Safety Messages

Lessons From Challenger


This Jan. 28, marks the 35th anniversary of the Challenger accident. The loss of the crew was a tragedy felt by their families, friends and coworkers at the agency, as well as people throughout the world.

The Challenger accident taught us tough lessons and brought forward what have become recognizable phrases: normalization of deviance, organizational silence and silent safety program. Sadly, we learned these lessons again in 2003 with the loss of Columbia and her crew. This shows how vital it is that we pause to revisit these lessons and never let them be forgotten. We cannot become complacent. 

In this month's Safety Message, Harmony Myers, director of the NASA Safety Center, discusses the Challenger accident and the lessons it continues to teach us today.

Reminders to Keep You Safe

Welcome to the Office of Safety and Mission Assurance Safety Message archive. This page contains Safety Message presentations and related media. While some of these presentations are not NASA related, all of them have certain aspects that are applicable to NASA. I encourage you to disseminate these to your organizations to promote discussion of these issues and possible solutions.

—W. Russ DeLoach, Chief, Safety and Mission Assurance

Safety of Small Unmanned Aircraft Systems Operations at NASA

Coordinating Requirements for Operation within the National Airspace System

December 01, 2016

It should come as no surprise that small Unmanned Aircraft Systems (sUAS) or “drones” are becoming more popular as NASA research platforms. Their use also has been on the rise in other arenas such as in facilities, protective services and construction. The potential applications of these vehicles are endless.

In August, the Federal Aviation Administration released new regulations that address the intense national interest in civil sUAS operations and provide guidelines for safe operation. Within NASA, NPR 7900.3C governs sUAS usage and recently was augmented to address the heavy increase in sUAS operations within the agency.

If your organization is considering applications that involve sUAS it is a good idea to partner with your center’s Aircraft Flight Operations Office for advice and guidance during planning and procurement actions. Please take the time to review the information in this month’s Safety Message, provided by the Aircraft Management Division, which oversees all sUAS applications at NASA.

Mining Your Federal Employee Viewpoint Survey for Weak Signals

November 22, 2016

In the U.S. Marine Corps, all leaders are asked to do two things: 1) accomplish the mission and 2) take care of your people. Usually, this is followed with “If you do No. 2, your people will take care of No. 1.”

There are a lot of things that fall under “taking care of your people.” Some of the more obvious ones are building unit cohesiveness, providing training and development at all levels, ensuring safe and adequate working spaces, and ensuring your people have the tools and equipment necessary for mission accomplishment.

Another critical part of taking care of your people is establishing a positive “command climate.” One definition of command climate is what life is like within the organization. It is the culture of the unit, the way it conducts its business. The leader of the organization is solely responsible for its command climate. This responsibility includes ensuring capable and competent management exists at all levels within the organization. The Federal Employee Viewpoint Survey (FEVS) offers senior leadership insight into both the performance of individual managers within the organization and the unit’s command climate. Question 17 in the FEVS asks if employees feel they can report an issue without fear of retribution. For NASA, the best place to work in the federal government, the percentage of positive responses to that question is approximately 80 percent. We can interpret that as one out of every five employees telling senior management, through this survey, that the climate in his or her unit needs to be improved. This particular issue is critically important to NASA because of the difficult and challenging nature of our missions. It is vital that managers are aware of any issues so they can evaluate the associated risk to people and missions. A command climate that didn’t encourage or tolerate people bringing up issues played a role in both shuttle mishaps.

I encourage you to mine your FEVS for information on the command climate throughout your organization. Question 17 is a good place to start. As the Aerospace Advisory Panel once reminded us, “It shouldn’t take an act of courage to raise an issue.”

Common Threads Among Catastrophic Mishaps

Lessons Not Learned, Workmanship Shortcomings, Process Control Failures, Failures to Control Ctirical Material Items and Fraud

August 01, 2016

When we look back at major mishaps in government and industry, it's natural to look for common themes. These themes can be extremely revealing and relevant in assessing the health of NASA’s current operations.

For this month's message, Office of Safety and Mission Assurance Technical Fellow for Quality Engineering Brian Hughitt evaluated catastrophic mishaps from various domains in order to identify common Quality themes. Four predominant themes calling for heightened attention emerged: ineffective corrective action in response to precursor events, fraud and unethical behavior, workmanship shortcomings, and material control inadequacies.

The Balance Zone

Preventing Slips, Trips and Falls

July 11, 2016

Ever since centers began recording slips, trips and falls, these incidents have remained the single most frequent cause of injury at NASA. Across the United States, slips, trips and falls are the leading cause of emergency room visits with more than 8 million cases per year, and, perhaps more surprisingly, they are the second leading cause of accidental deaths. Injuries sustained from a slip, trip or fall can lead to a lifetime of pain, not to mention the medical costs and lost productivity.

Kennedy Space Center (KSC) has developed a novel, highly effective approach to prevent injuries and close calls caused by slips, trips and falls, regardless of external hazards. The approach augments traditional efforts to maintain safe work areas and walking surfaces with specially designed balance workout areas called “Balance Zones.” Backed by classroom training and guest speakers, Balance Zones offer a new and interesting way for KSC employees to improve their overall balance and reaction to hazards.

Sharing these types of innovative initiatives across all NASA centers is another way we can work together to reduce injuries from slips, trips and falls.

The NASA Safety Center (NSC) has produced two campaigns to help raise agency awareness of slips, trips and falls, including an article and videos highlighting KSC's outstanding efforts. See these materials on the NSC's Slips, Trips and Falls page

Skin Cancer Prevention and Screening

A Life-Saving Survey

June 06, 2016

Each year in the U.S., over 5.4 million cases of non-melanoma skin cancer are treated in more than 3.3 million people. There are more new cases of skin cancer than breast, prostate, lung and colon cancer combined. One in five Americans will develop skin cancer over the course of a lifetime. Melanoma, the most lethal form of skin cancer, can develop from less dangerous types of skin cancer. Although simple screening exams can catch this process before it begins, one person dies of melanoma every hour. We are all vulnerable.

As a member of the National Council on Skin Cancer Prevention, NASA has been working to lower these statistics. The first year on the council, NASA was awarded the American Academy of Dermatology’s Golden Triangle Award for our agencywide skin cancer prevention efforts.

Please take time to view this message from Dr. J.D. Polk on behalf of the Office of the Chief Health and Medical Officer and remember to set up a screening exam during your next physical. It’s quick and simple and could possibly save your life.

MMS Transporter Fire

Importance of IRT Training

May 02, 2016

What would your project team do if your NASA-owned flight hardware suffered mishap-level damage during transport? Would someone be prepared to assume the duties of an incident commander or NASA Interim Response Team (IRT) lead?

That’s exactly what happened when one of Goddard Space Flight Center’s four Magnetospheric Multiscale Mission (MMS) spacecraft was almost damaged in a close call. After an internal fire that threatened the spacecraft was extinguished, the project safety manager who was traveling with the spacecraft secured the flight hardware, took photos, recorded witness statements and impounded data. Proper safety training and quick-acting personnel can mean the difference between a delay in a testing schedule or the total destruction of flight hardware. In this case, there was minimal impact to the schedule and no flight hardware damage.

Ground Effect

Gulfstream G650 Test Flight Crash

April 04, 2016

On April 2, 2011, four highly experienced, proficient flight test personnel were killed when a Gulfstream G650 crashed during certification testing. Gulfstream was focused on obtaining Federal Aviation Administration type certification by the third quarter of 2011. Among other factors, the crash was traced to incorrect calculation of takeoff and stall speeds and a superficial review of two previous similar near-crashes.

NASA is doing more development testing now than any time since Apollo. We must preserve essential testing against time and budget constraints. Let’s harness this Gulfstream event to make our tests sound and representative of environment, system and human interfaces. 

Lightning Safety

March 07, 2016

Lightning strikes the U.S. about 25 million times each year, killing an average of 49 people. Many more are struck and suffer severe injuries. Many of us may carry inaccurate, preconceived notions concerning what to do when lightning strikes. This month, Steve Cash, director of Safety and Mission Assurance at Marshall Space Flight Center, debunks the myths and shares the hard facts of lightning strikes. He also addresses what we can do to protect ourselves.

The Role of "Heart" in Heart Disease

February 01, 2016

As leaders, we often say, "Take care of your people." Some of the most serious risks we face pay no attention to workplace boundaries. This month, Grant Watson, director of Safety and Mission Assurance at Langley Research Center, shares his personal message of how his parents’ heart disease changed how he regarded his own heart health. May his message encourage you to reflect on your own story and on lowering heart disease risk.

Dissenting Opinions

January 04, 2016

After a mishap or major disaster, it’s natural to ask what we could have done better had we only known about a defect or flaw sooner. Sometimes those who see something before the test begins or the vehicle launches speak up. Sometimes they’re heard. NASA has experienced mishaps and tragedies where individuals within and outside of our agency had technically sound differing views that were never heard by decision-makers.

Although NASA’s process for submitting a dissenting opinion is outlined in NPD 1000.0B, NPR 7120.5E which includes the NASA Spaceflight Program and Project Management Handbook, Program and Project Managers should be actively seeking out dissenting opinions and addressing them in a clear, open and timely manner. This presentation will focus on the dissenting opinion process, identifying what a dissent is and how the process should unfold. Please take some time to thoughtfully reflect on this presentation; after all, it could be one of us whose choice to speak up could save lives at some point.

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