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Constellation Program Lessons Learned: Detailed Lessons Learned - Volume 2

These lessons learned are part of a suite of hardware, software, test results, designs, knowledge base, and documentation that comprises the legacy of the Constellation Program. The context, summary information, and lessons learned are presented in a factual format, as known and described at the time. While our opinions might be discernable in the context, we have avoided all but factually sustainable statements. Statements should not be viewed as being either positive or negative; their value lies in what we did and what we learned that is worthy of passing on. The lessons include both "dos" and "don ts." In many cases, one person s "do" can be viewed as another person s "don t"; therefore, we have attempted to capture both perspectives when applicable and useful. While Volume I summarizes the views of those who managed the program, this Volume II encompasses the views at the working level, describing how the program challenges manifested in day-to-day activities. Here we see themes that were perhaps hinted at, but not completely addressed, in Volume I: unintended consequences of policies that worked well at higher levels but lacked proper implementation at the working level; long-term effects of the "generation gap" in human space flight development, the need to demonstrate early successes at the expense of thorough planning, and the consequences of problems and challenges not yet addressed because other problems and challenges were more immediate or manifest. Not all lessons learned have the benefit of being operationally vetted, since the program was cancelled shortly after Preliminary Design Review. We avoid making statements about operational consequences (with the exception of testing and test flights that did occur), but we do attempt to provide insight into how operational thinking influenced design and testing. The lessons have been formatted with a description, along with supporting information, a succinct statement of the lesson learned, and recommendations for future programs and projects that may be placed in similar circumstances.

Jennifer Rhatigan

Apollo Lesson Sampler: Apollo 13 Lessons Learned

This CD-ROM contains a two-part case study of the Apollo 13 accident. The first lesson contains an overview of the electrical system hardware on the Apollo spacecraft, providing a context for the details of the oxygen tank explosion, and the failure chain reconstruction that led to the conditions present at the time of the accident. Given this background, the lesson then covers the tank explosion and immediate damage to the spacecraft, and the immediate response of Mission Control to what they saw. Part 2 of the lesson picks up shortly after the explosion of the oxygen tank on Apollo 13, and discusses how Mission Control gained insight to and understanding of the damage in the aftermath. Impacts to various spacecraft systems are presented, along with Mission Control's reactions and plans for in-flight recovery leading to a successful entry. Finally, post-flight vehicle changes are presented along with the lessons learned.

Interbartolo, Michael A.

MSFC Thermal Testing Lessons Learned Course. Section 3: Lessons Learned from Protoflight StarBurst Instrument Thermal Vacuum Test

MSFC thermal engineers will be presenting lessons learned while preparing and conducting thermal tests. This course will cover practical real world examples of thermal chamber and vacuum chamber testing from engineering development units to system level testing on flight hardware. Special topics include large scale testing preparation, requirement tailoring from parent documents, and cryogenic development testing.

thermal discipline

Lessons Learned Study Final Report for the Exploration Systems Mission Directorate

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.

Van Laak, Jim

Safety and Mission Assurance for In-House Design Lessons Learned from Ares I Upper Stage

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.

Anderson, Joel M.

Lessons Learned for Improving Spacecraft Ground Operations

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.

Bell, Michael

Best Practices for Researching and Documenting Lessons Learned

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.

Goodman, John L.

Logistics Lessons Learned in NASA Space Flight

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.

Evans, William A.

Lessons Learned and Technical Standards: A Logical Marriage

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.

Gill, Paul

Lessons Learned in Engineering

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.

Blair, J. C.

Lessons Learned in Engineering

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.

Blair, James C.

The Value of Identifying and Recovering Lost GN&C Lessons Learned: Aeronautical, Spacecraft, and Launch Vehicle Examples

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).

Dennehy, Cornelius J.

Selected Lessons Learned in Space Shuttle Orbiter Propulsion and Power Subsystems

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.

Hernandez, Francisco J.

Engineering Lessons Learned and Systems Engineering Applications

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

Gill, Paul S.