REG NASA-LLIS-1086--2000 Lessons Learned - Lack of Close Call Reporting and Corrective Action Development at GSFC.pdf

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1、Lessons Learned Entry: 1086Lesson Info:a71 Lesson Number: 1086a71 Lesson Date: 2000-03-24a71 Submitting Organization: GSFCa71 Submitted by: Suzanne Johnson / Eric RaynorSubject: Lack of Close Call Reporting and Corrective Action Development at GSFC Abstract: The incidents described in Lessons Learne

2、d #1084 and #1085 suggest a lack of awareness of what constitutes a close call and the fact that close calls should be reported into the NASA Mishap Reporting System.The lesson recommendations include a number of steps to provide more specific safety guidance, including definition of what constitute

3、s a “close call.” Description of Driving Event: A NASA Mishap Investigation Board (MIB) was tasked with investigating the perceived lack of corrective actions and lack of close call reporting of two incidents into the NASA Mishap Reporting System: the GSFC Building 24 pressurized steam line close ca

4、ll of August 19, 1999, and the GSFC Building 3/13/14 electrical manhole close call of December 26, 1998. For more detailed information about these two close calls, please refer to separately published lessons learned findings for each close call incident in the NASA Lessons Learned Information Syste

5、m (LLIS).Lesson(s) Learned: The primary cause of the lack of close call reporting of these incidents was a lack of awareness of what constitutes a close call and the fact that close calls should be reported into the NASA Mishap Reporting System via the 1627 Form. Personnel involved in the pressurize

6、d steam line incident were unaware that the 1627 Form should have been submitted. The delayed submittal of this form was due to the pending appointment of the MIB. Personnel involved in the electrical manhole incident did not believe it was a close call. The MIB identified two significant contributi

7、ng causes to these perceptions. The Code 220, Code 227 and NASA level guidance documents on close call/mishap Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-reporting as well as the mishap Form 1627 itself focus on mishaps. Most of the guidance prov

8、ided is mishap-specific such as attending to the injured and securing the scene, things that do not typically exist in close calls. While Code 220 and 227 guidance do require close call reporting, testimony indicated that it had become common practice to address close calls as an internal issue (in

9、the branch/section in which they occurred) and not pass the information up the management chain or to the GSFC Safety and Environmental Branch.Corrective actions were developed for both of these close call incidents. However, in the pressurized steam line incident the corrective actions were not ade

10、quate to prevent recurrence since they did not address the root causes of the incident.Employees cannot follow policies they are not aware of or are not clear. Even though NASA policies do require the reporting of close calls into the NASA mishap reporting system, if that information is not passed o

11、n to all employees in an easily understood and visible manner it will not be followed.Resolution of close calls is best accomplished through close cooperation between the organization in which the close call occurred and the Centers safety organization. Each organization brings unique knowledge skil

12、ls and abilities to the table that can be used to determine what went wrong and what can be done to prevent recurrence.If close calls are not investigated and addressed in a timely manner, the possible benefits derived from them (i.e., preventing mishaps caused by similar events) are lost.Lack of Kn

13、owledge of What Constitutes a Close Call: In both the Pressurized Steam Line and Electrical Manhole close calls, a general lack of knowledge of the definition of what constitutes a close call was evident. Witnesses testified in both cases that they did not consider the incidents close calls. In the

14、Steam line case, the Mechanical Maintenance Shop (MMS) worker did consider it a close call and did report it to his supervisor (as required) and the Safety and Environmental Branch (Code 205.2). The MMS supervisor informed the General Foreman and he brought the MMS and CPP groups together to solve t

15、he issue. They were not aware that a close call should be reported on a NASA Mishap Reporting Form (1627 Form). The MMS workers expected Code 205.2 to investigate and assist in resolving the issue. Code 205.2 expected Code 220 to file the 1627 Form and take action to resolve the issue. When the 1627

16、 Form was filled out 2 months later it appears to have been done without the information originally provided to Code 205.2 by the MMS worker. In the Electrical manhole incident, the supervisor did not consider the incident a close call and therefore did not consider taking any official action.Discus

17、sion of Close Call Reporting In Guidance Documents: The MIB reviewed the following documents to determine if they provided adequate instructions on how to handle close calls: A) Code 227 Safety Manual, Reference E; B) GSFC Facilities Management Division (Code 220) Safety and Health Program Plan (S C

18、) NPD 862 1.1.G, NASA Mishap Reporting and Investigating Policy, Reference A; and D) NHB; 1700.1 (-VI-B), NASA Safety Policy and Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Requirements Document, Reference B.In general, the documents coverage of

19、close calls is sparse. Close calls are identified as being one of the types of incidents covered, however, the majority of the guidance focuses heavily on aspects of mishaps that are not part of close calls (i.e., injuries, emergency situations). Discussion of close call reporting in the Code 227 Sa

20、fety Manual is particularly unclear. A close call or near miss is not separately defined but is included as part of an incident definition. The steps to be taken by personnel involved in incidents and their supervisors focus on mishaps. This could lead readers to believe that close calls are not inc

21、luded in reporting policies. The Code 220 S an explanation of the types of incidents that should be reported, the type of corrective actions should be developed by the reporting organization, calls for notification of the nature of close calls and corrective actions to the reporting organizations ma

22、nagement chain, and feedback on the results of Code 205s close call hazard reporting system to GSFC employees. Update the Code 227 Safety Manual to define close calls and near-misses separately from incidents and to list the steps to be taken in their reporting. Increase management involvement in Co

23、de 227 proactive investigation of close calls and development of appropriate corrective actions.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): a71 ScienceAdditional Key Phrase(s): a71 Administration/Organizationa71 Communication Systemsa71 Co

24、nfiguration Managementa71 Facilitiesa71 Human Factorsa71 Human Resources & Educationa71 Industrial Operationsa71 Logisticsa71 Mishap Reportinga71 Policy & Planninga71 Safety & Mission AssuranceProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Mishap Re

25、port References: Lack of Close Call Reporting and Corrective Action Development at GSFCAdditional Info: Approval Info: a71 Approval Date: 2002-02-12a71 Approval Name: Jay Liebowitza71 Approval Organization: GSFCa71 Approval Phone Number: 301-286-4467Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-