NASA Spacewalk Mishap Investigation Board Report


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In our business, we must always take the opportunity to infuse the lessons we have learned into everything we do. Despite our successes, what we do is inherently risky and difficult -- and surprises can emerge when we least expect it. This requires all of us to stay vigilant and inquisitive by constantly questioning commonly accepted principles or conceptions. 

- Full report (11.2 Mb PDF)

- News Conference Presentation - 2/26/14 (120 Kb PDF)

Last July, we ended a spacewalk by two crew members outside the International Space Station, less than 90 minutes after it began, when one of the astronauts reported a large quantity of water in his spacesuit helmet. The water increased as he worked and the source could not be identified, so termination of the EVA was directed by the Flight Director and the EVA team. Immediately following the incident, the International Space Station Program began an engineering inquiry, and a Mishap Investigation Board (MIB) worked for several months to gather information, analyze facts and uncover what caused this close call. The MIB has completed its work and is releasing its report to the public today.

I commend everyone involved in this incident -- the astronaut, Luca Parmitano, the rest of the space station crew, and the ground team -- for recognizing the seriousness of the problem and making a timely call to terminate the spacewalk. It is a testament to their preflight training and preparation that Luca got back into the space station airlock quickly and without harm. I also commend the work done afterward to regain capability for contingency spacewalks, two of which were completed safely to make space station repairs in December. William Gerstenmaier, NASA's Associate Administrator for Human Exploration and Operations, has accepted the mishap report and has directed the International Space Station Program at the agency's Johnson Space Center to submit to him within 15 days a corrective action plan that addresses all the findings and recommendations.  He also has directed the space station program's engineering team to finish the work necessary to determine a root cause for the hardware failure -- this means to find the source of  particulate matter believed to have clogged the fan pump separator.  Based on its findings, the corrective action plan will be modified as necessary.

While I am concerned about ensuring this particular incident does not happen again, I am especially concerned about cultural factors that may have contributed to the event. In our exuberance to get the job done, we may have allowed ourselves to accept the commonly accepted causes for small anomalies. We have a responsibility not to move on from any abnormal situation until we understand it fully or have suitable mitigations to prevent it happening again.  Our work both in-house and with our industry and commercial partners should entail diligence in assessing risk and commitment to ensuring mission safety.

As the person ultimately responsible for all we do as the NASA family, I implore you to welcome risks, because that is how we push the boundaries of our achievement, but at the same time, I must emphasize in the strongest terms that we must not be complacent in our quest to ensure the safety of our crew members and teams on the ground.

I look forward to visiting each of our centers to encourage our shared commitment to making the impossible possible; to always becoming a more effective agency where safety is our watchword; and to encourage the positive aspects of our culture demonstrated in the course of these events.

Charlie B.

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