Escolar Documentos
Profissional Documentos
Cultura Documentos
MishapInvestigationBoard
PhaseIReport
November10,1999
TableofContents
MarsClimateOrbiterMishapInvestigationBoardPhaseI
Report
SignaturePage(BoardMembers)
ListofConsultants
Acknowledgements
ExecutiveSummary
1.
MarsClimateOrbiter(MCO)andMarsPolarLander(MPL)
ProjectDescriptions
5.
2.
MCOMishap
3.
MethodofInvestigation
4.
MCORootCausesandMPLRecommendations
MCOContributingCausesandObservationsand
MPLRecommendations
6.
MCOObservationsandMPLRecommendations
7.
MPLObservationsandRecommendations
8.
PhaseIIPlan
Appendix:LetterEstablishingtheMCOMishapInvestigationBoard
Acronyms
SignaturePage
__________/s/________________
ArthurG.Stephenson
Chairman
GeorgeC.MarshallSpaceFlightCenter
Director
__________/s/_______________
Dr.DanielR.Mulville
ChiefEngineer
NASAHeadquarters
__________/s/_______________
FrankH.Bauer
Chief,Guidance,NavigationandControl
Center
GoddardSpaceFlightCenter
__________/s/_______________
GregA.Dukeman
GuidanceandNavigationSpecialist
VehicleFlightMechanicsGroup
GeorgeC.MarshallSpaceFlightCenter
__________/s/_______________
Dr.PeterNorvig
Chief,ComputationalSciencesDivision
AmesResearchCenter
__________/s/_______________
Approved
Dr.EdwardJ.Weiler
AssociateAdministrator
OfficeofSpaceScience
Advisors:
OfficeofChiefCounsel:MSFC/LouisDurnya
OfficeofPublicAffairs:HQs/DouglasM.Isbell
Consultants
AnnMerwarth
NASA/GSFCretired
Expertingroundoperations&flightsoftware
development
MosheF.Rubinstein
Prof.Emeritus,
UniversityofCalifornia,LosAngeles
Civilandenvironmentalengineering
JohnMari
VicePresidentofProductAssurance
LockheedMartinAstronautics
PeterSharer
SeniorProfessionalStaff
MissionConceptsandAnalysisGroup
TheJohnsHopkinsUniversity
AppliedPhysicsLaboratory
CraigStaresinich
ChandraXrayObservatoryProgramManager
TRW
Dr.MichaelG.Hauser
DeputyDirector
SpaceTelescopeScienceInstitute
TimCrumbley
DeputyGroupLead
FlightSoftwareGroup
AvionicsDepartment
GeorgeC.MarshallSpaceFlightCenter
DonPearson
AssistantforAdvancedMissionDesign
FlightDesignandDynamicsDivision
MissionOperationsDirectorate
JohnsonSpaceCenter
Acknowledgements
TheMarsClimateOrbiterMishapInvestigationBoardwishestothankthetechnical
teamsfromJetPropulsionLaboratory(JPL)andLockheedMartinAstronauticsfor
theircooperationwhichwasessentialinourreviewoftheMarsClimateOrbiterand
MarsPolarLanderprojects.SpecialthankstoLiaLaPianaandFrankBauerforpulling
thisreporttogetherwiththesupportoftheentireBoardandconsultants.
ExecutiveSummary
ThisPhaseIreportaddressesparagraph4.A.oftheletterestablishingtheMarsClimate
Orbiter(MCO)MishapInvestigationBoard(MIB)(Appendix).Specifically,paragraph
4.A.oftheletterrequeststhattheMIBfocusonanyaspectsoftheMCOmishapwhich
mustbeaddressedinordertocontributetotheMarsPolarLanderssafelandingon
Mars.TheMarsPolarLander(MPL)entrydescentlandingsequenceisscheduledfor
December3,1999.
ThisreportprovidesatopleveldescriptionoftheMCOandMPLprojects(section1),it
definestheMCOmishap(section2)andthemethodofinvestigation(section3)andthen
providestheBoardsdeterminationoftheMCOmishaprootcause(section4),theMCO
contributingcauses(section5)andMCOobservations(section6).BasedontheMCO
rootcause,contributingcausesandobservations,theBoardhasformulatedaseriesof
recommendationstoimprovetheMPLoperations.Theseareincludedintherespective
sections.Also,asaresultoftheBoardsreviewoftheMPL,specificobservationsand
associatedrecommendationspertainingtoMPLaredescribedinsection7.Theplanfor
thePhaseIIreportisdescribedinsection8.ThePhaseIIreportwillfocusonthe
processesusedbytheMCOmission,developlessonslearned,andmake
recommendationsforfuturemissions.
TheMCOMissionobjectivewastoorbitMarsasthefirstinterplanetaryweathersatellite
andprovideacommunicationsrelayfortheMPLwhichisduetoreachMarsin
December1999.TheMCOwaslaunchedonDecember11,1998,andwaslostsometime
followingthespacecraft'sentryintoMarsoccultationduringtheMarsOrbitInsertion
(MOI)maneuver.Thespacecraft'scarriersignalwaslastseenatapproximately09:04:52
UTConThursday,September23,1999.
TheMCOMIBhasdeterminedthattherootcauseforthelossoftheMCOspacecraftwas
thefailuretousemetricunitsinthecodingofagroundsoftwarefile,SmallForces,
usedintrajectorymodels.Specifically,thrusterperformancedatainEnglishunitsinstead
ofmetricunitswasusedinthesoftwareapplicationcodetitledSM_FORCES(small
forces).AfilecalledAngularMomentumDesaturation(AMD)containedtheoutputdata
fromtheSM_FORCESsoftware.ThedataintheAMDfilewasrequiredtobeinmetric
unitsperexistingsoftwareinterfacedocumentation,andthetrajectorymodelersassumed
thedatawasprovidedinmetricunitspertherequirements.
Duringthe9monthjourneyfromEarthtoMars,propulsionmaneuverswereperiodically
performedtoremoveangularmomentumbuildupintheonboardreactionwheels
(flywheels).TheseAngularMomentumDesaturation(AMD)eventsoccurred1014
timesmoreoftenthanwasexpectedbytheoperationsnavigationteam.Thiswasbecause
theMCOsolararraywasasymmetricalrelativetothespacecraftbodyascomparedto
MarsGlobalSurveyor(MGS)whichhadsymmetricalsolararrays.Thisasymmetric
effectsignificantlyincreasedtheSuninduced(solarpressureinduced)momentum
builduponthespacecraft.TheincreasedAMDeventscoupledwiththefactthatthe
angularmomentum(impulse)datawasinEnglish,ratherthanmetric,units,resultedin
6
smallerrorsbeingintroducedinthetrajectoryestimateoverthecourseofthe9month
journey.AtthetimeofMarsinsertion,thespacecrafttrajectorywasapproximately170
kilometerslowerthanplanned.Asaresult,MCOeitherwasdestroyedintheatmosphere
orreenteredheliocentricspaceafterleavingMarsatmosphere.
TheBoardrecognizesthatmistakesoccuronspacecraftprojects.However,sufficient
processesareusuallyinplaceonprojectstocatchthesemistakesbeforetheybecome
criticaltomissionsuccess.UnfortunatelyforMCO,therootcausewasnotcaughtbythe
processesinplaceintheMCOproject.
Asummaryofthefindings,contributingcausesandMPLrecommendationsarelisted
below.ThesearedescribedinmoredetailinthebodyofthisreportalongwiththeMCO
andMPLobservationsandrecommendations.
RootCause: Failuretousemetricunitsinthecodingofagroundsoftwarefile,
SmallForces,usedintrajectorymodels
ContributingCauses:1.Undetectedmismodelingofspacecraftvelocitychanges
2. NavigationTeamunfamiliarwithspacecraft
3. Trajectorycorrectionmaneuvernumber5notperformed
4. Systemengineeringprocessdidnotadequately
addresstransitionfromdevelopmenttooperations
5. Inadequatecommunicationsbetweenprojectelements
6. InadequateoperationsNavigationTeamstaffing
7. Inadequatetraining
8. Verificationandvalidationprocessdidnotadequatelyaddress
groundsoftware
MPLRecommendations:
VerifytheconsistentuseofunitsthroughouttheMPLspacecraft
designandoperations
Conductsoftwareauditforspecificationcomplianceonalldata
transferredbetweenJPLandLockheedMartinAstronautics
VerifySmallForcesmodelsusedforMPL
CompareprimeMPLnavigationprojectionswithprojections
byalternatenavigationmethods
TrainNavigationTeaminspacecraftdesignandoperations
Prepareforpossibilityofexecutingtrajectorycorrection
maneuvernumber5
EstablishMPLsystemsorganizationtoconcentrateon
trajectorycorrectionmaneuvernumber5andentry,descentand
landingoperations
Takestepstoimprovecommunications
MPLRecommendations(Continued):
AugmentOperationsTeamstaffwithexperiencedpeopleto
supportentry,descentandlanding
TrainentireMPLTeamandencourageuseofIncident,
Surprise,Anomalyprocess
Developandexecutesystemsverificationmatrixfor
allrequirements
Conductindependentreviewsonallmissioncriticalevents
ConstructafaulttreeanalysisforremainderofMPLmission
AssignoverallMissionManager
Performthermalanalysisofthrustersfeedlineheatersand
consideruseofpreconditioningpulses
Reexaminepropulsionsubsystemoperationsduring
entry,descent,andlanding
1. MarsClimateOrbiter(MCO)andMars
PolarLander(MPL)ProjectDescriptions
In1993,NASAstartedtheMarsSurveyorprogramwiththeobjectiveofconductingan
ongoingseriesofmissionstoexploreMars.TheJetPropulsionLaboratory(JPL)was
identifiedastheleadcenterforthisprogram.MarsGlobalSurveyor(MGS)was
identifiedasthefirstflightmission,withalaunchdateinlate1996.In1995,two
additionalmissionswereidentifiedforlaunchinlate1998/early1999.Themissionswere
theMarsClimateOrbiter(MCO)andtheMarsPolarLander(MPL).JPLcreatedthe
MarsSurveyorProject98(MSP98)officewiththeresponsibilitytodefinethe
missions,developbothspacecraftandallpayloadelements,andintegrate/test/launchboth
flightsystems.Inaddition,theProgramspecifiedthattheMarsSurveyorOperations
Project(MSOP)wouldberesponsibleforconductingflightoperationsforbothMCOand
MPLaswellastheMGS.
TheMSP98DevelopmentProjectusedaprimecontractvehicletosupportproject
implementation.LockheedMartinAstronautics(LMA)ofDenver,Coloradowasselected
astheprimecontractor.LMAscontracteddevelopmentresponsibilitiesweretodesign
anddevelopbothspacecraft,leadflightsystemintegrationandtest,andsupportlaunch
operations.JPLretainedresponsibilitiesforoverallprojectmanagement,spacecraftand
instrumentdevelopmentmanagement,projectsystemengineering,missiondesign,
navigationdesign,missionoperationsystemdevelopment,grounddatasystem
development,andmissionassurance.TheMSP98projectassignedtheresponsibilityfor
missionoperationssystems/grounddatasystems(MOS/GDS)developmenttotheMSOP,
LMAprovidedsupporttoMSOPforMOS/GDSdevelopmenttasksrelatedtospacecraft
testandoperations.
TheMCOwaslaunchedDecember11,1998,andtheMPLwaslaunchedJanuary3,
1999.BothwerelaunchedatopidenticalDeltaIIlaunchvehiclesfromLaunchComplex
17AandBatCapeCanaveralAirStation,Florida,carryinginstrumentstomapthe
planetssurface,profilethestructureoftheatmosphere,detectsurfaceicereservoirsand
digfortracesofwaterbeneathMarsrustysurface.
Thelanderalsocarriesapairofbasketballsizedmicroprobes.Thesemicroprobeswillbe
releasedasthelanderapproachesMarsandwilldivetowardtheplanetssurface,
penetratinguptoabout1meterundergroundtotest10newtechnologies,includinga
scienceinstrumenttosearchfortracesofwaterice.Themicroprobeproject,calledDeep
Space2,ispartofNASAsNewMillenniumProgram.
ThesemissionswerethesecondinstallmentinNASAslongtermprogramofrobotic
explorationofMars,whichwasinitiatedwiththe1996launchesofthecurrently
orbitingMarsGlobalSurveyorandtheMarsPathfinderlanderandrover.
TheMSOPassumedresponsibilityforbothMCOandMPLatlaunch.MSOPis
implementedinapartneringmodeinwhichdistinctoperationsfunctionsareperformed
byageographicallydistributedsetofpartners.LMAperformsallspacecraftoperations
functionsincludinghealthandstatusmonitoringandspacecraftsequencedevelopment.
Inaddition,LMAperformsrealtimecommandandmonitoringoperationsfromtheir
facilityinDenver,Colorado.JPLisresponsibleforoverallprojectandmission
management,systemengineering,qualityassurance,GDSmaintenance,navigation,
missionplanning,andsequenceintegration.Eachofthescienceteamsisresponsiblefor
planningandsequencingtheirinstrumentobservations,processingandarchivingthe
resultingdata,andperformingofflinedataanalysis.Theseoperationsaretypically
performedatthePrincipalInvestigatorshomeinstitution.MSOPpersonnelarealso
currentlysupportingMGSoperations.
Nineandahalfmonthsafterlaunch,inSeptember1999,MCOwastofireitsmainengine
toachieveanellipticalorbitaroundMars.Seefigure1.Thespacecraftwastothenskim
throughMarsupperatmosphereforseveralweeksinatechniquecalledaerobrakingto
reducevelocityandmoveintoacircularorbit.Frictionagainstthespacecraftssingle,5.5
metersolararraywastohaveslowedthespacecraftasitdippedintotheatmosphereeach
orbit,reducingitsorbitperiodfrommorethan14hoursto2hours.OnSeptember23,
1999theMCOmissionwaslostwhenitenteredtheMartianatmosphereonalowerthan
expectedtrajectory.
MPLisscheduledtolandonMarsonDecember3,1999,2to3weeksaftertheorbiter
wastohavefinishedaerobraking.Thelanderisaimedtowardatargetsectorwithinthe
edgeofthelayeredterrainnearMarssouthpole.
LikeMarsPathfinder,MPLwilldivedirectlyintotheMartianatmosphere,usingan
aeroshellandparachutescaleddownfromPathfindersdesigntoslowitsinitial
descent.Seefigures2and3.ThesmallerMPLwillnotuseairbags,butinsteadwill
relyononboardguidance,radar,andretrorocketstolandsoftlyonthelayeredterrain
nearthesouthpolarcapafewweeksaftertheseasonalcarbondioxidefrostshave
disappeared.Aftertheheatshieldisjettisoned,acamerawilltakeaseriesofpicturesof
thelandingsiteasthespacecraftdescends.
AsitapproachesMars,about10minutesbeforetouchdown,thelanderwillreleasethe
twoDeepSpace2microprobes.Oncereleased,theprojectileswillcollectatmospheric
databeforetheycrashatabout200meterspersecondandburythemselvesbeneaththe
Martiansurface.Themicroprobeswilltesttheabilityofverysmallspacecrafttodeploy
futureinstrumentsforsoilsampling,meteorologyandseismicmonitoring.Akey
instrumentwilldrawatinysoilsampleintoachamber,heatitanduseaminiaturelaserto
lookforsignsofvaporizedwaterice.
Alsoonboardthelanderisalightdetectionandranging(LIDAR)experimentprovided
byRussiasSpaceResearchInstitute.Theinstrumentwilldetectanddeterminethe
altitudeofatmosphericdusthazesandicecloudsabovethelander.Insidethe
instrumentisasmallmicrophone,furnishedbythePlanetarySociety,Pasadena,
California,whichwillrecordthesoundsofwindgusts,blowingdustandmechanical
operationsonboardthespacecraftitself.
10
Thelanderisexpectedtooperateonthesurfacefor60to90Martiandaysthroughthe
planetssouthernsummer(aMartiandayis24hours,37minutes).MPLwillusethe
MGSasadatarelaytoEarthinplaceoftheMCO.Themissionwillcontinueuntilthe
spacecraftcannolongerprotectitselffromthecoldanddarkoflengtheningnightsand
thereturnoftheMartianseasonalpolarfrosts.
Launch
Delta 7425
Launch 12/11/98
Arrival 9/23/99
MOI is the only use of the main
[biprop] engine. The 16- minute burn
depletes oxidizer and captures
vehicle into 1314 hour orbit.
Figure1
11
11 Month Cruise
Near-simultaneous
tracking w/ Mars Climate
Orbiter or MGS
during approach
Launch
Delta 7425
Launch 1/3/99
576 kg Launch Mass
Landed Operations
76 S Latitude, 195 W Longitude
Ls 256 (Southern Spring)
6090 Day Landed Mission
MVACS, LIDAR Science
Data relay via Mars Climate
Orbiter or MGS
Commanding via Mars Climate
Orbiter or direct-to-Earth high
gain antenna
Figure2
Entry/Descent/Landing Phase
GUIDANCE
SYSTEM
INITIALIZATION
(L 15 min)
125 km
6900 m/s
PARACHUTE DEPLOYMENT (L 2 min)
8800 m
490 m/s
4600 km
HEATSHIELD JETTISON (L 110 s)
7500 m
250 m/s
5700 m/s
RADAR GROUND
ACQUISITION (ALTITUDE)
(L 50 s)
2500 m
85 m/s
Figure3
TOUCHDOWN
2.5 m/s
SOLAR PANEL /
INSTRUMENT
DEPLOYMENTS
(L + 20 min)
12
2.MarsClimateOrbiter(MCO)Mishap
TheMCOhadbeenonatrajectorytowardMarssinceitslaunchonDecember11,1998.
Allspacecraftsystemshadbeenperformingnominallyuntilanabruptlossofmission
shortlyafterthestartoftheMarsOrbitInsertionburnonSeptember23,1999.
Throughoutspringandsummerof1999,concernsexistedattheworkinglevelregarding
discrepanciesobservedbetweennavigationsolutions.Residualsbetweentheexpected
andobservedDopplersignatureofthemorefrequentAMDeventswasnotedbutonly
informallyreported.AsMCOapproachedMars,threeorbitdeterminationschemeswere
employed.Dopplerandrangesolutionswerecomparedtothosecomputedusingonly
Dopplerorrangedata.TheDoppleronlysolutionsconsistentlyindicatedaflightpath
insertionclosertotheplanet.Thesediscrepancieswerenotresolved.
OnSeptember8,1999,thefinalplannedinterplanetaryTrajectoryCorrectionManeuver
4(TCM4)wascomputed.Thismaneuverwasexpectedtoadjustthetrajectorysuchthat
soonaftertheMarsorbitalinsertion(MOI)burn,thefirstperiapsealtitude(pointof
closestapproachtotheplanet)wouldbeatadistanceof226km.Seefigure4.Thiswould
havealsoresultedinthesecondperiapsealtitudebecoming210km,whichwasdesired
forthesubsequentMCOaerobrakingphase.TCM4wasexecutedasplannedon
September15,1999.
MarsorbitinsertionwasplannedonSeptember23,1999.Duringtheweeklong
timeframebetweenTCM4andMOI,orbitdeterminationprocessingbytheoperations
navigationteamindicatedthatthefirstperiapsedistancehaddecreasedtotherangeof
150170km
Duringthe24hoursprecedingMOI,MCObegantofeelthestrongeffectsofMars
gravitationalfieldandtrackingdatawascollectedtomeasurethisandincorporateitinto
theorbitdeterminationprocess.ApproximatelyonehourpriortoMOI,processingofthis
moreaccuratetrackingdatawascompleted.Basedonthisdata,thefirstperiapsealtitude
wascalculatedtobeaslowas110km.Theminimumperiapsealtitudeconsidered
survivablebyMCOis80km.
TheMOIenginestartoccurredat09:00:46(UTC)onSeptember23,1999.Allsystems
performednominallyuntilMarssoccultationlossofsignalat09:04:52(UTC),which
occurred49secondsearlierthanpredicted.Signalwasnotreacquiredfollowingthe21
minutepredictedoccultationinterval.Exhaustiveattemptstoreacquiresignalcontinued
throughSeptember25,1999,butwereunsuccessful.
OnSeptember27,1999,theoperationsnavigationteamconsultedwiththespacecraft
engineerstodiscussnavigationdiscrepanciesregardingvelocitychange(V)modeling
issues.OnSeptember29,1999,itwasdiscoveredthatthesmallforcesVsreportedby
thespacecraftengineersforuseinorbitdeterminationsolutionswaslowbyafactorof
4.45(1poundforce=4.45Newtons)becausetheimpulsebitdatacontainedintheAMD
filewasdeliveredinlbsecinsteadofthespecifiedandexpectedunitsofNewtonsec.
13
Finally,afterthefactnavigationestimates,usingallavailabledatathroughlossofsignal,
withcorrectedvaluesforthesmallforcesVs,indicatedaninitialperiapsis(lowest
pointoforbit)of57kmwhichwasjudgedtoolowforspacecraftsurvival.
Actual trajectory
and AMD Vs
ToEarth
Figure4
14
3.MethodofInvestigation
OnOctober15,1999,theAssociateAdministratorforSpaceScienceestablishedthe
NASAMCOMishapInvestigationBoard(MIB),withArtStephenson,Directorof
MarshallSpaceFlightCenter,Chairman.ThePhaseIMIBactivity,reportedherein,
addressesparagraph4.A,oftheletterestablishingtheMCOMIB(Appendix).
Specifically,paragraph4.A.requeststhattheMIBfocusonanyaspectsoftheMCO
mishapwhichmustbeaddressedinordertocontributetotheMarsPolarLanders
safelandingonMars.
ThePhaseIMishapInvestigationBoardmeetingswereconductedattheJetPropulsion
Lab(JPL)onOctober1822.MembersoftheJPL/LockheedMartinAstronauticsteam
providedanoverviewoftheMCOspacecraft,operations,navigationplan,andthe
softwarevalidationprocess.Thediscussionwasallowedtotransitiontoanysubjectthe
Boarddeemedimportant,sothatmanyissueswerecoveredingreatdepthinthese
briefings.
BriefingswerealsoheldontheMPLsystems,withemphasisontheinterplanetary
trajectorycontrolandtheEntry,Descent,andLandingaspectsofthemission.TheBoard
alsosentamembertoparticipateinMPLscriticaleventreviewforEntry,Descent,and
Landing(EDL)heldatLMADenveronOctober21.Severalsubstantialfindingswere
broughtbackfromthisreviewandincorporatedintotheBoardsfindings.Afocused
splintermeetingwasheldwiththeBoardsnavigationexpertsandtheJPLnavigation
teamonMCOandMPLquestionsandconcerns.Splintermeetingswerealsoheldwith
theJPLandLMApropulsionteamsandwiththeJPLMSP98projectscientists.
PriortotheestablishmentoftheMCOMIB,twoinvestigativeboardshadbeen
establishedbyJPL.BoththeNavigationFailureAssessmentTeamandtheJPLMishap
InvestigationBoardpresentedtheirdraftfindingstotheMCOBoard.
Therootcause,contributingcausesandobservationsweredeterminedbytheBoard
throughaprocessthatalternatedbetweenindividualbrainstormingandgroup
discussion.Inaddition,theBoarddevelopedMPLobservationsandrecommendations
notdirectlyrelatedtotheMCOmishap.
Anumberofcontributingcauseswereidentifiedaswellasnumberofobservations.The
focusofthesecontributingcausesandobservationswereonthosethatcouldimpactthe
MPL.RecommendationsfortheMPLweredevelopedandarepresentedinthisPhaseI
report.RecommendationsregardingchangingtheNASAprogramprocessestopreventa
similarfailureinthefuturearethesubjectofthePhaseIIportionoftheBoardsactivity
asdescribedinSection8ofthisreport.
TheMPLobservationscontainedinthisreportrefertoconditionsasofOctober22,1999,
anddonotreflectactionstakensubsequenttothatdate.
15
4. MarsClimateOrbiter(MCO)RootCauseandMars
PolarLander(MPL)Recommendations
Duringthemishapinvestigationprocess,specificpolicyisinplacetoconductthe
investigationandtoprovidekeydefinitionstoguidetheinvestigation.NASAProcedures
andGuidelines(NPG)8621Draft1,"NASAProceduresandGuidelinesforMishap
Reporting,Investigating,andRecordkeeping"providesthesekeydefinitionsforNASA
mishapinvestigations.NPG8621(Draft1)definesarootcauseas:Alongachainof
eventsleadingtoamishap,thefirstcausalactionorfailuretoactthatcouldhavebeen
controlledsystematicallyeitherbypolicy/practice/procedureorindividualadherenceto
policy/practice/procedure.Basedonthisdefinition,theBoarddeterminedthattherewas
onerootcausefortheMCOmishap.
MCORootCause
TheMCOMIBhasdeterminedthattherootcauseforthelossoftheMCOspacecraftwas
thefailuretousemetricunitsinthecodingofagroundsoftwarefile,SmallForces,
usedintrajectorymodels.Specifically,thrusterperformancedatainEnglishunitsinstead
ofmetricunitswasusedinthesoftwareapplicationcodetitledSM_FORCES(small
forces).TheoutputfromtheSM_FORCESapplicationcodeasrequiredbyaMSOP
ProjectSoftwareInterfaceSpecification(SIS)wastobeinmetricunitsofNewton
seconds(Ns).Instead,thedatawasreportedinEnglishunitsofpoundseconds(lbfs).
TheAngularMomentumDesaturation(AMD)filecontainedtheoutputdatafromthe
SM_FORCESsoftware.TheSIS,whichwasnotfollowed,definesboththeformatand
unitsoftheAMDfilegeneratedbygroundbasedcomputers.Subsequentprocessingof
thedatafromAMDfilebythenavigationsoftwarealgorithmtherefore,underestimated
theeffectonthespacecrafttrajectorybyafactorof4.45,whichistherequired
conversionfactorfromforceinpoundstoNewtons.Anerroneoustrajectorywas
computedusingthisincorrectdata.
MPLRecommendations:
TheBoardrecommendsthattheMPLprojectverifytheconsistentuseofunits
throughouttheMPLspacecraftdesignandoperation.TheBoardrecommendsasoftware
auditforSIScomplianceonalldatatransferredbetweentheJPLoperationsnavigation
teamandthespacecraftoperationsteam.
16
5. MarsClimateOrbiter(MCO)ContributingCauses
andMarsPolarLander(MPL)Recommendations
Section6ofNPG8621(Draft1)provideskeydefinitionsforNASAmishap
investigations.NPG8621(Draft1)definesacontributingcauseas:Afactor,eventor
circumstancewhichleddirectlyorindirectlytothedominantrootcause,orwhich
contributedtotheseverityofthemishap.Basedonthisdefinition,theBoarddetermined
thattherewere8contributingcausesthatrelatetorecommendationsfortheMarsPolar
Lander.
MCOContributingCauseNo.1:ModelingofSpacecraft
VelocityChanges
Angularmomentummanagementisrequiredtokeepthespacecraftsreactionwheels(or
flywheels)withintheirlinear(unsaturated)range.Thisisaccomplishedthroughthruster
firingsusingaprocedurecalledAngularMomentumDesaturation(AMD).Whenan
AMDeventoccurs,relevantspacecraftdataistelemeteredtotheground,processedby
theSM_FORCESsoftware,andplacedintoafilecalledtheAngularMomentum
Desaturation(AMD)file.TheJPLoperationsnavigationteamuseddataderivedfrom
theAngularMomentumDesaturation(AMD)filetomodeltheforcesonthespacecraft
resultingfromthesespecificthrusterfirings.Modelingofthesesmallforcesiscritical
foraccuratelydeterminingthespacecraftstrajectory.Immediatelyafterthethruster
firing,thevelocitychange(V)iscomputedusinganimpulsebitandthrusterfiringtime
foreachofthethrusters.Theimpulsebitmodelsthethrusterperformanceprovidedby
thethrustermanufacturer.Thecalculationofthethrusterperformanceiscarriedoutboth
onboardthespacecraftandongroundsupportsystemcomputers.Mismodelingonly
occurredinthegroundsoftware.
TheSoftwareInterfaceSpecification(SIS),usedtodefinetheformatoftheAMDfile,
specifiestheunitsassociatedwiththeimpulsebittobeNewtonseconds(Ns).Newton
secondsaretheproperunitsforimpulse(ForcexTime)formetricunits.TheAMD
softwareinstalledonthespacecraftusedmetricunitsforthecomputationandwas
correct.Inthecaseofthegroundsoftware,theimpulsebitreportedtotheAMDfilewas
inEnglishunitsofpounds(force)seconds(lbfs)ratherthanthemetricunitsspecified.
SubsequentprocessingoftheimpulsebitvaluesfromtheAMDfilebythenavigation
softwareunderestimatedtheeffectofthethrusterfiringsonthespacecrafttrajectorybya
factorof4.45(1poundforce=4.45Newtons).
DuringthefirstfourmonthsoftheMCOcruiseflight,thegroundsoftwareAMDfiles
werenotusedintheorbitdeterminationprocessbecauseofmultiplefileformaterrors
andincorrectquaternion(spacecraftattitudedata)specifications.Instead,theoperations
navigationteamusedemailfromthecontractortonotifythemwhenanAMD
desaturationeventwasoccurring,andtheyattemptedtomodeltrajectoryperturbationson
17
theirown,basedonthistiminginformation.Fourmonthswereusedtofixthefile
problemsanditwasnotuntilApril1999thattheoperationsteamcouldbeginusingthe
correctlyformattedfiles.Almostimmediately(withinaweek)itbecameapparentthat
thefilescontainedanomalousdatathatwasindicatingunderestimationofthetrajectory
perturbationsduetodesaturationevents.Thesefileformatandcontenterrorsearlyinthe
cruisemissioncontributedtotheoperationsnavigationteamnotbeingabletoquickly
detectandinvestigatewhatwouldbecometherootcause.
InApril1999,itbecameapparentthattherewassometypeofmismodelingoftheAMD
maneuvers.Inattemptingtoresolvethisanomaly,twofactorsinfluencedthe
investigation.First,therewaslimitedobservabilityofthetotalmagnitudeofthethrust
becauseoftherelativegeometryofthethrustersusedforAMDactivitiesandtheEarth
tospacecraftlineofsight.Thenavigationteamcanonlydirectlyobservethethrust
effectsalongthelineofsightusingthemeasurementsofthespacecraftsDopplershift.
InthecaseofMarsClimateOrbiter(MCO),themajorcomponentofthrustduringan
AMDeventwasperpendiculartothelineofsight.Thelimitedobservabilityofthedirect
effectofthethrusteractivitymeantasystematicerrorduetotheincorrectmodelingof
thethrustereffectswaspresentbutundetectedinthetrajectoryestimation.Second,the
primarycomponentofthethrustwasalsoperpendiculartothespacecraftsflightpath.
Seefigure4.InthecaseofMCO,thisperturbationtothetrajectoryresultedintheactual
spacecrafttrajectoryattheclosestapproachtoMarsbeinglowerthanwhatwasestimated
bythenavigators.
MPLRecommendation:
TheBoardrecommendsthatthesmallforcesmodelsusedforMPLbevalidatedto
assurethepropertreatmentofthemodeledforces,includingthrusteractivityusedfor
attitudecontrolandsolarradiationpressure.Additionally,severalothernavigation
methodsshouldbecomparedtotheprimenavigationmethodtohelpuncoverany
mismodeledsmallforcesonMPL
MarsClimateOrbiter(MCO)ContributingCauseNo.2:
KnowledgeofSpacecraftCharacteristics
Theoperationsnavigationteamwasnotintimatelyfamiliarwiththeattitudeoperations
ofthespacecraft,especiallywithregardtotheMCOattitudecontrolsystemandrelated
subsystemparameters.Thisunfamiliaritycausedtheoperationsnavigationteamto
performincreasednavigationanalysistoquantifyanorbitdeterminationresidualerror.
Theerrorwasmaskedbythelackofinformationregardingtheactualvelocitychange
(V)impartedbytheangularmomentumdesaturation(AMD)events.Alineofsight
errorwasdetectableintheprocessingofthetrackingmeasurementdata,butits
significancewasnotfullyunderstood.Additionally,aseparatenavigationteamwasused
fortheMCOdevelopmentandtestphase.Theoperationsnavigationteamcameonboard
shortlybeforelaunchanddidnotparticipateinanyofthetestingofthegroundsoftware.
TheoperationsnavigationteamalsodidnotparticipateinthePreliminaryDesignreview
18
norinthecriticaldesignreviewprocess.Criticalinformationonthecontroland
desaturationoftheMCOmomentumwasnotpassedontotheoperationsnavigation
team.
MPLRecommendation:
TheBoardrecommendsthattheMPLoperationsnavigationteambeprovidedwith
additionaltrainingandspecificinformationregardingtheattitudesubsystemsandany
othersubsystemwhichmayhaveanimpactontheaccuracyofnavigationsolutions.To
facilitatethis,aseriesfacetofacemeetingsshouldbeconductedwiththespacecraft
development,andoperationsteamstodisseminateupdatedinformationandtodiscuss
anomaliesfromthispointforward.LongtermonsitesupportofanLMAarticulationand
attitudecontrolsystem(AACS)personshouldbeprovidedtotheoperationsnavigation
teamoraJPLresidentAACSexpertshouldbebroughtontheteamtohelpfacilitate
bettercommunication.
MCOContributingCauseNo.3:TrajectoryCorrection
Maneuver(TCM5)
DuringtheMCOapproach,acontingencymaneuverplanwasinplacetoexecutean
MCOTrajectoryCorrectionManeuver(TCM)5toraisethesecondperiapsispassageof
theMCOtoasafealtitude.Foralowinitialperiapsis,TCM5couldalsohavebeenused
shortlybeforetheMarsOrbitInsertion(MOI)asanemergencymaneuvertoattaina
saferaltitude.ArequesttoperformaTCM5wasdiscussedverballyshortlybeforethe
MOIonboardprocedurewasinitiated,butwasneverexecuted.
SeveralconcernspreventedtheoperationsteamfromimplementingTCM5.Analysis,
tests,andprocedurestocommittoaTCM5intheeventofasafetyissuewerenot
completed,norattempted.Therefore,theoperationsteamwasnotpreparedforsucha
maneuver.Also,TCM5wasnotexecutedbecausetheMOImaneuvertimelineonboard
thespacecrafttookpriority.Thisonboardproceduredidnotallowtimefortheupload,
execution,andnavigationverificationofsuchamaneuver.Additionally,anychangeto
thebaselinedorbitscenariocouldhaveexceededthetimefortheMCOaerobraking
phasewhenMCOwasneededtosupportthecommunicationsoftheMPLspacecraft.
ThecriticalitytoperformTCM5wasnotfullyunderstoodbythespacecraftoperations
oroperationsnavigationpersonnel.
TheMPLmissionsequencealsocontainsacontingencyTCM5forafinalcorrection
oftheincomingtrajectorytomeettheentrytargetconditionsfortheMPLEntry,
Descent,andLanding(EDL)phase.TheMPLTCM5iscurrentlylistedasa
contingencymaneuver.ThisTCM5alsohasnotbeenexplicitlydeterminedasa
requiredmaneuverandthereisstillconfusionoverthenecessityandtheschedulingofit.
19
MPLRecommendation:
Theboardrecommendsthattheoperationsteamadequatelyprepareforthepossibilityof
executingTCM5.Maneuverplanningandschedulingshouldbebaselinedaswellas
specificcriteriafordecidingwhetherornotthemaneuvershouldbeexecuted.Thefull
operationsteamshouldbebriefedontheTCM5maneuverexecutionscenarioand
shouldbefullytrainedandpreparedforitsexecution.Ifpossible,anintegrated
simulationofthemaneuvercomputations,validation,anduplinkshouldbeperformedto
verifyteamreadinessandsufficienttimescheduling.Additionally,aTCM5leadshould
beappointedtodeveloptheprocessfortheexecutionandtestingofthemaneuverandto
addressthemultipledecisionprocessofperformingTCM5withrespecttotheEDL.
MCOContributingCauseNo.4:SystemsEngineeringProcess
OneoftheproblemsobservedbytheBoardonMCOwasthatthesystemsengineering
processdidnotadequatelytransitionfromdevelopmenttooperations.Therewerea
numberofopportunitiesforthesystemsengineeringorganizationtoidentifytheunits
problemleadingtomissionlossofMCO..Thelackofanadequatesystemsengineering
functioncontributedtothelackofunderstandingonthepartofthenavigationteamof
essentialspacecraftdesigncharacteristicsandthespacecraftteamunderstandingofthe
navigationchallenge.Italsoresultedininadequatecontingencypreparationprocessto
addressunpredictedperformanceduringoperations,alackofunderstandingofseveral
criticaloperationstradeoffs,anditexacerbatedthecommunicationsdifficultiesbetween
thesubsystemengineers(e.gnavigation,AACS,propulsion).
Forexample,theAngularMomentumDesaturation(AMD)eventsonMCOoccurred10
14timesmoreoftenthanwasexpectedbytheoperationsnavigationteam.Thiswas
becausetheMCOsolararraywasasymmetricalrelativetothespacecraftbodyas
comparedtoMarsGlobalSurveyorwhichhadsymmetricalsolararrays.Thisasymmetric
effectsignificantlyincreasedtheSuninduced(solarpressureinduced)momentum
builduponthespacecraft.Tominimizethiseffect,adaily180oflipwasbaselinedto
canceltheangularmomentumbuildup.Systemsengineeringtradestudiesperformed
laterdeterminedthatthissocalledbarbecuemodewasnotneededanditwasdeleted
fromthespacecraftoperationsplan.Unfortunately,thesesystemsengineeringdecisions
andtheirimpacttothespacecraftandthespacecrafttrajectorywerenotcommunicatedto
theoperationsnavigationteam.TheincreasedAMDeventsresultingfromthisdecision
coupledwiththefactthattheangularmomentum(impulse)datawasinEnglish,rather
thanmetric,unitscontributedtotheMCOmissionfailure.
MPLRecommendation:
TheBoardrecommendsthattheMPLprojectestablishandfullystaffasystems
engineeringorganizationwithrolesandresponsibilitiesdefined.Thisteamshould
concentrateontheTCM5andEDLactivities.TheyshouldsupportupdatingMPLrisk
assessmentsforbothEDLandMarsgroundoperations,andreviewthesystems
20
engineeringontheentireMPLmissiontoensurethattheMPLmissionisreadyfor
theEDLsequence.
MCOContributingCauseNo.5:CommunicationsAmong
ProjectElements
IntheMCOproject,andagainintheMPLproject,thereisevidenceofinadequate
communicationsbetweentheprojectelements,includingthedevelopmentand
operationsteams,theoperationsnavigationandoperationsteams,theproject
managementandtechnicalteams,andtheprojectandtechnicallinemanagement.
Itwasclearthattheoperationsnavigationteamdidnotcommunicatetheirtrajectory
concernseffectivelytothespacecraftoperationsteamorprojectmanagement.In
addition,thespacecraftoperationsteamdidnotunderstandtheconcernsofthe
operationsnavigationteam.TheBoardfoundtheoperationsnavigationteamsupporting
MCOtobesomewhatisolatedfromtheMCOdevelopmentandoperationsteams,aswell
asfromitsownlineorganization,byinadequatecommunication.Onecontributingfactor
tothislackofcommunicationmayhavebeentheoperationsnavigationteams
assumptionthatMCOhadMarsGlobalSurveyor(MGS)heritageandtheresulting
expectationthatmuchoftheMCOhardwareandsoftwarewassimilartothatonMGS.
Thisapparentlycausedtheoperationsnavigationteamtoacquireinsufficienttechnical
knowledgeofthespacecraft,itsoperation,anditspotentialimpacttonavigation
computations.Forexample,theoperationsnavigationteamdidnotknowuntillongafter
launchthatthespacecraftroutinelycalculated,andtransmittedtoEarth,velocitychange
datafortheangularmomentumdesaturationevents.Anearlycomparisonofthese
spacecraftgenerateddatawiththetrackingdatamighthaveuncoveredtheunitsproblem
thatultimatelyledtothelossofthespacecraft.Whenconflictsinthedatawere
uncovered,theteamreliedonemailtosolveproblems,insteadofformalproblem
resolutionprocessessuchastheIncident,Surprise,Anomaly(ISA)reportingprocedure.
Failingtoadequatelyemploytheproblemtrackingsystemcontributedtothisproblem
slippingthroughthecracks.
AsplintermeetingbetweensomemembersoftheBoardandtheoperationsnavigation
teamillustratedthefactthattherewasinadequatecommunicationbetweentheoperations
navigationteamandmissionoperationsteams.WhiletheBoardwasnotifiedofpotential
changesintheMPLlandingsite,itwasdiscoveredthatthisknowledgewasnotfully
conveyedtotheentireMPLoperationsnavigationteam.Inadequatesystemsengineering
supportexacerbatedtheisolationofthenavigationteam.Arobustsystemsengineering
teamcouldhavehelpedimprovecommunicationbetweentheoperationsnavigationteam
andother,navigationcriticalsubsystems(e.g.propulsion,AACS).Systemsengineering
supportwouldhaveenhancedtheoperationsnavigationteamsabilitiestoreachcritical
decisionsandwouldhaveprovidedoversightinnavigationmissionassurance.
21
Theoperationsnavigationteamcouldhavebenefitedfromindependentpeerreviewsto
validatetheirnavigationanalysistechniqueandtoprovideindependentoversightof
thetrajectoryanalyses.
DefensivemechanismshavealsodevelopedbetweentheteammembersonMPLasa
resultoftheMCOfailure.Thisiscausinginadequatecommunicationacrossproject
elementsandafailuretoelevateconcernswithfullendtoendproblemownership.
MPLRecommendations:
TheboardrecommendsthattheMPLprojectshouldstresstotheprojectstaffthat
communicationiscriticalandempowerteammemberstoforcefullyelevateanyissue,
keepingtheoriginatorintheloopthroughformalclosure.Projectmanagementshould
establishapolicyandcommunicateittoallteammembersthattheyareempoweredto
forcefullyandvigorouslyelevateconcernsashigh,eitherverticallyorhorizontallyinthe
organization,asnecessarytogetattention.Thispolicyshouldbeconstantlyreinforcedas
ameansformissionsuccess.
TheMPLprojectshouldincreasetheamountofformalandinformalfacetoface
communicationswithallteamelementsincludingscience,navigation,propulsion,etc.
andespeciallyforthoseelementsthathavecriticalinterfaceslikenavigationand
spacecraftguidanceandcontrol.(e.g.colocationofanavigationteammemberwiththe
spacecraftguidanceandcontrolgroup).
Theprojectshouldestablisharoutineforumforinformalcommunicationbetweenall
teammembersatthesametimesoeveryonecanhearwhatishappening.(e.g.a15
minutestanduptagupmeetingeverymorning).
TheprojectandJPLmanagementshouldencouragetheMPLteamtobeskepticsand
raiseallconcerns.AllmembersoftheMPLteamshouldtakeconcernspersonallyand
seethattheyreceiveclosurenomatterwhatittakes.
Theoperationsnavigationteamshouldimplementandconductaseriesofindependent
peerreviewsinsufficienttimetosupportMPLmissioncriticalnavigationevents.
TheBoardalsorecommendsthattheMPLprojectassignamissionsystemsengineeras
soonaspossible.Thismissionsystemsengineerwouldprovidethesystemsengineering
bridgebetweenthespacecraftsystem,theinstrumentsystemandtheground/operations
systemtomaximizetheprobabilityofmissionsuccess.
MCOContributingCauseNo.6:OperationsNavigationTeam
Staffing
TheBoardfoundthatthestaffingoftheoperationsnavigationteamwaslessthan
adequate.DuringthetimeleadinguptothelossoftheMCO,theMarsSurveyor
22
OperationsProject(MSOP)wasrunning3missionssimultaneously(MGS,MCO,MPL).
Thistendedtodilutethefocusonanyonemission,suchasMCO.Duringthetimebefore
Marsorbitinsertion(MOI),MCOnavigationwashandledbythenavigationteamlead
andtheMCOnavigator.DuetothelossofMCO,MPListohavethreenavigators,but
onlytwowereonboardatthetimeoftheBoardsmeetingsduringtheweekofOct.18
22,1999.TheBoardwastoldthat24hour/daynavigationstaffingisplannedforabrief
periodbeforeMPLentry,descent,andlanding(EDL).Suchcoveragemaybedifficult
evenforateamofthreenavigatorsandcertainlywasnotpossibleforthesinglenavigator
ofMCO.
MPLRecommendation:
TheBoardrecommendsthattheoperationsnavigationstaffbeaugmentedwith
experiencedpeopletosupporttheMPLEDLsequence.TheMPLprojectshouldassign
andtrainathirdnavigatortotheoperationsteamtosupporttheEDLactivitiesassoon
aspossible.Inaddition,theoperationsnavigationteamshouldidentifybackuppersonnel
thatcouldbemadeavailabletoserveinsomeofthecriticalrolesintheeventthatoneof
thekeynavigatorsbecomesillpriortotheEDLactivity.
TheBoardalsorecommendsthattheMPLprojectpreparecontingencyplansfor
backingupkeypersonnelformissioncriticalfunctionsinanyareaoftheProject.
MCOContributingCauseNo.7: TrainingofPersonnel
TheBoardfoundseveralinstancesofinadequatetrainingintheMCOproject.The
operationsnavigationteamhadnotreceivedadequatetrainingontheMCOspacecraft
designanditsoperations.SomemembersoftheMCOteamdidnotrecognizethe
purposeandtheuseoftheISA.Thesmallforcessoftwaredevelopmentteamneeded
additionaltraininginthegroundsoftwaredevelopmentprocessandintheuseand
importanceoffollowingtheMissionOperationsSoftwareInterfaceSpecification(SIS).
TherewasinadequatetrainingoftheMCOteamontheimportanceofanacceptable
approachtoendtoendtestingofthesmallforcesgroundsoftware.Therewasalso
inadequatetrainingontherecognitionandtreatmentofmissioncriticalsmallforces
groundsoftware.
MPLRecommendation:
TheBoardrecommendsthattheMPLoperationsnavigationteamreceiveproper
traininginthespacecraftdesignandoperations.IdentifytheMPLmissioncritical
groundsoftwareandensurethatallsuchgroundsoftwaremeetstheMPLsoftware
developmentplans.EnsurethattheentireMPLteamistrainedontheISAProcessand
itspurposeemphasizea"MissionSafetyFirst"attitude.Encourageanyissuetobe
writtenupasanISA.ReviewallcurrentanomaliesandgenerateappropriateISAs.
23
MCOContributingCauseNo.8:VerificationandValidation
Process
SeveralverificationandvalidationprocessissueswereuncoveredduringtheBoards
reviewoftheMCOprogramthatshouldbenoted.TheSoftwareInterfaceSpecification
(SIS)wasdevelopedbutnotproperlyusedinthesmallforcesgroundsoftware
developmentandtesting.Endtoendtestingtovalidatethesmallforcesgroundsoftware
performanceanditsapplicabilitytothespecificationdidnotappeartobeaccomplished.
Itwasnotclearthatthegroundsoftwareindependentverificationandvalidationwas
accomplishedforMCO.Theinterfacecontrolprocessandtheverificationofspecific
groundsysteminterfaceswasnotcompletedorwascompletedwithinsufficientrigor.
MPLRecommendation:
TheBoardrecommendsthattheMPLprojectdevelopasystemverificationmatrixforall
projectrequirementsincludingallInterfaceControlDocuments(ICDs).TheMPLteam
shouldreviewthesystemverificationmatrixatallremainingmajorreviews.TheMPL
projectshouldrequireendusersatthetechnicalleveltosignoffonthegroundsoftware
applicationsandproductsandtheMPLprojectshouldreviewallgroundsoftware
applications,includingallnewandreusedsoftwarepackagesforapplicabilityandcorrect
datatransfer.
24
6. MarsClimateOrbiter(MCO)Observationsand
Recommendations
Section6ofNPG8621(Draft1)provideskeydefinitionsforNASAmishap
investigations.NPG8621(Draft1)definesasignificantobservationas:Afactor,event
orcircumstanceidentifiedduringtheinvestigationwhichwasnotcontributingtothe
mishap,butifleftuncorrected,hasthepotentialtocauseamishap...orincreasethe
severityshouldamishapoccur.Basedonthisdefinition,theBoarddeterminedthat
therewere10observationsthatrelatetorecommendationsfortheMLP.
MCOObservationNo.1:TrajectoryMarginforMarsOrbit
Insertion
AstheMCOproceededthroughcruisephaseforthesubsequentMOIandaerobraking
phases,themarginsneededtoensureasuccessfulorbitcaptureerodedovertime.During
thecruisephaseandimmediatelyprecedingMOI,inadequatestatisticalanalyseswere
employedtofullyunderstandthedispersionsofthetrajectoryandhowthesewould
impactthefinalMOIsequence.Thisresultedinamisunderstandingoftheactualvehicle
trajectory.Asdescribedpreviously,theactualtrajectorypathresultedinaperiapsismuch
lowerthanexpected.Inaddition,TCM5contingencyplans,intheeventofananomaly,
werenotadequatelyworkedoutaheadoftime.Theabsenceofplanning,tests,and
commitmentcriteriafortheexecutionofTCM5mayhaveplayedasignificantrolein
thedecisiontonotchangetheMCOtrajectoryusingtheTCM5maneuver.Thefailureto
executeTCM5isdiscussedasacontributingcauseofthemishap.Spacecraftpropellant
reservesandschedulemarginsduringtheaerobrakingphaseswerenotusedtomitigate
theriskofuncertaintiesintheclosestapproachdistanceatMOI.
MPLRecommendations:
TheBoardrecommendsthattheMPLprojectimprovethedataanalysisproceduresfor
fittingtrajectorydatatomodels,thattheyimplementanindependentnavigationpeer
panelandnavigationadvisorygroupasameanstofurthervalidatethemodelstothe
trajectorydata,andthattheyengagetheentireMPLteaminTCMandEntry,Descent,
andLanding(EDL)planning.
MCOObservationNo.2:IndependentReviews
TheBoardnotedthatanumberofreviewstookplacewithouttheproperrepresentationof
keypersonnel;operationsnavigationpersonneldidnotattendthespacecraftPreliminaryand
CriticalDesignReviews.Attendanceoftheseindividualsmayhaveallowedtheflowof
pertinentandapplicablespacecraftcharacteristicstotheoperationsnavigationteam.
25
Knowledgeofthesecharacteristicsbytheoperationsnavigationmayhavehelped
themresolvetheproblem.
Keymodelingissuesweremissedintheinterpretationoftrajectorydatabytheoperations
navigationteam.Theabsenceofarigorous,independentnavigationpeerreviewprocess
contributedtotheseissuesbeingmissed.
MPLRecommendations:
Provideforoperationsnavigationdisciplinepresenceatmajorreviews.Ensuresubsystem
specialistsattendmajorreviewsandparticipateintransferoflessonslearnedtothe
operationsnavigationteamandothers.Implementaformalpeerreviewprocessonall
missioncriticalevents,especiallycriticalnavigationevents.
MCOObservationNo.3:ContingencyPlanningProcess
InadequatecontingencyplanningforTCM5wasobservedtoplayapartintheMCO
failure.TheMCOoperationalcontingencyplansforTCM5werenotwelldefinedand
orcompletelyunderstoodbyallteammembersontheMCOoperationalteam.
TheMCOprojectdidnothaveadefinedsetofGoNoGocriteriaforusingTCM5.
Therewasnoprocessinplacetoreviewtheevaluationanddecisioncriteriabythe
projectandsubsystemengineersbeforecommitmenttoTCM5.Pollingoftheteamby
theMCOFlightOperationsManagershouldestablishaclearcommitmentfromeach
subsystemleadthatheorshehasreviewedtheappropriatedataandbelievesthatthe
spacecraftisintheproperconfigurationfortheevent.
MPLRecommendations:
Contingencyplansneedtobedefined,theproductsassociatedwiththecontingencies
fullydeveloped,thecontingencyproductstestedandtheoperationalteamtrainedonthe
useofthecontingencyplansandontheuseoftheproducts.Sinceallpossible
contingencyplanscannotbedeveloped,asystematicassessmentofallpotentialfailure
modesmustbedoneasabasisforthedevelopmentoftheprojectcontingencyplans.The
MPLteamshouldestablishafirmsetofGonogocriteriaforeachcontingency
scenarioandtheindividualmembersoftheoperationsteamandsubsystemexperts
shouldbepolledpriortocommittingtotheevent.
MCOObservationNo.4:TransitionfromDevelopmentto
Operations
TheBoardfoundthattheoverallprojectplandidnotprovideforacarefulhandoverfrom
thedevelopmentprojecttotheverybusyoperationsproject.MCOwasthefirstJPL
26
missiontotransitionaminimalnumberofthedevelopmentteamintoamultimission
operationsteam.VeryfewJPLpersonnelandnoMCOnavigationpersonnel,
transitionedwiththeproject.Furthermore,MCOwasthefirstmissiontobesupportedby
themultimissionMSOPteam.
DuringthemonthsleadinguptoMCOMOI,theMSOPteamhadsomekeypersonnel
vacanciesandachangeintopmanagement.Theoperationsnavigationpersonnelin
MSOPwereworkingMGSoperations,whichhadexperiencedsomeinflightanomalies.
TheywereexpectingMCOtocloselyresembleMGS.Theyhadnotbeeninvolvedinthe
initialdevelopmentofthenavigationplananddidnotshowownershipoftheplan,which
hadbeenhandedofftothembytheMCOdevelopmentteam.TheMSOPhadnosystems
engineeringandnomissionassurancepersonnelwhomighthaveactedasanadditional
setofeyesintheimplementationoftheprocess.
ItshouldbenotedthattheMPLnavigationdevelopmentengineerdidtransitionto
operations.
MPLRecommendations:
IncreasetheMPLoperationsandoperationsnavigationteamsasappropriate.Augment
theteamsbyrecallingkeymembersofthedevelopmentteamandspecialistsfromthe
lineorganization.ConsidermorecollocationofJPL/LMApersonnelthroughEDL.
ConductarigorousreviewofthehandofffromtheJPLoperationsnavigationteamto
theLMAEDLteam,particularlytheICDandallcriticalevents.
MCOObservationNo.5:MatrixManagement
TheBoardobservedthatlineorganizations,especiallythatoftheoperationsnavigation
team,werenotsignificantlyengagedinprojectrelatedactivity.Inthecaseofnavigation,
theBoardobservedlittleevidenceofcontactbetweenlinesupervisionandnavigators
supportingtheproject.
MPLRecommendation:
Expeditiouslyinvolvelinemanagementinindependentlyreviewingand
followingthroughtheworkremainingtoachieveasuccessfulMPLlanding.
MCOObservationNo.6:MissionAssurance
TheBoardobservedtheabsenceofamissionassurancemanagerinMSOP.Itwasfeltthat
suchapresenceearlierintheprogrammighthavehelpedtoimproveproject
communication,insurethatprojectrequirementsweremet.Itemsthatthemission
assurancemanagercouldhaveaddressedforMCOincludedensuringthattheAMDfile
mettherequirementsoftheSISandtrackingISAresolutions.Themissionassurance
27
managerwouldpromotethehealthyquestioningofwhatcouldgowrong.TheBoard
explicitlyheardanintentiontofillthemissionassurancepositionforMPL,butthis
hadnothappenedasofOctober22,1999.
MPLRecommendation:
AssignamissionassurancemanagerinMSOPassoonaspossible.
MCOObservationNo.7:ScienceInvolvement
TheparadigmfortheMarsSurveyorprogramisacapabilitiesdrivenmissioninwhichall
elements,includingscience,weretradedtoachieveprojectobjectiveswithintheoverall
constraintsofcostandschedule.Successofsuchmissionsrequiresfullinvolvementof
themissionsciencepersonnelinthemanagementprocess.Inaddition,sciencepersonnel
withrelevantexpertiseshouldbeincludedinalldecisionswhereexpertknowledgeof
Marsisrequired.WhilethiswasgenerallythecasefortheMars98program,such
expertswerenotfullyinvolvedinthedecisionsnottoperformTCM5priortoMarsorbit
insertion.
MPLRecommendation:
FullyinvolvetheProjectScientistinthemanagementprocessfortheremainderofthe
MPLmission,includingdecisionsrelatingtoEntry,Descent,andLanding.
MCOObservationNo.8:NavigationCapabilities
JPLsnavigationofinterplanetaryspacecrafthasworkedwellfor30years.Inthecaseof
MCOtherewasawidespreadperceptionthatOrbitingMarsisroutine.Thisperception
resultedininadequateattentiontonavigationriskmitigation.
MPLRecommendation:
MPLprojectpersonnelshouldquestionandchallengeeverythingeventhosethings
thathavealwaysworked.JPLtopmanagementshouldprovidethenecessaryemphasis
tobringaboutaculturalchange.
MCOObservationNo.9:ManagementofCriticalFlight
Decisions
Duringitsdeliberations,theBoardobservedsignificantuncertaintyanddiscussionsabout
suchthingsastheprojectsplanfortrajectorycorrectionmaneuvers(TCMs)andthe
plannedprimaryandalternatelandingsitesforMPL.PlanningforTCM5onMCOwas
inadequate.TCM5forMPLwasstillbeingdescribedasacontingencymaneuverduring
28
theBoardsdeliberations.TheBoardalsonotesevidenceofdelayeddecisionsatthe
October21,1999,MPLCriticalEventsReviewforEntry,Descent,andLanding.
MPLRecommendation:
Requiretimely,disciplineddecisionsinplanningandexecutingtheremainderof
theMPLmission.
MCOObservationNo.10: AnalyzingWhatCouldGoWrong
TheBoardobservedwhatappearedtobethelackofsystematicanalysesofwhat
couldgowrongwiththeMars98projects.Forexample,theBoardobservednofault
treeorotherapriorianalysesofwhatcouldgowrongwithMCOorMPL.
MPLRecommendation:
ConductafaulttreeanalysisfortheremainderoftheMPLmission;followuponthe
results.Considerusinganexternalfacilitator;e.g.,fromnuclearindustryoracademia,if
thenecessaryexpertiseintheaprioriuseoffaulttreeanalysisdoesnotexistatJPL.
29
7. MarsPolarLander(MPL)Observations
andRecommendations
AspartoftheMCOPhaseIactivity,theBoarddevelopedeightMPLobservationsand
recommendationsnotdirectlyrelatedtotheMCOmishap.
MPLObservationNo.1:UseofSupplementalTrackingData
Types
Theuseofsupplementaltrackingdatatypestoenhanceorincreasetheaccuracyofthe
MPLnavigationsolutionswasdiscussed.OnedatatypelistedintheMPLMission
PlanningDatabookasarequirementtomeettheEntryDescentLanding(EDL)target
conditiontoaperformanceofbetterthan95percentistheNearSimultaneousTracking
(NST).Additionaldatatypesdiscussedweretheuseofathreewaymeasurementanda
differencerangeprocess.Thesedatatypeswouldbeusedindependentlytoassessthe
twowaycoherentmeasurementdatatypes(rangeandDoppler)baselinedbytheprime
operationsnavigationteam.DuringthepresentationstotheMIB,itwasstatedthatthe
MPLnavigationteamleadwouldbeinvolvedinthedetailedanalysisoftheNSTdata.
TheapplicationofaNSTdatatypeisrelativelynewtotheMPLmissionnavigation
procedure.ThesedatatypeshavenotbeenpreviouslyusedforMCOorMPLnavigation.
TheresultsofthenewdatatypesinadditiontorangeandDoppleronlysolutionscould
potentiallyaddtotheuncertaintyofthebestestimateofthetrajectoryattheEDL
conditions.
MPLRecommendation:
IdentifytherequirementfortheuseoftheNST,3way,anddifferencerange.Determine
iftheEDLtargetconditionscanbemetwithoutthem.Anindependentteamshouldbe
responsiblefortheprocessingandassessmentofthesealternativetrackingschemes.A
processshouldbedevelopedtoutilizethesedatatypesasacrosscheckofthecurrent2
waycoherentmethod.EnsurethattheNSTprocessisstreamlinedandwellunderstoodas
itisincorporatedintothenominaloperations.IfNSTisnecessary,focusworksoasto
notaffectotherroutinenavigationoperations.
MPLObservationNo.2:StarCameraAttitudeManeuver
(SCAM)
PriortoEntry,DescentandLanding(EDL),amultihourattitudecalibrationisplanned
onMPL.ThissocalledStarCameraAttitudeManeuver(SCAM)willreorientthe
spacecrafttoprovideoptimalobservationofstarsinthestarcamera.Thepurposeofthis
maneuveristocalibratethegyrodriftbiasanddeterminethevehicleattitudetoalevel
ofperformancenecessarytoinitiatetheEDLmaneuversequence.Thespecificattitude
requiredtosuccessfullyperformtheSCAMresultsinalossofspacecrafttelemetrydue
30
tothefactthattheMPLantennaispointedawayfromEarth.Currently,theexacttiming
oftheplannedSCAMactivityhasnotbeenfinalized.
MPLRecommendation:
TheMPLflightoperationsteamshouldestablishdefinitiveSCAMrequirements,
especiallytheattitudeaccuracyneededpriortoEDLandthelengthoftimethatMPL
isrequiredintheSCAMattitude.Clearoperationsscenariosshouldbedevelopedand
specificcontingencyoperationsproceduresshouldbedeveloped.
MPLObservationNo.3:VerificationandValidation(V&V)
ofLanderEntryStateFile
Althoughtheboardwasinformedthataplanexisted,thefinalendtoendverificationand
validationoftheEntryDescentLandingoperationalprocedureshadnotbeencompleted
whentheBoardreviewedtheproject.Thiscannotbecompleteduntilaftertheground
softwarehassuccessfullycompletedacceptancetesting.Moreover,thegenerationand
subsequentuseoftheLanderEntryStateFile(LESF)hasnotbeentested.Thedatainthe
LESFisusedtoupdatetheonboardestimateofMarsrelativepositionandvelocityjust
priortoentryinterface.ApparentlythisisarelativelynewprocedureforJPLandthus
shouldreceivefocusedattention.
MPLRecommendation:
TheBoardrecommendsthattheMPLteamperformanendtoendV&VtestofEDL
includinguseoftheLESF.Coordinatetransformationsandrelatedequationsusedinthe
generationofthisfileshouldbecheckedcarefully.Theendtoendtestshouldinclude
simulateduplinksoftheLESFtothespacecraftandpropagationofthesimulatedstate
vectortolandingina6degreeoffreedomsimulationliketheSimulationTest
Laboratory.Itmaybebeneficialtotestitmorethanoncewithperhapsdifferent
scenariosoruplinkedstatevectors.Relatedtothisissueistheneedtohaveabaselined
spacecrafttimelineespeciallywhenentryinterfaceisapproaching.Anyspacecraft
maneuvers,e.g.,SCAMmaneuvers,fromshortlybeforeuplinkoftheLESFuntilentry
interfaceneedtobewellplannedaheadoftime,i.e.,modeledbythenavigators,sothat
theonboardnavigationstateatentryinterfacewillbeasaccurateaspossible.
Ifpossible,provideforthecapabilitytouseapreliminarynavigationsolutionforEDL
navigationinitializationincaseofatemporaryuplinkproblem,i.e.,uplinkanLESF
filebeforeitisreallyneededsothatifananomalyoccursinthatprocess,theonboard
EDLnavigationsystemwillhavesomethingreasonabletoworkwith,albeitperhaps
notasaccurateasdesired.
31
MPLObservationNo.4:RolesandResponsibilitiesof
Individuals
InthewakeoftheMCOlossandthesubsequentaugmentationoftheMPLteam,the
BoardobservedthatrolesandresponsibilitiesofsomeindividualsinMSOPareunclear.
ArecurringthemeintheBoardsdeliberationswasoneofWhosincharge?Another
suchrecurringthemewasoneofWhosthemissionmanager?TheBoardperceived
hesitancyandwaveringonthepartofpeopleattemptingtoanswerthisquestion.One
answerwasthattheFlightOperationsManager(FOM)wasactinglikeamission
manager,butisnotactuallydesignatedassuch.
MPLRecommendation:
TheBoardrecommendsthattheMPLprojectclarifyrolesandresponsibilitiesforall
individualsontheteam.AssignapersontheroleofmissionmanagerforMPLand
ensurethattheentireteamunderstandstheleadershiprolethatthispersonisempowered
toprovidetotheMPLteam.
MPLObservationNo.5:ColdFiringofThrusters
Hydrazinehasphysicalpropertiesthatareverysimilartowater.Hydrazineisa
monopropellantthatwillbeusedinthrusterstoslowtheMPLspacecraftfromabout75
80meters/secondtoitslandingvelocityaround2.5meters/second.Thisisaccomplished
bysimultaneouslypulsemodefiringtwelve(12)parallelcatalyticthrusters.Thekey
concernisthefreezingpointofhydrazine.Hydrazinefreezesaround1to2C,
dependingontheexactenvironmentalconditionsandhydrazinespurity.Furthermore,
thespontaneouscatalyst(i.e.,initiateshydrazinedecompositionatroomtemperature)
usedinallthrustersflyingtoday,losesspontaneousreactivityasthecatalystbed
temperatureisloweredbelow7C.Ifthecatalystbedisverycold(i.e.wellbelow0C),
thentherewillbelongignitiondelayswhenthethrustersarecommandedtofire.The
resultsoftheseextremelycoldandlongignitiondelayfiringscouldproducehigh
pressurespikesandevenpossiblydetonations.Asaminimum,thecoldcatalystbed
inducedignitiondelaysandtheresultingirregular,pulsesonstartup,couldseriously
impactMPLdynamicsandpotentiallythestabilityofthevehicleduringtheterminal
descentoperations,possiblyleadingtoanonuprighttouchdown.
AdditionalconcernexistsastowhentheEDLoperationsteamplanstoturnonthe
heatersonthepropellantlinesfeedingthehydrazinethrusters.Theouterlinesandthe
thrusterswillhavebeencoldsoakingduringthe11monthtriptoMars.Ifanyof
theselinesarecoldenough(wellbelow0C),thenthehydrazinemightfreezewhen
bledintothethrustervalves.Ifthisoccurs,thentherewillbenoimpulsewhenthe
thrustersarecommandedtofire.
32
Itwasstatedbytheprojectoperationsmanagerthatall12thrusters(operatingat267
Newtonseach)mustalloperateascommanded.Therefore,theabovedescribedthermal
deficienciesshouldbeamajorconcernfortheMPLprojectteam.
MPLRecommendations
TheBoardrecommendsthattheMPLteamexaminethethermalanalysisanddetermine
whentheheatersonthelinesfeedingthethrustersshouldbeturnedontoensure
adequate,stableliquidflowwithsufficientpositivemargins.TheBoardalsosuggeststhat
theMPLteamshouldconsidertheuseofveryshortcatalystbedthermalpreconditioning
pulsesduringlanderpropulsionsystemutilization(i.e.,startup)toinsureuniformpulse
firingduringterminaldescent.
MPLObservationNo.6:MPLTerminalDescentManeuver
TheMPLterminaldescentmaneuverwillusesimultaneoussoftpulsemodefiringsof12
monopropellanthydrazinethrustersoperatingat267Newtonsofthrusteach.Allthese
thrustersmustoperateinunisontoensureastabledescent.Thistypeofpowereddescent
maneuverhasalwaysbeenconsideredtobeverydifficultandstressingforaplanetary
explorationsoftlanding.Hence,inthelast35yearsofplanetaryexploration,MPListhe
firstuserofthissoftpulsedthrustsoftlandingtechnique.
Theconcernhasbeenthatthefeedlinehydraulicsandwaterhammereffectscouldbe
verycomplexandinteractive.Thisissuecouldbefurtheraggravatedbyfuelslosh,
unevenfeedingofpropellantfromthetwotanksandpossiblecenterofgravity
mismatchonthevehicle.Additionalcomplicationscouldresultfromnonuniform
exhaustplumeimpingementonthelanderlegsstickingbelowthethrusternozzlesdue
toanyunevenpulsefirings.
Itshouldberecognizedthatunderextremeworstcaseconditionsforfeedline
interactions,itispossiblethatsomethrusterscouldproducenearzerothrustand
somecouldproducenearlytwicetheexpectedthrustwhencommandedtooperate.
MPLRecommendation:
ItwasstatedmanytimesbytheMPLprojectteamduringthereviewswiththeBoard,
thatavastnumberofsimulations,analysesandrigorousrealistictestswereallcarefully
conductedduringthedevelopmentprogramtoaccountforallthesefactorsduringthe
propulsivelandingmaneuver.
However,becauseoftheextremecomplexityofthislandingmaneuver,theEDL
teamshouldcarefullyreverifythatalltheabovedescribedpossibleeffectshavebeen
accountedforintheterminalmaneuverstrategiesandcontrollawsandtheassociated
softwareforEDLoperations.
33
MPLObservationNo.7:DecisionMakingProcess
DiscussionswithMPLteammembersrevealeduncertaintyaboutmissioncritical
decisionsthatinhibitedthemfromdoingtheirjobinatimelymanner.TheBoard
observedthattherewasdiscussionaboutthelandingsiteforMPLatthetimeofour
meetingsatJPL.Accordingtoplan,therewasconsiderationofmovingtothebackupsite
basedonnewinformationfromMGSregardinglandingsitecharacteristics.Some
elementsoftheProjectteam,e.g.,somemembersoftheoperationsnavigationteam,
werenotinformedofthisnewinformationorthefactthatthelandingsitewasbeing
reconsidered.Therealsowasapparentlyuncertaintyabouttheprocessforaddressingthis
timecriticaldecisionandaboutwhenitwouldbemade.
MPLRecommendation:
Communicatewidelytheneedfortimelydecisionsthatenablethevariouselementsof
theProjecttoperformtheirjobs.Establishaformaldecisionneeddatetrackingsystem
thatiscommunicatedtotheentireteam.Thissystemwouldidentifythelatestdecision
needdateandtheimpactofnotmakingthedecision.AllelementsoftheProjectshould
provideinputforestablishingthesedatesandbeinformedofthedecisionschedules.
AssignanoverallMissionManagerresponsibleforthesuccessoftheentiremission
fromspacecrafthealthtoreceiptofsuccessfulsciencedata.
MPLObservationNo.8:LanderScience
TheBoardwasinformedthatpreparationsfortheLanderscienceprogramwereinan
incompletestateatthetimeoftheBoardsmeetingduetotheimpactsresultingfromthe
lossoftheMCO.TheredirectionofresourcesduemainlytothelossofMCOcausedthe
scienceteamtobecomefurtherbehindinpreparationforMPLscienceoperations.Since
thelandedscienceprogramislimitedtoaboutthreemonthsbytheshortsummerseason
neartheMartianSouthPole,maximumsciencereturnrequiresfullreadinessforscience
operationspriortoEDL.Severaladditionalmanagerswerebeingassignedtoaddress
preparationsforthescienceprogram.
MPLRecommendation:
EnsurethatadetailedLanderscienceplan,tools,andnecessarysupportareinplace
beforethelanding.TheProjectScientistshouldbefullyinvolvedinthemanagementof
thescienceoperationsplanningandimplementation.
34
8.PhaseIIPlan
DuringthePhaseIIactivity,theBoardwillreviewandevaluatetheprocessesusedbythe
MCOandMPLmissionsandotherpastmissionsuccessesandfailures,developlessons
learned,makerecommendationsforfuturemissions,anddeliverareportnolaterthan
February1,2000.Thisreportwillcoverthefollowingtopicsandanyotheritemsthe
Boardfeelsrelevantaspartoftheinvestigationprocess.
1. Processestodetect,articulate,interpretandcorrecterrorstoensuremission
safetyandreliability
2. Systemsengineeringissues,including,butnotlimitedto:
Processestoidentifyprimarymissionsuccesscriteriaasweightedagainst
potentialmissionrisks
Operationalprocessesfordatavalidation
Managementstructureandprocessestoenableerrorfreecommunications
andproceduredocumentation
Processestoensurethatestablishedprocedureswerefollowed
3. Testing,simulationandverificationofmissionsoperations
4. WorkForceDevelopment
5. Workforceculture:confidenceorconcern?
6. Independentassessments
7. PlanetaryNavigationStrategies:GroundandAutonomous
Accuracy&Precisionthatcanbedelivered
Current&futuretechnologiestosupportMarsmissions
Navigationrequirementsandpreflightdocumentation
DuringthePhaseIIinvestigationprocess,theBoardwillobtainandanalyzewhatever
evidence,facts,andopinionsitconsidersrelevant.Itwillusereportsofstudies,findings,
recommendations,andotheractionsbyNASAofficialsandcontractors.TheBoardmay
conductinquiries,hearings,tests,andotheractionsitdeemsappropriate.Theywill
developrecommendationsforpreventiveandotherappropriateactions.Findingsmay
warrantoneormorerecommendations,ortheymaystandalone.Therequirementsinthe
NASAPolicyDocument(NPD)8621.1GandNASAProceduresandGuidelines(NPG)
8621.1(draft)willbefollowedforprocedures,format,andtheapprovalprocess.
35
Appendix
LetterEstablishingtheMarsClimateOrbiterMishap
InvestigationBoard
36
SD
TO:
Distribution
FROM:
SUBJECT:
1.
INTRODUCTION/BACKGROUND
The MCO spacecraft, designed to study the weather and climate of
Mars, was launched by a Delta rocket on December 11, 1998, from
Cape Canaveral Air Station, Florida. After cruise to Mars of
approximately 9 1/2 months, the spacecraft fired its main engine
to go into orbit around Mars at around 2 a.m. PDT on September
23, 1999.
Five minutes into the planned 16-minute burn, the spacecraft
passed behind the planet as seen from Earth. Signal
reacquisition, nominally expected at approximately 2:26 a.m. PDT
when the spacecraft was to reemerge from behind Mars, did not
occur. Fearing that a safehold condition may have been triggered
on the spacecraft, flight controllers at NASAs Jet Propulsion
Laboratory (JPL) in Pasadena, California, and at Lockheed Martin
Astronautics See figure 1. The spacecraft was to then skim
through Mars' upper atmosphere for several weeks in a
Efforts to find and communicate with MCO continued up until 3
p.m. PDT on September 24, 1999, when they were abandoned. A
contingency was declared by MCO Program Executive,
Mr. Steve Brody at 3 p.m. EDT on September 24, 1999.
2.
PURPOSE
This establishes the NASA MCO Mission Failure Mishap Investigation
Board and sets forth its terms of reference, responsibilities, and
membership in accordance with NASA Policy Directive (NPD) 8621.1G.
3.
ESTABLISHMENT
a. The MCO Mission Failure Mishap Investigation Board
(hereinafter called the Board) is hereby established in the
publics interest to gather information, analyze, and determine
the facts, as well as the actual or probable cause(s) of the MCO
Mission Failure Mishap in terms of (1) dominant root cause(s),
(2) contributing cause(s), and (3) significant observations and
to recommend preventive measures and other appropriate actions to
preclude recurrence of a similar mishap.
b. The chairperson of the board will report to the NASA Office
of Space Science (OSS) Associate Administrator (AA) who is the
appointing official.
4.
OBJECTIVES
A.
37
The Board will review and evaluate all the processes used by the
MCO mission, develop lessons learned, make recommendations for
future missions, and deliver a final mishap investigation report no
later than February 1, 2000. This report will cover the following
topics and any other items the Board thinks relevant.
i. Processes used to ensure mission safety and reliability
with mission success as the primary objective. This will include
those processes that do not just react to hard failures, but
identify potential failures throughout the life of the mission
for which corrective actions can be taken. It will also include
asking if NASA has the correct philosophy for mission assurance
in its space missions. That is:
ii.
to:
38
b.
39
6.
MEMBERSHIP
The chairperson, other members of the Board, and supporting
staff are designated in the Attachment.
7.
MEETINGS
The chairperson will arrange for meetings and for such records
or minutes of meetings as considered necessary.
8.
DURATION
The NASA OSS AA, as the appointing official, will dismiss
the Board when it has fulfilled its responsibilities.
10.
CANCELLATION
This appointment letter is automatically cancelled 1 year from
its date of issuance, unless otherwise specifically extended by
the approving official.
Edward J. Weiler
Enclosure
Distribution:
S/Dr. E. Huckins
S/Dr. C. Pilcher
SD/Mr. K. Ledbetter
SD/Ms. L. LaPiana
SD/Mr. S. Brody
SR/Mr. J. Boyce
SPR/Mr. R. Maizel
SPR/Mr. J. Lee
Q/Mr. F. Gregory
QS/Mr. J. Lloyd
JPL/180-904/Dr. E. Stone
JPL/180-704/Dr. C. Elachi
JPL/180-703/Mr. T. Gavin
JPL/230-235/Mr. R. Cook
JPL/264-426/Mr. C. Jones
JPL/180-904/Mr. L. Dumas
MCO FIB Board Members, Advisors, Observers, and Consultants.
40
ATTACHMENT
Mars Climate Orbiter (MCO) Failure Investigation Board (FIB)
Members
MSFC/Mr. Arthur G. Stephenson Chairperson
Director,
George C. Marshall Space
Flight Center
Executive Secretary
Consultants:
Ms. Ann Merwarth
NASA/GSFC-retired
41
TRW
Dr. Michael G. Hauser
Deputy Director
42
Observers:
JPL/Mr. John Casani
review team
JPL/Mr. John McNamee
Operations
NASA Headquarters
HQ/QE/Mr. Michael Card
(ex-officio)
Program Manager
NASA Headquarters
43
Acronymlist
AA=AssociateAdministrator
AACS=ArticulationandAttitudeControlSystem
AMD=AngularMomentumDesaturationEDL=
Entry,Descent,Landing
GDS=GroundDataSystem
ICD=InterfaceControlDocument
ISA=Incident,Surprise,Anomaly
JPL=JetPropulsionLaboratory
lbfs=pounds(force)second
LESF=LanderEntryStateFile
LIDAR=LightDetectionandRanging
LMA=LockheedMartinAstronautics
MCO=MarsClimateOrbiter
MGS=MarsGlobalSurveyor
MIB=MishapInvestigationBoard
MOI=MarsOrbitalInsertion
MOS=MissionOperationsSystem
MPL=MarsPolarLander
MSOP=MarsSurveyorOperationsProject
MSP=MarsSurveyorProgram
MSP98=MarsSurveyorProject98
NASA=NationalAeronauticsandSpace
AdministrationNPD=NASAPolicyDirective
NPG=NASAProceduresandGuidelines
Ns=Newtonseconds
NST=NearSimultaneousTracking
OSS=OfficeofSpaceScience
PDT=PacificDaylightTime
SCAM=StarCameraAttitudeManeuver
SIS=SystemInterfaceSpecifications
TCM=TrajectoryCorrectionManeuver
UTC=UniversalTimeCoordinated
V&V=VerificationandValidation
V=VelocityChange
44