While prior efforts to enhance the investigative process at Kennedy Space Center focused on building analytical capabilities into the human factors mishap investigation, the lack of the structured approach to the investigative process fostered the possibility of incomplete and incorrect assessments of human error. A standardized method was necessary to provide investigators with a process that allowed for a comprehensive examination of the facts and circumstances of events, while providing a more efficient and effective method for investigating mishaps.

For the first time in the history of the U.S. Space Program, human factors mishap investigations at KSC are being conducted in a process consistent with the multimodal transportation investigative community. Sound, time-proven incident and accident investigation principles and procedures are being implemented for use by investigators to enhance their abilities to conduct thorough investigations of mishaps. The entire standardized process will facilitate easier identification of problem areas around KSC, promote a more efficient investigative process, provide a means to train investigators more easily, and promote the recommendation of comprehensive improvements and enhancements centerwide.

While the purpose of the investigative process is to determine causal and contributing factors that led to incidents and accidents, the goal of the investigator is to provide meaningful, achievable recommendations to prevent a recurrence of events and enhance safety. The standardized investigation process being implemented at KSC is the key to attaining that goal. The phased approach to implementation of various elements of the standardized process is underway and has already been successful in promoting the comprehensive, efficient, and effective methodology of investigating mishaps that was desired.

Key accomplishments:

• August 2001: Development of the Mishap Investigation Operating Procedure.
• October 2001: Development of Phase II, including Interview Protocol and Investigators Standard Glossary.
• December 2001: Successful completion and implementation of Phase I, including the Standardized Investigation Protocol, the Standard Investigation Report Format, the Human Factors Investigation Checklist, and the Investigation Kit list.

Key milestones:

• April 2002: Purchase and acquisition of all items on the Investigation Kit list.
• August 2002: Successful completion and implementation of the Mishap Investigation Operating Procedure.
• December 2002: Completion and implementation of all Phase II elements.

Contact: M.M. Groh-Hammond (Marcia.Groh-Hammond-1@ksc.nasa.gov), PH-M3-A, (321) 861-0572
Participating Organization: United Space Alliance (L.A. Bottos, G.P. Sweeney, H.W. Riley, D.J. Godwin, P.A. Hollis, J.R. Ewald, and C.S. Oyler)