Overview of ISS Flight Controller Ratings on Organizational Risk and Tool Development Survey February 2004
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Executive Summary
In November 2003, 191 International Space Station (ISS) Flight Controllers completed an online survey on organizational and tool development. This survey was prepared by NASA Ames Research Center Human Factors and System Safety staff in collaboration with ISS Flight Controllers, Mission Operations Directorate (MOD) management, and the Operations Research Branch of MOD. The purpose of the survey was to identify organizational risks that could endanger the program and to generate tools to reduce these risks and facilitate tasks. The survey contained statements that were rated on a scale of 1 to 5, as well as questions that called for free text responses. The results presented in this report are based primarily on the ratings. Full analysis of the free text responses will be presented in a subsequent paper.
The survey results revealed many strengths in the organization, one area of critical vulnerability, and several areas which need improvement.
Strengths: Flight controllers feel free to speak up about safety concerns – a crucial component of a good safety culture. Flight controllers have positive attitudes towards their work and take pride in their jobs. They have good relationships with supervisors who are seen as accessible and who listen to what is said – which means there is a good flow of information from one level to the next. Flight teams are seen as performing very well. Individual discipline groups have many excellent, risk-reducing characteristics. Group members respect those who spot and elevate problems, support each other, and have good collaborations within their group and between groups. Discipline group meetings also have many risk reducing characteristics. Flight controllers feel free to disagree and are confident that their own input is considered.
Critical Vulnerability: There is an over-reliance on human operators to work around malfunctioning software. There are over 1,000 written work-arounds (called Station Program Notes, or SPNs) to software problems, and flight controllers report difficulties in remembering them. As one flight controller wrote, “I will be blunt – allowing the number of SPNs to get to where they are is NO different from allowing repeated foam strikes on the tile to be considered ok since we have survived it before.” Flight controllers rated software issues as compromising ISS safety. When flight controllers were asked to list the three most serious organizational vulnerabilities, software work-around issues were listed most frequently and rated as being the most serious. This vulnerability is compounded by a structural difficulty in communication, since the boards which have responsibility for making decisions on software are in a different directorate.
Need Improvement: (1) ISS history, decisions, and rationales are not accessible. Tools can be developed to address this need, such as the logging tools already underway. (2) There are inaccuracies in on-console documentation. (3) Better ISS system understanding on the part of flight controllers is needed. Development of simulation tools can address this need. (4) Communication with international partners could be improved. (5) Finally., anonymous surveys such as this which area administered at regular intervals can help forestall the development of critical vulnerabilities.
A summary of findings is presented in the following section.
Conclusion
The Columbia Accident investigation Board Report (CAIB) cited the need for
… organizations committed to effective communication [to] seek avenues through which unidentified and dissenting insights can be raised so that weak signals are not lost in background noise… [These avenues] must mitigate the fear of retribution, and management and technical staff must pay attention. (p. 192)
This survey, developed in collaboration with the flight controllers and MOD management, is such an avenue. MOD Management is to be congratulated for its support of the survey, and the flight controllers are to be congratulated for making their concerns known. Although more results from the survey will be made available later, it is already time to “pay attention.”
