REG NASA-LLIS-1438--2003 Lessons Learned Accident Investigations Background Information.pdf

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1、Lessons Learned Entry: 1438Lesson Info:a71 Lesson Number: 1438a71 Lesson Date: 2003-08-31a71 Submitting Organization: JSCa71 Submitted by: David LengyelSubject: Accident Investigations/Background Information Abstract: Because some investigation board members may have minimal knowledge of space fligh

2、t systems, NASA needs to anticipate this and be better prepared with technical and procedural materials to increase the board members learning curve.Description of Driving Event: Some Columbia Accident Investigation Board (CAIB) members arrived with minimal knowledge of Space Shuttle systems. Subseq

3、uently, the action/request for information system was flooded with informational and data requests to come up to speed, slowing down the NASA technical investigation/analysis.Lesson(s) Learned: NASA needs to be better prepared to handle the independent investigators in terms of technical and procedu

4、ral materials that will increase the learning curve of Board members.Recommendation(s): a71 Anticipate and prepare for an educational process for an independent accident investigation board. Readily available data such as drawing databases and existing websites that an independent Board can have imm

5、ediate access to should be kept up-to-date and more user friendly.a71 Create a directory or cheat sheet with pointers to existing databases, websites, etc. NASA contingency planning should maintain basic documentation procedures that will always be scrutinized in a major investigation (e.g. maintena

6、nce, facilities, safety programs, contracts, Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-training).a71 Improve archival system to provide the most rapid possible recovery and delivery of documentation that shows vehicle histories, problems, etc.a

7、71 Assign this background function to NASAs on-site library system or to the flight program offices. Evidence of Recurrence Control Effectiveness: TBD NASA ResponseDocuments Related to Lesson: Agency Contingency Action Plan for Space Flight OperationsMission Directorate(s): a71 Space Operationsa71 E

8、xploration SystemsAdditional Key Phrase(s): a71 Accident Investigationa71 Administration/Organizationa71 Human Resources & Educationa71 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-,-,-