Lessons learned from memory errors observed over the lifetime of Cielo.
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This report accompanies is a set of charts that will be presented at the 2024 LEARN Forum. This report is the result of an activity sponsored by Dr. Wanda Peters, Deputy Associate Administrator of Programs, who tasked Florence Tan and Carolyn Mercer with gathering insights from SmallSat/ Class D missions that could be extrapolated to enhance Class A-C missions.
This report is the final product of a 90-day study performed for the Exploration Systems Mission Directorate. The study was to assemble lessons NASA has learned from previous programs that could help the Exploration Systems Mission Directorate pursue the Exploration vision. It focuses on those lessons that should have the greatest significance to the Directorate during the formulation of program and mission plans. The study team reviewed a large number of lessons learned reports and data bases, including the Columbia Accident Investigation Board and Rogers Commission reports on the Shuttle accidents, accident reports from robotic space flight systems, and a number of management reviews by the Defense Sciences Board, Government Accountability Office, and others. The consistency of the lessons, findings, and recommendations validate the adequacy of the data set. In addition to reviewing existing databases, a series of workshops was held at each of the NASA centers and headquarters that included senior managers from the current workforce as well as retirees. The full text of the workshop reports is included in Appendix A. A lessons learned website was opened up to permit current and retired NASA personnel and on-site contractors to input additional lessons as they arise. These new lessons, when of appropriate quality and relevance, will be brought to the attention of managers. The report consists of four parts: Part 1 provides a small set of lessons, called the Executive Lessons Learned, that represent critical lessons that the Exploration Systems Mission Directorate should act on immediately. This set of Executive Lessons and their supporting rationale have been reviewed at length and fully endorsed by a team of distinguished NASA alumni; Part 2 contains a larger set of lessons, called the Selected Lessons Learned, which have been chosen from the lessons database and center workshop reports on the basis of their specific significance and relevance to the near-term work of the Exploration Directorate. These lessons frequently support the Executive lessons but are more general in nature; Part 3 consists of the reports of the center workshops that were conducted as part of this activity. These reports are included in their entirety (approximately 200 pages) in Appendix G and have significance for specific managers; Part 4 consists of the remainder of the lessons that have been selected by this effort and assembled into a database for the use of the Explorations Directorate. The database is archived and hosted in the Lessons Learned Knowledge Network, which provides a flexible search capability using a wide variety of search terms. Finally, a spreadsheet lists databases searched and a bibliography identifies reports that have been reviewed as sources of lessons for this task. NASA has been presented with many learning opportunities. We have conducted numerous programs, some extremely successful and others total failures. Most have been documented with a formal lessons learned activity, but we have not always incorporated these learning opportunities into our normal modes of business. For example, the Robbins Report of 2001 clearly indicates that many project failures of the past two decades were the result of violating well documented best practices, often in direct violation of management instructions and directives. An overarching lesson emerges: that disciplined execution in accordance with proven best practices is the greatest single contributor to a successful program. The Lessons Learned task team offers a sincere hope that the lessons presented herein will be helpful to the Exploration Systems Directorate in charting and executing their course. The success of the Directorate and of NASA in general depends on our collective ability to move forward without having to relearn the lessons of those who have gone before.
This viewgraph presentation identifies lessons learned in the course of the Ares I Upper Stage design and in-house development effort. The contents include: 1) Constellation Organization; 2) Upper Stage Organization; 3) Presentation Structure; 4) Lesson-Importance of Systems Engineering/Integration; 5) Lesson-Importance of Early S&MA Involvement; 6) Lesson-Importance of Appropriate Staffing Levels; 7) Lesson-Importance S&MA Team Deployment; 8) Lesson-Understanding of S&MA In-Line Engineering versus Assurance; 9) Lesson-Importance of Close Coordination between Supportability and Reliability/Maintainability; 10) Lesson-Importance of Engineering Data Systems; 11) Lesson-Importance of Early Development of Supporting Databases; 12) Lesson-Importance of Coordination with Safety Assessment/Review Panels; 13) Lesson-Implementation of Software Reliability; 14) Lesson-Implementation of S&MA Technical Authority/Chief S&MA Officer; 15) Lesson-Importance of S&MA Evaluation of Project Risks; 16) Lesson-Implementation of Critical Items List and Government Mandatory Inspections; 17) Lesson-Implementation of Critical Items List Mandatory Inspections; 18) Lesson-Implementation of Test Article Safety Analysis; and 19) Lesson-Importance of Procurement Quality.
NASA policy requires each Program or Project to develop a plan for how they will address Lessons Learned. Projects have the flexibility to determine how best to promote and implement lessons learned. A large project might budget for a lessons learned position to coordinate elicitation, documentation and archival of the project lessons. The lessons learned process crosses all NASA Centers and includes the contactor community. o The Office of The Chief Engineer at NASA Headquarters in Washington D.C., is the overall process owner, and field locations manage the local implementation. One tool used to transfer knowledge between program and projects is the Lessons Learned Information System (LLIS). Most lessons come from NASA in partnership with support contractors. A search for lessons that might impact a new design is often performed by a contractor team member. Knowledge is not found with only one person, one project team, or one organization. Sometimes, another project team, or person, knows something that can help your project or your task. Knowledge sharing is an everyday activity at the Kennedy Space Center through storytelling, Kennedy Engineering Academy presentations and through searching the Lessons Learned Information system. o Project teams search the lessons repository to ensure the best possible results are delivered. o The ideas from the past are not always directly applicable but usually spark new ideas and innovations. Teams have a great responsibility to collect and disseminate these lessons so that they are shared with future generations of space systems designers. o Leaders should set a goal for themselves to host a set numbers of lesson learned events each year and do more to promote multiple methods of lessons learned activities. o High performing employees are expected to share their lessons, however formal knowledge sharing presentation are not the norm for many employees.
Identification, resolution, and avoidance of technical and programmatic issues are important for ensuring safe and successful space missions. Although the importance of applying lessons learned to reduce risk is frequently stressed, there is little material available to help technical and management personnel research and document lessons learned. Collecting, researching, identifying, and documenting lessons learned that will be useful to current and future management and engineering personnel is not always a straightforward task. This white paper presents lessons learned and best practices concerning the research and documentation of technical and organizational lessons learned. It is intended to enable organizations to initiate or improve lessons learned research and documentation efforts. The content of this white paper is based on four technical lessons learned projects conducted by the United Space Alliance (USA) Flight Design and Dynamics Department, in support of the NASA/Johnson Space Center (JSC) Flight Design and Dynamics Division. Each project published a report, titled as follows: (1) GPS Lessons Learned From the ISS, Space Shuttle and X-38; (2) Lessons Learned From Seven Space Shuttle Missions; (3) Space Shuttle Rendezvous and Proximity Operations Experience Report; and (4) Navigation Technical History with Lessons Learned. The four projects were different in availability of subject matter experts and primary source material, subject scope, and the level of effort required to produce the final report. However, generic lessons can be drawn from all of them. The best practices will be discussed by the phases of report research and development: (1) Defining Report Requirements, Project Organization, and Schedule; (2) Collection and Analysis of Source Material; (3) Writing and Integrating the Report; and (4) Review and Revision of the Report.
The Vision for Space Exploration sets out a number of goals, involving both strategic and tactical objectives. These include returning the Space Shuttle to flight, completing the International Space Station, and conducting human expeditions to the Moon by 2020. Each of these goals has profound logistics implications. In the consideration of these objectives,a need for a study on NASA logistics lessons learned was recognized. The study endeavors to identify both needs for space exploration and challenges in the development of past logistics architectures, as well as in the design of space systems. This study may also be appropriately applied as guidance in the development of an integrated logistics architecture for future human missions to the Moon and Mars. This report first summarizes current logistics practices for the Space Shuttle Program (SSP) and the International Space Station (ISS) and examines the practices of manifesting, stowage, inventory tracking, waste disposal, and return logistics. The key findings of this examination are that while the current practices do have many positive aspects, there are also several shortcomings. These shortcomings include a high-level of excess complexity, redundancy of information/lack of a common database, and a large human-in-the-loop component. Later sections of this report describe the methodology and results of our work to systematically gather logistics lessons learned from past and current human spaceflight programs as well as validating these lessons through a survey of the opinions of current space logisticians. To consider the perspectives on logistics lessons, we searched several sources within NASA, including organizations with direct and indirect connections with the system flow in mission planning. We utilized crew debriefs, the John Commonsense lessons repository for the JSC Mission Operations Directorate, and the Skylab Lessons Learned. Additionally, we searched the public version of the Lessons Learned Information System (LLIS) and verified that we received the same result using the internal version of LLIS for our logistics lesson searches. In conducting the research, information from multiple databases was consolidated into a single spreadsheet of 300 lessons learned. Keywords were applied for the purpose of sorting and evaluation. Once the lessons had been compiled, an analysis of the resulting data was performed, first sorting it by keyword, then finding duplication and root cause, and finally sorting by root cause. The data was then distilled into the top 7 lessons learned across programs, centers, and activities.
This document presents a reconciliation of the lessons learned during a 2010 comprehensive evaluation of pertinent lessons learned from past and present high temperature gas-cooled reactors that apply to the Next Generation Nuclear Plant Project along with current and planned activities. The data used are from the latest Idaho National Laboratory research and development plans, the conceptual design report from General Atomics, and the pebble bed reactor technology readiness study from AREVA. Only those lessons related to the structures, systems, and components of the Next Generation Nuclear Plant (NGNP), as documented in the recently updated lessons learned report are addressed. These reconciliations are ordered according to plant area, followed by the affected system, subsystem, or component; lesson learned; and finally an NGNP implementation statement. This report (1) provides cross references to the original lessons learned document, (2) describes the lesson learned, (3) provides the current NGNP implementation status with design data needs associated with the lesson learned, (4) identifies the research and development being performed related to the lesson learned, and (5) summarizes with a status of how the lesson learned has been addressed by the NGNP Project.
A comprehensive database of lessons learned that corresponds with relevant technical standards would be a boon to technical personnel and standards developers. The authors discuss the emergence of one such database within NASA, and show how and why the incorporation of lessons learned into technical standards databases can be an indispensable tool for government and industry. Passed down from parent to child, teacher to pupil, and from senior to junior employees, lessons learned have been the basis for our accomplishments throughout the ages. Government and industry, too, have long recognized the need to systematically document And utilize the knowledge gained from past experiences in order to avoid the repetition of failures and mishaps. The use of lessons learned is a principle component of any organizational culture committed to continuous improvement. They have formed the foundation for discoveries, inventions, improvements, textbooks, and technical standards. Technical standards are a very logical way to communicate these lessons. Using the time-honored tradition of passing on lessons learned while utilizing the newest in information technology, the National Aeronautics and Space Administration (NASA) has launched an intensive effort to link lessons learned with specific technical standards through various Internet databases. This article will discuss the importance of lessons learned to engineers, the difficulty in finding relevant lessons learned while engaged in an engineering project, and the new NASA project that can help alleviate this difficulty. The article will conclude with recommendations for more expanded cross-sectoral uses of lessons learned with reference to technical standards.
This Contractor Report (CR) is a compilation of Lessons Learned in approximately 55 years of engineering experience by each James C. Blair, Robert S. Ryan, and Luke A. Schutzenhofer. The lessons are the basis of a course on Lessons Learned that has been taught at Marshall Space Flight Center. The lessons are drawn from NASA space projects and are characterized in terms of generic lessons learned from the project experience, which are further distilled into overarching principles that can be applied to future projects. Included are discussions of the overarching principles followed by a listing of the lessons associated with that principle. The lesson with sub-lessons are stated along with a listing of the project problems the lesson is drawn from, then each problem is illustrated and discussed, with conclusions drawn in terms of Lessons Learned. The purpose of this CR is to provide principles learned from past aerospace experience to help achieve greater success in future programs, and identify application of these principles to space systems design. The problems experienced provide insight into the engineering process and are examples of the subtleties one experiences performing engineering design, manufacturing, and operations.
This Contractor Report (CR) is a compilation of Lessons Learned in approximately 55 years of engineering experience by each James C. Blair, Robert S. Ryan, and Luke A. Schutzenhofer. The lessons are the basis of a course on Lessons Learned that has been taught at Marshall Space Flight Center. The lessons are drawn from NASA space projects and are characterized in terms of generic lessons learned from the project experience, which are further distilled into overarching principles that can be applied to future projects. Included are discussions of the overarching principles followed by a listing of the lessons associated with that principle. The lesson with sub-lessons are stated along with a listing of the project problems the lesson is drawn from, then each problem is illustrated and discussed, with conclusions drawn in terms of Lessons Learned. The purpose of this CR is to provide principles learned from past aerospace experience to help achieve greater success in future programs, and identify application of these principles to space systems design. The problems experienced provide insight into the engineering process and are examples of the subtleties one experiences performing engineering design, manufacturing, and operations. The supplemental CD contains accompanying PowerPoint presentations.
Within the broad aerospace community the importance of identifying, documenting and widely sharing lessons learned during system development, flight test, operational or research programs/projects is broadly acknowledged. Documenting and sharing lessons learned helps managers and engineers to minimize project risk and improve performance of their systems. Often significant lessons learned on a project fail to get captured even though they are well known 'tribal knowledge' amongst the project team members. The physical act of actually writing down and documenting these lessons learned for the next generation of NASA GN&C engineers fails to happen on some projects for various reasons. In this paper we will first review the importance of capturing lessons learned and then will discuss reasons why some lessons are not documented. A simple proven approach called 'Pause and Learn' will be highlighted as a proven low-impact method of organizational learning that could foster the timely capture of critical lessons learned. Lastly some examples of 'lost' GN&C lessons learned from the aeronautics, spacecraft and launch vehicle domains are briefly highlighted. In the context of this paper 'lost' refers to lessons that have not achieved broad visibility within the NASA-wide GN&C CoP because they are either undocumented, masked or poorly documented in the NASA Lessons Learned Information System (LLIS).
Over its 30 years of space flight history, plus the nearly 10 years of design, development test and evaluation, the Space Shuttle Orbiter is full of lessons learned in all of its numerous and complex subsystems. In the current paper, only selected lessons learned in the areas of the Orbiter propulsion and power subsystems will be described. The particular Orbiter subsystems include: Auxiliary Power Unit (APU), Hydraulics and Water Spray Boiler (WSB), Mechanical Flight Controls, Main Propulsion System (MPS), Fuel Cells and Power Reactant and Storage Devices (PRSD), Orbital Maneuvering System (OMS), Reaction Control System (RCS), Electrical Power Distribution (EPDC), electrical wiring and pyrotechnics. Given the complexity and extensive history of each of these subsystems, and the limited scope of this paper, it is impossible to include most of the lessons learned; instead the attempt will be to present a selected few or key lessons, in the judgment of the authors. Each subsystem is presented separate, beginning with an overview of the hardware and their function, a short description of a few historical problems and their lessons, followed by a more comprehensive table listing of the major subsystem problems and lessons. These tables serve as a quick reference for lessons learned in each subsystem. In addition, this paper will establish common lessons across subsystems as well as concentrate on those lessons which are deemed to have the highest applicability to future space flight programs.
Systems Engineering is fundamental to good engineering, which in turn depends on the integration and application of engineering lessons learned and technical standards. Thus, good Systems Engineering also depends on systems engineering lessons learned from within the aerospace industry being documented and applied. About ten percent of the engineering lessons learned documented in the NASA Lessons Learned Information System are directly related to Systems Engineering. A key issue associated with lessons learned datasets is the communication and incorporation of this information into engineering processes. Systems Engineering has been defined (EINIS-632) as "an interdisciplinary approach encompassing the entire technical effort to evolve and verify an integrated and life-cycle balanced set of system people, product, and process solutions that satisfy customer needs". Designing reliable space-based systems has always been a goal for NASA, and many painful lessons have been learned along the way. One of the continuing functions of a system engineer is to compile development and operations "lessons learned" documents and ensure their integration into future systems development activities. They can produce insights and information for risk identification identification and characterization. on a new project. Lessons learned files from previous projects are especially valuable in risk
This document (Volume I) provides an executive summary of the lessons learned from the Constellation Program. A companion Volume II provides more detailed analyses for those seeking further insight and information. In this volume, Section 1.0 introduces the approach in preparing and organizing the content to enable rapid assimilation of the lessons. Section 2.0 describes the contextual framework in which the Constellation Program was formulated and functioned that is necessary to understand most of the lessons. Context of a former program may seem irrelevant in the heady days of new program formulation. However, readers should take some time to understand the context. Many of the lessons would be different in a different context, so the reader should reflect on the similarities and differences in his or her current circumstances. Section 3.0 summarizes key findings developed from the significant lessons learned at the program level that appear in Section 4.0. Readers can use the key findings in Section 3.0 to peruse for particular topics, and will find more supporting detail and analyses in Section 4.0 in a topical format. Appendix A contains a white paper describing the Constellation Program formulation that may be of use to readers wanting more context or background information. The reader will no doubt recognize some very similar themes from previous lessons learned, blue-ribbon committee reviews, National Academy reviews, and advisory panel reviews for this and other large-scale human spaceflight programs; including Apollo, Space Shuttle, Shuttle/Mir, and the ISS. This could represent an inability to learn lessons from previous generations; however, it is more likely that similar challenges persist in the Agency structure and approach to program formulation, budget advocacy, and management. Perhaps the greatest value of these Constellation lessons learned can be found in viewing them in context with these previous efforts to guide and advise the Agency and its stakeholders.
Systems Engineering is fundamental to good engineering, which in turn depends on the integration and application of engineering lessons learned. Thus, good Systems Engineering also depends on systems engineering lessons learned from within the aerospace industry being documented and applied. About ten percent of the engineering lessons learned documented in the NASA Lessons Learned Information System are directly related to Systems Engineering. A key issue associated with lessons learned datasets is the communication and incorporation of this information into engineering processes. As part of the NASA Technical Standards Program activities, engineering lessons learned datasets have been identified from a number of sources. These are being searched and screened for those having a relation to Technical Standards. This paper will address some of these Systems Engineering Lessons Learned and how they are being related to Technical Standards within the NASA Technical Standards Program, including linking to the Agency's Interactive Engineering Discipline Training Courses and the life cycle for a flight vehicle development program.
Since its addition to the Formerly Utilized Sites Remedial Action Program (FUSRAP) in 2005, the Sylvania Corning FUSRAP Site (the Site) in Hicksville, New York, has provided challenges and opportunities from which to gain lessons learned for conducting investigation work at a complex multi-contaminant FUSRAP Site. The United States Army Corps of Engineers (USACE) and its contractors conducted a Comprehensive Environmental Response, Compensation and Liability Act (CERCLA) Remedial Investigation (RI) and are currently in the Feasibility Study (FS) phase at the Site. This paper presents the planning, execution, and reporting lessons learned by USACE during the RI/FS. The Site, operated from 1952 to 1967 for the research, development, and fabrication of nuclear elements under the Atomic Energy Commission, and other government and commercial contracts. Previous investigations performed by the New York State Department of Environmental Conservation (NYSDEC) and the current property owner have identified uranium, thorium, nickel, and chlorinated solvents, as Site contaminants [1]. The property owner is currently under two separate voluntary agreements with NYSDEC to investigate and remediate the Site. USACE's work at the site has been independent of this voluntary agreement and has moved on a parallel path with any work the property owner has completed. The project at the Site is complex because of the radiological and chemical concerns in both soils and groundwater, high hydraulically conductive soils, lack of a shallow aquiclude/aquitard, and a principal water table aquifer underlying the site. Contaminants are migrating from the Site and may potentially impact local drinking water supplies (municipal wells). During the RI/FS process the project team has encountered many issues and has thus developed many resolutions. The issues are organized into three categories: Planning and Contracting, Execution, and Reporting. Planning and Contracting lessons learned include: how to incorporate an overwhelming volume of historical data; how to manage a complex team of three prime contractors innovatively, and how to implement a project under an Award Fee task order. Execution lessons learned include: characterization of investigation derived wastes, and proper approach to radiological scanning of direct-push borings and soil cores. Reporting lessons learned include: coordinating multiple phase (iterative) reporting, large dataset presentation, and the National Priorities List (NPL) designation. The goal of this paper is to provide a resource for other project delivery teams that encounter similar situations on their projects to optimize cost savings, realization of efficiency, shorten schedules, or simply ensure higher quality deliverables. Each FUSRAP project is unique but there are many lessons we can apply to each site to gain efficiency and work more effectively. The Sylvania Corning FUSRAP site is a complex site with both soils and groundwater contamination, contamination to depths of 182 meters, and a highly politically charged environment of PRP involvement. Many of the lessons the project team has learned during the life of the project to date are being shared with others as well as being applied back to this project for future work. (authors)