Ames Research Center

Remarks to ASAP Training

Thomas R. Chidester

NASA Ames Research Center

Ames Research Center

Four Challenges

Goal is to uncover safety problems and accomplish corrective action

Recognizing contributing factors Analyzing high volume of data Completing actions beyond correcting

individuals Providing operational feedback &

publication

Ames Research Center

Recognizing Contributing Factors

Events may result from• Mistaken actions of front-line employees• Equipment design or interaction with operating procedures• Accommodating operational constraints• Corporate culture

Ask• Are individual actions within the bounds of policy,

procedure, and practice?• Did equipment and procedures function within

expectations?• What constraints did the operators perceive?• Were organizational pressures in the right direction?

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Analyzing High Volume of Data

Volume of data will quickly overwhelm your ability to remember events and factors

Computer storage, retrieval, and search

Regular review and reporting process

Remember • ASAP is limited to trends in reporting

• Integrate FOQA, LOSA, AQP data

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Completing actions beyond correcting individuals

Corrective actions may include• Individual remediation

• Procedure documentation review and revision

• Training development and revision

• Intra-organizational coordination

• Extra-organizational coordination

By national and organizational culture, we are biased toward individual• In real time, operator is last opportunity for prevention

• Looking forward, greatest prevention opportunity flows from management action

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Providing operational feedback & publication

Many events can only be prevented by front line employees• Actions of ERC are unobserved • How do you make line operators aware of what you have

learned? Publications are first vehicle for changing systemic

problems• Periodicals, training events, direct messages

Lack of publication • facilitates perception of ASAP as escape from consequences

of error• Probably changes report content

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Summary

Challenges• Recognizing contributing factors• Analyzing high volume of data• Completing actions beyond correcting individuals• Providing operational feedback & publication

Actions• Consider “functioning relative to expectations”• Regularly review and report on the data • Look to change more than individual action• Publish what you learn

Success depends upon commitment to corrective actions, wherever they may lead