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Software risk estimation and management techniques at JPL

In this talk we will discuss how uncertainty has been incorporated into the JPL software model, probabilistic-based estimates, and how risk is addressed, how cost risk is currently being explored via a variety of approaches, from traditional risk lists, to detailed WBS-based risk estimates to the Defect Detection and Prevention (DDP) tool.

software risk↗

Monitoring for Renal Stone Recurrence in Astronauts With History of Stone

After an initial stone episode persons are at increased risk for future stone formation. A systematic approach is required to monitor the efficacy of treatment and preventive measures, and to assess the risk of developing new stones. This is important for persons working in critical jobs or austere environments, such as astronauts. A literature review of the current standards of care for renal stone monitoring and imaging was done. Military and civil aviation standards were also reviewed, as well as the medical precedents from the space program. Additionally, a new, more effective, renal stone ultrasound protocol has been developed. Using this work, a monitoring algorithm was proposed that takes into consideration the unique mission and operational environment of spaceflight. The approach to imaging persons with history of renal stones varies widely in the literature. Imaging is often done yearly or biannually, which may be too long for mission critical personnel. In the proposed algorithm astronauts with a history of renal stone, who may be under consideration for assignment, are imaged by a detailed, physiciandriven, ultrasound protocol. Unassigned personnel are monitored by yearly ultrasound and urine studies. Any positive ultrasound study is then followed by low-dose renal computed tomography scan. Other criteria are also established. The proposed algorithm provides a balanced approach between efficacy and reduced radiation exposure for the monitoring of astronauts with a renal stone history. This may eventually allow a transition from a risk-averse, to a risk-modifying approach that can enable continued service of individuals with history of renal stone that have adequately controlled risk factors.

Reyes, David P.↗

ISS Utilization and Countermeasure Validation: Implementing the Critical Path Roadmap to Reduce Uncertainties of Extended Human Spaceflight Expeditions

Human exploration of space requires the ability to understand and mitigate risks to crews exposed to the conditions associated with such missions. This becomes a greater imperative as we prepare for interplanetary expeditions involving humans who will be subjected to long transit periods in microgravity as they travel to a distant planet such as Mars, embark and live on the planet's surface for an extended time, and finally, return to the 1 g environment of Earth. We need to know, more definitively, what the human health, safety, and performance risks are, and how to prevent or counteract them throughout all phases of a long duration mission. The Johnson Space Center's Space and Life Sciences Directorate along with the National Space Biomedical Research Institute (NSBRI) have been engaged in a strategic planning effort that identifies the most critical risks confronting humans who will venture forth on such missions and the types of research and technology efforts required to mitigate and otherwise reduce the probability and/or severity of those risks. This paper describes the unique approach used to define, assess and prioritize the risks and presents the results of the assessment with an emphasis on the research and technology priorities that will help us to meet the challenge of long duration human spaceflight missions.

Leveton, Lauren B.↗

Protecting Space Travelers from Kidney Stones: Renal Stone Risk During Space Flight

Renal stones, popularly known as kidney or bladder stones, are small rock-like objects formed in the kidneys or urinary tract by deposits of calcium and other minerals. The problem arises when the stones block the drainage of the kidney, resulting in urinary obstruction and pain. Passing these stones can be one of the most painful experiences a person will endure so doctors often prescribe pain relievers to ease the experience. Drinking plenty of fluids, which help flush waste out of the body, and eating a well-balanced diet are the first steps to preventing stones. For individuals at risk, this may not be enough, and a doctor may recommend a special diet and medications. Unfortunately, approximately 60 percent of people who have had a renal stone will experience a recurrence. This is particularly true of men, who are four to five times more likely to develop stones than women. Renal stones do not discriminate based on age; even children are at risk. Astronauts are particularly at risk of developing renal stones because they lose bone and muscle mass; calcium, other minerals, and protein normally used for bone and muscle end up in the bloodstream and then in the kidneys. Without plenty of fluid to wash them away, crystals can form and then grow into stones. This factor compounds the risk for astronauts, since they also perceive that they are less thirsty in space and will drink less than normal during the mission. To minimize all of these factors, doctors must instead treat the stone-forming compounds with medication. This study will use potassium citrate to reduce the risk of stone formation. Renal stones are never convenient, but they are a particular concern for astronauts who have limited access to treatment during flight. Researchers are examining how earthbound preventions for renal stone formation work in flight, ensuring missions are not ended prematurely due to this medical condition. During STS-107, earthbound preventions and treatments become astronauts' gain.

Whitson, Peggy↗

Microbial Monitoring of the International Space Station

Humans living and working in the harsh environment of space present many challenges for habitability engineers and microbiologists. Spacecraft must provide an internal environment in which physical (gas composition, pressure, temperature, and humidity), chemical, and biological environmental parameters are maintained at safe levels. Microorganisms are ubiquitous and will accompany all human-occupied spacecraft, but if biological contamination were to reach unacceptable levels, long-term human space flight would be impossible. Prevention of microbiological problems, therefore, must have a high priority. Historically, prevention of infectious disease in the crew has been the highest priority, but experience gained from the NASA-Mir program showed that microbial contamination of vehicle and life-support systems, such as biofouling of water and food, are of equal importance. The major sources of microbiological risk factors for astronauts include food, drinking water, air, surfaces, payloads, research animals, crew members, and personnel in close contact with the astronauts. In our efforts to eliminate or mitigate the negative effects of microorganisms in spacecraft, the National Aeronautics and Space Administration (NASA) implemented comprehensive microbial analyses of the major risk factors. This included the establishment of acceptability requirements for food, water, air, surfaces, and crew members. A robust monitoring program was then implemented to verify that the risks were within acceptable limits. Prevention of microbiological problems is preferred over mitigation of problems during flight, and preventive steps must begin very early in the design phase. Spacecraft development must include requirements to control free water from humidity, condensate, hygiene activities, and other releases. If water is available, microbes are likely to grow because sufficient nutrients are potentially available. Materials selected for the spacecraft must not promote or support microbial growth. Air filtration can dramatically reduce the number of airborne bacteria, fungi, and particulates in spacecraft breathing air. Waterborne bacteria can be reduced to acceptable levels by thermal inactivation of bacteria during water processing, along with a residual biocide, and filtration at the point of use can ensure safety. System design must include onboard capability to achieve recovery of the system from contamination. Robust housekeeping procedures that include periodic cleaning and disinfection will prevent high levels of microbial growth on surfaces. Food for consumption in space must be thoroughly tested for excessive microbial content and pathogens before launch. Thorough preflight examination of flight crews, consumables, payloads, and the environment can greatly reduce pathogens in spacecraft. Many of the lessons learned from the Space Shuttle and previous programs were applied in the early design phase of the International Space Station, resulting in the safest space habitat to date. This presentation describes the monitoring program for the International Space Station and will summarize results from preflight and on-orbit monitoring.

Pierson, Duane L.↗

Evaluating Liftoff Debris for NASA’s Space Launch System (SLS) Prior to the Artemis I Launch

The SLS Artemis I launch vehicle is the first of several planned Artemis launch vehicles, with a number of design differences from earlier NASA missions that incur liftoff debris risk to the mission. As a test vehicle, the Artemis I hardware also endured environments and tests not planned for future missions, which led to several additional factors contributing to an evolving liftoff debris risk to the SLS vehicle. This paper will summarize these risk factors and address the processes used to evaluate and communicate the risks to support a successful Artemis I launch. It will discuss how the evolving risks that were quantified and evaluated by a Cross-Program team of debris Subject Matter Experts to mitigate liftoff debris hazards and communicate updated risk to the SLS vehicle. This process was performed through the inaugural use of an SLS debris day-of-launch (DOL) standard operating procedure that will be used for subsequent Artemis missions. This paper addresses the risk of liftoff debris, debris released by the vehicle or from the launch pad during liftoff through vehicle tower clear. Expected liftoff debris is well understood from previous NASA programs’ experience and from tests of materials, processes and functions that are known to release liftoff debris. These expected sources were assessed and cleared well ahead of launch day. However, given the ever-changing schedules and environments, processes were in place to evaluate any additional potential liftoff debris risks identified during launch countdown. Although many of the Artemis vehicle hardware components are similar to those on the NASA Shuttle Program, there are important differences in the architecture of the Artemis I vehicle which require new assessments of liftoff debris risk for the Artemis missions. The more favorable Artemis crew module location and surfaces are far less vulnerable to debris impacts; however, the longer vehicle can result in higher liftoff debris impact energies to those components on the aft end of the vehicle. Additionally, the positional change of the RS-25 liquid engines to nearer the Booster nozzle exit plane along with the change in Booster throat plug design is a disadvantage to the overall liftoff debris risk which resulted in additional test and analysis efforts for evaluating the integrated vehicle debris risk. In spite of the comprehensive tests and analyses of Artemis I expected liftoff debris, a number of additional tests/processes were completed prior to the Artemis I mission that were required to support a complete understanding of a new launch vehicle, but increased the risk of releasing liftoff debris. The hardware endured several additional cryogenic loading cycles, including the Green Run tests at Stennis Space Center, Wet Dress Rehearsals at Kennedy Space Center, and multiple launch attempts. Each of these cycles induced stresses in the thermal protection system (TPS) materials, increasing the risk of damage to and release of the TPS. Additionally, induced and weather environmental factors that could increase the likelihood of debris release were significant. Vibrations and stresses in the TPS were induced by a required roll-back to the Vehicle Assembly Building before Hurricane Ian to protect the vehicle from damage by high winds. Wind damage and potential internal stresses to several outer mold line materials on the integrated SLS vehicle and mobile launcher were caused by weathering Hurricane Nicole at Pad 39B the week before launch. A thorough imagery scan of the vehicle was performed after each event and the damage observed was repaired, removed, or assessed and the risk to the mission evaluated. Mitigation of debris risk can occur by tests and analyses to show debris impacted components as damage tolerant, by new/improved processes for prevention of debris availability, or redesign. Risk mitigation processes for Artemis I-specific liftoff debris events and the development and use of the SLS debris day of launch (DOL) procedures that will be used for subsequent Artemis missions will be described.

Space Launch System↗

Evaluating Liftoff Debris for NASA’s Space Launch System (SLS) Prior to the Artemis I Launch

The SLS Artemis I launch vehicle is the first of several planned Artemis launch vehicles, with a number of design differences from earlier NASA missions that incur liftoff debris risk to the mission. As a test vehicle, the Artemis I hardware also endured environments and tests not planned for future missions, which led to several additional factors contributing to an evolving liftoff debris risk to the SLS vehicle. This paper will summarize these risk factors and address the processes used to evaluate and communicate the risks to support a successful Artemis I launch. It will discuss how the evolving risks that were quantified and evaluated by a Cross-Program team of debris Subject Matter Experts to mitigate liftoff debris hazards and communicate updated risk to the SLS vehicle. This process was performed through the inaugural use of an SLS debris day-of-launch (DOL) standard operating procedure that will be used for subsequent Artemis missions. This paper addresses the risk of liftoff debris, debris released by the vehicle or from the launch pad during liftoff through vehicle tower clear. Expected liftoff debris is well understood from previous NASA programs’ experience and from tests of materials, processes and functions that are known to release liftoff debris. These expected sources were assessed and cleared well ahead of launch day. However, given the ever-changing schedules and environments, processes were in place to evaluate any additional potential liftoff debris risks identified during launch countdown. Although many of the Artemis vehicle hardware components are similar to those on the NASA Shuttle Program, there are important differences in the architecture of the Artemis I vehicle which require new assessments of liftoff debris risk for the Artemis missions. The more favorable Artemis crew module location and surfaces are far less vulnerable to debris impacts; however, the longer vehicle can result in higher liftoff debris impact energies to those components on the aft end of the vehicle. Additionally, the positional change of the RS-25 liquid engines to nearer the Booster nozzle exit plane along with the change in Booster throat plug design is a disadvantage to the overall liftoff debris risk which resulted in additional test and analysis efforts for evaluating the integrated vehicle debris risk. In spite of the comprehensive tests and analyses of Artemis I expected liftoff debris, a number of additional tests/processes were completed prior to the Artemis I mission that were required to support a complete understanding of a new launch vehicle, but increased the risk of releasing liftoff debris. The hardware endured several additional cryogenic loading cycles, including the Green Run tests at Stennis Space Center, Wet Dress Rehearsals at Kennedy Space Center, and multiple launch attempts. Each of these cycles induced stresses in the thermal protection system (TPS) materials, increasing the risk of damage to and release of the TPS. Additionally, induced and weather environmental factors that could increase the likelihood of debris release were significant. Vibrations and stresses in the TPS were induced by a required roll-back to the Vehicle Assembly Building before Hurricane Ian to protect the vehicle from damage by high winds. Wind damage and potential internal stresses to several outer mold line materials on the integrated SLS vehicle and mobile launcher were caused by weathering Hurricane Nicole at Pad 39B the week before launch. A thorough imagery scan of the vehicle was performed after each event and the damage observed was repaired, removed, or assessed and the risk to the mission evaluated. Mitigation of debris risk can occur by tests and analyses to show debris impacted components as damage tolerant, by new/improved processes for prevention of debris availability, or redesign. Risk mitigation processes for Artemis I-specific liftoff debris events and the development and use of the SLS debris day of launch (DOL) procedures that will be used for subsequent Artemis missions will be described.

Space Launch System↗

Exploring the Complexities of Drug Formulation Selection, Storage, and Shelf-Life for Exploration Spaceflight

Medications have been a part of space travel dating back as far as the Apollo missions. Currently, medical kits aboard the ISS contain medications and supplies to help crew members cope with a variety of possible medical events. NASA reported that 1,867 medical events occurred from 1981 to 1998 on space shuttle flights, STS-1 to STS-89; 498 out of the 508 crewmembers on those flights reported experiencing a medical event other than space motion sickness. In 2000, the Institute of Medicine (IOM) convened a committee of experts, Committee on Creating a Vision for Space Medicine during Travel beyond Earth Orbit, to examine the issues surrounding astronaut health and safety for long duration space missions. The primary theme of the committee’s final report is that there is not enough known about the risks to human health during long-duration missions beyond Earth’s orbit and ways to effectively mitigate those risks in an environment of deep space. In 2014, the IOM convened the Committee on Ethics Principles and Guidelines for Health Standards for Long Duration and Exploration Spaceflights and released a report emphasizing the importance of prevention, mitigation, and treatment of major risks to human health during exploration spaceflight. NASA’s Human Research Program has organized five distinct categories of spaceflight hazards summarized by the acronym “RIDGE” (Space Radiation, Isolation and Confinement, Distance from Earth, Gravity fields, and Hostile/Closed Environments) that astronauts may encounter during exploration spaceflight. From those hazards, NASA further derived 30 of the most critical human health and performance risks, including limits to medical care resulting from pharmaceutical degradation. As we prepare for more distant exploration missions to Mars and beyond, risk management planning for astronaut healthcare should include the assembly of a medication formulary that is comprehensive enough to prevent or treat anticipated medical events, remains safe and chemically stable, and retains sufficient potency to last for the duration of the mission. The present editorial will summarize the current state of knowledge regarding innovative formulary optimization strategies, pharmaceutical stability assessment techniques, and storage and packaging solutions that could enhance drug safety and efficacy for future exploration spaceflight missions.

drug degradation risk assessment↗

Evaluating Failures and Near Misses in Human Spaceflight History for Lessons for Future Human Spaceflight

There have been a number of studies done in the past drawn on lessons learned with regard to human loss-of-life events. Generally, the systemic causes and proximate causes for fatal events have both been examined in considerable detail. However, an examination of near-fatal accidents and failures that narrowly missed being fatal could be equally useful, not only in detecting causes, both proximate and systemic, but also for determining what factors averted disaster, what design decisions and/or operator actions prevented catastrophe. Additionally, review of risk factors for upcoming or future programs will often look at trending statistics, generally focusing on failure/success statistics. Unfortunately, doing so can give a skewed or misleading view of past reliability or a reliability that cannot be presumed to apply to a new program. One reason for this might be that failure/success criteria aren't the same across programs, but also that apparent success can hide systemic faults that, under other circumstances, can be fatal to a program with different parameters. A program with a number of near misses can look more reliable than a consistently healthy program with a single out-of-family failure and provide very misleading data if it is not examined in detail. This is particularly true for a manned space program where failure/success includes more than making a particular orbit. Augmenting reliability evaluations with this near miss data can provide insight and expand on the limitations of a strictly pass/fail evaluation. Even more importantly, a thorough understanding of these near miss events can identify conditions that prevented fatalities. Those conditions may be key to a programs reliability, but, without insight to the repercussions if such conditions were not in place, their importance may not be readily clear. As programs mature and political and fiscal responsibilities come to the fore, often there is considerable incentive to eliminate unnecessary conservatism, design margin, redundancy, operational support, testing, training, or safety oversight. An evaluation that demonstrates how these features and capabilities averted disaster can ensure processes that saved lives or missions are not discarded without appropriate review and understanding. Close examination of accidents that almost were can also highlight differences in design from one program to another, either justifying reliability comparisons or negating them. It can also provide considerable insight into how those saving factors were developed and implemented so that similar methods can be used to ensure appropriate life-saving and mission saving factors can be developed, even for a dissimilar space program. The lessons are appropriate for seasoned manned space programs and agencies, but crucial for untried agencies and organizations that are interested in sending man into space. The large body of publicly available near miss and accident data available provide invaluable insight into programmatic, technical, and even political issues that can be addressed before they impact safety. In this paper, we examine a number of these near misses and accidents and steps a program, agency, or potential spacefaring company might take to improve their chances of success and avoid mission or safety disasters using this data.

Barr, Stephanie↗

A physician’s working group guides COVID-19 prevention in a mission critical environment

Background A team was assembled at the National Aeronautics and Space Administration’s (NASA) Johnson Space Center (JSC) to help navigate the shifting COVID-19 pandemic. Their goal was to mitigate the impact of COVID on astronauts, other essential personnel, and the human spaceflight program. This team supplemented the JSC Pandemic Incident Response Group, whose function is to set policy for the overall management of JSC’s COVID-19 mitigations for all onsite mission-essential and mission-critical activities, including health policy. Context The first mission to return to Earth from the International Space Station at the start of the pandemic returned when there was limited information about the transmission and prevention of COVID-19. The medical leadership at JSC determined that a dedicated team was required to navigate the uncharted waters of the pandemic. Description of Activities Issues tackled by this panel included: prevention of COVID-19 transmission during altitude, dive, and spacecraft training – activities that require prolonged close contact between multiple individuals who often cannot safely wear face masks; mitigating the risks of domestic and international travel for essential personnel; securing COVID-19 testing from local and foreign hospital systems; acquiring antigen and PCR analyzers for in-house testing; and the development of quarantine policies for crewed spacecraft launches and landings in Kazakhstan and the United States. The panel also provides clinical return-to-work guidance for cases of COVID-19 in essential personnel.

covid↗

Advances in lightning protection that satisfies contemporary standards

Described here are the LEC, Inc. Spline Ball Ionizer (trademark) (SBI) and the Spline Ball Terminal (trademark) (SBT) families and how their use in a conventional lightning protection system can achieve strike prevention in a conventional setting. A properly completed standards based system which is composed of the SBI and SBT in a hybrid system will provide two modes of lightning protection: (1) a stroke prevention mode that reduces the risk of a strike to the protected facility in proportion to the size of that facility and the size and number of SBI/SBT's used; and (2) a Stroke Collector-Diverter System that is far superior to any system now in use because it collects strokes entering the protected area from any direction and angle.

Carpenter, Roy B., Jr.↗

Surface, Water, and Air Biocharacterization (SWAB) Flight Experiment

The determination of risk from infectious disease during spaceflight missions is composed of several factors including both the concentration and characteristics of the microorganisms to which the crew are exposed. Thus, having a good understanding of the microbial ecology aboard spacecraft provides the necessary information to mitigate health risks to the crew. While preventive measures are taken to minimize the presence of pathogens on spacecraft, medically significant organisms have been isolated from both the Mir and International Space Station (ISS). Historically, the method for isolation and identification of microorganisms from spacecraft environmental samples depended upon their growth on culture media. Unfortunately, only a fraction of the organisms may grow on a specific culture medium, potentially omitting those microorganisms whose nutritional and physical requirements for growth are not met. To address this bias in our understanding of the ISS environment, the Surface, Water, and Air Biocharacterization (SWAB) Flight Experiment was designed to investigate and develop monitoring technology to provide better microbial characterization. For the SWAB flight experiment, we hypothesized that environmental analysis using non-culture-based technologies would reveal microorganisms, allergens, and microbial toxins not previously reported in spacecraft, allowing for a more complete health assessment. Key findings during this experiment included: a) Generally, advanced molecular techniques were able to reveal a few organisms not recovered using culture-based methods; however, there is no indication that current monitoring is "missing" any medically significant bacteria or fungi. b) Molecular techniques have tremendous potential for microbial monitoring, however, sample preparation and data analysis present challenges for spaceflight hardware. c) Analytical results indicate that some molecular techniques, such as denaturing gradient gel electrophoresis (DGGE), can be much less sensitive than culture-based methods. d) More sensitive molecular techniques, such as quantitative polymerase chain reaction (QPCR), were able to identify viral DNA from ISS environments, suggesting potential transfer of the organism between crewmembers. In addition, the hardware selected for this experiment represented advances for next-generation sample collection. The advanced nature of this collection hardware was noted, when the Sartorius MD8 Air Port air sampler from the SWAB experiment remained on board ISS at the request of JAXA investigators, who intend to use it in completion of their microbial ecology experiment.

Castro, V. A.↗

Risk analysis of earth return options for the Mars rover/sample return mission

Four options for return of a Mars surface sample to Earth were studied to estimate the risk of mission failure and the risk of a sample container breach that might result in the release of Martian life forms, should such exist, in the Earth's biosphere. The probabilities calculated refer only to the time period from the last midcourse correction burn to possession of the sample on Earth. Two extreme views characterize this subject. In one view, there is no life on Mars, therefore there is no significant risk and no serious effort is required to deal with back contamination. In the other view, public safety overrides any desire to return Martian samples, and any risk of damaging contamination greater than zero is unacceptable. Zero risk requires great expense to achieve and may prevent the mission as currently envisioned from taking place. The major conclusion is that risk of sample container breach can be reduced to a very low number within the framework of the mission as now envisioned, but significant expense and effort, above that currently planned is needed. There are benefits to the public that warrant some risk. Martian life, if it exists, will be a major discovery. If it does not, there is no risk.

Source record↗

Mission operations and command assurance - Automating an operations TQM task

A long-term program is in progress at JPL to reduce cost and risk of mission operations through defect prevention and error management. A major element of this program, Mission Operations and Command Assurance (MO&CA), provides a system level function on flight projects to instill quality in mission operations. MO&CA embodies the total quality management TQM principle of continuous process improvement (CPI) and uses CPI in applying automation to mission operations to reduce risk and costs. MO&CA has led efforts to apply and has implemented automation in areas that impact the daily flight project work environment including Incident Surprise Anomaly tracking and reporting; command data verification, tracking and reporting; and command support data usage. MO&CA's future work in automation will take into account that future mission operations systems must be designed to avoid increasing error through the introduction of automation, while adapting to the demands of smaller flight teams.

Welz, Linda↗

Mission Operations and Command Assurance: Automating an Operations TQM Task

A long-term program is in progress at JPL to reduce cost and risk of mission operations through defect prevention and error management. A major element of this program, Mission Operations and Command Assurance (MO&QA), provides a system level function on flight projects to instill quality in mission operations. MO&CA embodies the Total Quality Management (TQM) principle of Continuous Process Inprovement (CPI) and uses CPI in applying automation to mission operations to reduce risk and costs. MO&CA has led efforts to apply and has implemented automation in areas that impact the daily flight project environment including Incident Surprise Anomoly tracking and reporting; command data verification, tracking, and reporting; and command support data usage. MO&CA's future work in automation will take into account that future missions systems must be designed to avoid increasing error through the introduction of automation, while adapting to the demands of smaller flight teams.

automation↗

Space Program Advocacy Can Distort Project Management and Damage Systems Engineering

Over-optimistic project advocacy often causes exaggerated performance claims and underestimated costs and schedules. This can distort project management and damage systems engineering. NASA projects such as the space shuttle and Hubble are extreme examples. NASA's spectacular success in the Apollo moon landings seems to have produced overconfidence and carelessness, but also to have gained tolerance for unrealistic claims and forgiveness when they were proven wrong. Apollo risk analysis predicted many astronaut fatalities. This was believed but was potentially damaging to the Apollo program, so risk analysis was discontinued. The moon landings beat bad odds because Apollo obsessively reduced risk. Its success seemed to confirm that risk analysis was unreasonably pessimistic and that risk could be overcome by good engineering. This understanding caused risk to be increased during space shuttle engineering and led to an unnecessarily dangerous approach. The shuttle design placed a fragile spacecraft next to the fuel tanks and failed to provide crew escape or launch abort. These design decisions directly caused the Challenger and Columbia tragedies. After Challenger, risk analysis was re-established. The current rocket and capsule design does consider risk and the result strongly resembles Apollo. Apollo advocacy led NASA to abandon risk analysis and this was ultimate cause of the Shuttle tragedies. Excessive advocacy that distorts risk, cost, and schedule could be prevented in an ideal organization that used systems engineering to make rational and fair decisions. However, most real organizations accommodate human and group needs using informal methods often described as "the system." Humans have biases, use innate decision making heuristics, instinctively rely on "gut feel," and establish deviant groups through groupthink. Expecting organizations to become totally rational is impractical, but specific problems such as neglecting risk and underestimating cost and schedule can be directly challenged with some hope of success.

Jones, Harry W.↗

Challenges and Lessons Learned in the Application of Autonomy to Space Operations

NASA's Space Operations Management Office (SOMO) is working toward a goal of providing an integrated infrastructure of mission and data services for space missions undertaken by NASA enterprises. A significant portion of this effort is focused on reducing the cost of these services. We are interested in the potential of autonomy to reduce operations costs. SOMO services support space missions, but are not part of the mission objectives; therefore the level of acceptable risk is very low. In fact, SOMO could be effective ly prevented from applying autonomy if customers merely perceive it as adding risk to their mission(s). We are interested in this workshop from the standpoint of understanding what can be done to realize the potential cost savings due to autonomy while maintaining acceptable risk and serving the needs of our customers. We would like to present our lessons learned so far in adopting autonomy and automation, which we think will contribute to clarifying the challenges facing the use of such technology. SOMO provides services to a diverse and ambitious set of mission customers. Many of these missions are groundbreaking missions for which communications, data, and other operations requirements sometimes cannot be clearly articulated early in the program. This motivates a need for systems that are robust in the face of unanticipated situations so that customer missions are not unreasonably constrained or impacted by "shortcomings" in SOMO services. One of SOMO's primary goals is to realize a paradigm in which SOMO acts as a service provider to organizations that fly space missions for NASA, other government agencies, and even the commercial sector. These organizations purchase SOMO services "by the pound" as customers. We have to provide systems that are not experiments themselves, but rather stable bases from which to do bold experiments. To this end, SOMO also seeks to work closely with industry to see that robust autonomy technology gets infused into products and services for the space industry and beyond. The potential for application of these technologies spans space-based communications networks (e.g. TDRSS) and ground-based assets including communication and tracking antenna systems, data networks, and control centers. There are several problems that are candidates for the application of autonomy, if it can be made reliable enough, including: antenna control, antenna scheduling, communication link scheduling and operation, navigation, attitude determination, fault detection, isolation, and reconfiguration (for spacecraft or ground assets), and mission-level planning and scheduling. Some attempts have been made to apply autonomy and automation in these areas in the past with varying degrees of success. We will present relevant case histories and the lessons inferred from them. Combining this past experience with anticipated future needs, we can clarify the challenges that must be met in order to realize the benefits of autonomy.

Forrest, David J.↗

Risk Tolerance and Safety Culture: Minimizing the Risk of Catastrophe by Bringing the Lessons of Space Home

The Johnson Space Center has pursued integrating risk management practices and techniques throughout a large organization with an extraordinarily diverse mission. Past mission and institutional failures have been used to inform NASA's safety culture and a implement a uniform risk management environment. Basics from the loss prevention industry have influenced NASA's approach to sustaining its unique, yet aging, infrastructure. Lessons learned at NASA can augment and enhance occupational safety, health and risk management capabilities within hazardous industries. By focusing on risk informed decision-making, building a pervasive safety culture, and accommodating human factors, NASA's safety capabilities have been specifically developed to minimize the risk of loss of life and loss of mission.

Loyd, David↗