National Aeronautics and Space Administration
EVA crew member (EV2) exposed to potential loss of life during EVA 23. UO-1
Flight Control Team/Crew did not terminate EVA as soon as w ater w as reported in the helmet. ECFT-3
EVA 23 Crew did not immediately recognize the severity of the event
Ground Team did not immediately recognize severity of the event.
Flight Control Team did not understand the failure mode.
Ground Team focused on the drink bag as the source of the w ater.
Critical Information w as not communicated betw een Crew and Ground Team ECFT-3.2.3
EV1 initially focused on drink bag as source in EVA 23. ECFT-188.8.131.52
Crew attributed w ater in EV2's helmet after EVA 22 to the drink bag.
Crew w as not trained to recognize this failure mode.
Flight Control Team did not perform investigation of w ater source.
Crew Member Training did not include this failure mode.
FCT's perception of the anomaly report process as being resource intensive made them reluctant to invoke it. ECFT-184.108.40.206.1.1.3
Flight Control Team accepted the explanation that the w ater w as from the drink bag. ECFT-220.127.116.11.1.1.1
Ground team allow ed pressures of impending EVA to influence actions.
ISS Community Perception w as that drink bags leak.
Program Pressure w as to maximize crew time on orbit for utilization.
EMU Hazard Report did not identify the hazard.
Minor amounts of w ater in the helmet w as normalized.
Engineering Team did not understand the failure mode.
Safety Team did not understand the failure mode.
MOD did not understand the failure mode. ECFT-18.104.22.168.2.1.1
FMEA/CIL did not effectively quantify the amounts of w ater entering the vent loop from the PLSS. ECFT-22.214.171.124.126.96.36.199.2
FMEA/CIL did not effectively describe the behavior of w ater entering the vent loop from the PLSS. ECFT-188.8.131.52.184.108.40.206.1
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-220.127.116.11.18.104.22.168.1.1
FMEA/CIL did not undergo thorough review and update periodically. ECFT-22.214.171.124.126.96.36.199.1.2
ISS program FMEA/CIL requirement did not require complete FMEA/CIL periodic update. ECFT-188.8.131.52.184.108.40.206.1.2.1
Program cut funding.
Community had lost sight of the value of the FMEA/CIL effort. ECFT-220.127.116.11.18.104.22.168.22.214.171.124
No one applied know ledge of the physics of w ater behavior in zero g to w ater coming from the PLSS vent loop ECFT-126.96.36.199.188.8.131.52.1
No one applied know ledge of the physics of w ater behavior in zero g to w ater coming from the PLSS vent loop ECFT-184.108.40.206.220.127.116.11.1
Minimal Formal Training on EMU function existed for the Safety Team. ECFT-18.104.22.168.22.214.171.124.2
Requirement for specific EVA/EMU trianing of Safety personnel did not exist. ECFT-126.96.36.199.188.8.131.52.2.1
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...