NASAs Space Flight Resource Management Program

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NASAs Space Flight Resource Management Program

• A Successful Human Performance Error Management
  Program
• presented by
• David Rogers
• For Space Ops 2002

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Petrol-Chemical Plant Explosion

• Crew sent to perform routine maintenance.
• Established written procedures not followed
• Agent released which found an ignition source
• Explosion killed half of the on-duty personnel
  and nearly leveled the plant

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Medication Dosage Error Causes Death

• Doctors orders for a 10 cc per hour
  intravenous solution containing a blood thinner.
• Nurse found the IV pump running at 110 cc per
  hour or 11 times the prescribed dose.
• The staff choose not to call the attending
  doctor.
• The patient died 18 hours later

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In the Space Program...

• our successes are spectacular

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Apollo Slide Here!
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Apollo XIII
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But...

• our failures have also been spectacular
• and tragic

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Challenger DisasterSTS-51L
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MARS?
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(2) Rigorous Cockpit Resource Management (CRM)
as applied in other critical phases of a mission
was not applied to SPARTAN operations. There
was no plan or procedure to verify that all
necessary steps had been accomplished in a
positive manner or by independent means prior to
deploy.
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SFRM
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SFRM is training designed for personnel to
improve their ability to manage the occurrence
and effects of operational errors by establishing
habit patterns that reinforce team-centered
self-critiques.
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Program Philosophy

• Error Management philosophy
• Skill-based
• Maintain operational relevance
• Full integration
• Continually reinforced

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Design Philosophy

• Engage the student
• Build bridges for the student
• Cutting-edge instructional technology
• Ensure continuity of SFRM training
• Establish debrief expectations
• Facilitate team-centered debriefs

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SFRM Performance Elements
Decision Making
Situational Awareness
Communication
Workload Management
Leadership
Command
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Debrief Expectations

• Team-Centered Debriefs
• Raise and initiate discussion of SFRM topics
• directly with each other
• Critically analyze the situation and discuss
  the
• impact that SFRM skills had on the scenarios
• outcome
• Develop and implement strategies
• Develop self-critiquing habits

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Reasons for Success

• Vision Extended Across the Entire NASA Team
• Strong Management Support
• Training Fit Organizational Culture
• Maintained Operational Relevance
• Technical and SFRM Have Equal Importance
• Responsive to Changing Requirements
• Maintained Patience

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Summary

• Remember
• SFRM requires a commitment
• The habit patterns established during
  training
• will be the ones present on your mission
• Hold yourself and others accountable during
  debriefs
• SFRM is a NASA program that
• begins with each one of us but extends to ALL
  of us

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