Dealing with ISAs in the Problem Reporting System (PRS)
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Incident, Surprise, Anomaly (ISA)↗
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Analyzing human errors in flight mission operations
A long-term program is in progress at JPL to reduce cost and risk of flight mission operations through a defect prevention/error management program. The main thrust of this program is to create an environment in which the performance of the total system, both the human operator and the computer system, is optimized. To this end, 1580 Incident Surprise Anomaly reports (ISA's) from 1977-1991 were analyzed from the Voyager and Magellan projects. A Pareto analysis revealed that 38 percent of the errors were classified as human errors. A preliminary cluster analysis based on the Magellan human errors (204 ISA's) is presented here. The resulting clusters described the underlying relationships among the ISA's. Initial models of human error in flight mission operations are presented. Next, the Voyager ISA's will be scored and included in the analysis. Eventually, these relationships will be used to derive a theoretically motivated and empirically validated model of human error in flight mission operations. Ultimately, this analysis will be used to make continuous process improvements continuous process improvements to end-user applications and training requirements. This Total Quality Management approach will enable the management and prevention of errors in the future.
Bruno, Kristin J.↗
Modeling to Improve the Risk Reduction Process for Command File Errors
The Jet Propulsion Laboratory has learned that even innocuous errors in the spacecraft command process can have significantly detrimental effects on a space mission. Consequently, such Command File Errors (CFE), regardless of their effect on the spacecraft, are treated as significant events for which a root cause is identified and corrected. A CFE during space mission operations is often the symptom of imbalance or inadequacy within the system that encompasses the hardware and software used for command generation as well as the human experts and processes involved in this endeavor. As we move into an era of increased collaboration with other NASA centers and commercial partners, these systems become more and more complex. Consequently, the ability to thoroughly model and analyze CFEs formally in order to reduce the risk they pose is increasingly important. In this paper, we summarize the results of applying modeling techniques previously developed to the DAWN flight project. The original models were built with the input of subject matter experts from several flight projects. We have now customized these models to address specific questions for the DAWN flight project and formulating use cases to address their unique mission needs. The goal of this effort is to enhance the project's ability to meet commanding reliability requirements for operations and to assist them in managing their Command File Errors.
spacecraft↗
Anomaly Trends for Missions to Mars: Mars Global Surveyor and Mars Odyssey
The long term flight operations of the Mars Global Surveyor and Mars Odyssey spacecraft give us an excellent chance to examine the operations of two long lived spacecraft in orbit around Mars during overlapping time periods. This study examined the anomalies for each mission maintained for NASA at the Jet Propulsion Laboratory. By examining the anomalies each mission encountered during their multiyear missions, trends were identified related to when anomalies occurred during each mission, the types of anomalies encountered, and corrective actions taken to mitigate the effects of the anomalies. As has been discovered in previous studies the numbers of anomalies directly correlate with mission activity and show a decreasing trend with elapsed mission time. Trend analysis also identified a heavy emphasis on software as the source or solution to anomalies for both missions.
Mars↗