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.

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

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)