteen selected for further study, four finally selected as best suited for human spaceflight. Probabilistic Risk Analysis (PRA) + Human Reliability Analysis (HRA) enabled incorporating effects and probabilities of human errors. While four down-selected methods deemed appropriate for failure assessment, it did not appear that these methods could be concisely applied to perform major system-wide assessment of probability of failure of a conceptual design without becoming unwieldy."Engineering a Safer World", Detailed, comprehensive study external to NASA Leveson N. G., MIT, 2011.Systems-Theoretic Accident Model and Processes (STAMP). All-encompassing accident model based on systems theory analyzed accidents after they occurred and created approaches to prevent occurrence in developing systems not focused on failure prevention per se, but rather reducing hazards by influencing human behavior through use of constraints, hierarchical control structures, and process models to improve system safetySystem Theoretic Process Analysis (STPA) addresses predictive part of problem (a "hazard analysis"). Includes all causal factors identified in STAMP: "...design errors, software flaws, component interaction accidents, cognitively complex human decision-making errors, and social organizational and management factors contributing to accidents" can guide design process rather than require it to exist before-hand did not appear capable of concise application for system-wide assessment of probability of failure of a conceptual design without becoming unwieldy.

Williams, Craig H.↗
NASA NTRS2018

The Growth of Mass and Reliability Source Database and Me

Mass and Reliability Source (MaRS) is a database which draws together information from multiple other sources and databases (MADS, VMDB, ISS PART, Bayesian PowerPoint, etc.). Information such as mass, operating hours, and failure data are compiled to create a tool for the building of probabilistic Risk Assessment (PRA) models. MaRS also has great potential for deep space mission planning. Understanding the lowest point of failure within an ORU helps to inform the efficient selection of spare parts necessary for a journey where mass and volume are at a premium and resupply is not possible.

George, Cory A.↗
NASA NTRS2015

Simulation of Liquid Rocket Engine Failure Propagation Using Self-Evolving Scenarios

Traditional probabilistic risk assessment approaches often require failure scenarios to be explicitly defined through event sequences that are then quantified as part of the integrated analysis. This approach becomes difficult when failure propagation paths change as a function of the system operation. Additionally, if the propagation paths represent interactions among even a modest number of components, the scenario count becomes combinatorially intractable. This paper presents an alternate approach for quantifying the probability of failure propagation in such a case. Rather than explicitly defining scenario sequences, simple physical models are created for each of the components. In this way, only the physical states and rules of component interactions must be defined, rather than event sequences for each individual scenario. Initiating failures are introduced into the system, either randomly or as defined by relative likelihood, and the failures cascade through the system via the interaction rules. This process is repeated using Monte Carlo methods and, as a result, the most probable scenarios “self-evolve” in terms of both sequence path and frequency. This approach was applied to failures occurring in the engine compartment of a space launch vehicle with four liquid rocket engines and four high-pressure helium tanks. Each engine was modeled with key components, such as turbomachinery, combustion chamber, propellant lines, and additional support systems. Three test cases were conducted with different high-energy engine failures. End results of interest included an additional engine-out failure and tank burst, which represent the loss-of-mission (LOM) and loss-of-crew (LOC) failure environments, respectively. Observations show that almost every scenario outcome is unique and that many scenarios involve complex chain reactions that are difficult to predict. This validates the usefulness of the modeling approach in assessing the overall risks to the crew during a launch vehicle abort.

Rocket Engine↗
NASA NTRS2019

The Effect of Heroic Medical Care on Mission Medical Outcomes

Study Objective: A catastrophic medical event depletes medical resources. What happens to the rest of the mission’s medical outcomes after such an event? Use Probabilistic Risk Assessment (PRA) to see if we can find out. What is the Integrated Medical Model? PRA model using Monte Carlo methodology; Used to assess mission risk due to in-flight medical events; User defined Design Reference Missions (DRM) (crew, duration, EVA (Extra-Vehicular Activity), etc.); Considers outcomes for 100 medical conditions that have or may occur in-flight; 100,000 trials conducted per DRM.

Reyes, David P.↗
NASA NTRS2019

Prognostic Launch Vehicle Probability of Failure Assessment Methodology for Conceptual Systems Predicated on Human Causal Factors

Lessons learned from past failures of launch vehicle developments and operations were used to create a new method to predict the probability of failure of conceptual systems. Existing methods such as Probabilistic Risk Assessments and Human Risk Assessments were considered but found to be too cumbersome for this type of system-wide application for yet-to-be-flown vehicles. The basis for this methodology were historic databases of past failures, where it was determined that various faulty human-interactions were the predominant root causes of failure rather than deficient component reliabilities evaluated through statistical analysis. This methodology contains an expert scoring part which can be used in either a qualitative or a quantitative mode. The method produces two products: a numerical score of the probability of failure or guidance to program management on critical areas in need of increased focus to improve the probability of success. In order to evaluate the effectiveness of this new method, data from a concluded vehicle program (USAF's Titan IV with the Centaur G-Prime upper stage) was used as a test case. Although the theoretical vs. actual probability of failure was found to be in reasonable agreement (4.46% vs. 6.67% respectively) the underlying sub-root cause scoring had significant disparities attributable to significant organizational changes and acquisitions. Recommendations are made for future applications of this method to ongoing launch vehicle development programs.

Craig H Williams↗
NASA NTRSDate not supplied

Developing A New Medical Condition List for Exploration Spaceflight

For the last decade, the National Aeronautics and Space Administration (NASA) has utilized a probabilistic risk analysis tool called the Integrated Medical Model (IMM), which contains 100 medical conditions, to conduct medical trade-space analyses and risk assessments for International Space Station (ISS) operations. Planning for future missions to the Moon and Mars will require updated tools and evidence that consider the unique features of exploration missions. To address this need, the Exploration Medical Capability (ExMC) Element of the NASA Human Research Program is developing an advanced trade-space analysis tool suite, IMPACT. As a part of this effort, ExMC has produced the IMPACT version 1 Condition List (ICL 1.0) which expands the scope and definition of medical conditions.

Amy Jean Kreykes↗
NASA NTRSDate not supplied

Crowd Sourcing Medical Data Collection Using Medical Students

OBJECTIVE We undertook an upgrade of the Evidence Library database of NASA HRP’s Integrated Medical Model, assessing 120 medical conditions which integrate with a novel probabilistic risk assessment (IMPACT) tool of medical risk and resource utilization for long duration exploration human spaceflight. This data collection process included a selection of these conditions crowd sourced over one year via three 4-week medical student electives at the University of Colorado School of Medicine (IDPT 8059 Space Medicine: Human Spaceflight Factors & Medical Risk Assessment). Students undertook a rapid systematic review of each medical condition, under close preceptors with backgrounds in clinical medicine, library science, epidemiology, biostatistics, and evidence-based medicine. As part of the elective, students also received instruction in core space medicine concepts, evidence based medicine and problem based learning sessions as a flight surgeon supporting a simulated Mars mission. METHODS The list of 120 medical conditions includes both common, terrestrial illness/injury (epistaxis, diverticulitis) as well as spaceflight-specific ones (space adaptation conditions, EVA-related injuries). A rapid systematic review process was developed that would allow students to find the data for determining disease incidence/prevalence, return to definitive care (often a surrogate such as hospitalization rates), loss of crew life, and treatment duration. Each data point required a tailored, specialized search process using different databases and corresponding specialized search filters. Databases were selected on their ability to provide high quality literature in an efficient manner and prioritized by their ability to provide graded evidence via a set rubrics specific to human spaceflight. Students were responsible for performing all literature searches and identifying the highest quality available evidence for each data point. Completed student data sheets underwent initial review by faculty preceptors followed by a secondary editing review by the ExMC Clinical Science Team. RESULTS Over the course of three electives, approximately 105 medical conditions were researched by students using spreadsheets with pre-crafted search strategies. Overall, this process was successful in allowing students to perform the preponderance of work to update incidence, treatment duration, return to definitive care, and loss of crew life data points. Students were successful in running searches, identifying the necessary data points within the literature, and determining the types of terrestrial data that most aligns with the astronaut population for successful completion of their tasks. Limitations included variable student experience with search methodologies [PubMed], differing values of evidence grading [best practice evidence based medicine vs. relevant to spaceflight], and students’ unfamiliarity with spaceflight specific conditions. CONCLUSION Finding the relevant literature for medical conditions in spaceflight within terrestrial databases in a systematic method is time consuming and not intuitive. However, the stepwise process that balanced sensitivity with specificity allowed for students to be highly successful in a short amount of time. Additionally, as the process was refined over the course of three electives, preceptors were better able to anticipate where students were likely to encounter barriers, which allowed the course to be adjusted to account for certain data points needing more time for completion. This replicable process may be an efficient way to accomplish rapid systematic reviews for a large volume of data in a short amount of time.

J Lemery↗
NASA NTRSDate not supplied

Use of Preliminary PRA to Inform Decisions During Initial NASA Gateway Development

How do you use Probabilistic Risk Assessment (PRA) to support a program in development before designs are even known? Traditional PRAs require detailed design information and early in a program life cycle such information is not available. National Aeronautics and Space Administration (NASA) Safety and Mission Assurance (SMA) developed a preliminary PRA for the Gateway Program based upon NASA reference designs utilizing data and models from pervious PRA studies as surrogates for the Gateway systems. Gateway will be a lunar outpost that supports missions to the moon and includes several elements/modules developed by NASA and International Partners. NASA SMA began supporting Gateway in fall 2017 during initial formulation and continues to support the Gateway Program today. This paper will explore how the NASA SMA developed preliminary PRA was used to inform Gateway Program decisions with specific examples provided.

PRA↗
NASA NTRSDate not supplied

Medical Database Accomplishments and Lessons Learned - 2021

The Medical Database (MD) is a virtual repository consisting of two software components: the Medical Item Database (MedID) and the Evidence Library (EL). MedID consists of engineering data and associated information for specific medical resource items (e.g., pharmaceutical, medical devices, and supporting components), while the EL is a tool which provides all of the medical evidence necessary. The Medical Database will serve as the single “source of truth” for the Informing Mission Planning via Analysis of Complex Tradespaces (IMPACT) tool suite for both medical evidence and medical resource engineering data. It will be used in conjunction with the IMPACT tool suite to inform research prioritizations and perform systematic trade study evaluations using probabilistic risk assessment and simulated human spaceflight missions to aid stakeholders in making informed decisions during Pre-Phase-A planning of human spaceflight missions. The IMPACT project is conducted under the Exploration Medical Capability (ExMC) element of the Human Research Program (HRP), within NASA’s Human Exploration and Operations Mission Directorate. Over the past year, the MedID software has been successfully merged with the Evidence Library into one cohesive Medical Database with two independent user interface experiences for modifying either clinical evidence or resource engineering data. As MD has evolved substantially over the past year, a number of challenges have been encountered and overcome along the way. A number of ‘lessons learned’ and practical/logistical realizations have emerged which will be detailed in the forthcoming Medical Database presentation.

Exploration Medical Capability↗