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A principal too under development as part of the NASA Failure Detection and Prevention Program is the Defect Detection and Prevention(DDP) tool.
A discussion of Systems Engineering principles as related to failure prevention methodologies and technologies. The presentation outlines requirements development, design reviews, verification and validation, and finally risk management prectices.
The Software QA / V&V guide will be reviewed and updated based on feedback from NASA organizations and others with a vested interest in this area. Hardware, EEE Parts, Reliability, and Systems Safety are a sample of the future guides that will be developed. Cost Estimates, Lessons Learned, Probability of Failure and PACTS (Prevention, Avoidance, Control or Test) are needed to provide a more complete risk management strategy. This approach to risk management is designed to help balance the resources and program content for risk reduction for NASA's changing environment.
As NASA continues to impement its Faster, Better, Cheaper philosophy, new approaches for implementing Mission Assurance activities are being developed.
The US civil aerospace program has been a great contributor to the creation and implementation of techniques and methods to identify, analyze, and confront risk. NASA has accomplished mission success in many instances, but also has had many failures. Anomalies have kept the Agency from achieving success on other occasions, as well. While NASA has mastered ways to prevent risks, and to quickly and effectively react and recover from anomalies or failures, it was not until few years ago that a comprehensive Risk Management process started being implemented in some of its programs and projects. A Continuous Risk Management (CRM) cycle process was developed and has been promoted and used successfully in programs and projects across the Agency.
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.
The Johnson Space Center has pursued integrating safety culture and 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.
As climate change increases the risk of large-scale wildfires, wildfire ignitions from electric power lines are a growing concern. To mitigate the wildfire ignition risk, many electric utilities de-energize power lines to prevent electric faults and failures. These preemptive power shutoffs are effective in reducing ignitions, but they could result in wide-scale power outages. Advanced technology, such as networked microgrids, can help reduce the size of the resulting power outages; however, even microgrid technology might not be sufficient to supply power to everyone, thus forcing hard questions about how to prioritize the provision of power among customers. In this paper, we present an optimization problem that configures networked microgrids to manage wildfire risk while maximizing the power served to customers; however, rather than simply maximizing the amount of power served in kilowatts, our formulation also considers the ability of customers to cope with power outages, as measured by social vulnerability, and it discourages the disconnection of particularly vulnerable customer groups. To test our model, we leverage a synthetic but realistic distribution feeder, along with publicly available social vulnerability indices and satellite-based wildfire risk map data, to quantify the parameters in our optimal decision-making model. Our case study results demonstrate the benefits of networked microgrids in limiting load shed and promoting equity during scenarios with high wildfire risk.
As part of its commitment to advancing safety and reliability assessment methodologies, Argonne National Laboratory pioneered the use of an evaluation method called the Success Path Method (SPM) to improve risk management for offshore oil and gas operations. The development of the SPM at Argonne has been driven by the need to improve existing risk assessment methodologies by focusing on the steps necessary for success rather than failure modes alone. This is particularly important for industrial environments like offshore facilities that perform multiple functions under a continuously evolving set of operational conditions – such as water depth and temperature, currents, and weather conditions. In these dynamic environments, the traditional Probabilistic Risk Assessment (PRA) approach is far too complex as it focuses on what can go wrong – which comprises an infinite failure space that must be fully explored and understood. By shifting the focus to a finite space of success paths, the SPM enables operators and decision makers to prioritize a manageable number of steps that must go right to ensure success. Building on its five decades of experience in safety assessments for the nuclear industry, Argonne made major adaptations to existing risk assessment methods utilizing features similar to fault trees that are traditionally used in PRA to map all pathways in which the system can malfunction. In contrast, SPM identifies the components and processes that must function correctly to achieve specific outcomes – such as preventing the uncontrolled release of hydrocarbons during drilling operations. The SPM framework integrates equipment, procedures, software, processes, and human actions to ensure that physical barriers meet critical safety functions in dynamic operational conditions. This approach helps identify failure modes and improve operational risk management by narrowing the focus to key success elements, which in turn reduces uncertainty and helps users understand, manage, and respond to failures.
This white paper explores how to increase the success and operation of critical, complex, national systems by effectively capturing knowledge management requirements within the federal acquisition process. Although we focus on aerospace flight systems, the principles outlined within may have a general applicability to other critical federal systems as well. Fundamental design deficiencies in federal, mission-critical systems have contributed to recent, highly visible system failures, such as the V-22 Osprey and the Delta rocket family. These failures indicate that the current mechanisms for knowledge management and risk management are inadequate to meet the challenges imposed by the rising complexity of critical systems. Failures of aerospace system operations and vehicles may have been prevented or lessened through utilization of better knowledge management and information management techniques.
The NASA Integrated Action Team (NIAT) was formed by the NASA Administrator in March 2000. The purpose of this team was to identify the actions that NASA must take to address systemic findings reported in 4 different anomaly investigations. Team membership represented senior managers from all the field centers and NASA Headquarters. NIAT report addressed 165 findings and developed 17 action plans that are described in five themes: people and teams, technology, risk, formulation rigor, and communications. The NIAT actions present a systems solution for strengthening formulation and implementation of programs and improving the environment for their support. NIAT results included: enhancing success by avoiding failures that could have been prevented through good planning and sound practice; ensuring that prudent risks do not compromise safety; and ensuring that mission risks are objectively assessed, appropriately mitigated and consciously accepted by the program team and customers. Definitions of Faster, Better, Cheaper and Success Criteria were also developed and included as part of the NIAT report. As a result of the NIAT report, program and project management process changes were incorporated into NASA's quality system documentation, including NPG 7120.513, "NASA Program and Project Management Processes and Requirements. This paper describes the NIAT results and the resulting updates to NPG 7120.5 that keep this program and project management description a living process.
The DAHCS (pronounced “Dax”) MC is a 7-year, $\$$45 million research portfolio within Sandia’s Laboratory Directed Research and Development program. The DAHCS MC arose in response to a great need: to ensure that the use of digital technologies does not weaken our nation’s high consequence systems. Digital technologies offer many benefits in speed, cost, and flexibility, and we seek to reap those benefits without introducing new system failures. However, digital technologies cannot be evaluated the same way as analog technologies. Initiatives across the nation highlight the capability gap that prevents efficient, effective digital assurance. The Challenge Today’s digital assurance tools, techniques, and methods are inadequate to confidently characterize, assess, and manage digital risk; they are ad hoc, slow, costly, and rarely scalable to increasingly complex digital technologies. The rapidly evolving cyber threat landscape exacerbates this problem because digital assurance now must secure against digital risks now and in the future, including those introduced by rapidly evolving technologies, adversaries, and systems.
This Conference convened approximately 86 registered participants of invited guest speakers, NASA presenters, and a broad spectrum of the Occupational Health disciplines representing NASA Headquarters and all NASA Field Centers. Two days' Professional Development Courses on Exposure Assessment Strategies and Statistics and on Advanced Cardiac Life Support training and recertification preceded the Conference. With the theme, 'Risk Assessment and Management in 2001,' conferees were first provided updates from the Program Principal Center Office and the Headquarters Office. Plenary sessions elaborated on several topics: biological terrorism, OSHA recordability, Workers' Compensation issues, Federal ergonomic standards, bridging aerospace medicine and occupational health-especially in management of risk in spaceflight, and EAP operations with mission failures. A keynote address dealt with resiliency skills for 21st century workers and two NASA astronaut speakers highlighted a tour of the Johnson Space Center. During discipline specific breakout sessions, current issues in occupational health management and policy, credentialing and privileging, health risk assessment, measurement and standardization, audits, database development, prevention and rehabilitation, international travel and infection control, employee assistance, nursing process, and environmental health were presented.
The National Renewable Energy Laboratory's (NREL) Hydrogen Safety Research and Development (HSR&D) program in collaboration with the University of Maryland's Systems Risk and Reliability Analysis Laboratory (SyRRA) are working to improve reliability and reduce risk in hydrogen systems. This approach strives to use quantitative data on component leaks and failures, together with Prognosis and Health Management (PHM), and Quantitative Risk Assessment (QRA) to identify at-risk components, reduce component failures and downtime, and predict when components require maintenance. Hydrogen component failures increase facility maintenance cost, facility downtime, and reduce public acceptance of hydrogen technologies, ultimately increasing facility size and cost because of potentially overly conservative requirements. Leaks are a predominant failure mode for hydrogen components. However, uncertainties in the amount of hydrogen emitted from leaking components and the frequency of those failure events limit the understanding of the risks that they present under real-world operational conditions. NREL has deployed a test fixture, the Leak Rate Quantification Apparatus (LRQA), to quantify the mass flow rate of leaking gases from medium and high-pressure components that have failed while in service. Quantitative hydrogen leak rate data from this system could ultimately be used to better inform risk assessment and Regulation Codes and Standards (RCS). Parallel activity explores the use of PHM and QRA techniques to assess and reduce risk, thereby improving safety and reliability of hydrogen systems. The results of QRAs could further provide a systematic and science-based foundation for the design and implementation of RCS, as in the latest versions of the NFPA 2 code for gaseous hydrogen stations. Alternatively, data-driven techniques of PHM could provide new damage diagnosis and health-state prognosis tools. This research will help end users, station owners and operators, and regulatory bodies move towards risk-informed preventative maintenance versus emergency corrective maintenance, reducing cost and improving reliability. Predictive modelling of failures could improve safety and affect RCS requirements such as setback distances at liquid refuelling sites. The combination of leak rate quantification research, PHM, and QRA can lead to better informed models enabling data-based decision to be made for hydrogen system safety improvements.
A systematic approach for the development of a hardware qualification approach is described. This approach stems from the need to break the "Catch-22" of not being able to fly new technology because it hasn't flown. A physics of failure approach is used to identify failure modes and the impact and likelihood of these failures on the mission requirements is plotted in a Requirements Matrix. These same failure modes are plotted against the effectiveness of the available Preventions, Analyses, Control and Tests (PACTs) at screening for, or eliminating, these failure modes in a Test Effectiveness Matrix. Matrix multiplication results in a ranked set of PACTs which can be sorted according to cost and redundancy with other PACTs. This, and other information which results from the process, will allow project managers to make more informed decisions regarding the cost and risk tradeoffs inherent in any qualification program.
Integrated Systems Health Management (ISHM) is intended to become a critical capability for all space, lunar and planetary exploration vehicles and systems at NASA. Monitoring and managing the health state of diverse components, subsystems, and systems is a difficult task that will become more challenging when implemented for long-term, evolving deployments. A key technical challenge will be to ensure that the ISHM technologies are reliable, effective, and low cost, resulting in turn in safe, reliable, and affordable missions. To ensure safety and reliability, ISHM functionality, decisions and knowledge have to be incorporated into the product lifecycle as early as possible, and ISHM must be considered as an essential element of models developed and used in various stages during system design. During early stage design, many decisions and tasks are still open, including sensor and measurement point selection, modeling and model-checking, diagnosis, signature and data fusion schemes, presenting the best opportunity to catch and prevent potential failures and anomalies in a cost-effective way. Using appropriate formal methods during early design, the design teams can systematically explore risks without committing to design decisions too early. However, the nature of ISHM knowledge and data is detailed, relying on high-fidelity, detailed models, whereas the earlier stages of the product lifecycle utilize low-fidelity, high-level models of systems and their functionality. We currently lack the tools and processes necessary for integrating ISHM into the vehicle system/subsystem design. As a result, most existing ISHM-like technologies are retrofits that were done after the system design was completed. It is very expensive, and sometimes futile, to retrofit a system health management capability into existing systems. Last-minute retrofits result in unreliable systems, ineffective solutions, and excessive costs (e.g., Space Shuttle TPS monitoring which was considered only after 110 flights and the Columbia disaster). High false alarm or false negative rates due to substandard implementations hurt the credibility of the ISHM discipline. This paper presents an overview of the current state of ISHM design,and a review of formal design methods to make recommendations about possible approaches to enable the ISHM capabilities to be designed-in at the system-level, from the very beginning of the vehicle design process.