6.4.1 A Case Study of the Near‐Catastrophic Mir‐Progress 234 Collision with Emphasis on the Human Factors/Systems‐Level Issues Surrounding this Mishap

6.4.1 A Case Study of the Near‐Catastrophic Mir‐Progress 234 Collision with Emphasis on the Human Factors/Systems‐Level Issues Surrounding this Mishap
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6.4.1 近乎灾难性的 Mir-Progress 234 碰撞案例研究,重点关注与该事故相关的人为因素/系统级问题

DOI:
10.1002/j.2334-5837.2002.tb02544.x
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发表时间:
2002
期刊:
INCOSE International Symposium
影响因子:
--
通讯作者:
D. Holland
D. Holland
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--
文献类型:
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作者:
D. Holland

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本文研究了1997年6月进步号234补给飞船与俄罗斯和平号空间站之间的碰撞。这艘无人驾驶的“进步234”号货运飞船当时正手动飞向和平号空间站,与和平号空间站的“Spektr”模块相撞。结果是耐压外壳被刺破,导致减压,几乎迫使机组人员在紧急模式下离开空间站。对这次碰撞的分析表明,许多系统和人为因素问题共同促进了这种碰撞发生的机会。这些增加碰撞发生概率的系统级属性包括:执行困难任务的地面控制压力,繁忙的操作节奏,以及之前各种机载系统故障导致机组人员处于压力状态的“险情”。对接设备本身的系统故障导致对接尝试比通常情况下更加困难。俄罗斯和乌克兰经济状况的普遍恶化似乎也对这种尝试的做法起到了微妙的促进作用,因为任务付款/激励结构要求机组人员完成某些任务,并且难以以合理的价格从乌克兰人那里获得自动对接设备。导致此次事故的人为因素包括:事故发生前长时间的睡眠不足导致的慢性疲劳,在尝试对接的条件下非常糟糕的显示控制界面,以及之前与Progress 233对接失败造成的内在心理/财务压力。从人为因素的角度来看,由于视觉显示和控制信息不足,特别是关于Progress 234补给船的位置、距离和速度信息,在手动Progress 234对接尝试期间,MIR指挥官的态势感知能力急剧下降。
This paper examines the June 1997 collision between the Progress 234 Supply Ship, and the Russian Mir Space Station. The unmanned Progress 234 cargo supply ship was being flown manually on a practice approach to MIR, when it collided with the Spektr module of the MIR station. The result was a punctured pressure hull, which resulted in a decompression that nearly forced the crew to leave the station in an emergency mode. An analysis of this collision reveals that a host of systems and human factors issues combined to promote the chances for such a collision occurring. These systems‐level attributes that increased the probability of a collision happening included: ground‐control pressure to perform a difficult task, a hectic pace of operations, and previous “close calls” with a variety of on‐board systems failures that left the crew in a stressed state. Systems failures in the docking apparatus itself contributed to making the attempted docking more difficult than would normally have been the case. The general deterioration of economic conditions in Russia and the Ukraine also appears to have played a subtle predisposing role for this type of practice approach to be attempted to begin with due to the mission payment/incentive structure that required the crew to complete certain tasks, and the difficulties involved with obtaining automatic docking devices from the Ukrainians for a reasonable price. Human factors issues that are noted as contributing to this mishap include chronic fatigue from the loss of sleep for an extended period just prior to the mishap, very poor display‐control interfacing under the conditions that the docking was attempted, and embedded psychological/financial pressures resulting from the previous docking failure with Progress 233. From a human factors perspective, the MIR Commander's situation awareness was dramatically degraded during the manual Progress 234 docking attempt due to inadequate visual display and control information, particularly with regard to the position, range, and velocity information of the Progress 234 supply ship.