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ISS EVA-23 Suit Water Intrusion Mishap Investigation Board Report



 
 
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  #1  
Old February 27th 14, 12:50 AM posted to sci.space.station
David Spain
external usenet poster
 
Posts: 2,901
Default 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



  #2  
Old February 27th 14, 09:16 AM posted to sci.space.station
Brian Gaff[_2_]
external usenet poster
 
Posts: 58
Default 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





  #3  
Old February 27th 14, 10:02 AM posted to sci.space.station
Brian Gaff[_2_]
external usenet poster
 
Posts: 58
Default 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





  #4  
Old February 27th 14, 02:19 PM posted to sci.space.station
Jeff Findley[_4_]
external usenet poster
 
Posts: 411
Default 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
  #5  
Old February 27th 14, 05:05 PM posted to sci.space.station
David Spain
external usenet poster
 
Posts: 2,901
Default 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  
Old February 27th 14, 07:56 PM posted to sci.space.station
Brian Gaff[_2_]
external usenet poster
 
Posts: 58
Default 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



  #7  
Old February 27th 14, 07:58 PM posted to sci.space.station
Brian Gaff[_2_]
external usenet poster
 
Posts: 58
Default 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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