REG NASA-LLIS-1477--2003 Lessons Learned Accident Investigations Minutes Taking Support to Board.pdf

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1、Lessons Learned Entry: 1477Lesson Info:a71 Lesson Number: 1477a71 Lesson Date: 2003-08-31a71 Submitting Organization: JSCa71 Submitted by: David LengyelSubject: Accident Investigations/Minutes Taking Support to Board Abstract: The hiring of safety and mission assurance/engineering personnel, not ski

2、lled in minutes taking, to support the Investigation Board provided unsatisfactory results. Subsequent hiring of skilled minutes-takers resolved the problem.Description of Driving Event: The Columbia Task Force (CTF) was tasked with hiring minutes-taking support for the Columbia Accident Investigati

3、on Board (CAIB). The CTF hired safety and mission assurance/engineering personnel from The Aerospace Corporation to do this task. These personnel were not skilled in minutes taking and regressed to a process of audio recording of board deliberations. The Aerospace personnel then provided quasi-trans

4、cripts of these tapes as minutes. The products were not delivered in a timely fashion (sometimes weeks after the meeting) for review by the CAIB executive secretary and were, for the most part, of very poor quality. Tracking of meeting minutes was also problematic with the Aerospace personnel. This

5、problem was remedied finally by the hiring of a skilled minutes-taking person who produced a quality set of minutes within hours of the board meeting.Lesson(s) Learned: To support the minutes taking requirements of an accident investigation board in a professional manner, the hiring of non-skilled p

6、ersonnel to do this task is totally unacceptable.Recommendation(s): a71 Hire professional meeting minute takers at the outset of the investigationa71 Add this requirement to the Contingency Action Plan (CAP) Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IH

7、S-,-,-Evidence of Recurrence Control Effectiveness: TBD NASA ResponseDocuments Related to Lesson: Agency Contingency Action Plan for Space Flight OperationsMission Directorate(s): a71 Space Operationsa71 Exploration SystemsAdditional Key Phrase(s): a71 Accident Investigationa71 Administration/Organi

8、zationa71 NASA Standardsa71 Policy & Planninga71 Safety & Mission AssuranceAdditional Info: 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-,-,-

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