EErrrroorr PPrreevveennttiioonn PPrroocceessss OOvveerrvviieeww JJiimm AAlllliissoonn EErrrroorr PPrreevveennttiioonn LLeeaadd,, UUnniitteedd LLaauunncchh AAlllliiaannccee ((UULLAA)) DDeecceemmbbeerr 22001100 PPrreesseenntteedd aatt:: TThhee UUnniitteedd SSttaatteess AAiirr FFoorrccee SSppaaccee SSaaffeettyy CCoouunncciill,, UUnniitteedd SSttaatteess AAiirr FFoorrccee AAccaaddeemmyy,, CCoolloorraaddoo SSpprriinnggss,, CCoolloorraaddoo,, DDeecceemmbbeerr 66--1100,, 22001100 J.Allison Copyright ©2010 United Launch Alliance, LLC. All Rights Reserved. Error Prevention Process Objective (cid:137) –Share ULA’s Error Prevention Process & Experience • ULA & Error Prevention Background/History • Error Prevention Specific Definitions • ULA Error Prevention Process Overview • ULA Error Prevention Publications • More Lessons Learned –Questions are Always Welcome J. Allison | 1 Background: Who/What is ULA? ULA Launch Vehicles United Launch Alliance •Formed in 2006 as a 50-50 Joint Venture Between Atlas Delta Lockheed Martin & Boeing •Provides Two World Class Launch Systems Operating as a Single Provider to the U.S. Government – Atlas V Product Line – Delta IV Product Line – Delta II Product Line •Employs More Than 3500 Employees •More Than a Century of Combined Experience in Expendable Launch System Production & Operation Providing Assured Access to Space •Pooled Experience of Nearly 1300 Launches 440011 443311 555511 HHLLVV DDeellttaa 22 MMeeddiiuumm 44 MMeeddiiuumm 55,,44 HHeeaavvyy •Legacy Reaching Back to 1950s Vandenberg Air Force Base Denver, CO (VAFB), CA Decatur, AL Pueblo, CO San Diego, CA Harlingen, TX Cape Canaveral Air Force Station (CCAFS), FL J. Allison | 2 Great News! ERRORS J. Allison | 3 Identify the Hazards Recognizing When Others are Taking a Risk is Easy Recognizing When You are About to Take a Risk Requires Both Effort & Practice STOP & THINK Before You Act STOP When Risks/ Hazards Exist Picture used with permission from thereifixedit.com; There, I Fixed It™ is a trademark of Pet Holdings, Inc. © 2007-2010 Pet Holdings, Inc. J. Allison | 4 ULA Error Prevention History ss EEvveenntt RReeppoorrtteedd tt nn ee vv f Ef E MMiisshhaapp OOccccuurrrreennccee $ OO $ TIROS Satellite # # TTiimmee Incident LMC Atlas/Boeing Delta ULA 2003 2004 2005 2006 2007 2008 LMC SSC EPC ULA EPC Atlas Operational Fishbones ULA Mandatory Error Prevention Training for ALL Employees ULA Delta Reporting ULA SS Command Media • Active Atlas Reporting Since 2004 Err Prev Publications • Full Implementation of Delta Reporting Began in 2008 On-site Error Prevention Support Organization Reporting J. Allison | 5 Definitions Event: An incident that has a negative impact on production or launch operations. An EVENT is considered a potential MISHAP warning. Mishap: An EVENT resulting in incurred costs over $20K or consequences with high or significant impact. Critical Mishap: A Mishap resulting in incurred costs over $100K. Support Organization Event: An EVENT that occurs as a result of a Support Organization’s action. EVENT MISHAP J. Allison | 6 Definitions AESOP™ Huddle: An Error Prevention technique used to ensure that all personnel associated with an operation are familiar with & understand their roles & responsibilities in the operation & that risks of failure are identified & mitigated. Flash Notice: A preliminary notice to Executive Management & other personnel that a Mishap or Event has occurred. Corrective Action Board (CAB): A board to ensure effective corrective action processes are implemented & closed. CAB evaluates issues/problems/products/ processes & approves or directs corrective actions as necessary to remedy critical problems in a timely manner. AESOP™is a federally protected trademark of the Error Prevention Institute, Inc. ©2000 Error Prevention Institute, Inc., 888-0599-8715, all rights reserved. J. Allison | 7 Definitions EErrrroorr PPrreevveennttiioonn EEErrrrrrooorrr PPPrrreeevvveeennntttiiiooonnn EEErrrrrrooorrr PPPrrreeevvveeennntttiiiooonnn PPrroocceessss PPrriinncciipplleess PPPrrroooccceeessssss PPPrrriiinnnccciiipppaaalllsss PPPrrroooccceeessssss PPPrrriiinnnccciiipppaaalllsss ••••AAAAcccchhhhiiiieeeevvvveee eeeexxx eccceeexllllllceeeennnccclleeee iiinnnnce in everything eeevvveeerrryyyttthhhiiinnnggg wwweee dddooo we do Perfect Product Delivery Ethic: •••CCCooonnntttiiinnnuuuooouuussslllyyy iiimmmppprrrooovvveee • Continuously • Relentless pursuit of perfection to achieve excellence in imeeevvvpeeerrrryyyo pppvrrreooo ccceeeesssvssse aaarnnnyddd everything we do; process & product ppprrroooddduuucccttt • Applies our passion for Mission Success to continuously improve every process and product, to completely meet ••••DDDDeeeevvvveeeelllooolpppo paaa wwwaooo rrrlllddd---ccclllaaassssss world-class the needs of every customer; and wwwooorrrkkk eeennnvvviiirrrooonnnmmmeeennnttt work environment • Inspires and empowers all employees to dedicate our •••DDDeeellliiivvveeerrr ppprrrooogggrrraaammm innovative talents to deliver program success and develop • Deliver program ssssuuuucccccccceeeessssssss a world-class work environment. UULLAA’’ss EErrrroorr PPrreevveennttiioonn PPrrooggrraamm iiss FFoouunnddeedd oonn UULLAA’’ss PPeerrffeecctt PPrroodduucctt DDeelliivveerryy EEtthhiicc J. Allison | 8 ULA Error Prevention Process Technical Paper Available: Learning from Mistakes: ULA’s Error Prevention Program by James E. Allison Presented at the International System Safety Conference 2009 “The successful man will profit The ULA Error Prevention Process Flow is from his mistakes and try again in Fed by Ongoing Voluntary Event Disclosure a different way. ” –Dale Carnegie Error Prevention Process Flow This Paper Describes How United Launch Alliance’s (ULAs) Error Prevention Program EEvveenntt Applies This Concept to Rocket Production, Test & Launch Operations EEEEErrrrrrrrooorroorrr rrPPP PPrrreeerreevvvvveeeeennnnntttiiittoooiioonnnnn PPPPPrrrooorrooccccceeeeessssssssss PPP PPrrriiirrnnniinnccccciiipppiipplaaeaallsssll ss EEvveennt tR Reeppoortritningg Ongoing Voluntary ••AAcchhiieevvee eexxcceelllleennccee iinn PProrocceessss ULAs Error Prevention Program Event Disclosures eevveerryytthhiinngg wwee ddoo • Recognizes Errors as Learning Via Workforce Opportunities ••CCoonnttiinnuuoouussllyy iimmpprroovvee Cause Analysis Cause Analysis • Encourages Error Reporting Instead eevveerryy pprroocceessss aanndd && C Coorrrerecctitvivee A Acctitoionn Process of Punishing Employees When Errors pprroodduucctt Process Occur ••DDeevveelloopp aa wwoorrlldd--ccllaassss • Extracts & Shares Lessons Learned wwoorrkk eennvviirroonnmmeenntt Corrective Action Corrective Action Company Wide BBooaardrd ••DDeelliivveerr pprrooggrraamm • Issues Action Items to Reduce Error ssuucccceessss Occurrence Company Wide Error Prevention Error Prevention Council Continuous Feedback Council Each Reported Error is Tracked Through Review Process Review Process Encourages Ongoing Disclosure: Resolution as Follows •Company Wide Event Reporting • Root Cause Analysis •Weekly Attention To Detail Emails Share Lessons • Corrective Action Review Boards (CABs) Share Lessons •Periodic Safety Bulletin Releases Learned Process Learned Process • Executive Management Review (Called •Error Prevention Web Site Access an Error Prevention Council or EPC) Published Copy Available J. Allison | 9
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