1、Lessons Learned Entry: 1067Lesson Info:a71 Lesson Number: 1067a71 Lesson Date: 1999-02-01a71 Submitting Organization: HQa71 Submitted by: David M. LengyelSubject: Space Shuttle Program/Operations-Processing/Documentation Description of Driving Event: Incorrect Documentation “Paperwork“ is Causing Pr
2、ocessing ErrorsLesson(s) Learned: A principal cause of Space Shuttle processing errors is incorrect documentation (“paperwork“).Recommendation(s): NASA and Shuttle Processing Contract (SPC) must place increased priority on determining error sources, causes, and corrective actions for inadequacies in
3、 the documentation on which Space Shuttle processing is based and develop a management system that drastically reduces the time that it takes to incorporate paperwork changes.Evidence of Recurrence Control Effectiveness: NASA concurs with the recommendation. NASA and SPC have established metrics to
4、identify the types of errors and error sources in the processing documentation. During daily interface, NASA and SPC discuss these metrics and perform causal analysis to identify the need for corrective action. For critical procedures, SPC has implemented a check and balance in the work instruction
5、generation process to increase the procedure quality before it is worked. Additionally, NASA and SPC have an initiative to reduce the complexity of work procedures, increase the procedure standardization, and reduce the time for paperwork generation for work not requiring engineering disposition.Mor
6、e importantly, SPC is developing, as a high priority, a paperless system. Specifically, the Ground Operations organization at KSC is implementing an integrated on-line system that ensures total Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-process
7、rigor and mitigates the potential for human error in accomplishing space flight work. This system incorporates recognized “best practices“ for authoring work documents including on-line review and approval, and the ability for authors to automatically update and incorporate work document deviations.
8、 Required checks and balances are inherent in the system to maintain the integrity, safety and quality of both flight and ground work performed. Work documents will clarify user understanding by incorporating enhanced explanations with in-line graphics, sound and video where required. The goal of th
9、is activity is to ensure that a properly certified person, utilizing the right work instructions, has safely accomplished all required work.Documents Related to Lesson: N/AMission Directorate(s): a71 Space Operationsa71 Exploration SystemsAdditional Key Phrase(s): a71 Aerospace Safety Advisory Panel
10、a71 Ground Operationsa71 Human Factorsa71 Policy & Planninga71 SpacecraftAdditional Info: Approval Info: a71 Approval Date: 2002-01-07a71 Approval Name: Bill Loewya71 Approval Organization: HQa71 Approval Phone Number: 202-358-0528Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
