Analyses of recent major aerospace mishaps have identified human and organizational
factors as frequent contributing causes, including failures of risk perception,
risk communication, contingency planning, decision making, and drift from safe
practices. Advanced concepts and tools will be developed to support risk management
in future exploration missions to the Moon and Mars.
Missions Operations Risk Management
Risk management is necessary during both mission planning and in real-time mission
operations. Observations, interviews, and surveys have been used to identify
human and organizational risks during planning and operations for unmanned deep-space
missions (e.g., Mars Exploration Rover) and crewed missions involving the ISS,
Mir, and space shuttles. Conceptual, methodological and operational gaps exist
between mission planners, engineers, controllers, scientists and managers, gaps
which are exacerbated in remote operations. Research will contribute to ASCT
goals by developing and assessing tools and methods to control risks during
operation of complex human and automated systems in manned space missions. Data
will feed into system analysis and design of advanced operational concepts for
exploration systems. Prototypes will contribute to reliable and responsive ground
operations systems, with emphasis on real-time risk assessment, communication,
and risk-informed decision making.
Organizational risk models were developed by combining theories from the organizational
and team literatures with insights derived from observations from NASA work
domains. Surveys, observations, and interviews have been collected from several
NASA sites, including JSC Mission Control, JSC Vehicle Integrated Performance
and Environmental Resources (VIPER) Team, and JPL conceptual design teams (e.g.,
Image left: A risk tool suite for system design has been developed.
One area this group has studied, in detail, is distributed teams. Distributed
teams entail major requirements for information sharing in support of collaboration
and coordination. Individuals in distributed teams, whether engaged in mission
design or operations, may lack the big picture concerning systems or missions;
information updates may be problematic, and misunderstandings may arise due
to false assumptions. Organizational barriers may impede timely and complete
information flow across teams, especially between contractors, international
partners, and government organizations.
Based on these sources of data, an organizational risk ontology (relational
and taxonomic database) has been developed which has fed a risk tool suite for
system design. The ontology includes mission objectives, mission features, threats,
risks (likelihoods and consequences), and mitigations. This database is a prototype
of what would be a useful, searchable tool for project managers and mission
designers. Other systems, tools and procedures are needed to support knowledge
sharing and appropriate decision making across time and space. During design
processes, distributed teams may assign different meanings to terms or use different
methods, differences that may not be obvious. Multiyear projects require documentation
of assumptions and decision rationales held by original mission designers so
that individuals engaged in mission operations years later can understand why
systems and procedures were designed as they were. Exceptions and revised plans
must be updated regularly during mission operations and must be accessible.
Shift-handovers are routine, but potential sources of risk, especially in off-nominal
Risk surveys can also act as tools to measure safety climate and detect when
an organization is drifting too close to the boundaries of safe practices. Knowledge
management tools can provide support for real-time decisions about production
and safety tradeoffs.
Risk management strategies have been identified in several high-reliability
organizations. Recommendations will be developed and assessed for application
in NASA environments.
Risk management depends on the perception and recognition of sources of risk
in all phases of a mission. Analyses of high-reliability organizations have
identified generic risk factors; others are specific to NASA operations. Three
conditions that can cause mission and safety failures are finite resources,
task and organizational uncertainty, and changing, dynamic environments. Specific
features common to all high-risk environments also include mission and systems
complexity and distributed teams (engaged in both design and operations). Both
features require huge amounts of coordination and information sharing, which
are potential sources of risk.
Image right: Risk Ontology is key in changing, dynamic environments.
Human and organizational risks can be analyzed at several levels: the organization,
the team, and the individual. Risk factors at the organizational level include
organizational culture, schedule, cost, and pressure from various governmental
bodies. Values and attitudes toward safety and mission goals, blame-free reporting
procedures, organizational flexibility, and open communication channels that
support voicing of minority opinions help to manage known organizational risks.
International partners entail risks associated with different levels and types
of risk tolerance, lines of authority, added procedures, and lack of defined
roles and responsibilities. Even within organizations, goal and role conflicts
can exist between scientists and engineers, between different levels of management,
and between teams.
Risks at the individual level have been most thoroughly studied: These include
training, workload and fatigue, job satisfaction, morale and attrition. Individual
level factors can percolate up to influence team and organizational level risks
just as organizational decisions can influence the capability of individuals
to function effectively.