# Presentation: 241069

## Shuttle Service Life Extension

- (1)

**Michoud Assembly Facility, La.**
**19, 20 March ‘03**

- Bryan O’Connor
- NASA Safety Officer

***Safety Message***

## 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*

## 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*

## 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*

## 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?

**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***

**The Risk Iceberg (3 levels, not 2)**

## Flying Safely to 2020 and beyond means attacking relentlessly 

*Flying Safely to 2020 and beyond means attacking ****relentlessly**** *
*all three levels of the risk iceberg!*

**Safety Thought of the Day **

## Shuttle Service Life Extension

- (1)

**Michoud Assembly Facility, La.**
**20 March ‘03**

- Bryan O’Connor
- NASA Safety Officer

***Safety Message***

## 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*

## 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****** ***

## Safety: What does NASA mean?

**	****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**

**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**

## 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**

## 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***