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ISS EVA-23 Suit Water Intrusion Mishap Investigation Board Report
In case you missed this over in sci.space.news, this report is now
available from NASA here along with the affiliated news conference audio and presentation: http://www.nasa.gov/stationnews/#.Uw55zRCGfZw There is a link from this site to the report which is a 222 page PDF document which I've linked to he http://www.nasa.gov/sites/default/fi...n_Report.p df I'll summarize with a quote from section 4.4 (pg 142) of the report entitled Root Causes: RC-1 Program emphasis was to maximize crew time on orbit for utilization. RC-2. ISS Community perception was that drink bags leak. RC-3. Flight Control Team's perception of the anomaly report process as being resource intensive made them reluctant to invoke it. RC-4. No one applied knowledge of the physics of water behavior in zero-g to water coming from the PLSS vent loop. RC-5. Minor amounts of water in the helmet was normalized. Draw your own conclusions after reading. I have not yet read through all of this report. BTW, I want to commend NASA on the release of this. This report is something to laud *not* beat NASA over the head with. This is what having transparency in your space program is all about.... Dave |
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ISS EVA-23 Suit Water Intrusion Mishap Investigation Board Report
sounds like they need aspace plumber who would know what happens to water in
low gravity situations. Brian -- From the Sofa of Brian Gaff Reply address is active "David Spain" wrote in message ... In case you missed this over in sci.space.news, this report is now available from NASA here along with the affiliated news conference audio and presentation: http://www.nasa.gov/stationnews/#.Uw55zRCGfZw There is a link from this site to the report which is a 222 page PDF document which I've linked to he http://www.nasa.gov/sites/default/fi...n_Report.p df I'll summarize with a quote from section 4.4 (pg 142) of the report entitled Root Causes: RC-1 Program emphasis was to maximize crew time on orbit for utilization. RC-2. ISS Community perception was that drink bags leak. RC-3. Flight Control Team's perception of the anomaly report process as being resource intensive made them reluctant to invoke it. RC-4. No one applied knowledge of the physics of water behavior in zero-g to water coming from the PLSS vent loop. RC-5. Minor amounts of water in the helmet was normalized. Draw your own conclusions after reading. I have not yet read through all of this report. BTW, I want to commend NASA on the release of this. This report is something to laud *not* beat NASA over the head with. This is what having transparency in your space program is all about.... Dave |
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ISS EVA-23 Suit Water Intrusion Mishap Investigation Board Report
Well, I have only read part of it as it is quite long. However it does seem
that there is criticism of the tendency to assume common things commonly occur. Some might call it complacency, but in fact its more like a probability evaluation without enough input data. E if they checked every time any water in the helmet occurred, they would have found more than a leaky drinks bag, and been wiser in the event, or prevented it completely. I'm more intrigued what this non organic material actually is. Also how it can be of a size to block holes. My feeling than is that its either inadequate cleaning, accelerated wear, fan blades hitting things were mentioned, or bearing wear, coating shedding etc. Just removing this every time during the process of getting the system ready to be used would have prevented this, and possibly added to the comfort of other EVAs as well. Interesting and a job well done I think. Brian -- From the Sofa of Brian Gaff Reply address is active "David Spain" wrote in message ... In case you missed this over in sci.space.news, this report is now available from NASA here along with the affiliated news conference audio and presentation: http://www.nasa.gov/stationnews/#.Uw55zRCGfZw There is a link from this site to the report which is a 222 page PDF document which I've linked to he http://www.nasa.gov/sites/default/fi...n_Report.p df I'll summarize with a quote from section 4.4 (pg 142) of the report entitled Root Causes: RC-1 Program emphasis was to maximize crew time on orbit for utilization. RC-2. ISS Community perception was that drink bags leak. RC-3. Flight Control Team's perception of the anomaly report process as being resource intensive made them reluctant to invoke it. RC-4. No one applied knowledge of the physics of water behavior in zero-g to water coming from the PLSS vent loop. RC-5. Minor amounts of water in the helmet was normalized. Draw your own conclusions after reading. I have not yet read through all of this report. BTW, I want to commend NASA on the release of this. This report is something to laud *not* beat NASA over the head with. This is what having transparency in your space program is all about.... Dave |
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ISS EVA-23 Suit Water Intrusion Mishap Investigation Board Report
In article , nospam@
127.0.0.1 says... In case you missed this over in sci.space.news, this report is now available from NASA here along with the affiliated news conference audio and presentation: http://www.nasa.gov/stationnews/#.Uw55zRCGfZw There is a link from this site to the report which is a 222 page PDF document which I've linked to he http://www.nasa.gov/sites/default/fi...n_Report.p df This is interesting: P1 ECFT-1: The ISS Program conducted EVA 23 without recognizing the EMU failure which occurred on EVA 22 The MIB learned that on EVA 22, EV2 in suit 3011 experienced water in the helmet during repress. This failure was misdiagnosed and not determined to be a constraint to EVA 23. The MIB has determined that had the source of the water at the end of EVA 22 been investigated thoroughly, EVA 23 and the subsequent mishap would not have occurred. Unfortunately, this sort of thing seems to happen from time to time. Anomalies become common and are dismissed without proper, time consuming, analysis. Unfortunately, this anomaly could only be duplicated in microgravity, not on the ground, so it was immediately misunderstood. To complicate matters: RC1 ECFT-1.1.1.2.1: Program emphasis was to maximize crew time on orbit for utilization. The ISS Program must place a strong emphasis on performing utilization with the ISS; it is in fact the very reason ISS exists. However, the strong emphasis on utilization was leading team members to feel that requesting on-orbit time for anything non-science related was likely to be denied and therefore tended to assume their next course of action could not include on-orbit time. The danger with that thought process is that lower level team members were in effect making risk decisions for the Program, without necessarily having a Program wide viewpoint or understanding of the risk trades actually being made at a Program level. and RC3 ECFT-1.1.1.3: Flight Control Team?s perception of the anomaly report process as being resource intensive made them reluctant to invoke it. Based on interviews and MIB investigation, it was clear that several ground team members were concerned that if the assumed drink bag anomaly experienced at the end of EVA 22 were to be investigated further, it would likely lead to a long, intensive process that would interfere with necessary work needed to prepare for the upcoming EVA 23, and that this issue would likely not uncover anything significant enough to justify the resources which would have to be spent. I'd summarize these two sections as: Program inertia dominated the decision making progress regarding a potential safety issue. We've seen this sort of thinking before with both the Challenger accident and Columbia accident. Thankfully, this time, the "anomaly" did not result in any deaths. ISS is primarily a research program and EMU's being used without regular ground servicing is still relatively new for NASA. Despite the relatively low number of ISS EVA's, it appears that the people involved lapsed into treating them as "routine", even though by the EVA numbering (EVA 22 and EVA 23), it's clear to this outsider that less than two dozen should *not* be considered routine. Jeff -- "the perennial claim that hypersonic airbreathing propulsion would magically make space launch cheaper is nonsense -- LOX is much cheaper than advanced airbreathing engines, and so are the tanks to put it in and the extra thrust to carry it." - Henry Spencer |
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ISS EVA-23 Suit Water Intrusion Mishap Investigation Board Report
One quick comment then I have to get back to work.
Hopefully this weekend I will have time to read this more thoroughly and may have something more substantial to contribute. One thing to mention which I did not find (yet) fully described in the PDF document but was mentioned in the audio to the affiliated press conference by Mr. Gerstenmaier. The PDF document has been redacted for public release due to ITAR restriction placed on some of the "sensitive" text and drawings. That means some of the drawings and text in the previously linked document have been blanked out on purpose. You cannot beat up NASA for following the law. They are doing the best they can. I suspect if you write to the NASA PAO there is probably a procedure in place for American citizens to obtain the non-redacted version. Proof of citizenship and perhaps a statement of awareness and commitment to abide by the ITAR regulations may also be required. (Which means no republishing to the Internet unless you are willing to invite legal prosecution and risk the very real possibility of financially crippling fines and jail). However, this won't prevent *me* from making the snide observation that ITAR restrictions on technology already aboard the ISS and presumably whose functionality has already been fully disclosed to the Russians is somewhat amusing, but I suppose typical for government wheels that turn slowly. I'm assuming here of course that Russian crew members have been fully briefed and trained on the EMU. Unless the ISS is "Balkanized" to the point only Americans or citizens of ITAR sanctioned countries can don EMUs and the Russians have to fend for themselves. Somehow I don't think that's the way it really works on ISS tho... :-) Dave |
#6
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ISS EVA-23 Suit Water Intrusion Mishap Investigation Board Report
It seems strange to me that this sort of thinking happens, when as I recall
in the issues with gloves some years back all sorts of things were tried and the constant glove inspections started. I think the one biggy here is that it was not realised how bad zero g watter could be, and hopefully this has now been rectified. Even on the ground you can drown in a puddle of course. Brian -- From the Sofa of Brian Gaff Reply address is active "Jeff Findley" wrote in message ... In article , nospam@ 127.0.0.1 says... In case you missed this over in sci.space.news, this report is now available from NASA here along with the affiliated news conference audio and presentation: http://www.nasa.gov/stationnews/#.Uw55zRCGfZw There is a link from this site to the report which is a 222 page PDF document which I've linked to he http://www.nasa.gov/sites/default/fi...n_Report.p df This is interesting: P1 ECFT-1: The ISS Program conducted EVA 23 without recognizing the EMU failure which occurred on EVA 22 The MIB learned that on EVA 22, EV2 in suit 3011 experienced water in the helmet during repress. This failure was misdiagnosed and not determined to be a constraint to EVA 23. The MIB has determined that had the source of the water at the end of EVA 22 been investigated thoroughly, EVA 23 and the subsequent mishap would not have occurred. Unfortunately, this sort of thing seems to happen from time to time. Anomalies become common and are dismissed without proper, time consuming, analysis. Unfortunately, this anomaly could only be duplicated in microgravity, not on the ground, so it was immediately misunderstood. To complicate matters: RC1 ECFT-1.1.1.2.1: Program emphasis was to maximize crew time on orbit for utilization. The ISS Program must place a strong emphasis on performing utilization with the ISS; it is in fact the very reason ISS exists. However, the strong emphasis on utilization was leading team members to feel that requesting on-orbit time for anything non-science related was likely to be denied and therefore tended to assume their next course of action could not include on-orbit time. The danger with that thought process is that lower level team members were in effect making risk decisions for the Program, without necessarily having a Program wide viewpoint or understanding of the risk trades actually being made at a Program level. and RC3 ECFT-1.1.1.3: Flight Control Team?s perception of the anomaly report process as being resource intensive made them reluctant to invoke it. Based on interviews and MIB investigation, it was clear that several ground team members were concerned that if the assumed drink bag anomaly experienced at the end of EVA 22 were to be investigated further, it would likely lead to a long, intensive process that would interfere with necessary work needed to prepare for the upcoming EVA 23, and that this issue would likely not uncover anything significant enough to justify the resources which would have to be spent. I'd summarize these two sections as: Program inertia dominated the decision making progress regarding a potential safety issue. We've seen this sort of thinking before with both the Challenger accident and Columbia accident. Thankfully, this time, the "anomaly" did not result in any deaths. ISS is primarily a research program and EMU's being used without regular ground servicing is still relatively new for NASA. Despite the relatively low number of ISS EVA's, it appears that the people involved lapsed into treating them as "routine", even though by the EVA numbering (EVA 22 and EVA 23), it's clear to this outsider that less than two dozen should *not* be considered routine. Jeff -- "the perennial claim that hypersonic airbreathing propulsion would magically make space launch cheaper is nonsense -- LOX is much cheaper than advanced airbreathing engines, and so are the tanks to put it in and the extra thrust to carry it." - Henry Spencer |
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ISS EVA-23 Suit Water Intrusion Mishap Investigation Board Report
No its not, I have never seen a Russian in an EMU, but from comments heard
some years back now it is clear that they are very well versed in their operation and servicing. Maybe they are all scared of the Chinese making cheaper copies and selling them! Brian -- From the Sofa of Brian Gaff Reply address is active "David Spain" wrote in message ... One quick comment then I have to get back to work. Hopefully this weekend I will have time to read this more thoroughly and may have something more substantial to contribute. One thing to mention which I did not find (yet) fully described in the PDF document but was mentioned in the audio to the affiliated press conference by Mr. Gerstenmaier. The PDF document has been redacted for public release due to ITAR restriction placed on some of the "sensitive" text and drawings. That means some of the drawings and text in the previously linked document have been blanked out on purpose. You cannot beat up NASA for following the law. They are doing the best they can. I suspect if you write to the NASA PAO there is probably a procedure in place for American citizens to obtain the non-redacted version. Proof of citizenship and perhaps a statement of awareness and commitment to abide by the ITAR regulations may also be required. (Which means no republishing to the Internet unless you are willing to invite legal prosecution and risk the very real possibility of financially crippling fines and jail). However, this won't prevent *me* from making the snide observation that ITAR restrictions on technology already aboard the ISS and presumably whose functionality has already been fully disclosed to the Russians is somewhat amusing, but I suppose typical for government wheels that turn slowly. I'm assuming here of course that Russian crew members have been fully briefed and trained on the EMU. Unless the ISS is "Balkanized" to the point only Americans or citizens of ITAR sanctioned countries can don EMUs and the Russians have to fend for themselves. Somehow I don't think that's the way it really works on ISS tho... :-) Dave |
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