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.