Commercial Space Vehicles Lessons Learned Needs Workshop

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Commercial Space Vehicles Lessons Learned Needs
WorkshopNASA Implementation of a Formal
Lessons Learned Process

• David Oberhettinger
• Office of the Chief Engineer
• Jet Propulsion Laboratory, California Institute
  of Technology
• September 18, 2006

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Technical Excellence/Mission Success

• Why is NASA placing a renewed emphasis on lessons
  learned?
• Repeated mistakes, or violation of known best
  practices, pose a risk that is potentially
  avoidable
• Progress, far from consisting of change, depends
  on retentiveness... Those who cannot remember the
  past are condemned to repeat it. -George
  Santayana
• An expert is someone who knows some of the worst
  mistakes that can be made in his subject, and how
  to avoid them. -Werner Karl Heisenberg
• "Why - I learnt what one ought not to do, and
  that is always something."
• 
  - The Duke of Wellington describing the
  failed Dutch campaign of 1794
• Diaz Report assessed the agency-wide
  applicability of the CAIB report
• require that everyone understand their
  responsibilities and are given the authority to
  perform their jobs, with the accountability for
  their individual and programs successes and
  failures, including lessons learned. (Diaz Rpt,
  Page 10)
• The CAIB concluded NASA has not demonstrated
  the characteristics of a learning organization
  after investigators observed mistakes being
  repeated and lessons from the past apparently
  being relearned. (Diaz Rpt, Page 11)

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A Formal Lessons Learned Process

• NASA has maintained a lessons learned system
  since 1992
• NASA lessons learned repository has 1500 lessons,
  an advanced search capability, and is accessed
  2500 times per month
• The new NASA Engineering Network (NEN) replaces
  the former repository, and links to additional
  engineering information (project documentation,
  guidance from experts) related to each lesson
  learned
• Public access Lessons Learned Site
  http//llis.nasa.gov
• JPL has had a formal lessons learned process
  since 1984
• JPL Lessons Learned Committee that meets weekly,
  and recent emphasis on lessons learned infusion
  into rules for spacecraft design, test, and
  mission operations
• NASA NPD 7120.6, The NASA Lessons Learned
  Process, issued in March 2005
• Implements a formal system, based on the JPL
  model, to ensure important lessons are captured
  and that they are used

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LL Identification Documentation

• JPL criteria for a valid lesson learned
• Candidate must (1) effect mission success, (2) be
  relevant to JPL projects, (3) not duplicate a
  previously published lesson learned
• Sources MIB reports, FRACAS, project-maintained
  list, rumor mill
• Lessons Learned Committee role
• Members report recent events, identify and
  prioritize potential topics, validate each
  candidate lesson, review the text, verify the
  facts, approve the lesson, disseminate to member
  orgs (JPL tech divisions)
• Lesson learned structure and format
• Abstract, Event Description, Lesson Learned
  summary, (implementable) Recommendation(s),
  references, metadata
• Example Control Blow-By From Pyrotechnic
  Devices

Information File
Pyro Video
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(No Transcript)
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Recent JPL Lessons Learned

• Managing Mars Rover/Mars Orbiter Relay Link
  Prediction Variability
• The difference between the predicted versus
  achieved data volume returned by the Mars
  Exploration Rover relay link impacted the daily
  planning of rover driving and science data
  collection. This problem can be alleviated by
  refining the operations and science data return
  planning process.
• Mitigating the Risk of Single String
  Spacecraft Architecture
• Mars Exploration Rover met and exceeded mission
  requirements, despite a largely single string
  spacecraft architecture, due to effective risk
  management, ample fault tolerance, flight system
  flexibility, access to experienced designers,
  ample stress testing, use of proven designs, and
  a rigorous approach to fault protection.
• The Pitfalls of Engineering-by-Presentation
• The increased use of e-mails and slides instead
  of formal engineering documentation may be
  inhibiting the ability of NASA projects to
  reference the basis for technical decisions and
  to validate or verify engineering designs.
• Genesis Sample Return Mishap
• The Genesis sample return mishap was attributed
  to a design error in which the gravity switches
  that activate the parachute deployment sequence
  were phased (oriented) incorrectly so that their
  mechanisms could not detect the atmospheric
  entry.
• If You Dont Understand an Environment, Provide
  Well-Margined Capabilities to Encompass the
  Worst Case
• Mars Exploration Rover designers responded to a
  high level of uncertainty regarding Martian winds
  that could damage the lander by providing a set
  of small, sideways-pointing rockets and adding a
  capability to directly sense horizontal motion.
• Mate/Demate, Verify, and Document Connectors
  One-at-a-Time
• An integration and test failure was traced to the
  difficulty of confirming, verifying, and
  documenting that a flight connector had been left
  unmated in a crowded and physically constrained
  assembly.

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NASA Best Practices for Design Test

• 180 docs that each define a NASA-consensus
  engineering practice
• Example Environmental best practices (total of
  10)
• - Micrometeoroid Protection
• - Monitoring Spacecraft Exposure to
  Magnetic Fields
• - Optical Fiber Cable Terminations and
  Procedures
• Example Engineering Design best
  practices/guidelines (total of 88)
• - EEE Parts Derating
• - Electrical Grounding Practices for
  Aerospace Hardware
• - Thermal Design Practices for Electronic
  Assemblies
• - Contamination Control of Space Optical
  Systems
• - Space Radiation Effects on Electronic
  Components
• - Material Selection Practices
• - Selection of Electric Motors for
  Aerospace Applications
• - Vehicle Integration/Tolerance Build-up
  Practices
• - Active Redundancy
• - Pre-Ship Review

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NASA Best Practices (Continued)

• Example Analysis best practices/guidelines (total
  of 23)
• - Problem/Failure Report Independent
  Review/Approval
• - Part Electrical Stress Analysis
• - Redundancy Switching Analysis
• - Thick Dielectric/Internal Electrostatic
  Discharge (IESD)
• - Failure Modes, Effects, and Criticality
  Analysis (FMECA)
• Example Test best practices/guidelines (total of
  48)
• - Pyrotechnic Shock Testing
• - Radiated Susceptibility System
  Verification
• - Sine-Burst Load Test
• - Heat Sinks for Parts Operated in Vacuum
• - RF Breakdown Characterization
• - Voltage/Temperature Margin Testing
• - Power System Corona Testing
• - Selection of Spacecraft Materials and
  Supporting Vacuum Outgassing Data
• - Spacecraft Deployed Appendage Test
  Guidelines

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Lessons Learned Infusion

• Iterative review of 1500 lessons learned by
  projects is difficult, so infuse the
  recommendations into NASA procedures and training
• Use of JPL engineering process owners and
  closed-loop corrective action system to assure
  recommendations are infused
• Focusing on infusion into key rules for design
  and for project management
• Other NASA Centers have primary standards
  equivalent to JPLs Design Principles and Flight
  Project Practices documents that distill decades
  of mission experience
• The NASA Technical Standards Program is the
  repository for NASA standards and guidelines,
  plus subscriptions to industry standards used by
  NASA. http//standards.nasa.gov/
• JPL Standards Specs Access Site for Contractors
  and Bidders
• Other resources technical documentation in NASA
  Center flight project libraries, memos, and
  procedures repositories such as JPLRules!