Learning from near-misses to avoid future catastrophes

Robin L. Dillon

doi:10.1117/12.2068470

13 November 2014 Learning from near-misses to avoid future catastrophes

Robin L. Dillon

Proceedings Volume 9197, An Optical Believe It or Not: Key Lessons Learned III; 919709 (2014) https://doi.org/10.1117/12.2068470
Event: SPIE Optical Engineering + Applications, 2014, San Diego, California, United States

Abstract

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.

Citation Download Citation

Robin L. Dillon "Learning from near-misses to avoid future catastrophes", Proc. SPIE 9197, An Optical Believe It or Not: Key Lessons Learned III, 919709 (13 November 2014); https://doi.org/10.1117/12.2068470

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