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's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation.
He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean.
Mark is also a Senior Advisor to the technology company KaiNexus.