NASA NTRS · 20240014343
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Josh Moorhouse, Becky MacLaren. Human Systems Integration and Engineering (HSI&E). https://ntrs.nasa.gov/citations/20240014343
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The primary objective of the Space Transportation System mission 93 (STS-93) was to deploy the Chandra X-Ray Observatory. Chandra, the world's most powerful X-Ray telescope, allowed scientists from around the world to study some of the most distant and dynamic objects in the universe. Stripped of nearly 7,000 pounds of its own gear to make room for the payload, the orbiter assigned to this mission was Space Shuttle Columbia. Prior to STS-93, Columbia had flown 25 flights and was NASA's oldest and heaviest orbiter. On July 23, 1999, after two prior launch scrubs, Eileen Collins and her crew of four launched from Kennedy Space Center. About five seconds after launch, Mission Control at Johnson Space Center detected a voltage drop on one of Columbia's electrical buses. As a result of this power fluctuation, a primary and back-up Main Engine controller dropped offline. Given design redundancy, the two remaining controllers supported all three engines. If there had been any other AC bus issues, one engine of the three on the Orbiter would have shut down. The redundant set of digital computer units in each engine controller saved Columbia and her crew from a very risky contingency abort. Post-flight inspection revealed soot on a screw head and a hole in an adjacent Kapton insulated wire. The single strand of polyimide wire was located nearly half-way down the payload bay. The Shuttle Independent Assessment Team (SIAT) reported that the wire had rubbed and chaffed against a burred screw head. The burr was later determined to be the result of overtightening of the screw by a technician during a maintenance refurbishment. Alone, the burr may not have been problematic, but later, during another ground processing event, possibly years after, someone inadvertently stepped on the wiring harness. With the pressure and motion of unintended contact, some of the Kapton insulation rubbed off against the burred screw head. The SIAT suspected the wire damage was pre-existing and was caused 4 or 5 years prior to the flight. Finally, the intense vibrations during the launch sequence allowed contact between the exposed conductor and exposed metal area on the burred screw head, resulting in the arcing and shorting of the wire. Due to the quick turnaround times of Space Shuttle Orbiters, wiring issues caused from multiple maintenance events were often overlooked. Additionally, failing to incorporate thorough and early inclusion of human systems integration (HSI) applications as a crucial part of the decision process can result in these types of misshaps. In order to reduce human error associated with integrated manufacturing, maintenance, refurbishment and flight preparations, wire inspection criteria should be refined and standardized, visual inspection processes should be quantified, and technicians should be certified by specially trained instructors. This case, among many others, unveils why human error management and development of safety metrics is a vital piece in the development of complex systems, and why it should be supported aggressively and implemented program wide.
During the Acquisition Life Cycle for a program, there are several opportunities for the system in design to be adjusted in accordance with its changing landscape as it is being shaped by evolving policy and organizational culture. Human Systems Integration is integral to identifying these opportunities of change as there are a set number of activities that may account for altered operational states, human performance deviations, and overall component engagement if HSI is enacted early enough in the life cycle. Some changes that occur in the operational environment may not be accounted for since the organizational culture and practices are not currently a part of the HSI focus. Likewise, policy changes themselves from a top-to-bottom analysis may not have the appearance of effecting human performance until having gone through a trail-and-error period. Workarounds to adjust for unforeseen policy affects become the system's solution that usually includes changes in the training and education of the operators, maintainers, and support personnel. A system full of workarounds and off-normal practices, that cause operators to disregard the purpose of the design, coupled with the false notion that these activities are proven for successful system operation, is the very definition of “an accident waiting to happen”. Unforeseen changes in policies and practices that cause new and unusual activities to successfully and keep the system running, should be considered latent factors that may cause a potential mishap, and not part of the resilience that humans provide to the successful operation of the system. This presentation will explore how latent factors may find their way into system operations and how they can be identified and addressed.