1. Ames Research Center Remarks to ASAP Training Thomas R. Chidester NASA Ames Research Center

2. Ames Research Center Four Challenges Goal is to uncover safety problems and accomplish corrective action  Recognizing contributing factors  Analyzing high volume of data  Completing actions beyond correcting individuals  Providing operational feedback & publication

3. Ames Research Center Recognizing Contributing Factors  Events may result from Mistaken actions of front-line employees Equipment design or interaction with operating procedures Accommodating operational constraints Corporate culture  Ask Are individual actions within the bounds of policy, procedure, and practice? Did equipment and procedures function within expectations? What constraints did the operators perceive? Were organizational pressures in the right direction?

4. Ames Research Center Analyzing High Volume of Data  Volume of data will quickly overwhelm your ability to remember events and factors  Computer storage, retrieval, and search  Regular review and reporting process  Remember ASAP is limited to trends in reporting Integrate FOQA, LOSA, AQP data

5. Ames Research Center Completing actions beyond correcting individuals  Corrective actions may include Individual remediation Procedure documentation review and revision Training development and revision Intra-organizational coordination Extra-organizational coordination  By national and organizational culture, we are biased toward individual In real time, operator is last opportunity for prevention Looking forward, greatest prevention opportunity flows from management action

6. Ames Research Center Providing operational feedback & publication  Many events can only be prevented by front line employees Actions of ERC are unobserved How do you make line operators aware of what you have learned?  Publications are first vehicle for changing systemic problems Periodicals, training events, direct messages  Lack of publication facilitates perception of ASAP as escape from consequences of error Probably changes report content

7. Ames Research Center Summary  Challenges Recognizing contributing factors Analyzing high volume of data Completing actions beyond correcting individuals Providing operational feedback & publication  Actions Consider “functioning relative to expectations” Regularly review and report on the data Look to change more than individual action Publish what you learn  Success depends upon commitment to corrective actions, wherever they may lead