1、Lessons Learned Entry: 0929Lesson Info:a71 Lesson Number: 0929a71 Lesson Date: 2000-11-29a71 Submitting Organization: JPLa71 Submitted by: K. Atkins, D. OberhettingerSubject: Planning Effective Project Reviews (1999) Abstract: The root cause of the Mars Climate Orbiter (MCO) mission failure was iden
2、tified as cumulative navigation errors. These errors resulted, in part, from operational procedures and software that were inadequately reviewed, evaluated, and implemented. A high degree of formality, anomaly follow-up and close out, selection of reviewers and penetration of technical issues is ess
3、ential in the review process, including the design, operational, and peer reviews.Description of Driving Event: The root cause of the Mars Climate Orbiter (MCO) mission failure was identified as cumulative navigation errors. These errors resulted, in part, from operational procedures and software th
4、at were inadequately reviewed, evaluated, and implemented.During development and operational phases, review board membership frequently did not include the appropriate discipline experts to identify important issues. For example, the Navigation line organization was not represented at the “MOI (Mars
5、 orbit insertion) and Aerobraking Readiness Review“ during which information on cumulative navigational errors was provided. Contrary to established best practices, requests for action were not generated to address issues identified during this review. Neither the project nor the line organizations
6、utilized peer reviews to their full potential.References:1. “Management of MCO Risks During Mars Encounter,“ Lesson Learned No. 09162. “Report on the Loss of the Mars Climate Orbiter Mission,“ JPL D-18441, JPL Special Review Board, November 11, 1999.3. “Phase I Report,“ (NASA) Mars Climate Orbiter M
7、ishap Investigation Board, November 10, Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-19994. “Mars Climate Orbiter Mishap Investigation Board Phase I Report“, Lesson Learned Number 0641, December 1, 19995. Corrective Action Notice No. Z66277, MCO-J
8、PL/SRB Finding #4.11: “Effectiveness of Reviews,“ November 23, 1999.6. Corrective Action Notice No. Z69160, Mars Program Investigation Results: Review Process, May 1, 2000.7. JPL Policy: “Reviews,“ Rev. 7, JPL Document DMIE-10389, October 18, 2000; JPL Guidelines for Reviews (D-10401), Rev. A, JPL D
9、ocument DMIE-35163, August 15, 1998.Lesson(s) Learned: A high degree of formality and penetration of technical issues is essential in the review process, including the design, operational, and peer reviews.Recommendation(s): 1. Line organizations should assign appropriate representatives to attend r
10、eviews in their respective disciplines. For example, the Navigation line organization should be involved in system design reviews and attend all launch readiness and mission orbit insertion reviews.2. Review boards should assess the project proposed review agendas as stated in JPL/NASA center policy
11、 and guidelines for reviews. (see Reference 7 for JPL review policy) The board chairman should review with the board the criteria for reviews. The review board chair should review the planned implementation of the established guidelines and procedures with the process owner for technical reviews.3.
12、Review board members should be advised by the board chair to pursue reasons for all anomalies revealed during reviews and ensure that appropriate action items are documented.4. JPL/NASA center policy and guidelines should be modified as necessary to emphasize the need to conduct, the value of, and t
13、he implementation of peer reviews.Additional Keyword: Formal ReviewEvidence of Recurrence Control Effectiveness: A JPL Corrective Action Notice has been assigned and practices have been modified.Documents Related to Lesson: N/AMission Directorate(s): Provided by IHSNot for ResaleNo reproduction or n
14、etworking permitted without license from IHS-,-,-a71 Exploration Systemsa71 Sciencea71 Space Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Aircrafta71 Flight Operationsa71 Flight Equipmenta71 Ground Equipmenta71 Launch Processa71 Payloadsa71 Policy & Planninga71 Risk Management/Ass
15、essmenta71 Safety & Mission Assurancea71 SpacecraftAdditional Info: Approval Info: a71 Approval Date: 2001-03-05a71 Approval Name: Eric Raynora71 Approval Organization: QSa71 Approval Phone Number: 202-358-4738Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
