Report Says NASA Not Sharing Knowledge of Past Mistakes

Florida Today ^ | Sept. 7, 2001 | Frank Oliveri

[anymouse]

Lessons learned from past NASA gaffs are not being taught agency-wide, exposing it to the potential of similar mistakes, says an interim government report released Thursday.

The 18-page report included a survey of 192 program and project managers in each of NASA's key enterprise areas, covering 244 programs and or projects. It reveals an agency with serious communication problems - so serious that many managers did not even know a "lessons learned" process exists within NASA. And it shows how little information is shared across programs.

"The staff does not feel that the process works," said Allen Li, a General Accounting Office investigator and author of the report. The GAO is the investigative arm of Congress. "It goes back to the initial point of this study: Why is it there are some things that don't appear to be learnedThe report comes as NASA officials are conducting top to bottom reviews of the International Space Station program, where numerous reports and investigations have revealed mismanagement that led to $4.8 billion in cost overruns. Those overruns have forced NASA to cut science on the station, the heart of the effort, by about 40 percent.

One key problem was simple communication.

"Communication is one that seems to be a constant in many of the incidents that have occurred," Li said.

Li said that communication was a failing in the X-33 program, which was a prototype to replace the space shuttle. Li also mentioned that the Mars Polar Lander and the Mars Climate Orbiter also failed in 1999 in part as a result of communication problems.

Those failures raised concerns that lessons learned from past mishaps and programs were not being applied.

Only 17 percent of responded ever used a lesson identified in NASA's special learning process.

Forty-three percent of managers never submitted lessons gleaned from work and experiments. Just 39 percent believed that lessons learned wouldn't help much in their programs.

Li said the survey found some efforts to pass on lessons, but they typically are not identified, collected or shared by program managers.

The report quoted one manager who wrote that there is an "unwillingness...to share information or air dirty laundry. If you made a mistake, you might not be deemed to be a good project manager."

One area NASA managers cited as a real need was mentoring in the form of storytelling and post mortems. Li said typically lessons were only passed on within small groups and among individuals, but not across the agency, Li said.

NASA largely concurred with the findings of the report. Daniel Mulville, NASA's associate deputy administrator, said the agency is making major revisions to its operating guidelines. Those will include instructions for improving the Lessons Learned Information System.

"NASA must do a better job of communicating the various lessons learned sources," Mulville said.

A final GAO report will be completed early next year.

[anymouse]

Those who refuse to learn from history are doomed to repeat it.

[onedoug]

"...for Nature cannot be fooled." Richard Feynman in Appendix to Challenger accident panel report.