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USAF B-2 Mishap

The Unknown Known

USAF B-2 Mishap

In NASA's climate of daring enterprise and unparalleled innovation, our efforts can be foiled by the challenge of simple communication. In this month's case study, the Department of Defense lost a $1.4 billion aircraft because one maintenance technician working on the aircraft was not aware of a workaround developed in the field. The technique was only informally communicated with local personnel and never incorporated into standard procedures. The Air Force investigation concluded that if personnel had had a better understanding of how critical specific systems were to the overall performance of the aircraft, they would have insisted on formally communicating the technique. The only people who truly understood the system interfaces were former B-2 engineers who had designed the aircraft ten years prior to the mishap. The operating organization lacked profound systems knowledge when a new environment required it. At NASA, we must continue to improve our strategies for capturing and transferring knowledge from personnel before they retire or move on to a new project. We must aggressively document changes and workarounds developed in the field. Lastly, we must strive to develop a broader understanding of the systems and programs we work with so we can recognize — and share — critical information. Even brilliant engineering and design will fail without effective communication in the face of change.