REG NASA-LLIS-1475-2003 Lessons Learned Accident Investigations Investigation Organizer (IO) IO Utilization for Major Mishap Investigations.pdf

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1、Lessons Learned Entry: 1475Lesson Info:a71 Lesson Number: 1475a71 Lesson Date: 2003-08-31a71 Submitting Organization: JSCa71 Submitted by: David LengyelSubject: Accident Investigations/Investigation Organizer (IO)/IO Utilization for Major Mishap Investigations Abstract: The “Investigation Organizer“

2、 management and modeling tool was the primary investigation management tool for the Columbia accident investigation; however, acceptance of the tool was not consistent across investigative groups because some investigators considered it a developmental tool rather than an operational tool.Descriptio

3、n of Driving Event: Investigation Organizer (IO) - is a Web-based pre-decisional collaborative information management and modeling tool designed to support mishap investigation teams. IO provides a centralized information repository that can be used by a distributed team of investigators to store di

4、gital products relevant to an ongoing mishap investigation. It was used by the Columbia Accident Investigation Board (CAIB) to connect data from various sources to the storyboard that the Board used to guide its investigation. IO was developed, maintained and hosted at NASA Ames Research Center (ARC

5、). IO maintainers, Ames Research Center civil servants and contractors, pull required data electronically from the NASA-provided Process Based Mission Assurance (PBMA) database to populate the IO fault tree. IO representatives were placed within each investigation group of the CAIB. Documents, digit

6、al photographs/video, links were uploaded to the IO database to support the engineering/management investigation logic tree. The logistics “footprint” of IO-trained personnel was extensive.Lesson(s) Learned: Although Investigation Organizer was the primary investigation management tool for the Colum

7、bia accident investigation, it was not initially utilized across all investigative groups within the CAIB. It had been previously used on only one other investigation, the loss of the CONTOUR spacecraft. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-

8、,-Acceptance of the tool was not consistent across groups. Some investigators complained that the Board was being forced to use a developmental tool in an operational environment.Recommendation(s): a71 Move the IO tool from a development environment to an operational environment to gain acceptance a

9、s the primary investigative tool across the Agency. This will require continued IO development and training across the NASA investigative community. The ARC IO personnel should expect to support logistics/training during investigations unless the tool can be made easier to use.a71 Codify IO use in t

10、he NASA Mishap Investigation Plan, NPG 8621. 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(s): a71 Accident

11、 Investigationa71 Administration/Organizationa71 Computersa71 Information Technology/Systemsa71 NASA Standardsa71 Policy & Planninga71 Research & Developmenta71 Safety & Mission 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-,-,-