1、Lessons Learned Entry: 1066Lesson Info:a71 Lesson Number: 1066a71 Lesson Date: 1999-02-01a71 Submitting Organization: HQa71 Submitted by: David M. LengyelSubject: Space Shuttle Program/Operations-Processing/Metrics Description of Driving Event: Finding and Reporting of Mishaps and “Close Calls“Lesso
2、n(s) Learned: It is often difficult to find meaningful metrics that directly show safety risks or unsafe conditions. Safety risks for a mature vehicle, such as the Space Shuttle, are identifiable primarily in specific deviations from established procedures and processes, and they are meaningful only
3、 on a case-by-case basis. NASA and Shuttle Processing Contract (SPC) have a procedure for finding and reporting mishaps and “close calls“ that should produce far more significant insight into safety risks than would mere metrics.Recommendation(s): In addition to standard metrics, NASA should be inti
4、mately aware of the mishaps and close calls that are discovered, followup in a timely manner, and concur on the recommended corrective actions. Evidence of Recurrence Control Effectiveness: NASA agrees with the recommendation. In addition to standard metrics, NASA is intimately aware of the mishaps
5、and close calls and is directly involved in the investigations and approval of corrective actions. Current requirements contained in various NASA Center and contractor safety plans include procedures for reporting of mishaps and close calls. These reports are investigated and resolved under the lead
6、ership of NASA representatives with associated information being recorded and reported to NASA management. NASA is intimately aware of and participates in the causal analysis and designation of corrective action for each mishap. Additionally, NASA performs trend Provided by IHSNot for ResaleNo repro
7、duction or networking permitted without license from IHS-,-,-analysis of metrics as part of the required insight activities. Definitions relating to “close call“ have been expanded to include any observation or employee comment related to safety improvement. Close call reporting has been emphasized
8、in contractor and NASA civil servant performance criteria and a robust management information system is being incorporated to monitor and analyze conditions and behavior having the potential to result in a mishap. Various joint NASA/contractor forums exist to review, evaluate, and assign actions ass
9、ociated with reported close calls. As an example, the KSC NASA Human Factors Integration Office leads the NASA/Contractor Human Factors Integrated Product Team (IPT) in the collection, integration, analysis, and dissemination of root cause and contributing cause data across all KSC organizations. Th
10、e KSC Human Factors IPT is also enhancing the current close call process, which includes tracking of mishaps with damage below $1000 and injuries with no lost workdays. The SSP has revised its Preventive/Corrective Action Work Instruction to include mandatory quarterly review of close call reports.
11、Several initiatives are in place to increase awareness of the importance of close call reporting and preventive/corrective action across the SSP and the supporting NASA Centers and contractors. Under this new approach to close call reporting, a metric indicating an increase in close call reporting a
12、nd preventive action is considered highly desirable as it indicates an increased involvement by the workforce in identifying and resolving potential hazards. Care is taken in over emphasizing the number of close calls reported as a performance metric to prevent reluctance in reporting. NASA is worki
13、ng hard to shift the paradigm from the negative aspects of reporting close calls under the previous definition to being a positive aspect of employee identification of close calls under the new definition.Documents Related to Lesson: N/AMission Directorate(s): a71 Space Operationsa71 Exploration Sys
14、temsAdditional Key Phrase(s): a71 Administration/Organizationa71 Aerospace Safety Advisory Panela71 Ground Operationsa71 Human Resources & Educationa71 Policy & Planninga71 Safety & Mission AssuranceProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Additional Info: Approval Info: a71 Approval Date: 2001-12-19a71 Approval Name: Bill Loewya71 Approval Organization: HQa71 Approval Phone Number: 202-358-0528Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
