Improving the recognition of near-miss events on NASA missions

• Main Authors: Dillon, R. L., Rogers, E. W., Madsen, P., Tinsley, C. H.
• Format: Conference Proceeding
• Language: English
• Subjects: NASA; Propulsion; Space vehicles
• ISSN: 1095-323X; 2996-2358
• DOI: 10.1109/AERO.2013.6496846

Organizations that ignore near-miss data may be inappropriately rewarding risky behavior. If managers engage in risky behavior and succeed, research shows that these managers are likely to be promoted without close scrutiny of their risky decisions, even if the success is because of good fortune. Over time such risk taking compounds as similar near-misses are repeatedly observed and the ability to recognize anomalies and document the events decreases (i.e., normalization of deviance). History from the shuttle program shows that only the occasional large failure increases attention to anomalies again. This research demonstrates the presence of normalization of deviance in NASA missions and also examines a factor (the significance of the project) that may increase people's awareness of near-misses to counter this trend. Increasing awareness of chance success should increase the likelihood that significant learning can occur from the mission regardless of outcome. We conclude with prescriptions for project managers based on several on-going activities at NASA Goddard Space Flight Center (GSFC) to improve organizational learning. We discuss how these efforts can contribute to reducing near-miss bias and the normalization of deviance. This research should help organizations design learning processes that draw lessons from near-misses.