REG NASA-LLIS-1251-2001 Lessons Learned Failure to Report an Incident as a NASA Mishap.pdf

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1、Lessons Learned Entry: 1251Lesson Info:a71 Lesson Number: 1251a71 Lesson Date: 2001-04-21a71 Submitting Organization: GSFCa71 Submitted by: Susan Breon/ Catherine BowerSubject: Failure to Report an Incident as a NASA Mishap Description of Driving Event: Early on Saturday, April 21, 2001, a pipe in t

2、he secondary water system failed in the basement of Building 8 at the NASA Goddard Space Flight Center. The primary asset damaged by the resulting flood was the NASA photo archive, located immediately below the location where the pipe failed. Although the incident was reported verbally and by e-mail

3、 to Goddard management, no formal NASA Mishap Report Form 1627 was filed until 6 weeks after the incident. The supervisors who were affected by the flood were unaware of their responsibility to file a written report. One supervisor who did attempt to write up the incident could not complete the repo

4、rt because of lack of information on the value of the damaged asset. The process for submitting the NASA Mishap Report Form 1627 is cumbersome and ill-defined. Most supervisors who do not have frequent experiences with mishaps and mishap reporting are unaware that they are responsible for the paperw

5、ork. The form also requires an assessment of the value of the damaged asset, which in this case could not be determined. Finally, the form is not available on-line at Goddard, but employees are directed to request a copy from the Safety and Environmental Branch.Lesson(s) Learned: Supervisors who are

6、 dealing with a crisis would benefit from outside support in understanding and carrying out their reporting responsibilities. They also need periodic reminders of their responsibilities and updates on changes in procedures.Recommendation(s): Streamline the reporting of incidents. There are organizat

7、ions at Goddard who have regular contact with the mishap reporting system: let them provide the necessary training and guidance to supervisors in the event of a mishap. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Evidence of Recurrence Control Ef

8、fectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Administration/OrganizationAdditional Info: Approval Info: a71 Approval Date: 2002-07-09a71 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-,-,-