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#11
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![]() My question is this: Is the culture worse at NASA than other places, or does NASA have problems that are in other industries, and these other places get away with it because the problem with their culture doesn't result in a highly visible catastrophic event. That's pretty much it. Screw ups at most companies just end up wasting loads of time and money. Products that had flawed marketing research, or flawed overall systems architecture would be worked on for months. Usually lots of attention is focused on lower level details, but any misgivings on the overall thing would rarely be mentioned. Or only to non-managers say at off site lunches or such. No real point in telling the bosses, the project might just get canceled now instead of a year later. At least you have time to find a new job so you can bail out of that place before it crashes and burns.... Some problems can crop up if there are many younger guys just out of college. Things like schedules on projects on things never done before, vs school projects that have been done thousands of times before. I eventually figured out that a boss wants a schedule that depends on no major showstoppers happening. But that nobody gets canned because of a showstopper that slips the schedule. And it's actually rare that a project actually gets done on the original optimistic schedule. Other things that look to be crazy at first (like doing some tasks early on before you really know if you'll really need them or not) turn out to be sensible (you have a crew of workers with not much to do until you get the overall scheme of the project worked out, but it's still a good bet that whatever form it takes you will still need sub-assembly X, Y and Z, so you might as well have the idle crewmembers do those. At worse maybe Y was a waste of time, but so would have having them do nothing would be a bigger waste of time). This stuff doesn't get taught in engineering school, it's probably just assumed that you would know it. At most companies, managers trying to intimidate the engineers to get something to work is fairly common. But you can't intimidate hardware into working. Then you get O ring failures on shuttles... One thing you start to take some comfort in is that you realize that your competitors are likely equally screwed up. Another thing is that I would estimate that maybe 5% of everything I ever worked on actually got used and "saw the light of day". Not that I'm particularly incompetent, :-) but just that most work just gets abandoned one way or another. The cartoon "Dilbert" rings true suprizingly often.... |
#12
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Derek Lyons wrote:
"Danny Dot" wrote: Let me ask you this: If management made a decision that you thought was unsafe, would you feel comfortable speak up against the decision? At NASA most would not. Management would bully the person that spoke up. At least this is my opinion of the matter. Ah yes - the engineer puts his 'comfort' and job ahead of the lives he's been entrusted with. But its all managements fault. D. Here are two pages with some information directly pertaining to nasa culture, and how recomnedations from the Diaz report to the caib are being implemented to improve the issues (raised by both the columbia and challenger tragedy investigatory bodies) inside nasa. http://www.onenasa.nasa.gov/NEWS/Archives_of_News.htm Release of Implementation Plan for Diaz Team Report An Agency-wide team, under the leadership of Mr. Al Diaz, former Director of the Goddard Space Flight Center, was commissioned to assess the broader implications of the Columbia Accident Investigation Board's (CAIB) Report on activities across the agency. The final Diaz Team Report is entitled "A Renewed Commitment to Excellence: An Assessment of the NASA Agency-wide Applicability of the Columbia Accident Investigation Board Report and was released on January 30, 2004 (problematic viewing report in Netscape's older versions). During the NASA Update conducted on February 9, 2004, the Administrator indicated that the One NASA Team would be responsible for creation of the Implementation Plan for the Diaz Team Report. On March 30, 2004, the One NASA Team, along with members of senior management and their staff who served as Action Leads, completed the implementation plan - "The Implementation of the NASA Agency-wide Application of the Columbia Accident Investigation Board Report: Our Renewed Commitment to Excellence." The Implementation Plan was put into effect and many of the Actions of the plan were completed. A follow-up detailed review of the Actions was performed and it found that ten of the 24 actions were completed (see briefing to Operations Management Council). Three were terminated because their focus had been adopted by other studies. Ten actions were converted to functional organization activities and one action, #5, remains pending a briefing by OSMA to the Operations Management Council. The Deputy Administrator's memo of March 27, 2005 documents the disposition of the actions." http://www.onenasa.nasa.gov/NEWS/SMS...mary_Final.pdf "Safety and Mission Success Week Agency-Wide Summary Executive Summary Safety and Mission Success Week was designed to facilitate open communication, and to engage the entire NASA community in addressing the CAIB Report. Each Center Director was asked to champion the week's events and collect feedback from their workforce. After holding the work unit discussions, Center Directors were asked facilitate a data rollup into the main ideas from their Center. Data roll up validated the results of the CAIB and the Diaz Forty Actions. Data from center roll ups were analyzed by a subset of the One NASA Team. The "One NASA Data Team" included members from ARC, GSFC, GRC, and JSC. The team examined the final Center reports and after completing their three-phase analysis arrived at summary descriptions of the themes submitted by the Centers as well as the following 12 cross-cutting themes. Each cross cutting theme was a major idea or theme in at least two Center Reports. 1. NASA should willfully seek out and understand minority opinions. This includes establishing a process to collect anonymous feedback, and holding meetings that encourage open discussion. 2. Resources including time, human capital, and cash flow should be allocated realistically and according to the design standards set forth at project conception. 3. Strategic planning should be relevant for every employee, include human capabilities needed for the future, and be the baseline for on going initiatives. 4. The Agency needs a strategy for leadership development that includes/supports a specific set of skills for all levels of management. These skills should then be used for evaluating performance and making personnel decisions such as promotions and awards. 5. Decisions should be made based on what is best for the Agency, be placed in context using Agency priorities, guide allocation of resources, and be fully rationalized and communicated to the workforce. 6. NASA needs a truly independent safety organization as described in the CAIB report. This organization should serve as a clearinghouse for any safety related concerns from any employee. 7. NASA needs to clarify the organizational structure of the Agency. Current matrix system is too complex and is not perceived as a useful management tool. 8. Safety expertise should exist for every specific discipline within the Agency. 9. NASA needs an increased value on respect for others. All those affected by the decision should be part of the decision making process. Leaders should have the responsibility to provide employees with full information regarding decisions, including options considered, and rationale for making final choice. 10. NASA needs more emphasis on the entire lifespan of projects to avoid being tied up in unnecessary processes, or lengthy approvals that draw resources away from goal achievement. Appropriate procedures should be established, and followed from project conception to completion. 11. NASA should use/design ONE tool to capture expertise and lessons learned in all areas. The tool should be easily accessible, and actively used by the workforce. 12. Contractors should not be used to supply core competency expertise. Building from an inclusive strategic plan the Agency should determine what capabilities should be kept in house, and what capabilities should be provided by contractors. The themes were mapped against the 7 Diaz Team goals outlined in: A Renewed Commitment to Excellence: An Assessment of the NASA Agency-wide Applicability of the Columbia Accident Investigation Board Report. This document is intended to provide a clear picture of the steps taken to analyze the Safety and Mission Success Week...." Open sharing of information is crucial to improving everybody's understanding of the universe around us. Tom |
#14
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Terrell Miller wrote: "read the book "Normal Accidents" by Charles
Perrow. Very common phenomenon (esp. in teh industries you mentioned) created by scheduling pressure. 9/11 was a prime example, as was every fatal manned spacecraft accident, as was the big power blackout a couple years ago, as was the BP accident recently." Interesting examples you have cited above, each of which is unique, but interconnect by the use of managing risks, and risk analysis. The manned space program has many similarities with large corporations when it comes to the topic management, and specifically managing risks, and risk analysis, as nasa itself is comprised of many centers, each of which interacts with vendors uniquely for the purpose of developing new safe technologies or maintaining current programs safely. Now with respect to you're example of 9/11 or specifically national security, a quantitative risk assessment will assist the intelligence community in managing the massive amounts of data gathered and categorizing high and low level threats, something recommended by the 9/11 commission Now back on topic with the nasa and the shuttle, as the purpose of conducting a full system quantitative risk analysis on the space shuttle system is to help nasa managers in making their professional decisions of managing risks and operating the space shuttle safely within its designed parameters and in compliance with all human space flight procedures through retirement. Now implementing the recommendations contained in the diaz report to the caib, in conjunction with a full quantitative risk assessment of the shuttle system would provide nasa managers with the communication structure, information, and technology to manage and understand the technical input from others up and down the decision making process in operating the shuttle safely within it's capabilities throughout the fleets retirement process. Here are two pages with some information directly pertaining to nasa culture, and how Recommendations from the diaz report to the caib are being implemented to improve issues inside nasa. http://www.onenasa.nasa.gov/NEWS/Archives_of_News.htm Release of Implementation Plan for Diaz Team Report An Agency-wide team, under the leadership of Mr. Al Diaz, former Director of the Goddard Space Flight Center, was commissioned to assess the broader implications of the Columbia Accident Investigation Board's (CAIB) Report on activities across the agency. The final Diaz Team Report is entitled "A Renewed Commitment to Excellence: An Assessment of the NASA Agency-wide Applicability of the Columbia Accident Investigation Board Report and was released on January 30, 2004 (problematic viewing report in Netscape's older versions). During the NASA Update conducted on February 9, 2004, the Administrator indicated that the One NASA Team would be responsible for creation of the Implementation Plan for the Diaz Team Report. On March 30, 2004, the One NASA Team, along with members of senior management and their staff who served as Action Leads, completed the implementation plan - "The Implementation of the NASA Agency-wide Application of the Columbia Accident Investigation Board Report: Our Renewed Commitment to Excellence." The Implementation Plan was put into effect and many of the Actions of the plan were completed. A follow-up detailed review of the Actions was performed and it found that ten of the 24 actions were completed (see briefing to Operations Management Council). Three were terminated because their focus had been adopted by other studies. Ten actions were converted to functional organization activities and one action, #5, remains pending a briefing by OSMA to the Operations Management Council. The Deputy Administrator's memo of March 27, 2005 documents the disposition of the actions." http://www.onenasa.nasa.gov/NEWS/SMS...mary_Final.pdf "Safety and Mission Success Week Agency-Wide Summary Executive Summary Safety and Mission Success Week was designed to facilitate open communication, and to engage the entire NASA community in addressing the CAIB Report. Each Center Director was asked to champion the week's events and collect feedback from their workforce. After holding the work unit discussions, Center Directors were asked facilitate a data rollup into the main ideas from their Center. Data roll up validated the results of the CAIB and the Diaz Forty Actions. Data from center roll ups were analyzed by a subset of the One NASA Team. The "One NASA Data Team" included members from ARC, GSFC, GRC, and JSC. The team examined the final Center reports and after completing their three-phase analysis arrived at summary descriptions of the themes submitted by the Centers as well as the following 12 cross-cutting themes. Each cross cutting theme was a major idea or theme in at least two Center Reports. 1. NASA should willfully seek out and understand minority opinions. This includes establishing a process to collect anonymous feedback, and holding meetings that encourage open discussion. 2. Resources including time, human capital, and cash flow should be allocated realistically and according to the design standards set forth at project conception. 3. Strategic planning should be relevant for every employee, include human capabilities needed for the future, and be the baseline for on going initiatives. 4. The Agency needs a strategy for leadership development that includes/supports a specific set of skills for all levels of management. These skills should then be used for evaluating performance and making personnel decisions such as promotions and awards. 5. Decisions should be made based on what is best for the Agency, be placed in context using Agency priorities, guide allocation of resources, and be fully rationalized and communicated to the workforce. 6. NASA needs a truly independent safety organization as described in the CAIB report. This organization should serve as a clearinghouse for any safety related concerns from any employee. 7. NASA needs to clarify the organizational structure of the Agency. Current matrix system is too complex and is not perceived as a useful management tool. 8. Safety expertise should exist for every specific discipline within the Agency. 9. NASA needs an increased value on respect for others. All those affected by the decision should be part of the decision making process. Leaders should have the responsibility to provide employees with full information regarding decisions, including options considered, and rationale for making final choice. 10. NASA needs more emphasis on the entire lifespan of projects to avoid being tied up in unnecessary processes, or lengthy approvals that draw resources away from goal achievement. Appropriate procedures should be established, and followed from project conception to completion. 11. NASA should use/design ONE tool to capture expertise and lessons learned in all areas. The tool should be easily accessible, and actively used by the workforce. 12. Contractors should not be used to supply core competency expertise. Building from an inclusive strategic plan the Agency should determine what capabilities should be kept in house, and what capabilities should be provided by contractors. The themes were mapped against the 7 Diaz Team goals outlined in: A Renewed Commitment to Excellence: An Assessment of the NASA Agency-wide Applicability of the Columbia Accident Investigation Board Report. This document is intended to provide a clear picture of the steps taken to analyze the Safety and Mission Success Week...." Open sharing of information is crucial to improving everybody's understanding of the universe around us. Tom |
#15
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After reading the posts to this thread, maybe something different with NASA
is the time frame for a bad management decision to result in the catastrophe. At NASA it may be just a few hours. The dissenting engineer at NASA doesn't have time to get his fellow engineers and low level managers on his side and let the decision makers realize what his happening. Time from discovery to failure is longer for most industries than it is for NASA???? Just a thought on my part. Danny Dot www.mobbinggonemad.org |
#16
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Danny Dot wrote:" After reading the posts to this thread, maybe
something different with NASA is the time frame for a bad management decision to result in the catastrophe. At NASA it may be just a few hours. The dissenting engineer at NASA doesn't have time to get his fellow engineers and low level managers on his side and let the decision makers realize what his happening. Time from discovery to failure is longer for most industries than it is for NASA???? Just a thought on my part." The purpose of establishing the independent technical authority within nasa is so that "All programs should have the benefit of an independent engineering authority to ensure that technical standards are being met" according to the diaz report to the caib and that a flights readiness is independently verified. Now implementing the recommendations contained in the diaz report to the caib, in conjunction with a full quantitative risk assessment of the shuttle system would provide nasa managers the communication structure, information, and technology to manage and understand the technical input from engineers up and down the decision making process in determining flight readiness. Providing an independent authority in backing minority opinions who are opposed to declaring a flight is ready, should help improve communications and speed up the process for flight readiness determination as managers will have assistance in correlating the minority opinion with things such as previously granted waivers.. The establishment of the independent technical authority is a definite step in a positive direction for nasa, as they are currently implementing a partial quantitative risk assessment (qra), but a full shuttle system qra will assist nasa engineers and managers in operating the shuttle safely within it's capabilities throughout the fleets retirement process. Diaz report to the caib page and pertinent factors Diaz report to the caib page a-9 Caib report recomnedations Engineering Authority that is responsible for technical requirements and all waivers tto them, and will build a disciplined, systematic approach to identifying, analyzing, and controlling hazards throughout the life cycle of the Shuttle System. The independent technical authority does the following as a minimum: · Develop and maintain technical standards for all Space Shuttle Program projects and elements · Be the sole waiver-granting authority for all technical standards · Conduct trend and risk analysis at the sub-system, system, and enterprise levels · Own the failure mode, effects analysis and hazard reporting systems · Conduct integrated hazard analysis · Decide what is and is not an anomalous event · Independently verify launch readiness · Approve the provisions of the recertification program called for in Recommendation R9.1-1 The Technical Engineering Authority should be funded directly from NASA Headquarters, and should have no connection to or responsibility for schedule or program cost. Diaz summary discussion All programs should have the benefit of an independent engineering authority to ensure that technical standards are being met. No programs should have the ability to waive technical standards or compromise a standard without the review and approval of an appropriate engineering authority. All projects and programs should conduct risk analysis consistent with Agency policy regarding risk management. All Centers should have the capability in either their engineering or Safety and Mission Assurance (SMA) organizations to perform and or review failure modes and effects analysis, and hazard analysis. For manned and unmanned flights and launches, Centers should establish flight, mission, or launch readiness certification processes that include verification by the independent engineering and SMA organizations. Independence is defined as both organizational (outside the operations, project or program structure) as well as financial (funding allocation decisions made or approved) at the first organizational level that owns both the operation, project or program and the center engineering and SMA" tom |
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