1、Lessons Learned Entry: 0199Lesson Info:a71 Lesson Number: 0199a71 Lesson Date: 1992-11-04a71 Submitting Organization: KSCa71 Submitted by: Lisa L. MusgraveSubject: Flight Readiness Review (FRR) Description of Driving Event: The FRR process which leads to the launch decision is a part of a total mana
2、gement system comprised of many reviews. The chain of events which culminated in the STS 51-L accident indicates that the management process applied to critical flight safety issues was inadequate. The basic engineering understanding of the SRB field joint and the effects of operating at low tempera
3、tures was lacking. Prior qualification testing and analyses were not adequate to support SRB use in temperature ranges forecasted for the STS 51-L launch. The management tools, including the critical items list, did not adequately protect against the possibility of a fatal mishap. The launch decisio
4、n followed established directives, but the engineering knowledge base supporting the launch decision was inadequate.Lesson(s) Learned: The FRR inadequately addressed areas involving Solid Rocket Booster (SRB) flight safety issues which later proved to be critical.Recommendation(s): Revise the launch
5、 decision process to enlarge the engineering data base and ensure critical issues are properly addressed during vehicle processing.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from I
6、HS-,-,-N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Administration/Organizationa71 Policy & Planninga71 Risk Management/Assessmenta71 Safety & Mission AssuranceAdditional Info: Approval Info: a71 Approval Date: 1994-06-06a71 Approval Name: James G. Klinea71 Approval Organization: KSC/HEIa71 Approval Phone Number: 407-867-7614Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
