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Since the Columbia accident, the National Aeronautics and Space Administration (NASA) has worked extensively to improve its "Lessons Learned" processes so that NASA can avoid repeating past decision making errors. This paper identifies the most serious pitfalls in lessons learned processes that support decisions that must be made in situations with significant risks. We focus on three steps...
The Columbia Accident Investigation Board (CAIB) report states that NASA needs to develop an organizational culture that reflects the best characteristics of a learning organization and that NASA historically has not demonstrated such characteristics. When there is a technical failure, most organizations are good at identifying the technical cause and learning not to repeat that same mistake. However,...
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