National Aeronautics and Space Administration
EMU Hazard Report did not identify the hazard. ECFT-184.108.40.206
FMEA/CIL did not effectively describe the behavior of w ater entering the vent loop from the PLSS. ECFT-220.127.116.11.1
No one applied our know ledge of the physics of w ater behavior in zero g to w ater coming from the PLSS vent loop ECFT-18.104.22.168.1.1
FMEA/CIL did not effectively quantify the amounts of w ater entering the vent loop from the PLSS. ECFT-22.214.171.124.2
FMEA/CIL did not undergo thourough review and update periodically. ECFT-126.96.36.199.1.2
ISS program FMEA/CIL requirement did not require complete FMEA/CIL periodic update. ECFT-188.8.131.52.1.2.1
Program cut funding
Community had lost sight of the value of the FMEA/CIL effort. ECFT-184.108.40.206.220.127.116.11
Figure 3-59 Causes and Contributing Factors under ECFT 18.104.22.168 ECFT-22.214.171.124 â€“ EMU Hazard Report did not identify the hazard. (Intermediate Cause 16) Supporting Evidence: See ECFT-126.96.36.199.1 branch, EMU Hazard Report did not identify the hazard, for discussion of this and lower level causes.
Published on Feb 27, 2014
Report of the NASA Mishap Investigation Board examining the high visibility close call event of July 16, 2013 when ESA astronaut Luca Parmit...