2006-2007 - Kennedy Space Center Technology Transfer Office

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Influence Map Methodology for Evaluating Systemic Safety Issues“Raising the bar” in safety performance is a critical challenge for many organizations,Task/ProcessModeling and including Kennedy Space Center. Contributing-factor taxonomies organize informationSimulation about the reasons accidents occur and therefore are essential elements of accidentinvestigations and safety reporting systems. Organizations must balance efforts to identifycauses of specific accidents with efforts to evaluate systemic safety issues in order to become moreproactive about improving safety.This project successfully addressed the following two problems: (1) methods and metrics to supportthe design of effective taxonomies are limited and (2) influence relationships among contributingfactors are not explicitly modeled within a taxonomy. The primary result of the taxonomicrelationshipmodeling efforts was an innovative “dual-role” taxonomy that is more comprehensiveand has better diagnostics than existing contributing-factor taxonomies. The influence mapmethodology graphically and analytically combines the dual-role taxonomy and influencerelationship models.Influence maps were developed for an initial sample of safety incidents at Kennedy Space Center. Ateam of experts used the new dual-role taxonomy and influence chain methodology to evaluate theaccuracy and completeness of contributing factors identified during formal incident investigations.Using the influence map methodology, the team identified 116 contributing factors. Only 16 percentof these events or conditions were identified as contributing factors, contributing causes, or rootcauses with traditional tools during the formal incident investigations, and over half of the 116contributing factors were not addressed by the findings and recommendations in the formal incidentreports.Influence chains of contributing factors in mobile crane mishap.98 Process and Human Factors Engineering Technologies
Type of mobile crane that impacted thecrossover between the KSC VehicleAssembly Building and a utility annex.Location and close-up of damage to the crossover between the KSC VehicleAssembly Building and a utility annex.Accomplishments of this ongoing project include the following:• comparatively analyzing industry and government contributing factor taxonomies (2002),• developing the dual-role taxonomy (2003),• developing the influence chain methodology (2004),• initially testing and evaluating the influence map methodology with incident data from Shuttle GroundOperations and applying taxonomy analysis results to the efforts of the NASA Engineering and Safety Center’staxonomy working group (2005),• refining the influence map methodology and documenting the approach (2006),• analyzing a representative sample of Shuttle processing incidents occurring since February 2003 with theinfluence map methodology (2007),• delivering recommendations to (1) address the most significant systemic safety issues in Shuttle GroundOperations, (2) prevent recurrence of specific mishap types, (3) address design considerations that will benefitConstellation systems, and (4) improve the quality of incident investigations (2008), and• applying the influence map tool to Orion processing, historical NASA events, and additional safety domains(2008).Contact: Timothy S. Barth , NASA Engineering and Safety Center, (321) 867-6230Participating Organizations: United Space Alliance (Donna M. Blankmann-Alexander and Blake Parker) and NASA Ames ResearchCenter (Dr. Barbara Kanki)KSC Technology Development and Application 2006-200799
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ForewordSuccessful technology devel
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ContentsSpaceport Structures and Ma
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Contents (continued)Process and Hum
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IntroductionJohn F. Kennedy Space C
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Constellation SystemsSurfaceSystems
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Spaceport Structures and MaterialsK
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20181614∆ E1210Modified Sensor Be
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Initial results of the EDEM model o
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Contacts: Dr. Carlos I. Calle ,NASA
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Close examination of the corrosions
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Adhesion at Failure (psi)2500200015
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Figure 1. After 500 hours of salt f
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Contacts: Dr. Paul E. Hintze , NASA
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Figure 2. Repairs to various types
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on top of the cuvette contains the
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Figure 2. A corrugated NiTi sheet e
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The PLTD can be used to (1) calibra
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SEM images of neat MWNT fibers: (a)
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Contacts: Trent M. Smith
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Figure 1. An isometric cutaway view
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Figure 2. Quartz sand flowing in th
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Figure 2. Top images show how the e
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Sand volume fraction contour at t =
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Integrated LWRD/RVC engineering bre
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Mean relative percentage change in
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We compared the model’s predictio
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Figure 2. Three-dimensional simulat
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Figure 3. Camera calibration model.
Page 61 and 62: The sketch in Figure 2 shows alaunc
Page 63: Figure 2. Signal generator (right)
Page 66 and 67: Hail Size Distribution MappingA 3-D
Page 68 and 69: Launch Pad 39 Hail Monitor Array Sy
Page 70 and 71: Autonomous Flight Safety System - P
Page 72 and 73: The Photogrammetry CubeSpaceport/Ra
Page 74 and 75: Bird Vision SystemThe Bird Vision s
Page 76 and 77: Automating Range Surveillance Throu
Page 78 and 79: Next-Generation Telemetry Workstati
Page 80 and 81: GPS Metric Tracking UnitAs Global P
Page 82 and 83: Space-Based RangeSpace-Based Range
Page 85 and 86: Fluid System TechnologiesKSC Techno
Page 87 and 88: 0.900.850.80Discharge Coefficient,
Page 89 and 90: Composite seals for performance eva
Page 91 and 92: 140000120000100000Signal80000600004
Page 93 and 94: Contacts: Dr. Barry J. Meneghelli ,
Page 95 and 96: 60555045Comparative k-value (mW/m-K
Page 97 and 98: a compatible spacecraft model where
Page 99 and 100: In an ongoing effort for improvemen
Page 101: Low-gravity probe prototype test.th
Page 104 and 105: Countermeasure for Radiation Protec
Page 106 and 107: Focused Metabolite Profiling for Di
Page 109 and 110: Process and Human FactorsEngineerin
Page 111: DON uses game technology to enable
Page 115 and 116: SALT proof-of-concept communication
Page 117 and 118: SSLM CAD model.Our design offers th
Page 119 and 120: Variables that can be integrated by
Page 121: Exploration Supply Chain Simulation
Page 124 and 125: Nanosensors for Evaluating Hazardou
Page 126 and 127: Sixty-four-Channel Inline Cable Tes
Page 128 and 129: Wireless Inclinometer Calibration S
Page 130 and 131: Generating Safety-Critical PLC Code
Page 132 and 133: Spacecraft Electrostatic Radiation
Page 134 and 135: Ion Beam Propulsion StudySpacecraft
Page 136 and 137: RT-MATRIX: Measuring Total Organic
Page 139 and 140: Appendix AKSC High-Priority Technol
Page 141 and 142: Risk Assessment ToolMission Data Fe
Page 143 and 144: Appendix BInnovative Partnership Pr
Page 145 and 146: system for the Government, using th
Page 147: tracking objects after launch, and
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2006-2007 - Kennedy Space Center Technology Transfer Office

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