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This viewgraph presentation gives an overview of the investigation of a fire at NASA Stennis Space Center (SSC) on February 21, 2004. The fire occurred during structural welding to accomodate a new propellant tank. The presentation includes images of the fire damage, as well as findings/recommendations from the investigators.
Planning for sample preservation and curation was part of mission design from the beginning. One of the scientific objectives for Genesis included collecting samples of three regimes of the solar wind in addition to collecting bulk solar wind during the mission. Collectors were fabricated in different thicknesses for each regime of the solar wind and attached to separate frames exposed to the solar wind during specific periods of solar activity associated with each regime. The original plan to determine the solar regime sampled for specific collectors was to identify to which frame the collector was attached. However, the collectors were dislodged during the hard landing making identification by frame attachment impossible. Because regimes were also identified by thickness of the collector, the regime sampled is identified by measuring fragment thickness. A variety of collector materials and thin films applied to substrates were selected and qualified for flight. This diversity provided elemental measurement in more than one material, mitigating effects of diffusion rates and/or radiation damage. It also mitigated against different material and substrate strengths resulting in differing effects of the hard landing. For example, silicon crystal substrates broke into smaller fragments than sapphire-based substrates and diamond surfaces were more resilient to flying debris damage than gold. The primary responsibility of the curation team for recovery was process documentation. Contingency planning for the recovery phase expanded this responsibility to include not only equipment to document, but also gather, contain and identify samples from the landing area and the recovered spacecraft. The team developed contingency plans for various scenarios as part of mission planning that included topographic maps to aid in site recovery and identification of different modes of transport and purge capability depending on damage. A clean tent, set-up at Utah Test & Training Range to control the environment for processing the sample return capsule and cleanly installing a nitrogen purge to the canister, was used to control the environment for extracting collector fragments from the damaged canister and to document and package over 10,000 collector fragments.
KSC Medical Operations, in exercising the KSC Psychological Triage Plan, provided crewmember family support following notification of the Columbia accident. KSC Medical Operations also provided field support in working with FEMA and EPA to assure adequate occupational medicine and environmental health care of KSC workers. In addition, the development of policy and procedures for handling and clearing biohazardous debris material in the KSC reconstruction hangar was prepared and implemented.
Instability associated with the Helios Prototype HPO3-2 vehicle was a nonlinear stability and control problem involving complex interactions among the flexible structure, the unsteady aerodynamics, the flight control system, the environmental conditions, and vehicle flight dynamics. Analysis tools and solution techniques were constrained by conventional and segmented linear methodologies that did not provide the proper level of complexity to understand the technology interactions on the vehicle s stability and control characteristics. More advanced, multidisciplinary (structures, aeroelastic, aerodynamics, atmospheric, materials, propulsion, controls, etc) "time-domain" analysis methods appropriate to highly flexible, "morphing" vehicles are required. Ground-test procedures and techniques appropriate to this class of vehicle are needed to validate new analysis methods and predictions
After several decades of human spaceflight, the community of space-faring nations has accumulated a diverse and sometimes harrowing history of toxicological events that have plagued human space endeavors almost from the very beginning. Lessons have been learned in ground-based test beds and others were discovered the hard way - when human lives were at stake in space. From such lessons one can build a risk-management framework for toxicological events to minimize the probability of a harmful exposure, while recognizing that we cannot foresee all events. Space toxicologists have learned that relatively harmless compounds can be converted by air revitalization systems into compounds that cause serious harm to the crew. Our toxic risk management strategy now includes an assessment of the fate of any compound that might be released into the atmosphere. Propellants are highly toxic compounds, yet we have not always been able to thoroughly isolate the crew from exposure to these toxicants. Leakage of fluids from systems has resulted in hazardous conditions at times, and the behavior of such compounds inside a spacecraft has taught us how to manage potentially harmful escapes should they occur. Potential combustion events are an ever-present threat to the wellbeing of the crew. Such events have been sufficiently common that we have learned that one cannot judge the health threat of a given fire by the magnitude of the event. Management of such risks demands monitoring of combustion products. In the category of unpredictable toxic events, if one assumes that fires are predictable, we can place experience with toxic microbial metabolites, upsets during repair operations, and discharges from filters that have accumulated a substantial load of pollutants in their absorption beds. Management of such events requires a broad-spectrum, real-time analytical capability to discern the identity and concentrations of pollutants if they enter the atmosphere. Adverse events are an integral part of any human activity, and the spacefaring community must learn as much as possible from mistakes and near misses.
This slide presentation reviews the accident that occurred in 1985 when a bay bucket hoist fell from its stowed position. This accident damaged the orbiter, injured a technician, and delayed the launch. The accident was investigated, and the cause of the accident was determined to be the practice of two-blocking. Two-blocking is the result of hoisting beyond the intended safe upper limit of hook travel to the point of solid contact between the load block and the upper block or hoist/trolley structure. The usual result is immediate failure of the wire rope, due to the ropes being cut by the grooves of the drum or sheaves. The design of the hoist, the inspection, and the operator training were all in part responsible for this failure.
The presentation was developed for speakers to use for outreach purposes. Discusses the accidents/mishaps with NASA's space craft,and lessons learnecl
No abstract available
A summary of Air Force turbulence related mishaps for the last ten years of Air Force mishaps is presented from a perspective of where it has been, where it is now, and where it is going. In addition to accounts of major mishaps, a summary of what actions were taken to preclude future similar mishaps is presented. Also, a discussion of some of the things being done now and being planned for the future to prevent turbulence related mishaps is presented.
With the increasing packing densities in VLSI technology, Single Event Upsets (SEU) due to cosmic radiations are becoming more of a critical issue in the design of space avionics systems. In this paper, a method is introduced to compute the fault (mishap) probability for a computer memory of size M words. It is assumed that a Hamming code is used for each word to provide single error correction. It is also assumed that every time a memory location is read, single errors are corrected. Memory is read randomly whose distribution is assumed to be known. In such a scenario, a mishap is defined as two SEU's corrupting the same memory location prior to a read. The paper introduces a method to compute the overall mishap probability for the entire memory for a mission duration of T hours.
This Annual Report of the Aerospace Safety Advisory Panel (ASAP) presents results of activities during calendar year 2001. The year was marked by significant achievements in the Space Shuttle and International Space Station (ISS) programs and encouraging accomplishments by the Aerospace Technology Enterprise. Unfortunately, there were also disquieting mishaps with the X-43, a LearJet, and a wind tunnel. Each mishap was analyzed in an orderly process to ascertain causes and derive lessons learned. Both these accomplishments and the responses to the mishaps led the Panel to conclude that safety and risk management is currently being well served within NASA. NASA's operations evidence high levels of safety consciousness and sincere efforts to place safety foremost. Nevertheless, the Panel's safety concerns have never been greater. This dichotomy has arisen because the focus of most NASA programs has been directed toward program survival rather than effective life cycle planning. Last year's Annual Report focused on the need for NASA to adopt a realistically long planning horizon for the aging Space Shuttle so that safety would not erode. NASA's response to the report concurred with this finding. Nevertheless, there has been a greater emphasis on current operations to the apparent detriment of long-term planning. Budget cutbacks and shifts in priorities have severely limited the resources available to the Space Shuttle and ISS for application to risk-reduction and life-extension efforts. As a result, funds originally intended for long-term safety-related activities have been used for operations. Thus, while safety continues to be well served at present, the basis for future safety has eroded. Section II of this report develops this theme in more detail and presents several important, overarching findings and recommendations that apply to many if not all of NASA's programs. Section III of the report presents other significant findings, recommendations and supporting material applicable to specific program areas. Appendix A presents a list of Panel members. Appendix B contains the reaction of the ASAP to NASA's response to the calendar year 2000 findings and recommendations. In accordance with a practice started last year, this Appendix includes brief narratives as well as classifications of the responses as 'open,' 'closed,' or 'continuing.' Appendix C details the Panel's activities during the reporting period.
On January 7, 2001, the Genesis spacecraft lifted off from Cape Canaveral. Its mission was to collect solar wind samples and return those samples to Earth for detailed analysis by scientists. The mission proceeded successfully for three-and-a-half years. On September 8, 2004, the spacecraft approached Earth, pointed the Sample Return Capsule (SRC) at its entry target, and then fired pyros that jettisoned the SRC. The SRC carried the valuable samples collected over the prior 29 months. The SRC also contained the requisite hardware (mechanisms, parachutes, and electronics) to manage the process of entry, descent, and landing (EDL). After entering Earthas atmosphere, the SRC was expected to open a drogue parachute. This should have been followed by a pyro event to release the drogue chute, and then by a pyro event to deploy the main parachute at an approximate elevation of 6.7 kilometers. As the SRC descended to the Utah landing site, helicopters were in position to capture the SRC before the capsule touched down. On September 8, 2004, observers of the SRCas triumphant return became concerned as the NASA announcer fell silent, and then became even more alarmed as they watched the spacecraft tumble as it streaked across the sky. Long-distance cameras clearly showed that the drogue parachute had not deployed properly. On September 9, 2004, General Eugene Tattini, Deputy Director of the Jet Propulsion Laboratory formed a Failure Review Board (FRB). This board was charged with investigating the cause of the Genesis mishap in close concert with the NASA Mishap Investigation Board (MIB). The JPL-FRB was populated with experts from within and external to the Jet Propulsion Laboratory. The JPL-FRB participated with the NASA-MIB through all phases of the investigation, working jointly and concurrently as one team to discover the facts of the mishap.
The initial X-43A flight test, June 2, 2001, resulted in a mishap and loss of the vehicle. A mishap investigation board (MIB) report and findings, including the established root cause, were publicly released on July, 23, 2003. The X-43A Flight 1 Hyper-X Launch Vehicle (HXLV) failed because the vehicle control system design was deficient for the trajectory flown due to inaccurate analytical models (Pegasus heritage and HXLV specific), which overestimated the (control) system margin ? X-43A Mishap Investigation Report, Vol. I. ? included as Reference 1. Several specific errors were noted, 1) HXLV aerodynamics ? failure to model changes to wing, fin and rudder airfoil shapes due to addition of thermal protection system (TPS); 2) Fin actuation system (FAS) modeling ? under prediction of the control surface hinge moments and FAS compliance; and 3) Parametric uncertainties ? insufficient variation in the aerodynamic, FAS and control system models. In response to the MIB findings, the X-43A program has been working RTF through an approved Corrective Action Plan (CAP) over the last two years.
A system that allows a team of geographically dispersed users to collaboratively analyze a mishap event. The system includes a reconfigurable ontology, including instances that are related to and characterize the mishap, a semantic network that receives, indexes and stores, for retrieval, viewing and editing, the instances and links between the instances, a network browser interface for retrieving and viewing screens that present the instances and links to other instances and that allow editing thereof, and a rule-based inference engine, including a collection of rules associated with establishment of links between the instances. A possible conclusion arising from analysis of the mishap event may be characterized as one or more of: not a credible conclusion; an unlikely conclusion; a credible conclusion; conclusion needs analysis; conclusion needs supporting data; conclusion proposed to be closed; and an un-reviewed conclusion.
Manned space flight is risky business. Accidents have occurred and may occur in the future. NASA's manned space flight programs, with all their successes, have had three fatal accidents, one at the launch pad and two in flight. The Apollo fire and the Challenger and Columbia accidents resulted in a loss of seventeen crewmembers. Russia's manned space flight programs have had three fatal accidents, one ground-based and two in flight. These accidents resulted in the loss of five crewmembers. Additionally, manned spacecraft have encountered numerous close calls with potential for disaster. The NASA Johnson Space Center Flight Safety Office has documented more than 70 spacecraft incidents, many of which could have become serious accidents. At the Johnson Space Center (JSC), medical contingency personnel are assigned to a Mishap Investigation Team. The team deploys to the accident site to gather and preserve evidence for the Accident Investigation Board. The JSC Medical Operations Branch has developed a flight surgeon accident response training class to capture the lessons learned from the Columbia accident. This presentation will address the NASA Mishap Investigation Team's medical objectives, planned response, and potential issues that could arise subsequent to a manned spacecraft accident. Educational Objectives are to understand the medical objectives and issues confronting the Mishap Investigation Team medical personnel subsequent to a human space flight accident.
The Implementation of Human Systems Integration (HSI) presents challenges within the acquisition community for two reasons. The first is that misconceptions of HSI still exist, with many Program Managers (PMs) and leadership uncertain of the value or where to begin. The second is due to an unbalanced approach to HSI in its own framework. These implementation challenges lead to barriers in the early prevention of mishaps. Understanding HSI practices and how they should be implemented in the Acquisition Product Life Cycle (PLC) has been a challenge across the government, leaving the value of HSI unknown and misunderstood with Program Managers. In the case for many acquisition programs, HSI is not implemented in early design, losing the perspective on human capabilities and limitations, creating impacts on human-centered design. Expectations in human performance are not clearly set and operations are baselined with no margin for changes in technology and processes that will affect system performance. The HSI framework addresses total system performance holistically using collaboration as the primary tool. The goal is to create a system with efficiencies while minimizing risk to the operators, maintainers, and support personnel, as well as any collateral personnel and systems. To accomplish this, HSI should be implemented as part of preemptive measures to minimize potential human error and mishaps during the operation phase. Investigative and assessment tools exist that consider events, issues, and other outside influences of a system that may not fall under the current construct of the HSI domains, leaving gaps in early HSI implementation and affecting the prevention of human errors and mishaps. This presentation will outline what NASA HSI is doing to support Early HSI implementation and Operational Performance shifts that affect human performance.
Introduction: In 1997 NASA’S Discovery Program selected the Genesis mission proposal to return solar wind samples to Earth for laboratory analyses. Principal Investigator Donald S. Burnett and the science team defined the purity of collector materials and ability to analyze solar wind composition to the precision required for planetary science. As a small mission, focused on a well-defined science goal, yet needing careful attention to engineering details, the communication among scientists and engineers, nurtured by Don Burnett, was exceptional. Genesis Mission and Curation Legacy: Genesis, as the first U. S. spacecraft to return astromaterial samples since Apollo, not only integrated the mission planning and flight teams, but also the science and sample curation teams during the mission development period. Since Genesis is a sample return mission, the Science Team was essential in certifying the collectors (sample containers for solar atoms). From inception, Genesis established mission funding for returned sample curation. JSC was lead in contamination control during mission preparation, including establishment of an ISO 4 cleanroom facility and use of ultrapure water (UPW) for cleaning flight hardware (and, as it turned out, for cleaning collectors after the mishap). Reliable, fast communication among scientists, engineers and curators at the hands-on level established deep respect among team members and efficient decision-making. JSC’s 50-years of astromaterial sample curation provided experienced sample processors onsite during recovery in Utah (a deep bench for emergency response). Post-recovery curation included iterative collaboration with science sample users to clean or verify cleanliness of samples. The science legacy from Genesis is addressed by Burnett and Jurewicz, this volume. In The Beginning: After Apollo sample return, Burnett and Marcia Neugebauer at JPL began discussing a solar wind sample return, with Neugebauer arguing that separate collection of solar wind regimes was essential science. By 1992 a solar wind sample return mission was presented at a workshop, and by 1994 a mission was proposed named Suess-Urey. The mission was re-proposed under a new name GENESIS and selected in 1997. Susan Niebur captured the Genesis mission history and stories, from high level management documents and from many interviews with participants [2]. Her account lets readers glimpse personality of participants in quotations from interviews. Need and Scope for Detailed Technical Timeline: A timeline constructed from lower level task documents has been initiated to document the resources and skills actually used, as well as task sequence or concurrency. Timelines for high level mission events are captured in two documents [1] [2] and for detailed re-entry events in [3]. A detailed technical timeline for Genesis mission and curation activities will provide data points for lower level tasks, such as ISO 4 curation facility construction time, preparation for nominal sample field recovery, mishap recovery, and UPW expansion. Changes in technology context 1990-2024: Semiconductor technologies were easily accessible in the U.S.A. (1990-1999), and the Genesis team used those resources for cleanroom design and UPW system expansion. Image documentation was changing from film to digital during cleanroom construction and payload cleaning (1997-2001). Engineering design was done using computer aided design proprietary software, making more difficult the archiving of payload configuration and materials. Email of documents, tracked delivery service and virtual meeting capability greatly improved communication efficiency. Information sources – Pre-launch mission preparation: Examples of mission science, engineering and contamination control are collector purity testing, payload design/fabrication and ISO 4 cleanroom construction. Information on timing of these activities comes from facility readiness reviews, management reviews, shipping documents, procurement documents, test reports, travel documents, laboratory logs, Quality Assurance documents, dates on images, participant notebooks and emails. Information sources – Sample return re-entry and field recovery activities: Information comes from event timelines produced by Mid-Air Recovery team, Lockheed team lead notes and from chase video, JPL Quality Assurance. Information also comes from images and logbooks from UTTR cleanroom operations and from curatorial documents. Information sources – Resulting science and sample cleaning processes: Agendas from the annual gatherings of the science team initially trace testing for collector purity/cleanliness, and after sample recovery, include collector cleaning and cleanliness assessment. Post-recovery documents include curatorial orders and procedures, sample allocation documents and LPSC abstracts. Timeline Objectives: A simple spreadsheet timeline with headers DATE, EVENT, PEOPLE, COMMENT, INFORMATION SOURCE has been initiated and currently has over 90 entries. While this is not definitive historical research, it is a quick look at the evolution of Genesis curation with pointers to documents or people with information. Engineers for future missions may find useful points of comparison for development of facilities. References:[1] Genesis Mission Reference Document, (2011) JPL D-62382.[2] Niebur S. M., edited by Brown D. W. (2023) NASA’s Discovery Program: The First 20 Years of Competitive Planetary Exploration, NASA-SP-2023-4238.[3] Genesis Mishap Investigation Board Report, Vol. 1 (July 2005).