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Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
Michael.hulet
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Michael.hulet

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  • 1. National Aeronautics and Space Administration LEARNING FROM PAST EXPERIENCES Michael W. Hulet NASA Johnson Space Centerwww.nasa.gov 1 12/507
  • 2. National Aeronautics and Space Administration IntroductionThe goal of this presentation is to examinewhat we can extrapolate from previousLessons Learned attempts and suggestpossible improvements. 2
  • 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 3
  • 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 4
  • 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 5
  • 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 6
  • 7. National Aeronautics and Space Administration Close Calls• Nitrogen Asphyxiation• MIWG MISHAP• Galileo Moisture Damage 7
  • 8. National Aeronautics and Space Administration Close Call Web SiteCloseCallWebSite 8
  • 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 AdministrationHazard Abatement Tracking System (HATS) What is the HATS? Why do we have a HATS? Who maintains the HATS? • The Occupational Safety Team, NS2 10
  • 11. National Aeronautics and Space Administration Porcelain Press (What’s Wrong with this Picture) 11
  • 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? 12
  • 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? 13
  • 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? 14
  • 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 15
  • 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 16
  • 17. National Aeronautics and Space Administration Summary (cont.)• The final analysis of the effectiveness in using Lessons Learned is how diligently we use them 17

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