National Aeronautics and Space Administration
See ECFT-188.8.131.52 ECFT-184.108.40.206.1.1.1 – Crew incorrectly attributed water in EV2's helmet after EVA 22 to the drink bag. (Intermediate Cause 1) Supporting Evidence: See ECFT-1.1 ECFT-220.127.116.11.1.1.2 – Crew was not trained to recognize this failure mode. (Intermediate Cause 7) Supporting Evidence: See ECFT-3.1.2
Ground Team focused on the drink bag as the source of the w ater. ECFT-3.2.2
The Team had Channelized Attention on the drink bag as the primary source of w ater in the helmet ECFT-18.104.22.168
Team's set of responses led to a delay in identifying the vent loop as the source of the w ater leak. ECFT-22.214.171.124
Ground team did not identify PLSS as actual source of w ater. ECFT-126.96.36.199
Cognitive Task Oversaturation contributed to the team’s delayed identification of the actual source of ECFT-188.8.131.52
Figure 3-67. Contributing Factors under ECFT 3.2.2 for reference ECFT-184.108.40.206 Cognitive Task Oversaturation contributed to the team’s delayed identification of the actual source of the water leak. (Contributing Factor 5) Supporting Evidence: Based on MIB previous experience, emergencies which are not covered by training have the potential to open a plethora of technical resources and information that must be deciphered in a very short amount of time. The information that the individual must process may exceed their cognitive resources, given a limited amount of time. In reviewing transcripts and interviews from several team members, it appears that some individuals were cognitively task oversaturated by the events of EVA 23. In addition to processing technical information, the team members also had to process verbal information, which in itself can lead to cognitive oversaturation if an individual is simultaneously trying to listen and respond to multiple conversations. From interviews, the MIB learned that due to the “multiple communications” going on at the same time, some team members didn’t have sufficient time to work through the suspicion that the drink bag was not the source of water. There were many tasks required of controllers at each position within mission control. They were mentally engaged in EVA operations, dealing with off-nominal events, communicating on the comm loops, accessing flight rules, referencing flight notes, and, at times, navigating a host of other informational databases. Multi-tasking of this nature can lead to cognitive task over-saturation see Human Factors section (Appendix A).
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...