REG NASA-LLIS-0625-1998 Lessons Learned Lewis Spacecraft Mission Failure Investigation Board.pdf

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1、Lessons Learned Entry: 0625Lesson Info:a71 Lesson Number: 0625a71 Lesson Date: 1998-02-12a71 Submitting Organization: GSFCa71 Submitted by: Charles VanekSubject: Lewis Spacecraft Mission Failure Investigation Board Description of Driving Event: The Lewis Spacecraft was procured by NASA via a 1994 co

2、ntract with TRW, Inc., and launched on 23 August 1997. Contact with the spacecraft was subsequently lost on 26 August 1997. The spacecraft re-entered the atmosphere and was destroyed on 28 September 1997.The Lewis Spacecraft Mission Failure Investigation Board was established to gather and analyze i

3、nformation and determine the facts as to the actual or probable cause(s) of the Lewis Spacecraft Mission Failure. The Board was also tasked to review and assess the “Faster, Better, Cheaper“ Lewis spacecraft acquisition and management processes used by both NASA and the contractor in order to determ

4、ine if they may have contributed to the failure. The investigation process used by the Board was to individually interview all persons believed to have had a substantial involvement in the Lewis spacecraft acquisition, development, management, launch, operations and the events that may have led to t

5、he eventual loss. These interviews were aimed at not only understanding the facts as they occurred but also at understanding the individual perceptions that may have been instrumental in the decisions and judgments as made on this Program.Lesson(s) Learned: The Board found that the loss of the Lewis

6、 Spacecraft was the direct result of an implementation of a technically flawed Safe Mode in the Attitude Control System. This error was made fatal to the spacecraft by the reliance on that unproven Safe Mode by the on orbit operations team and by the failure to adequately monitor spacecraft health a

7、nd safety during the critical initial mission phase.The Board also discovered numerous other factors that contributed to the environment that allowed the direct causes to occur. While the direct causes were the most visible reasons for the failure, the Board believes that the indirect causes were al

8、so very significant contributors. Many of these factors Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-can be attributed to a lack of a mutual understanding between the contractor and the Government as to what is meant by Faster, Better, Cheaper. Th

9、ese indirect contributors are to be taken in the context of implementing a program in the Faster, Better, Cheaper mode:a71 Requirement changes without adequate resource adjustmenta71 Cost and schedule pressuresa71 Program Office movea71 Inadequate ground station availability for initial operationsa7

10、1 Frequent key personnel changesa71 Inadequate engineering disciplinea71 Inadequate management disciplineThe Board strongly endorses the concept of “Faster, Better, Cheaper“ in space programs and believes that this paradigm can be successfully implemented with sound engineering, and attentive, and e

11、ffective management. However the role changes for Government and Industry are significant and must be acknowledged, planned for and maintained throughout the program.Since these roles are fundamental changes in how business is conducted, they must be recognized by all team members and behaviors adju

12、sted at all levels. The Board observed an attempt during the early phase of the Lewis Program to work in a Faster, Better, Cheaper culture, but as the Program progressed the philosophy changed to business as usual with dedicated engineers working long hours using standard processes to meet a short s

13、chedule and skipping the typical Government oversight functions.Recommendation(s): Based on observations from the Lewis Program, the Board offers the following recommendations in order to enhance mission success in future programs performed under this new paradigm:Balance Realistic Expectations of F

14、aster, Better, Cheaper.Meaningful trade space must be provided along with clearly articulated priorities. Price realism at the outset is essential and any mid-program change must be implemented with adequate adjustments in cost and schedule. This is especially important in a program that has been im

15、plemented with minimal reserves.Establish Well Understood Roles and Responsibilities.The Government and the contractor must be clear on the mutual roles and responsibilities of all parties, including the level of reviews and what is required of each side and each participant in the Integrated Produc

16、t Development Team.Adopt Formal Risk Management Practices.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Faster, Better, Cheaper methods are inherently more risk prone and must have their risks actively managed. Disciplined technical risk management

17、 must be integrated into the program during planning and must include formal methods for identifying, monitoring and mitigating risks throughout the program. Individually small, but unmitigated risks on Lewis produced an unpredicted major effect in the aggregate.Formalize and Implement Independent T

18、echnical ReviewsThe internal Lewis reviews did not include an adequate action response and closure system and may have received inadequate attention from the contractors functional organizations. The Government has the responsibility to ensure that competent and independent reviews are performed by

19、the Government, the contractor, or both.Establish and Maintain Effective CommunicationsA breakdown of communications and a lack of understanding contributed to wrong decisions being made on the Lewis program. For example the decision to operate the early on orbit mission with only a single shift gro

20、und control crew was not clearly communicated to senior TRW or NASA management. The Board believes that, especially in a “Faster, Better, Cheaper“program these working relationships are the key to successful program implementation.Although this report necessarily focused on what went wrong with the

21、Lewis Program, much also went right due to the skill, hard work, and dedication of many people. In fact, these people completely designed, constructed, assembled, integrated and tested a very complex space system within the two-year goal and probably came very close to mission success.Evidence of Re

22、currence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): a71 ScienceAdditional Key Phrase(s): Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Administration/Organizationa71 Communication Systemsa71 Computersa71 F

23、inancial Managementa71 Flight Operationsa71 Flight Equipmenta71 Ground Operationsa71 Hardwarea71 Information Technology/Systemsa71 Mishap Reportinga71 Risk Management/Assessmenta71 Softwarea71 SpacecraftMishap Report References: Lewis Spacecraft Mission Failure Investigation Board ReportAdditional Info: Approval Info: a71 Approval Date: 1999-06-04a71 Approval Name: Eric Raynora71 Approval Organization: QSa71 Approval Phone Number: 202-358-4738Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-