National Aeronautics and Space Administration
This puts personnel with incomplete training in positions where they are asked to make decisions based on incomplete knowledge and incomplete procedure validation. Personnel have been turned down so many times when they have requested access that they self-censor their requests and therefore do not ask. (This also was a factor in personnel proceeding with the on-orbit vent-loop dry out procedure when it had not been validated on an actual flight unit.) Rationale provided by the supporting organization is that it would interrupt the processing, negatively impact the processing schedule, and since the hardware is so limited, they cannot risk the potential that the hardware might be broken. This is equivalent to the message that it is acceptable to accept the risk to hardware and personnel on-orbit over the risk to hardware on the ground. A â€œtest like you flyâ€? philosophy should be the default position by the technical teams. This is not to say there needs to be unfettered access to flight hardware, but access by various members of the EVA community, particularly operations (including crew) and safety who do not routinely have access to flight hardware is necessary to ensure high quality training. Historically, the broader EVA community including the Astronaut Office, MOD EVA, and S&MA personnel were given routine access to flight hardware at events such as chamber runs and equipment bench reviews. Close out photos were taken of all hardware to document the precise configuration of what is flying to facilitate effective communication between the ground and crew in flight. All procedures were validated on flight hardware if the procedure required a functioning system versus a fit check. From interviews and discussions, it has been found that by and large these opportunities have been eliminated from the program. The reasons cited are mainly due to budget and schedule impacts. On a related issue, the idea that one instance of EVA hardware is identical to all others is also fundamentally flawed. This was illustrated in the planned on-orbit changeout of the water line vent tube assembly in the HUT of EMU 3010. The Engineering and Operations personnel supporting the changeout were given the understanding that the fiberglass panel that covers the interface was velcroed in place. It turned out that some units have the panel bonded in place. This wasted crew time and if nothing else was embarrassing. Close out photos of each piece of hardware flying is vitally important. Accurate configuration records are also necessary to be maintained and made available to all support personnel with a real-time need. The Crew timeline was adversely impacted due to a misunderstanding of the onorbit configuration of the EMU hardware due to the fact that there were no closeout photos of the hardware. Recommendation R-23: The ISS Program and the EVA Project Office should put schedules and processes in place to ensure access to flight hardware to the broader EVA community including the Astronaut Office, MOD EVA, and S&MA personnel. Recommendation R-24: The ISS Program and the EVA Project Office should require close out photos be taken of all hardware with the participation of operations personnel to document the precise configuration of what is flying as well as accurate configuration records maintained and made available to real-time support personnel to facilitate effective communication between the ground and crew in flight. Recommendation R-25: The ISS Program and the EVA Project Office should ensure that all procedures are validated on flight hardware if the procedure requires a functioning system versus a fit check.
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...