This document discusses ways to improve how NASA communicates lessons learned from past experiences and mishaps. It outlines various techniques NASA currently uses to communicate lessons, including emails, websites, and briefings. However, it notes NASA still repeats mishaps, so communication efforts need improvement. It suggests verifying that lessons are flowing to all relevant parties and publicizing the online lessons learned system more broadly. The overall goal is to better protect people and assets by diligently applying lessons from the past.

1. National Aeronautics and Space Administration
LEARNING
FROM PAST
EXPERIENCES
Michael W. Hulet
NASA
Johnson Space Center
www.nasa.gov 1
12/507

2. National Aeronautics and Space Administration
Introduction
The goal of this presentation is to examine
what we can extrapolate from previous
Lessons Learned attempts and suggest
possible improvements.
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3. National Aeronautics and Space Administration
Background
• Modernization project involving risk
management & program assurance tasks
• Electrical near-fatality MIB identified 2
similar previous occurrences in the same
facility
• Gulfstream III aircraft engine overheating
• Unexpected odor in the EMU
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4. National Aeronautics and Space Administration
Communication Techniques
• Mr. Griffin’s emails contain pointers
• Mr. O’Connor publicizes good reports
• HQ Mishap POC emails mishap
highlights to Center POCs
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5. National Aeronautics and Space Administration
Communication Techniques (cont.)
• JSC Website has a Close Call database
• JSC Hazard Abatement Process on-line
• JSC Sr. Staff Page has mishap report links
• JSC Management Council Briefings
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6. National Aeronautics and Space Administration
Communication Techniques (cont.)
• Some JSC Directorates have email lists
for initial mishap reporting
• JSC Safety Alert
• WSTF has a link to on-site mishap reports
on the homepage
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7. National Aeronautics and Space Administration
Close Calls
• Nitrogen Asphyxiation
• MIWG MISHAP
• Galileo Moisture Damage
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8. National Aeronautics and Space Administration
Close Call Web Site
Close
Call
Web
Site
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9. National Aeronautics and Space Administration
JSC’s Top Level Close Call Process Flow
Actionee
Reporter Safety Office (Fac Mgr, COD,
ISD, etc.)
Investigates &
Reports Close Call Logs into database Sends to Actionee
develops action plan
Sends
Investigation
Sends response Logs response Results to Safety
to Reporter into database (results and action
plan) & proceeds
with action
Forwards Comments to Actionee
Investigatio
Note: After one cycle, Safety will decide
n Results
how to proceed with resolving the issue
adequate?
to avoid an “endless loop.”
N
Y
Answers
Actions N Reporter
complete? concerns and
revises action
Y plan if
Track to completion necessary
Close
the
Close
Call 9

10. National Aeronautics and Space Administration
Hazard Abatement Tracking System (HATS)
What is the HATS?
Why do we have a HATS?
Who maintains the HATS?
• The Occupational Safety Team, NS2
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11. National Aeronautics and Space Administration
Porcelain Press
(What’s Wrong with this Picture)
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12. National Aeronautics and Space Administration
Possible General Improvements
• Verification of flow-down efforts for
findings (lateral and down). This should
include all communication efforts.
• Is the the LLIS on-line location publicity
geared to both to design engineers and
facility safety engineers?
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13. National Aeronautics and Space Administration
Design Improvements
• Is configuration management part of the
process?
• How closely do the system safety analysts
and the quality control assurance people
work?
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14. National Aeronautics and Space Administration
MIB Improvements
• Looking at possible communication
improvements
• Are the same issues that restrict initiating
MIBs also a problem with identifying and
communicating findings?
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15. National Aeronautics and Space Administration
Summary
• NASA has a history of repeating mishaps
• Various tools to mitigate risk
• Communication opportunities available to
prevent repetitive incidents
• We need to do a better job of protecting
NASA people, programs, facilities, and the
public from NASA incidents
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16. National Aeronautics and Space Administration
Summary (cont.)
• Things to consider before and after
mishaps
• What have we done to improve our efforts
to communicate lessons learned?
• Heighten awareness of the Lessons
Learned Information System
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17. National Aeronautics and Space Administration
Summary (cont.)
• The final analysis of the effectiveness in
using Lessons Learned is how diligently
we use them
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