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Proceedings Paper

Learning from near-misses to avoid future catastrophes
Author(s): Robin L. Dillon
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Paper 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.

Paper Details

Date Published: 13 November 2014
PDF: 4 pages
Proc. SPIE 9197, An Optical Believe It or Not: Key Lessons Learned III, 919709 (13 November 2014); doi: 10.1117/12.2068470
Show Author Affiliations
Robin L. Dillon, Georgetown Univ. (United States)

Published in SPIE Proceedings Vol. 9197:
An Optical Believe It or Not: Key Lessons Learned III
Mark A. Kahan, Editor(s)

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