1. NASA’s Mars Climate Orbiter Mishap

2. References Official investigation report IEEE Spectrum investigation report Official report on project management at NASA 2

3. Agenda Spacecraft and its mission Mission failure Failure causes root cause contributing causes NASA’s mission planning paradigm 3

4. Agenda Spacecraft and its mission Mission failure Failure causes root cause contributing causes NASA’s mission planning paradigm 4

5. Mars Climate Orbiter - Mission The first weather satellite for another planet profile Martian atmosphere map Martian surface Mars Polar Lander support relay for future missions 5

6. Mars Climate Orbiter - Spacecraft Assymetric solar array Attitude control coarse: jet thrusters fine: 3x flywheels Single onboard computer IBM PowerPC 20MHz 128MB RAM no tape or solid-state recorder 18MB flash 6

7. Mars Climate Orbiter – Flight to Mars 7

8. Agenda Spacecraft and its mission Mission failure Failure causes root cause contributing causes NASA’s mission planning paradigm 8

9. Mars Climate Orbiter - Mishap went off course by 100 km hit the atmosphere and burned ? passed the atmosphere and went on ? $125.000.000 loss 9

10. Agenda Spacecraft and its mission Mission failure Failure causes root cause contributing causes NASA’s mission planning paradigm 10

11. Mission Failure – Root Cause In NASA nomenclature a root cause is: Along a chain of events leading to a mishap, the first causal action or failure to act that could have been controlled by policy/practice/procedure Root Cause – failure to use metric system in ground software files used in trajectory models 11

12. Mars Climate Orbiter - Spacecraft Assymetric solar array Attitude control coarse: jet thrusters fine: 3x flywheels AMD – Angular Momentum Desaturation 12

13. Mission Failure – Contributing Causes In NASA nomenclature a contributing cause is: A factor, event or circumstance which led directly or indirectly to the dominant root cause or which contributed to the severity of the mishap 13

14. Mission Failure – Contributing Causes Contributing causes undetected mismodelling of velocity changes navigation team unfamilliar with spacecraft failure to perform emergency trajectory correction poor system engineering process informal communication of project teams insufficient staff training insufficient navigation team stuffing poor verification of ground software 14

15. Mission Failure – Contributing Cause 1 Contributing causes undetected mismodelling of velocity changes navigation team unfamilliar with spacecraft failure to perform emergency trajectory correction poor system engineering process informal communication of project teams insufficient staff training insufficient navigation team stuffing poor verification of ground software 15

16. Mission Failure – Contributing Cause 2 Contributing causes undetected mismodelling of velocity changes navigation team unfamilliar with spacecraft failure to perform emergency trajectory correction poor system engineering process informal communication of project teams insufficient staff training insufficient navigation team stuffing poor verification of ground software 16

17. Mission Failure – Contributing Cause 3 Contributing causes undetected mismodelling of velocity changes navigation team unfamilliar with spacecraft failure to perform emergency trajectory correction poor system engineering process informal communication of project teams insufficient staff training insufficient navigation team stuffing poor verification of ground software 17

18. Mission Failure – Contributing Cause 4 Contributing causes undetected mismodelling of velocity changes navigation team unfamilliar with spacecraft failure to perform emergency trajectory correction poor system engineering process informal communication of project teams insufficient staff training insufficient navigation team stuffing poor verification of ground software 18

19. Mission Failure – Contributing Cause 5 Contributing causes undetected mismodelling of velocity changes navigation team unfamilliar with spacecraft failure to perform emergency trajectory correction poor system engineering process informal communication of project teams insufficient staff training insufficient navigation team stuffing poor verification of ground software 19

20. Mission Failure – Contributing Cause 6 Contributing causes undetected mismodelling of velocity changes navigation team unfamilliar with spacecraft failure to perform emergency trajectory correction poor system engineering process informal communication of project teams insufficient staff training insufficient navigation team stuffing poor verification of ground software 20

21. Mission Failure – Contributing Cause 7 Contributing causes undetected mismodelling of velocity changes navigation team unfamilliar with spacecraft failure to perform emergency trajectory correction poor system engineering process informal communication of project teams insufficient staff training insufficient navigation team stuffing poor verification of ground software 21

22. Mission Failure – Contributing Cause 8 Contributing causes undetected mismodelling of velocity changes navigation team unfamilliar with spacecraft failure to perform emergency trajectory correction poor system engineering process informal communication of project teams insufficient staff training insufficient navigation team stuffing poor verification of ground software 22

23. Agenda Spacecraft and its mission Mission failure Failure causes root cause contributing causes NASA’s mission planning paradigm 23

24. NASA’s Mission Planning Paradigm „Faster, better, cheaper“ approach 24

25. NASA’s Mission Planning Paradigm „Mission success first“ approach defining a minimum set of mission success criteria sufficient analysis and verification prior to launch assurance and robustness of the design ability to learn from failure 25

26. NASA’s Mission Planning Paradigm „Mission success first“ approach defining a minimum set of mission success criteria sufficient analysis and verification prior to launch assurance and robustness of the design ability to learn from failure 26

27. NASA’s Mission Planning Paradigm „Mission success first“ approach defining a minimum set of mission success criteria sufficient analysis and verification prior to launch assurance and robustness of the design ability to learn from failure 27

28. NASA’s Mission Planning Paradigm „Mission success first“ approach defining a minimum set of mission success criteria sufficient analysis and verification prior to launch assurance and robustness of the design ability to learn from failure 28

29. NASA’s Mission Planning Paradigm „Mission success first“ approach defining a minimum set of mission success criteria sufficient analysis and verification prior to launch assurance and robustness of the design ability to learn from failure 29

30. NASA’s Mars Climate Orbiter Mishap Thank you! 30