By November 19, 2008 0 Comments Read More →

Lost in Space

My Way News – Lost tool bag forces changes to planned spacewalks

This makes wonder if the space program uses any concepts that we’d call “Lean” even if they don’t. This story makes me think of Error Proofing, Standardized Work, and Failure Modes Effects Analysis (FMEA).

Flight controllers were revamping plans Wednesday for the remaining spacewalks planned during space shuttle Endeavour’s visit to the international space station, after a crucial tool bag floated out to space during a repair trip.

The briefcase-sized tool bag drifted away from astronaut Heidemarie Stefanyshyn-Piper on Tuesday as she cleaned and lubed a gummed-up joint on a wing of solar panels on the space station. She and fellow astronaut Stephen Bowen were midway through the first of four spacewalks planned for the mission. The tool bag was one of the largest items ever lost by a spacewalker.

I hope NASA’s response to this involves something other than blaming the astronaut.

As Stefanyshyn-Piper cleaned up a large gob of grease that seeped from a gun used to lubricate the joint, the tool case somehow became untethered from a larger bag and floated away along with a pair of grease guns, wipes and a putty knife attached to it.

“What it boils down to is all it takes is one small mistake for a tether not to be hooked up quite correctly or to slip off, and that’s what happened here,” said lead spacewalk officer John Ray.

So it sounds like Standardized Work was not followed? They don’t have a process to double check (which is inspection — a form of waste) or error proof the tethering so it can’t slip off?

NASA could write this off as “human error,” but it’s important to learn from these mistakes so they don’t happen again. Or, should they have been able to proactively prevent the error?

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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

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