REG NASA-LLIS-1476-2003 Lessons Learned Accident Investigations Investigation Organizer (IO) IO Standard and Ad Hoc Report Capability.pdf

1、Lessons Learned Entry: 1476Lesson Info:a71 Lesson Number: 1476a71 Lesson Date: 2003-08-31a71 Submitting Organization: JSCa71 Submitted by: David LengyelSubject: Accident Investigations/Investigation Organizer (IO)/IO Standard and Ad Hoc Report Capability Abstract: A combination of factors, including

2、 lack of time by investigators to search through “Investigation Organizer“ links on a personal computer and the tools lack of a logic tree report capability severely limited its use.Description of Driving Event: Investigation Organizer (IO) - is a Web-based pre-decisional collaborative information m

3、anagement 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 digital products relevant to an ongoing mishap investigation. IO was used by the Columbia Accident Investigati

4、on Board (CAIB) to connect data from various sources to the storyboard that the Board used to guide its investigation. Documents, digital photographs/video, links were uploaded to the IO database to support the engineering/management investigation logic tree. IO however did not have a capability to

5、provide printed output (reports) for the investigators. Investigators characterized IO as a “one way street” with data going in, and no value to their activities coming out.Lesson(s) Learned: Investigation Organizer (IO) was touted supporting the CAIBs engineering/management investigation logic tree

6、. It was believed that the extensive linking of data gathered across the groups would prevent “stove piping” of data and allow investigators to cross-reference information in support of their findings and recommendations. A combination of factors, including lack of time by investigators to search th

7、rough the IO links on a personal computer and IOs lack of logic tree report capability, severely limited use of the system by other than personnel keying in IO data.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Recommendation(s): The IO Project at

8、ARC must: a71 Develop a set of standard and ad hoc reports for use by investigators. Particular attention should be given to logic trees and lists of supporting data. While it is useful for investigators of major mishaps to spend time behind a personal computer sorting through various logic trees an

9、d their associated linked documents, their time to accomplish this is very limited. This leads to the rendering of IO to a data archiving tool and not an investigative tool. Evidence of Recurrence Control Effectiveness: TBD NASA ResponseDocuments Related to Lesson: Agency Contingency Action Plan for

10、 Space Flight OperationsMission Directorate(s): a71 Space Operationsa71 Exploration SystemsAdditional Key Phrase(s): a71 Accident Investigationa71 Computersa71 Information Technology/Systemsa71 NASA Standardsa71 Policy & Planninga71 Research & Developmenta71 Safety & Mission AssuranceAdditional Info

11、: 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-,-,-