REG NASA-LLIS-1449--2003 Lessons Learned - Accident Investigations Action Request System.pdf

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1、Lessons Learned Entry: 1449Lesson Info:a71 Lesson Number: 1449a71 Lesson Date: 2003-08-31a71 Submitting Organization: JSCa71 Submitted by: David LengyelSubject: Accident Investigations/Action Request System Abstract: Complex Action/Request for Information Forms require numerous iterations to impleme

2、nt cross-organizationally and may cause the authorization process to break down.Description of Driving Event: For the Columbia accident investigation, the Action/Request for Information Form format took a long time to establish, which caused many investigators to use obsolete and discontinued format

3、s. A significant amount of time was spent backtracking and cataloging actions and responses/data that were created prior to selecting a specific format.Lesson(s) Learned: Complex forms will take endless iterations to implement evenly across all organizations and may cause the action authorization pr

4、ocess to break down.Recommendation(s): a71 Establish the Action Request process within the first days of Board arrival.a71 Have all action/information requests screened by Task Force technical leads to ensure the requests are detailed enough to be accurately interpreted during initial review by NASA

5、 data providers and specifically germane to the investigation. Forms, tracking logs, and files/database must accommodate sensitive/proprietary (legal, medical, contractual, national security, export control (ITAR) data and generic/public data required by the Investigative Board as well as unsolicite

6、d data provided by the public, private industry, and/or political sector.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Establish an authoritative lead immediately for sensitive/secure data to determine what data should be evaluated and marked (

7、export controlled, sensitive, proprietary, etc.) or whether all documentation should be protected with a global/generic statement.a71 Inform the Board early on known sensitive data process requirements. Ensure that this authority reviews any data that are to be released to the public.a71 Audit the s

8、ystem process regularly. Board and TF CM leads must:a71 Create an action tracking form immediately that captures actions and closure response processes tailored to the accident specifics (recommend the attached). Evidence of Recurrence Control Effectiveness: TBD NASA ResponseDocuments Related to Les

9、son: Agency Contingency Action Plan for Space Flight OperationsMission Directorate(s): a71 Space Operationsa71 Exploration SystemsAdditional Key Phrase(s): a71 Accident Investigationa71 Administration/Organizationa71 Configuration Managementa71 NASA Standardsa71 Policy & Planninga71 Safety & Mission

10、 AssuranceAdditional Info: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-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-,-,-