Mission Success Starts With Safety

Shuttle Service Life Extension

(1)

Michoud Assembly Facility, La.

19, 20 March ‘03

Bryan O’ConnorNASA Safety Officer

Safety Message

Mission Success Starts With Safety

2 19 March ‘03

Part of the Story: Reacting to the Mishap

Once harm has been done, even a fool can understand

it

Homer, The Illiad, Book XVII, 1.32

Mission Success Starts With Safety

3 19 March ‘03

Safety Upgrades: How do We Know What to Fix?

One should expect that the expected can be prevented, but the unexpected

should have been expected

Augustine’s Laws, XLV

Mission Success Starts With Safety

4 19 March ‘03

Safety Upgrades: How do We Know What to Fix?

There are things we know that we know,

There are things we know we don’t know,

There are things we don’t know we don’t know.

Donald Rumsfeld, U. S. SecDef

NATO HQ Press Conference, June ‘02

Mission Success Starts With Safety

5 19 March ‘03

• Mishap recommendations

• Problem solutions

• IFA fixes

• FMEA/Hazard controls

• Close call recommendations

• Ignored close calls?

• Old cert, new environment?

• Inadvertent excursions out of cert/family?

• Hardware talking…nobody listening?

The Risk Iceberg (3 levels, not 2)

Mission Success Starts With Safety

6 19 March ‘03

Flying Safely to 2020 and beyond means attacking

relentlessly all three levels of the risk

iceberg!

Safety Thought of the Day

Mission Success Starts With Safety

Shuttle Service Life Extension

(1)

Michoud Assembly Facility, La.

20 March ‘03

Bryan O’ConnorNASA Safety Officer

Safety Message

Mission Success Starts With Safety

8 19 March ‘03

Safety: What does it mean?

•The condition of being free from harm

•Secure from the threat of danger

•A technical contrivance to prevent an accident

•Unlikely to produce controversy

Webster’s Unabridged Dictionary

Mission Success Starts With Safety

9 19 March ‘03

Safety: How does it fit in our priorities?

• First Shuttle program priority:

Fly Safely

• Note: Safety is not the first priority!

• If it were, we would just stop flying and avoid all risk

• SLEP means doing what it takes to fly (safely) through 2020

• Therefore,

Supportability and safety share first priority

Mission Success Starts With Safety

10 19 March ‘03

Safety: What does NASA mean?

Objectives (in rank order):– Protect the public– Protect astronauts and

pilots– Protect our workforce– Protect our high value

equipment and facilities

Core Elements:– Management commitment– Employee involvement– Hazard analysis– Risk mitigation– Training and education

•Strategic Plan•Safety is a core value (not a mission) •Think of it as an adverb that modifies all Agency verbs

•Agency Safety Initiative 1999

Mission Success Starts With Safety

11 19 March ‘03

Safety: What about maintaining vs. improving?

• Maintaining safety is not good enough– Today’s safety level (even after fixing Columbia problems) is only

appropriate for a going out of business schedule• Unknown unknowns must be balanced by known unknown mitigators

or they will slowly increase overall risk• We must also figure out ways to limit the number of unknown

unknowns• Overall risk level is too high for a long term commitment (O’Connor

philosophy issue)

• Extending shuttle through 2020 demands that we improve safety, not just maintain it

• Real world says that safety improvement upgrades will be limited by resources available…

• Suggestion: do not let mission changes compete for SLEP resources…demand that new missions bring money

Mission Success Starts With Safety

12 19 March ‘03

Safety perspective on SLEP priorities

1. Fly to 2020 and maintain overall safety at current level (this means some improvements required to counter unknown risk creep)

2. Improve safety with ASI priorities in mind1. Public

2. Our people

3. Our high value equipment and facilities

3. Meet the manifest (schedule dependability and current mission success improvements

4. Improve the system (efficiencies, and everything else that does not fall under 1-3)

Note: new missions bring money