HUMAN SPACE ANOMALIES AND LESSONS LEARNED

Course Summary

Course attendees will be exposed to a survey of major anomalies in the US space program over the past six decades, plus a few challenges in the Russian program. While safety efforts have improved it remains critically important to learn the hard lessons related to leadership, management practices, technology integration, human factors, maintaining high degrees of human performance in challenging environments, and person-rated systems integration. The course includes an overview of human systems integration and basic medical aspects of human spaceflight that have operational implications. Early human space endeavors focused on testing while achieving safe return of astronauts. Next, a major goal was to keep a human being well enough to do useful mission-related work while in orbit. This phase of flight involved many failures and complications, as well as notable successes. At the core of many failures were the “unknown unknowns.” Later, there were the “known but risky” endeavors. Overlay on this the occasional disregard for known problems by management and leadership teams, plus less than optimal decision-making for risk mitigation. The importance of group dynamics and culture for longer missions is also reviewed and stressed through case studies and historical events.

Course Materials

Each attendee will receive a copy of the presentation and reference materials as well as individual Certificates of Completion.

Who Should Attend

• Space industry professionals, policymakers, investors
• Business leaders in space-related and high human performance organizations
• Space systems integration professionals
• Considerations for Testing and Meeting FAA Commercial Space Regulations
• Satellite operators and program managers
• Space mission designers and operations managers
• Flight safety officers and managers
• Industrial and academic researchers
• Space scientists and technologists
• Space entrepreneurs and consultants
• Technologists involved in developing future space applications

What You Will Learn

Investigations of historical spacecraft anomalies, failures, and other challenges will create a critical knowledge base for increased future mission successes. The many lessons learned are important for management, engineering professionals and human factors leaders who are responsible for crew and spacecraft safety and proper systems operations. The course content will help participants understand how to think at multiple levels of analysis, especially with regard to leadership, decision-making, and human systems integration for space operations. An overview of some tools for assessing human factors is included. This course will enhance the resilience of the entire organizational process as space operations evolve.

Course Outline

1. Macro-overview of some Key Anomalies Encountered during the Space Age and What can We Learn from Them
2. Allied Space Medicine Overview-- Where are the Physiological Changes, Timelines, Risks Based Upon Data and "Best Guesses", and Mitigation Strategies
3. What is Human Factors, Human Sensory Processing, and Human Systems Integration, and How Do They Fit into a Robust Systems Engineering Design Process for Research, Development, Test and Evaluation, and Later Sustained Operations for Complex Aerospace Systems
4. Overview of the Reason “Swiss Cheese” Model for Mishap Causation; and Overview of the Human Factors Analysis and Classification Systems (HFACS) Approach to Mishaps, and Possible Prevention
5. What are the FAA and NASA's Key Documents Pertaining to Commercial Operations in Space and Human Systems Integration
6. What Role does Fatigue Play in this Area, and how Does it Affect the Body and Human Performance in Aerospace Systems?
7. What are the Basic Key Tools Used to Assess Workloads in Aerospace Systems and What is the Notion of Assessing Situation Awareness in Complex Scenarios?
8. What are some Key Statistical Concerns for Evaluating Human Performance
9. What is the Role of Leadership and Good Management Overall in These Problem Areas; Can we Learn Leadership and Organizational Lessons from Past Failures, or Major Successes?
10. Mercury Program: Alan Shepard’s Delayed Launches; The Problem of Gus Grissom’s Blown Hatch; John Glenn’s Terminated Orbital Flight; and Scott Carpenter’s Inattention to Flight Details which Ruined his Astronaut Career
11. Gemini Program: Gemini’s Neil Armstrong and Dave Scott Emergency with a Stuck Thruster, Resulting in Out-of-Control Rapid Spinning in Gemini VIII with Emergency Re- Entry; Gene Cernan’s Dangerous Spacewalk, Dehydration, and Fogged up Visor in Gemini IX with Tom Stafford.
12. A Few X-15 Rocket Plane Close Calls, and the Mike Adams' X-15 Crash – A Classic Case Study for Human Systems Integration, Controls and Displays and Workloads
13. Lifting Body Flight Test Problems of Stability and Workload — some Human Factors and Flying Handling Qualities Converging
14. Known Russian Space Program Challenges in the 1960’s
15. The Apollo 1 Flash Fire on the Pad with 100% Oxygen Environment and Lack of Quick Escape Ability
16. NASA Astronaut T-38 Aircraft Deaths—Why did Excellent Pilots Seem to Crash the “Sport Car of the USAF T-38’s” at a High Rate in the Astronaut Corps. The Problem of Management Leadership and Situation Awareness Combined.
17. Neil Armstrong’s Close Call with the Lunar Lander Simulator and later Approach to the Moon with the LEM Flight Computer Overloaded During Descent, Low on Fuel, and the Intended Landing Site Full of Boulders
18. Apollo 13— “Failure is not an Option”
19. Lunar Surface Operations Challenges with Spacesuit Center of Gravity Issues, and Very Fatiguing Lunar Work Experiences; High Stress Hormonal and Low Ion States as a Potential Physiological Exhaustion Hypothesis; the Mechanical and Physiological Problems of Lunar Dust as a Reactive Substance
20. 1971 Russian Salyut Reentry Failure with Decompression and 3 Astronaut deaths
21. Skylab Failure of Solar Panel to Deploy and Canopy Fix to Keep the Station Cool; Skylab Crew Work Challenges and Lessons Learned from that Experience
22. Space Shuttle Approach to Landing Test Problem in 1977 from a Flight Controls Gain Standpoint; Later STS-3 Auto-Pilot Shuttle Crew Interface Problem; SpaceShipOne Longitudinal Gain Control Challenge
23. Space Shuttle Challenger— O-ring Known Problems and Decision to Launch in Cold Weather in Jan 1986; A Case Study in Management and Organizational Decision Making and Complacency
24. Mir-Progress 234 Collision in 1997 that Nearly Destroyed Phase 1 of the International Space Station Program Cooperation Between the USA and Russia— a now Classic Case Study with Issues at Every Level of Human Systems Operations and Integration— including the Human Factors Aspects of Remotely Piloted Operations
25. The Space Shuttle Columbia Crash of 2003 – Decision-making, Complacency, and Failure to Plan for Contingencies
26. EVA Challenges and Other Surrounding Factors
27. The Scaled Composites Flights of SpaceShipOne, and Later Loss of
    1. Challenges in Flight Test and Failure to Consider Human Systems Integration in Flight Test, Despite Warnings to Do So.
28. Overview of B737MAX Human Systems Integration and Certification Issues, and an Update on the Boeing Starliner Challenges
29. The future of AI, Adaptive Systems, and Remotely Piloted or Robotics Operations— Humans in-the-Loop, On-the-Loop, or Surfing in and out of the Loop and Trust for AI Answers and Inputs... the Brave New World of Systems Integration and Test for Space Operations.
30. How can We Build Resilience into Human-Rated Systems Operations, Management Structures and Decision-Making with Enhanced Leadership Training in Empathy and Emotional Intelligence?
31. Conclusions

Instructor

DWIGHT A. HOLLAND, MD, PhD

Dr. Dwight Holland is an award-winning former USAF Officer, Antarctic Field Geophysicist, and envisioner/co-author of the acclaimed NASA book "Breaking the Mishap Chain" -- relating to Human Systems Integration and similar problems in the testing of complex aerospace systems. He has been recognized as an Academician in the International Academy of Aviation and Space Medicine and is a Fellow of the Aerospace Medical Association (AsMA), a Fellow in the Royal Aeronautical Society, among others. He has over 130 abstracts, proceedings, papers, and other academic works to his credit. He is a subject matter expert that utilizes allied medicine and organizational science to improve human systems integration with a systems perspective to reduce injuries and enhance human performance. His expertise also involves consideration of leadership and group dynamics to aid in improved decision-making, situation awareness and resilience in a wide variety of systems. Dr. Holland has chaired 60+ academic panels at various professional meetings. He has over 2,000 hours in 35+ aircraft and simulators in various capacities-- also with an FAA Commercial/Jet Type Rating and was an Instructor/Staff/Consultant at the USN and USAF Test Pilot Schools for over a decade. Dr. Holland is a Past President of the International Association of Military Flight Surgeon Pilots, the Space Medicine Association, the Aerospace Human Factors Association, and the Life Sciences and Biomedical Engineering Branch of AsMA, among others. In addition, he has also served as the Technical Co-Chair/ Leadership Track organizer for the largest International Systems Engineering Conference to date and was the Field Grade Officer of the Year at Edwards AFB, CA (as IMA in the USAF Test Pilot School). Dr. Holland is also certified in the use of the Human Factors Analysis and Classification System (HFACS).