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Aviation Safety Program Atmospheric Environment Safety Technologies (AEST) Project

Engine Icing: Characterization and Simulation Capability: Develop knowledge bases, analysis methods, and simulation tools needed to address the problem of engine icing; in particular, ice-crystal icing Airframe Icing Simulation and Engineering Tool Capability: Develop and demonstrate 3-D capability to simulate and model airframe ice accretion and related aerodynamic performance degradation for current and future aircraft configurations in an expanded icing environment that includes freezing drizzle/rain Atmospheric Hazard Sensing and Mitigation Technology Capability: Improve and expand remote sensing and mitigation of hazardous atmospheric environments and phenomena

Colantonio, Ron↗

Safety Culture at the World’s Premier Multi-User Spaceport

NASA’s Agency-wide Safety Culture is implemented at the Kennedy Space Center (KSC) using a unique strategy due an unparalleled approach in making human spaceflight history. Kennedy Space Center, the world’s premier multi-user spaceport, enables U.S. government and commercial space access, while providing the world a resource to allow the exploration of and the ability to work in space. A consistently healthy safety culture at KSC is imperative for mission success: desired achievements, protection of space flight hardware, and ultimately, the preservation of human life requires the support of a healthy safety culture. Emphasis on the NASA Agency-wide development of Safety Culture began with the conception of the NASA Agency Safety Culture Working Group. After the devastating loss of life and mission of the Space Shuttle Colombia, a broken safety culture was identified as an organizational cause by the Columbia Accident Investigation Board Report. Thus, the Agency Safety Culture Working Group was developed in 2009 to assess the status of the Agency’s Safety Culture, while addressing safety culture concerns at the NASA Center-level. A Five-factor model was developed to serve as the guiding principles for Safety Culture: 1) Reporting Culture, 2) Just Culture, 3) Flexible Culture, 4) Learning Culture, and 5) Engaged Culture. These five factors are included in the NASA Safety Culture logo, which was intentionally designed as a DNA double helix to prompt the permeation of safety into day-to-day work. KSC specifically implements the NASA Agency-wide Safety Culture principles in a tailored approach that is relevant to the diversity of work being performed. An emphasis is placed on the implementation to include safety at home, not exclusively at work. This emphasis is a KSC-specific element that has been intentionally added to promote a closed loop Safety Culture. To advertise the safety culture, various safety and health events are held throughout the calendar year, providing innovative speakers and engaging activities, while also promoting a wide range of curated safety initiatives. Development and continuous improvement of the KSC safety tracking database, allows for advanced tracking-to-closure, along with providing data sets used to identify areas of emphasis. Other safety initiatives rely solely on employee participation, such as the photo challenges; participants are encouraged to identify and capture themselves, coworkers, or family members participating in safe or healthy activities to share with others within the Center and at Agency levels. Fabrication of exclusive videos and graphics are utilized to advertise and inform employee of safety initiatives, upcoming safety events, and general dispersion of safety information. In addition, an anonymous Agency-wide Safety Culture Survey is advertised, administered, and analyzed at Kennedy Space Center, with the purpose of receiving basic feedback on Safety Culture perceptions to help prevent future incidents from occurring. Through these briefly identified means, and many other forms of employee engagement, Kennedy Space Center aims to maintain safety in the forefront, while creating an environment where everyone trusts that safety is a priority.

Larrin E. Moody↗

Gateway Program Safety and Mission Assurance Integration - the Future of Safe Deep Space Human Exploration

As a foundational element of the National Aeronautics and Space Administration (NASA) Artemis Campaign, the Gateway is an incrementally built cislunar spacecraft that will serve as a platform for deep space human exploration, science, and technology demonstration. The Gateway will be a unifying catalyst for international partners around the world to establish sustained deep space scientific investigations, lunar surface access, and missions to Mars. As human exploration moves farther away from Earth, spacecraft designs must prioritize and optimize mass and volume allocations, while minimizing human and spacecraft risk. To accomplish this objective, the Gateway Program Safety and Mission Assurance functions develop, implement, and ensure compliance with requirements, in concert with the accurate characterization and transparent communication of residual hazard risks, for integrated safety, reliability and maintainability and quality assurance. Safety and Mission Assurance was a key contributor during Gateway program pre-formulation and formulation activities where safety and reliability analysis was embedded in the Gateway Systems Engineering and Integration team. During these early program stages, a preliminary Gateway Integrated Hazard Analysis and Preliminary Gateway Probabilistic Risk Assessment assisted in Gateway architectural and operational definition as part of a risk-informed design process. As the deep space architecture has matured, the integrated Safety and Mission Assurance analyses have matured, new safety review processes have been developed, and requirements have been refined to ensure compliance with integrated safety and mission assurance objectives. The Gateway Program is currently concluding the preliminary design review informed milestone, where the primary objectives included: - Ensured completeness and consistency of the preliminary design, including the meeting of all requirements within appropriate margins and acceptable risk posture. - Identification of any major issues moving forward to the Critical Design phase. At this milestone, Safety and Mission Assurance provided numerous products, including Gateway Top Risks and Risk Mitigation Plans, updated integrated hazard analyses, updated probabilistic risk assessment, Crew Survival Analysis Report, and updated Safety and Mission Assurance Requirements and Plans. These products provide a many-faceted perspective on the inherent risk and available mitigations involved in flying the current proposed vehicle design and anticipated stack configurations. In addition, Safety and Mission Assurance identified top technical, process and workforce concerns to be addressed as the program progresses toward the critical design phase. This paper will detail the evolution of the Gateway Program Safety and Mission Assurance integration functions, provide its current status and lessons learned for future human spaceflight programs. Throughout this paper the key tenets of the Gateway Program Safety and Mission Assurance will be discussed: - Application of a risk-informed approach to identify and mitigate areas of highest risk. - Leverage of valuable processes and lessons learned from earlier spaceflight programs. - Development of Safety and Mission Assurance products to inform design risk trades. - Utilization of common Safety and Mission Assurance practices to identify safety risks for multiple perspectives: top-down, bottom-up, and across lines of integration. - Approval of safety hazards at the appropriate level of authority, keeping most deliberation closest to design expertise and elevating risks of greatest concern for program-level consideration. - Championing of Safety and Mission Assurance processes and forums to foster a pervasive safety culture that is transparent, inclusive, and collaborative between all partners. These tenets have allowed the Gateway Safety and Mission Assurance function to play a key role in optimized vehicle design evolution, and early identification and mitigation of Gateway program and Artemis mission risk.

Helen Vaccaro↗

Designing for Advanced Aerial Mobility: Human-Autonomy Teaming and In-Time System-Wide Safety Assurance

The continued growth of aviation shall require new innovative technologies and operational concepts to meet the ever-increasing demands on air transportation. The NASA Advanced Air Mobility (AAM) project focuses on emerging aviation markets, such as Urban Air Mobility (UAM). UAM is defined as “...a safe and efficient system for air passenger and cargo transportation within an urban area. It is inclusive of small package delivery and other urban unmanned aerial system services and supports a mix of onboard/ground-piloted and increasingly autonomous operations” ([1]). The AAM project emphasizes technology development and validating system-level concepts and solutions in coordination with other NASA Aeronautics Research Mission Directorate (ARMD) projects to enable UAM metro- and micro-plex vertiport and airspace concepts of operations. The NASA AAM research portfolio includes the concepts of Remote Supervisor-in-Command (RSC) and Fleet and Airspace Manager (FAM) as possible human roles for consumer fleet providers. NASA research in RSC is focused on development of guidelines and standards for remote pilots/operators passively and actively controlling a large fleet of autonomous aircraft. For FAM, flight and ground system concepts and technologies to enable high density homogeneous operations at increased scale from vertiport(s), and coordination with other humans in the systems (e.g., UAM urban airspace manager, Air Traffic Control) are key research areas. The envisioned UAM operations are posited to require autonomous systems to enable functions ranging from fleet and resource management to vehicle control. Although automation has become increasingly sophisticated and ubiquitous in civil aviation, autonomy represents a significant evolution in automation, which has generally been limited in functional scope and capability. As autonomy takes on increasing responsibilities, humans and machines will be required to work together in new and different ways [2], rather than traditional design approaches focused on how machines (i.e., autonomy) can do the work of people. The emerging field of human-autonomy teaming (HAT) represents a comprehensive and prioritized research-driven approach to enable the success of future emerging aviation market applications through capabilities and principles that facilitate humans and machine working and thinking better together. The NASA Transformational Tools and Technologies (TTT) Autonomous System (AS) Sub-project was created to assist with the transition into higher levels of autonomy to enable new modes of air transportation, such as UAM. TTT-AS has identified HAT as a key research need to enable UAM while maintaining today’s ultra-safe aviation system safety levels. The latter challenge has been taken up by the NASA System-Wide Safety (SWS) Project, which recognizes that aviation safety, as it evolves, shall require new ways of thinking about safety to include integration of a wide-range of existing and new safety systems and practices, enhanced tools and technologies, increased access to data and data fusion, improved data analysis capabilities, enhanced in-time risk monitoring and detection, hazard prioritization and mitigation, safety assurance decision-support, and in-time integrated system analytics [3].The operational concept of UAM represents a variety of work that has been termed, “work-as-imagined” to characterize the idea that how people think that work is done and how work is actually done are often not the same [4]. To ensure design success and system safety, looking at “work-as-done” provides a comparative approach toward UAM concept and technology design through examination of corresponding analogs found today in aviation (e.g., on-demand operations) and other transportation domains (e.g., port operations). The paper shall discuss various alternative applications with specific focus on airline operation center (AOC) operations, and unmanned aerial system (UAS) command-and-control to inform scaled-versions of FAM and RSC, respectively, and with consideration of the national airspace system contextual environment. The tenets and principles of the HAT field and current NASA research efforts under the TTT-AS sub-project shall also be described. Finally, the SWS sub-project efforts to develop In-Time System-Wide Safety Assurance (ISSA) and In-Time Safety Management Systems (IASMS) are discussed in terms of how “in-time” safety assurance may be conceptualized for the on-demand mobility air taxi “work-as-imagined” operational concept [5]. As part of this effort, concepts from the emerging field of resilience engineering, are being studied. Traditional approaches to aviation safety have focused on what can go wrong and how to prevent it. Another approach to thinking about system safety should reflect not only “avoiding things that go wrong” (protective safety) but also “ensuring that things go right” (productive safety), that enables a system to exhibit the resilient performance [6] necessary for the success of the future aviation system emerging concepts of operations. The paper shall describe efforts focused on how productive safety and resilience may enable a more complete approach to system safety thinking and design of ISSA and IASMS for UAM. Future directions and research needs shall also be discussed.

resilience↗

NASA Range Safety Annual Report 2007

As always, Range Safety has been involved in a number of exciting and challenging activities and events. Throughout the year, we have strived to meet our goal of protecting the public, the workforce, and property during range operations. During the past year, Range Safety was involved in the development, implementation, and support of range safety policy. Range Safety training curriculum development was completed this year and several courses were presented. Tailoring exercises concerning the Constellation Program were undertaken with representatives from the Constellation Program, the 45th Space Wing, and the Launch Constellation Range Safety Panel. Range Safety actively supported the Range Commanders Council and it subgroups and remained involved in updating policy related to flight safety systems and flight safety analysis. In addition, Range Safety supported the Space Shuttle Range Safety Panel and addressed policy concerning unmanned aircraft systems. Launch operations at Kennedy Space Center, the Eastern and Western ranges, Dryden Flight Research Center, and Wallops Flight Facility were addressed. Range Safety was also involved in the evaluation of a number of research and development efforts, including the space-based range (formerly STARS), the autonomous flight safety system, the enhanced flight termination system, and the joint advanced range safety system. Flight safety system challenges were evaluated. Range Safety's role in the Space Florida Customer Assistance Service Program for the Eastern Range was covered along with our support for the Space Florida Educational Balloon Release Program. We hope you have found the web-based format both accessible and easy to use. Anyone having questions or wishing to have an article included in the 2008 Range Safety Annual Report should contact Alan Dumont, the NASA Range Safety Program Manager located at the Kennedy Space Center, or Michael Dook at NASA Headquarters.

Dumont, Alan G.↗

Nuclear Safety [Vol. 32, No. 1, January-March 1991]

Nuclear Safety is a review journal that covers significant developments in the field of nuclear safety. Its scope includes the analysis and control of hazards associated with nuclear energy, operations involving fissionable materials, and the products of nuclear fission and their effects on the environment. Primary emphasis is on safety in reactor design, construction, and operation; however, the safety aspects of the entire fuel cycle, including fuel fabrication, spent-fuel processing, nuclear waste disposal, handling of radioisotopes, and environmental effects of these operations, are also treated. Table of Contents for this issue follows. GENERAL SAFETY CONSIDERATIONS: 1 The Safety Review and Approval Process for Space Nuclear Power Sources, G. L. Bennett; 19 Report on the American Nuclear Society International Topical Meeting: "The Safety, Status, and Future of Non-Commercial Reactors and Irradiation Facilities", E. G. Silver; 35 Book Review: Fission Product Transport Processes in Reactor Accidents, Proceedings to the International Centre tor Heat and Mass Processes T. S. Kress; 38 Fast Reactor Technology in the 1990s: A Summary of the 1990 International Fast Reactor Safety Meeting, A. E. Levin; ACCIDENT ANALYSIS: 56 Effects of Chemical Phenomena on LWR Severe Accident Fission Product Behavior, A. P. Malinauskas and T. S. Kress; CONTROL AND INSTRUMENTATION: 65 Technical Note: Safety Parameter Display Systems—10 Years Later, R. J. Eckenrode; 68 Potential Application of Neural Networks to the Operation of Nuclear Power Plants, R. E. Uhrig; DESIGN FEATURES: 80 Twenty-First DOE/NRC Nuclear Air-Cleaning Conference, R. R. Bellamy, D. W. Moeller, and M. W. First; 91 Impact of an Apparent Radiation Embrittlement Rate on the Life Expectancy of PWR Vessel Supports, R. D. Cheverton, G. C. Robinson, W. E. Pennell, and R. K. Nanstad; ENVIRONMENTAL EFFECTS: 103 Technical Note: The Impact of Offsite Factors on the Safety Performance of Small Nuclear Power Plants, Yu. D. Baranaev and A. N. Viktorov; WASTE AND SPENT FUEL MANAGEMENT: 109 Activities Related to Waste Management, Compiled by E. G. Silver; OPERATING EXPERIENCES: 118 Reactor Shutdown Experience, Compiled by J. W. Cletcher; 121 Selected Safety-Related Events, Compiled by G. A. Murphy; 123 Operating U.S. Power Reactors, Compiled by E. G. Silver; RECENT DEVELOPMENTS: 140 General Administrative Activities, Compiled by E. G. Silver; 150 Reports, Standards, and Safety Guides, D. S. Queener; 155 Status of Power-Reactor Licensing Activities, Compiled by E. G. Silver; 157 Proposed Rule Changes as of Sept. 30, 1990; ANNOUNCEMENTS: 79 MIT Offers Summer Program on Nuclear Power Reactor Safety; 108 Harvard School of Public Health Offers Several Short Courses; 139 Short Course and Workshop on Nuclear Criticality Safety at University of New Mexico; 160 SCK/CEN Announces Training Course on Emergency Planning and Response; 161 The Authors; 164 Indexes to Nuclear Safety, Volume 31

11 NUCLEAR FUEL CYCLE AND FUEL MATERIALS↗

Nuclear Safety [Vol. 29, No. 1, January-March 1988]

Nuclear Safety is a review journal that covers significant developments in the field of nuclear safety. Its scope includes the analysis and control of hazards associated with nuclear energy, operations involving fissionable materials, and the products of nuclear fission and their effects on the environment. Primary emphasis is on safety in reactor design, construction, and operation; however, the safety aspects of the entire fuel cycle, including fuel fabrication, spent-fuel processing, nuclear waste disposal, handling of radioisotopes, and environmental effects of these operations, are also treated. Table of Contents for this issue follows. THE CHERNOBYL ACCIDENT: 1 Core History and Nuclide Inventory of the Chernobyl Core at the Time of Accident by Gerald Kirchner and Cornelius C. Noack; GENERAL SAFETY CONSIDERATIONS: 6 Nonprescriptive Nuclear Safety Regulation: The Example of Loss of Offsite Power by M. W. Golay, V. P. Manno, and C. Vlahoplus, Jr., 20 Nuclear Power Safety Goals in Light of the Chernobyl Accident by C. Whipple and C. Starr; ACCIDENT ANALYSIS: 29 Containment Loads from Severe Accidents—U.S. Program by W. Kerr and M. K. Dey; PLANT SAFETY FEATURES: 36 Safety Characteristics of Modern High-Temperature Reactors: Focus on German Designs by W. Kröger, H. Nickel, and R. Schulten; ENVIRONMENTAL EFFECTS: 49 Radiation Hormesis and Nuclear Safety by C. C. Congdon; OPERATING EXPERIENCES: 58 Evaluation of Nonradiological Water Chemistry at Power Reactors by Harvey Zibulsky, James J. Kottan, Walter J. Pasciak, Mary Ann Castrogivanni, and Sujit Banerjee, 64 Reactor Shutdown Experience Compiled by J. W. Cletcher, 67 Operating U.S. Power Reactors Compiled by E. G. Silver; RECENT DEVELOPMENTS: 85 General Administrative Activities Compiled by E. G. Silver, 94 Reports, Standards, and Safety Guides by D. S. Queener, 100 Status of Power-Reactor Projects Undergoing Licensing Review Compiled by E. G. Silver, 103 Proposed Rule Changes as of Sept. 30, 1987; ANNOUNCEMENTS: 5 Northwestern University Short Course on Radiation Safety, 28 International Approach to Nuclear Safety (After Three-Mile Island and Chernobyl), 57 RPI Short Course on Modern Developments in Boiling Heat Transfer and Two-Phase Flow, 107 20th DOE/NRC Nuclear Air Cleaning Conference, 110 Third International Topical Meeting on Nuclear Power Plant Thermal Hydraulics and Operations, 108 The Authors, 111 Indexes to Nuclear Safety, Volume 28.

11 NUCLEAR FUEL CYCLE AND FUEL MATERIALS↗

Nuclear Safety [Vol. 29, No. 3, July-September 1988]

Nuclear Safety is a review journal that covers significant developments in the field of nuclear safety. Its scope includes the analysis and control of hazards associated with nuclear energy, operations involving fissionable materials, and the products of nuclear fission and their effects on the environment. Primary emphasis is on safety in reactor design, construction, and operation; however, the safety aspects of the entire fuel cycle, including fuel fabrication, spent-fuel processing, nuclear waste disposal, handling of radioisotopes, and environmental effects of these operations, are also treated. Table of Contents for this issue follows. GENERAL SAFETY CONSIDERATIONS: 259 Fifteenth Water Reactor Safety Information Meeting by E. G. Silver; CONTROL AND INSTRUMENTATION: 284 Reliability Technology to Improve and/or Maintain Emergency Diesel Generator Performance by S. Karimian and J. H. Taylor, 293 A Noise Diagnostics System for Operator Advice by G. Hessel, P. Liewers, P. Schumann, W. Schmitt, and F.-P. Weiss; PLANT SAFETY FEATURES: 307 A Passive Containment System for Advanced Light-Water Reactors by O. B. Falls, Jr., and F. W. Kleimola; ENVIRONMENTAL EFFECTS: 318 Data Base Construction for a Computerized Radiological Risk Investigation System by L. M. Hively, J. E. Nyquist, J. L. Bledsoe, and A. L. Sjoreen, 326 Erratum to "Radiation Hormesis and Nuclear Safety," Vol. 29, No. 1; OPERATING EXPERIENCES: 327 Operational Safety Experience and Passive Safety Testing at the Fast Flux Text Facility by Q. L. Baird, J. L. Rathbun, D. D. Stepnewski, R. L. Stover, and A. E. Waltar, 344 Backfilling of Independent Residual Heat Removal Systems in West Germany and Switzerland by G. Eckert and Y. Salomon, 353 Reactor Shutdown Experience Compiled by J. W. Cletcher, 356 Selected Safety-Related Events Compiled by G. A. Murphy, 363 Operating U.S. Power Reactors Compiled by E. G. Silver; RECENT DEVELOPMENTS: 384 General Administrative Activities Compiled by E. G. Silver, 390 Reports, Standards, and Safety Guides by D. S. Queener, 395 Status of Power-Reactor Projects Undergoing Licensing Review Compiled by E. G. Silver, 400 Proposed Rule Changes as of Mar. 31,1988; ANNOUNCEMENTS: 283 International ENS/ANS Conference on Thermal Reactor Safety "NUCSAFE 88", 317 Northwestern University Short Course on Radiation Safety, 407 Second International Seminar on Small- and Medium-Sized Nuclear Reactors, 407 International Workshop on New Developments in Occupational Dose Control and ALARA Implementation at Nuclear Power Plants and Similar Facilities, 408 Fourth International Topical Meeting on Nuclear Reactor Thermal Hydraulics (NURETH-4), 404 The Authors.

11 NUCLEAR FUEL CYCLE AND FUEL MATERIALS↗

Success Path Method: Conformance with Safety Management Systems

All industrial facilities deal with safety hazards such as equipment failures, chemical and toxic releases, and fires and explosions just to name a few. A disciplined framework for managing the integrity of operating systems and processes that handle hazardous substances by applying good design principles, engineering, and operating practices is called process safety. The goal of such framewoks is to prevent the release of energy or material that could cause harm to people or damage to equipment and/or environment. Process safety covers all aspects of facility operation also including design, maintenance, and human and organizational factors that could possibly have effect on process safety. As it will be seen from the discussion below, process safety is just one of the pieces of the much bigger matter, a safety culture. Many industries have long recognized the importance of safety culture in their day-to-day operation. Although the definition of safety culture can slightly differ from organization to organization, in general, a safety culture is how things are done to demonstrate a commitment to safety by everyone involved. An organization acquires safety culture over time as the product of individual and group values, actions, and behaviors toward overall safety. It is important to note that safety culture should not be viewed as some static state that an organization wants to reach. It is more like a constantly evolving level of “how things are done when nobody is watching.” Safety culture is an inherent characteristic of an organization, it is always present, but the level can range on a continuum from undesirable to desirable or more commonly used, from negative to positive. An example for an undesirable, negative safety culture would be a company in which accidents resulting in harm (physical and/or emotional) of its employees, equipment or surrounding environment and community occur frequently. At the other end of the spectrum would be a company in which such accidents are rare or do not occur at all (desired or positive safety culture). Every company/industry exists somewhere within this spectrum.

42 ENGINEERING↗

NASA's Software Safety Standard

NASA relies more and more on software to control, monitor, and verify its safety critical systems, facilities and operations. Since the 1960's there has hardly been a spacecraft launched that does not have a computer on board that will provide command and control services. There have been recent incidents where software has played a role in high-profile mission failures and hazardous incidents. For example, the Mars Orbiter, Mars Polar Lander, the DART (Demonstration of Autonomous Rendezvous Technology), and MER (Mars Exploration Rover) Spirit anomalies were all caused or contributed to by software. The Mission Control Centers for the Shuttle, ISS, and unmanned programs are highly dependant on software for data displays, analysis, and mission planning. Despite this growing dependence on software control and monitoring, there has been little to no consistent application of software safety practices and methodology to NASA's projects with safety critical software. Meanwhile, academia and private industry have been stepping forward with procedures and standards for safety critical systems and software, for example Dr. Nancy Leveson's book Safeware: System Safety and Computers. The NASA Software Safety Standard, originally published in 1997, was widely ignored due to its complexity and poor organization. It also focused on concepts rather than definite procedural requirements organized around a software project lifecycle. Led by NASA Headquarters Office of Safety and Mission Assurance, the NASA Software Safety Standard has recently undergone a significant update. This new standard provides the procedures and guidelines for evaluating a project for safety criticality and then lays out the minimum project lifecycle requirements to assure the software is created, operated, and maintained in the safest possible manner. This update of the standard clearly delineates the minimum set of software safety requirements for a project without detailing the implementation for those requirements. This allows the projects leeway to meet these requirements in many forms that best suit a particular project's needs and safety risk. In other words, it tells the project what to do, not how to do it. This update also incorporated advances in the state of the practice of software safety from academia and private industry. It addresses some of the more common issues now facing software developers in the NASA environment such as the use of Commercial-Off-the-Shelf Software (COTS), Modified OTS (MOTS), Government OTS (GOTS), and reused software. A team from across NASA developed the update and it has had both NASA-wide internal reviews by software engineering, quality, safety, and project management. It has also had expert external review. This presentation and paper will discuss the new NASA Software Safety Standard, its organization, and key features. It will start with a brief discussion of some NASA mission failures and incidents that had software as one of their root causes. It will then give a brief overview of the NASA Software Safety Process. This will include an overview of the key personnel responsibilities and functions that must be performed for safety-critical software.

Ramsay, Christopher M.↗