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.