REG NASA-LLIS-1237-2002 Lessons Learned Mishap Investigation Boards (MIBs) MIB Policy and Procedures Classification of Mishaps.pdf

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1、Lessons Learned Entry: 1237Lesson Info:a71 Lesson Number: 1237a71 Lesson Date: 2002-06-17a71 Submitting Organization: HQa71 Submitted by: David LengyelSubject: Mishap Investigation Boards (MIBs)/MIB Policy and Procedures/Classification of Mishaps Description of Driving Event: Current policy for clas

2、sification of mishaps, and hence mishap investigation procedures is done by dollar value of loss or injury severity.Lesson(s) Learned: Mishaps involving NASA assets are typically classified only by the actual dollar losses or injury severity caused by the event.Recommendation(s): Consider implementi

3、ng a system in which all mishaps, regardless of actual loss or injury, are assessed by a standing panel of accident investigation specialists. The panel would have the authority to elevate the classification level of any mishap based on its potential for harm. Evidence of Recurrence Control Effectiv

4、eness: NASA NPD 8621.1G defines a mishap as any unplanned occurrence or event resulting from any NASA operation or NASA equipment anomaly. Current human space flight problem reporting systems require reporting and analysis of all operational or equipment anomalies against criteria that includes addr

5、essing the potential for significant loss of life or assets. At this level, the investigative experts are the engineers, managers, and maintainers of the equipment. If an actual mishap were to occur, the Mishap Investigation Team (MIT) would be the first response. All members of this team have had a

6、ccident investigation training and the Chairman has completed the NTSB accident investigation school and USC Aviation Safety curriculums.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Documents Related to Lesson: N/AMission Directorate(s): a71 Explo

7、ration Systemsa71 Sciencea71 Space Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Administration/Organizationa71 Aerospace Safety Advisory Panela71 Policy & Planninga71 Risk Management/Assessmenta71 Safety & Mission AssuranceAdditional Info: Approval Info: a71 Approval Date: 2002-06-27a71 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-,-,-