KEYWORDS: Space operations, Mars, Hubble Space Telescope, Mirrors, Space telescopes, Telescopes, Foam, Chemical elements, Safety, Interference (communication)
Organizations that fail to use known near-miss data when making operational decisions may be inadvertently rewarding risky behavior. Over time such risk taking compounds as similar near-misses are repeatedly observed and the ability to recognize anomalies and document the events decreases (i.e., normalization of deviance [1,2,3]). History from the space shuttle program shows that only the occasional large failure increases attention to anomalies again. This paper discusses prescriptions for project managers based on several on-going activities at NASA Goddard Space Flight Center (GSFC) to improve the lesson learning process for space missions. We discuss how these efforts can contribute to reducing near-miss bias and the normalization of deviance. This research should help organizations design learning processes that draw lessons from near-misses.
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