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National Aeronautics and Space Administration

EVA23Water Intrusion

Board’s) to investigate critical on-orbit anomalies, to identify immediate on-orbit corrective actions to prevent/mitigate on-orbit impacts to the ISS and/or crew, and to prevent/minimize recurrence of the anomaly.” Similar language is used by the Flight Director Office when describing a “Team 4” activity. From the Flight Control Operations Handbook (FCOH) Standard Operating Procedure “The Team 4 group will perform an evaluation of any major ISS systems anomaly requiring time-critical resolution and, if required, develop a contingency operations plan which can be implemented by the realtime mission controllers and the onboard crew. The conflict may be due to the fact that the work instruction, although signed at the Program level and in the document is stated to be “…applicable to any organization that is called upon to support the investigation and resolution of ISS on-orbit anomalies…” including the Flight Control Team. Unfortunately, no one from MOD is a signatory to this document to agree with it. Furthermore, there seems to be an inconsistent understanding on the part of the MER personnel concerning their understanding that the job of risk acceptance for execution planning and real-time operations rests with the Flight Control Team when the need arises to provide support with best engineering judgment. Recommendation R-43: The ISS Program must define The Roles and Responsibilities of the MER and the FCT to a level whereby each position (FCT and MER) on either side clearly understands their role and the role of their counterparts and mutual expectations must be established and agreed to. As part of this effort, the Program needs to reinforce the understanding that it is the FCT that is authorized to accept risk on behalf of the Program in real-time operations requiring best engineering judgment. Recommendation R-44: The ISS Program must establish a protocol whereby whenever conflicts arise between the MER and FCT concerning roles and responsibilities or one party’s performance during a particular event, the appropriate management from each side must meet to discuss the conflict and revise the roles and responsibilities or expectations accordingly. Supporting Evidence: In the course of the investigation from interviews with cognizant personnel, it was determined that the certification requirements for each MER console position or MER Subsystem Team (MST), as they are known, varied by subsystem and the various teams have differing requirements for certification currency. From discussions it was concluded that at the MST level the certification requirements are satisfactory. It should be noted that the MIB did not perform an audit of each position. However, one area did stand out as a notable exception: the MER Managers who are charged with the responsibility of managing the resources of the MER as well as providing integrated responses to the FCT in a timely manner are certified for their positions once and have no recertification or proficiency requirements. Furthermore, the MER managers, due to their workload, have little time for additional training to deepen their understanding of ISS systems. MER Managers are funded for approximately 12 full time positions consisting of 6 Contractor and 6 civil servant personnel. Currently, due to attrition, their numbers have been reduced to 10. Even at full staffing MER Managers are unable to find time to augment their experience with training to broaden their experience. The MIB further found that the system currently in place where MER Managers rotate around to different functional areas for periods of time is to be commended and encouraged as a good way to provide broadening, however, it does not replace good, solid training as is required and provided to their Flight Control counterparts.


ISS EVA Suit Water Intrusion Mishap Investigation Report  

Report of the NASA Mishap Investigation Board examining the high visibility close call event of July 16, 2013 when ESA astronaut Luca Parmit...