Shuttle Service Life Extension

1. Shuttle Service Life Extension Michoud Assembly Facility, La. 19, 20 March ‘03 Safety Message Bryan O’Connor NASA Safety Officer (1)

2. 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

3. 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

4. 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

5. The Risk Iceberg (3 levels, not 2) • 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? Known Knowns Known Unknowns Unknown Unknowns

6. Safety Thought of the Day Flying Safely to 2020 and beyond means attacking relentlessly all three levels of the risk iceberg!

7. Shuttle Service Life Extension Michoud Assembly Facility, La. 20 March ‘03 Safety Message Bryan O’Connor NASA Safety Officer (1)

8. 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

9. 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

10. 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 Safety: What does NASA mean? • 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

11. 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

12. Safety perspective on SLEP priorities • Fly to 2020 and maintain overall safety at current level (this means some improvements required to counter unknown risk creep) • Improve safety with ASI priorities in mind • Public • Our people • Our high value equipment and facilities • Meet the manifest (schedule dependability and current mission success improvements • Improve the system (efficiencies, and everything else that does not fall under 1-3) Note: new missions bring money