REG NASA-LLIS-1434--2003 Lessons Learned Accident Investigations Transition Process Integration Functions.pdf

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1、Lessons Learned Entry: 1434Lesson Info:a71 Lesson Number: 1434a71 Lesson Date: 2003-08-31a71 Submitting Organization: JSCa71 Submitted by: David LengyelSubject: Accident Investigations/Transition Process/Integration Functions Abstract: As evidenced by the fact that the Columbia Task Force was often

2、required to be a major integration function between CAIB investigation teams, an independent accident investigation board may require NASA help integrating itself.Description of Driving Event: Columbia Task Force (CTF) was often required to be the major integration function between the Columbia Acci

3、dent Investigation Board (CAIB) Group/Subgroup investigation teams.Lesson(s) Learned: An Independent Accident Board is composed of many diverse members and may not be capable of integrating itself without help from NASA.Recommendation(s): a71 Establish an internal integration function to ensure that

4、 groups and teams integrate their goals, responsibilities, data requests, etc.a71 Select a leader for Each Group/Team within the Boards organization to regulate Group discussion.a71 Define roles and/or areas of investigative responsibility for each Group/Sub-Group member.a71 Identify any overlap of

5、responsibilities for the entire Board.a71 Anticipate when warranted, but it may not be possible to predict an independent investigation Boards structural organization because of a Chairmans personal style, or what flight or ground phase the accident occurred in. Provided by IHSNot for ResaleNo repro

6、duction or networking permitted without license from IHS-,-,-Evidence of Recurrence Control Effectiveness: TBD NASA ResponseDocuments Related to Lesson: Agency Contingency Action Plan for Space Flight OperationsMission Directorate(s): a71 Space Operationsa71 Exploration SystemsAdditional Key Phrase(

7、s): a71 Accident Investigationa71 Administration/Organizationa71 NASA Standardsa71 Policy & Planninga71 Safety & Mission AssuranceAdditional Info: Approval Info: a71 Approval Date: 2004-06-16a71 Approval Name: Ronald Montaguea71 Approval Organization: JSCa71 Approval Phone Number: 281-483-8576Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-