Organiza(onalSilence

AStoryfortheSafetyAwarenessCampaign(withcolorfulandexci(ngillustra(ons)

NormalSilence

Organiza(onalSilence

Itisunwisetoleavealivedragonoutofyourcalcula.ons,ifyoulivenearhim.‐‐JRRTolkien(TheHobbit)

NASAlivesnearthedragons•  Mission‐ProjectDriven•  Largebutcloseknitorganiza(onwithpowerfulleaders

•  Highlyvisible,complexprojectswithschedulewithbudgetpressure

•  Teamenvironmentwheretheteamischargedwithachievingsuccess•  And……thereareACTUALpeopleinvolved

Thesecondi(onsarethebreedinggroundfortheDragon

Introduc(ontoaDragonWaterInges(onProjects

•  DemonstrateimmunityofnewaircraNdesignstoinges(onofstandingwaterattakeoff/landingspeeds.

AnatomyofaDragon

•  Needed:–  1ModifiedaircraN

•  Withtestpilot–  Aflat,lowtrafficrunway–  ControltowerwithOpsLead–  Cameraswithagoodviewoftheairintakes–  2weeks(accoun(ngforweather,technicalglitches)

•  Process–  PlacewateronrunwayatFAA‐specifieddepths–  AircraNrollsthroughattakeoff/landingspeed–  Snappictureofengineairintake

LOOKINGCAMERAS(C2&C2)EQUIPMENTVANS(V2);DistanceFromRunway:~200N#Personnel:3

C1C2

CFR

IFLOT(C1)EQUIPMENTVAN(V1)DistanceFromRunway;~200N#Personnel:2

CFR/FAAWATERTANKERDistanceFromRunway;~200N#Personnel:5

RADARGUNANDOPERATOR(V3);DistanceFromRunway:~200N#Personnel:1

V1

V2T1

Opera.onsPlan

TheDragonGrows•  Opera(onReviewedandApproved

–  Opera(oniscompletelyencompassedbypastexperience•  AircraNsizes,speeds,technicalrequirements

–  ThenormalANDEXPECTEDproceduresandsafetymeasuresareinplace

–  LessonsLearnedfrompastmissionsincorporatedintoopera(onsplans•  Visualcues,instrumentplacement,wind/speedlimits,CrashFireRescuestaging,cameraselec(on

•  Experiencedteam•  Opera(onsproceedswellthroughmul(ple

runs•  Minorrequirementschangeswitheachrun

aNerday1–  Reviewedandapprovedbyteamandcustomer

LOOKINGCAMERAS(C2&C2)EQUIPMENTVANS(V2);DistanceFromRunway:~75N#Personnel:3

C1

C2

C3

CFR

IFLOT(C1)EQUIPMENTVAN(V1)DistanceFromRunway;~200N#Personnel:2

CFR/FAAWATERTANKERDistanceFromRunway;~200N#Personnel:5

RADARGUNANDOPERATOR(V3);DistanceFromRunway:~75N#Personnel:1

V1

V2V3

T1

MissionOpera.onsatLastRun(Run11)(Implementa.onaWeriteratedsmallchanges)

LOOKINGCAMERAS(C2&C2)EQUIPMENTVANS(V2);DistanceFromRunway:~200N#Personnel:3

C1C2

CFR

IFLOT(C1)EQUIPMENTVAN(V1)DistanceFromRunway;~200N#Personnel:2

CFR/FAAWATERTANKERDistanceFromRunway;~200N#Personnel:5

RADARGUNANDOPERATOR(V3);DistanceFromRunway:~200N#Personnel:1

V1

V2T1

OriginalOpera.onsPlanforComparison

WhattheDragonlookslikewhenitisfinallyafacking

ElementsofandThoughtson

Organiza(onalSilence,Dragons,andDragonSlaying

Welosesomedexterity,butweareveryconfident

Today’sCrisis

Let’sneverforgetthatthepublic’sdesirefortransparencymustbebalancedagainstourneedforautonomy.

Ithoughthewasabouttobeknighted,didn’tyou?

You will make the same foolish mistakes you have made before, not only once but many many times again

Management

Engineering

Opera.ons

ShamelessappealtoanOscarwinningfilm

What“EVERYONE”Knows

•  Whatalmosthurtsomeonelast(me.

•  Howfaristoofar,ortoomuch,ortoolong,ortoohard…andhowclosewearetotheedge.

•  Whichorganiza(ons/peopledon’tgetalongANDhowthatstressimpactscommunica(on.

•  HowthingsREALLYhappenandwhich“rules”don’tgetfollowed.•  What‘really’wentwrong

•  Whatalmostwentwrongandwho‘really’savedtheday.

•  That“LL”doesn’tstandfor‘lessonslearned’.Itreallyjustmeans‘lessonslisted’un(lsomethingisdone.

•  Whatplaceswillnevergetseenduringtheinspec(on‐‐‐becausetheywouldneverpassit.

•  Thatthechecklistdoesn’treallymaferasmuchasthepersoncheckingtheboxes.

•  Thatorganiza(onsdon’tfixproblems…peoplefixproblems.

•  Whichmanageryoucantalktowhensomethingiswrong….andwhichoneyoucan’t.

Itreallyistruethat“everyoneknows”…..

Maybe,YOUknow….

Theques(onis,

Whatareyougoingtodoaboutit?

Youronlyweaponisawillingnesstocommunicate.

Youhaveasword.Itisseemssmall,butit’sallyouhave.….it’sallWEhave.