Former NASA Director offers risk management advice

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Paul Dye, the longest-serving Flight Director in NASA’s human spaceflight program and commercial pilot with more than 4,500 hours, knows a few things about risk. And he’s more than happy to share what he knows.

Recently he shared risk management tips with members of Experimental Aviation Association Chapter 17 members during their annual membership banquet in Knoxville, Tenn. Although the audience was made up mostly of pilots, his advice applies equally to just about every industry, so we thought we’d summarize his tips here. We hope it helps you make some positive changes in your risk-management program.

Click on each tip to read more…

Tip #1: Understand Your Real Risk

“In the Space Shuttle program we trained in the Control Center several times a week whether we were flying or not,” Dye said. The personnel trained by simulating numerous failures, “most of those failure never ever happened in real flight.”

The failures actually encountered during real flight were things they had never thought of before. “Analyze the risks. Understand the risks. Look for ways to mitigate the ones you can,” he said, “and then you end up with these residual risks you can do nothing about except to accept them. Hopefully those are astronomically unlikely risks.”

Tip #2: Always Have a Backup Plan

While you may not like the realities of your back-up plan, it is always a good idea to have one.

“Space story,” Dye began with a chuckle. The Space Shuttle program used to fly the European Space Lab into orbit. After three flights, he explained, the engineers realized that once the Space Lab was placed in the Shuttle’s cargo bay, there was no way for an astronaut to reach the furthest cargo bay latch.

“We had a risk here that we had not been managing, so we needed a backup plan,” he said.

He and several experts went into an office and came up with a plan. When they presented the plan, the flight director said: “Are you nuts…? I like it.”

The plan was for the astronaut to space walk to the aft hatch, close it manually and ride home in the cargo bay. It would be a rough 5-minute ride, but at least they had a way to bring everyone home alive if the problem ever arose.

Tip #3: Understanding Unlike Redundancy

“Having two of the same item to accomplish a function is not always a good idea,” Dye offered. “If the first something failed, why won’t the second one?”

For example, if you’re using GPS to navigate in a hot and humid environment and it quits working, having a second identical GPS unit may fail identically because it’s in the same conditions, using the same hardware, with the same software. So Dye suggests having a main “something” of one brand/make while having a second “something” of a completely different brand/make just in case. In other words, dissimilar or unlike redundancy.

Tip #4: Keep things Simple

This one is so easy it’s hard.

“The more complicated something is,” he said, “the more chances you have to screw it up.”

Dye recounted an old engineering saying that goes like this: Perfection in design comes when there is nothing left to be taken away.

“When a function is critical, simplicity is the best,” he said. “The simplest thing with the fewest parts is the best way to make it work.”

Tip #5: Provide Margin

Lots of people make fun of Mooney airplanes with the signature forward-swept tail, but Dye showed the audience a photograph of what looks like dozens of people standing together on the wings of a single Mooney aircraft. The Mooney, he explained, had a one-piece spar that could withstand that much weight without breaking.

“Never take any system all the way to ultimate failure,” Dye warned emphatically. “Always know where your margin is.” Structural. Equipment. Operational.

His point, ultimately was that just because a system can withstand a certain amount of strain, it’s better not to push the limits…in case you need a little bit of wiggle room.

“If my wife and I have to be someplace, we plan to fly ourselves, but we buy a ticket on the airlines” just in case, he said.

Tip #6: Make Data-based Decisions

“The Engineering Support room in Mission Control is a huge room,” Dye said, beginning a story about why it’s important to use real information to make decisions. “Over the door of the Engineering Support room is a sign that says: ‘In God we trust. All others must bring data.’”

This famous Edwards Deming quote reminds one that something is only true if you can demonstrate the data that backs up that truth.

“Hanger Flyer opinions are just that: opinions,” Dye said. “Don’t trust your life to rumors and old wives’ tales. More importantly, don’t give into peer pressure. Just because everyone at an airport does it a certain way, doesn’t mean it’s right.”

Tip #7: Testing is Better Than Analysis

“We have become a generation of analysts,” Dye warned sternly.

Engineers use computer models to test structures and programs, he said. “That’s okay as long as those programs have been tested against real life. If they have not, then you need to suspect them.”

He recommended, that if you have a hypothesis about how your aircraft or engine or instruments will behave in a certain situation, do the research and test your hypothesis.

Tip #8: Know How Your Stuff Works

Dye recommends everyone knows how something works, “not just how to work it.”

“If you get in the air and various things start to fail,” Dye said, “you need to know what is connected to what.”

Basically, it’s harder (if not impossible) to solve a problem you don’t understand.

Tip #9: Develop Your Flight Rules

Any tip is made better when you can find a Far Side cartoon to illustrate it. In this case, Dye shared a cartoon that showed a huge Wooly Mammoth with his legs in the air, a tiny arrow stuck in his side and two cavemen standing next to the dead body. The caption reads: “Maybe we should write that spot down.”

Dye defined a Flight Rule for the audience.

“A flight rule is a decision made in the cool of the day, so you don’t have to make something up in the heat of the night.”

Figure out what works, write it down, commit to it and refrain from bending the rules, Dye said.

Tip #10: Know Your Requirements

“Don’t be the kid in the candy store,” Dye warned. “There’s everything out there and you want it all, but what do you really need?”

His advice? “Determine what you want it to do, not how you want it to do it.”

“Mission creep frequently leads to unfinished projects,” Dye explained. “Once you have determined what you want your airplane to do, be very, very, very, very cautious about making changes to your requirements or you will never finish it.”

Dye debunked the myth about the US-developed million-dollar “Space Pen” that can write in zero gravity. The old punch line is: the Russians use a pencil. Dye confirmed to the chuckling audience, that the US Space Program does too, while pointing out the requirement was not to have a fancy ball-point pen that writes upside down in zero gravity. The requirement, he insisted, “was to make marks on paper.”

Tip #11: Details Count

It’s an old saying, and it goes like this:  “For want of a single bolt, the aircraft was lost.”

“It is rarely a single large failure that causes a problem,” Dye said.  “It is usually a string of failures, individual things, that then depend on one last little problem.”

And to drive that point home, Dye explained that in the software code that runs the Space Shuttle, there is one tiny spot in millions of lines of code where the software engineer can put either the minus sign or the plus sign.  And this tiny detail determines whether the rocket goes up, or the rocket goes down.

“There is nothing you can take for granted in an airplane,” Dye said.  “Airplanes exist because they are built light, and they are light because they don’t include anything they don’t need.”

For example, there may only four bolts that attach the engine to the airframe.

Tip #12: Learn from History

And another old saying goes like this: “You will never have enough time in your life to make all the mistakes yourself.”

Dye explained that after every shuttle mission the engineering team created a “lessons learned” document.

Cauliflower in cheese sauce. This, according to Dye, was the worst space food ever made.

“They managed to make it woody and slimy at the exact same time,” Dye said. “That was a lesson learned, and we wrote those kinds of things down so people wouldn’t forget them.”

Dye’s advice was simple: Read as much reference material as you can.   For example you may read AC 43.13-1B – Acceptable Methods, Techniques, and Practices – Aircraft Inspection and Repair, but if you don’t like that one, Dye mentioned that the Experimental Aircraft Association is in the process of creating a Best Practices Guide for Homebuilders.

Tip #13: Teamwork Works!

A Space Station Team today may include members in control centers in Houston, Russia, Munich, Canada and Japan.

“They are all part of the team,” Dye said. “It helps to have a network. You don’t need to build in a vacuum. If you’re building in a vacuum, you’re making a mistake.”

He also pointed out there are no merit badges given for solving a problem a second time.

Tip #14: Hope is NOT a Plan

“Do you hope it will work?” Dye asked. “Or do you know it will work?”

So you’ve tried to tie off your safety wire six times but cut it off and tried again because it wasn’t quite right.

“That seventh time still doesn’t look quite right, but you can’t figure out how to do it any better, and you say, ‘Well… I hope that’ll work.’”

This, according to Dye, is not a good way to do business.

“You need to be honest with yourself and if you have any doubts at all, you need to follow it up,” he cautioned. “The most common human error is bad judgement.”