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Proceedings Paper

Use of a position-sensitive multi-anode photomultiplier tube for finding gamma-ray source direction
Author(s): Sanjoy Mukhopadhyay; Richard Maurer; Paul Guss
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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: 5 September 2014
PDF: 8 pages
Proc. SPIE 9213, Hard X-Ray, Gamma-Ray, and Neutron Detector Physics XVI, 92131A (5 September 2014); doi: 10.1117/12.2066238
Show Author Affiliations
Sanjoy Mukhopadhyay, National Security Technologies, LLC (United States)
Richard Maurer, National Security Technologies, LLC (United States)
Paul Guss, National Security Technologies, LLC (United States)

Published in SPIE Proceedings Vol. 9213:
Hard X-Ray, Gamma-Ray, and Neutron Detector Physics XVI
Arnold Burger; Larry Franks; Ralph B. James; Michael Fiederle, Editor(s)

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