National Aeronautics and Space Administration
EV1 initially focused on drink bag as source in EVA 23.
Flight Rule to address this failure mode did not exist.
EMU Hazard Report did not identify the hazard.
Engineering Team did not understand the failure mode.
Safety Team did not understand the failure mode.
FMEA/CIL did not effectively describe the behavior of water entering the vent loop from the PLSS.
4.3 Contributing Factors A Contributing Factor is an event or condition that may have contributed to the occurrence of an undesired outcome but, if eliminated or modified, would not by itself have prevented the occurrence. Contributing Factors increase the probability that an event or condition will occur. Based on this definition, the MIB noted 13 contributing factors. CF-1.
Flight Control Team sent EV2 back to Airlock unaccompanied during EVA termination.
EV2 did not have the experience base to immediately recognize the severity of the situation.
EV2 was unable to communicate the severity of his condition after the terminate call.
Ground team did not identify PLSS as actual source of water.
Cognitive Task Oversaturation contributed to the teamâ€™s delayed identification of the actual source of the water leak.
EV2â€™s comm system failed due to water.
FMEA/CIL did not effectively quantify the amounts of water entering the vent loop from the PLSS.
Minimal Formal Training on EMU function existed for the Safety Team.
FMEA/CIL did not undergo thorough review and update periodically.
Requirement for specific EVA/EMU training of Safety personnel did not exist.
ISS program FMEA/CIL requirement did not require complete FMEA/CIL periodic update.
Program cut funding.
Community had lost sight of the value of the FMEA/CIL effort.
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...