REG NASA-LLIS-1381--1999 Lessons Learned ProSEDS Risk Review.pdf

1、Lessons Learned Entry: 1381Lesson Info:a71 Lesson Number: 1381a71 Lesson Date: 1999-12-30a71 Submitting Organization: MSFCa71 Submitted by: Leslie A. CurtisSubject: ProSEDS Risk Review Abstract: Many of the problems experienced by NASA projects are not as unique as they may first seem. This lesson c

2、ontains major findings from a 1999 review of the Mars Climate Observer (MCO) mishap report to gather “lessons learned“ which might be applied to help the ProSEDS project team assure mission success. All MCO contributing causes & corrective actions were reviewed and a list of “lessons“ was developed

3、to help assure ProSEDS mission success.Description of Driving Event: Following the MCO mishap, the ProSEDS team decided to perform an in-depth review of the MCO mishap report to gather lessons learned and recommendations that could prevent future problems for ProSEDS project and would help prevent N

4、ASA from repeating past mistakes. Lesson(s) Learned: Many of the problems experienced by NASA projects are not unique. The review of problem and failure reports, and the application of lessons learned must be done to prevent repeating past mistakes. The following specific “lessons“ learned from the

5、MCO mishap were applied to ProSEDS: 1. Inconsistent use of English versus metric units can have a disastrous impact.2. Project managers must assure that mission operations & data analysis personnel, often excluded from engineering and design reviews, have an adequate understanding of the systems cri

6、tical performance characteristics so that operational personnel can make better “real-time“ decisions during mission ops.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-3. Systems engineering must be done to assure adequate transition from developmen

7、t to operations and to assure proper flow of information between engineering/navigation and operations personnel.4. Unless a formal method of documenting “concerns“ exists and is available to all disciplines, concerns can continue to “slip through the cracks.“5. Assure adequate staffing to support c

8、ritical operations.6. For incident, anomaly, and similar reporting systems to be successful, personnel must be aware of such systems exist and should know when and how to use them.7. End-to-end software verification & validation must be performed to minimize potential software vulnerabilities.8. It

9、is beneficial for a project to have a single point of contact whose job is to continuously ask the healthy question, “What could possibly go wrong?“9. Formal analysis methods such as fault tree analysis, FMEA, etc. should be employed in analyzing potential hazards, concerns, etc.Recommendation(s): M

10、ajor Recommendation: Project teams should review failure reports and seek lessons learned to apply to their own situations. Secondary Recommendations related to project management: 1. Make provisions for effectively managing the use of English & Metric engineering units and conversions.2. Assure tha

11、t operational personnel are involved enough with the engineering/design disciplines. This helps operations personnel more effective and helps assure “minor“ changes will not become major problems.3. Systems engineering must be done to assure adequate transition from development to operations and to

12、assure proper flow of information between all disciplines, including operations.4. A formal method of documenting project “concerns“ should exist and be made available to all disciplines.5. Assure adequate staffing to support critical operations, especially during operation.6. Project personnel must

13、 be aware of the projects reporting mechanisms for incidents, anomalies, concerns, and should be trained in when and how to use them.7. End-to-end software verification & validation must be performed to minimize potential software vulnerabilities.8. Assign a person who is responsible for continually

14、 asking “What could possibly go wrong?“9. Take full advantage of formal analysis methods such as fault tree analysis, FMEA, etc. to help analyze potential hazards, concerns, etc. This makes the process less subjective, therefore less prone to error.Evidence of Recurrence Control Effectiveness: Provi

15、ded by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-N/ADocuments Related to Lesson: ProSEDS Mission Safety/Success Review ReportMission Directorate(s): a71 Exploration Systemsa71 Sciencea71 Space Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71

16、 Accident Investigationa71 Mishap Reportinga71 Program and Project Managementa71 Risk Management/AssessmentAdditional Info: Approval Info: a71 Approval Date: 2004-02-09a71 Approval Name: Lisa Boninea71 Approval Organization: MSFCa71 Approval Phone Number: 256-544-2544Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-