REG NASA-LLIS-1511--2003 Lessons Learned - Orbital Space Plane - Deemphasis of Safety.pdf

1、Lessons Learned Entry: 1511Lesson Info:a71 Lesson Number: 1511a71 Lesson Date: 2003-07-01a71 Submitting Organization: MSFCa71 Submitted by: Lisa CarrSubject: Orbital Space Plane - Deemphasis of Safety Abstract: The Orbital Space Plane (OSP) Program took many proactive management steps to increase ou

2、r emphasis on safety. Safety must be NASAs highest priority. Description of Driving Event: Significant flaws existed in OSPs implementation approach resulting in a misunderstanding of the S however, safety is most effective when woven into the fabric of all organizational elements from the start of

3、a program.Additionally:a. S therefore, these S&MA documents did not go through a thorough review and feedback process. The “catch-up” desired never materialized, and as a result, the normal safety products expected at SDR were deficient.c. S&MA Requirements. Adequate S&MA requirements were not conta

4、ined in the Level 2 requirements document, and insufficient attention was paid to S&MA data requirements in the contracts. The Program placed so much emphasis on the HRR that we overlooked many, equally important S&MA requirements.d. Level 3 and Level 4 S&MA Requirements Development. Given the inade

5、quate Level 2 S&MA requirements, the Contractors were unable to develop appropriate Level 3 and 4 S&MA requirements.e. Incomplete Understanding. NASA should not assume the Contractor workforce understands the Governments human space flight expectations. Discipline working groups were needed to provi

6、de a forum to assure mutual understanding/interpretation of the S&MA requirements and processes between participating NASA centers, contractors, and related stake holders. Without functioning working groups, the contractors interpretation and implementation of S&MA requirements were questioned and d

7、ebated at each program review. Recommendation(s): Safety must be NASAs highest priority. S&MA managers and support personnel should be involved at the on-set of the program development, and staffing projections should be commensurate with the roles and responsibilities as defined by the program requ

8、irements. The absence of clearly defined success criteria for Program reviews is detrimental to the Program end products, and potentially provides a negative impact to safety. Do not overlook S&MA requirements. Without functioning working groups, the contractors interpretation and implementation of

9、S&MA requirements were questioned and debated at each program review. Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-N/AMission Directorate(s): a71 Exploration Systemsa71

10、Space Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Safety & Mission AssuranceAdditional Info: Approval Info: a71 Approval Date: 2005-04-12a71 Approval Name: Lisa Carra71 Approval Organization: MSFCa71 Approval Phone Number: 256-544-2544Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-