National Aeronautics and Space Administration

A Catalog of NASA-Related Case Studies

Compiled by the Office of the Chief Knowledge Officer
Goddard Space Flight Center, NASA
Updated as of September 2011
Contact

Dr. Edward W. Rogers

Chief Knowledge Officer
Office of the Chief Knowledge Officer
Goddard Space Flight Center
NASA

Version 1.8
Publication Date: September 2011

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Cover Image: The TacSat-2 launches from Wallops Flight Facility. Credit: NASA
ALPHABETICAL INDEX
Case Title Length Subject Focus Page
ABCs of OCI: Know You Don’t 4 Contract management; Decision making 1
AGATE: The Turning Point for Project management; Revitalizing industry
35 2
General Aviation
Atlas Centaur-67: Go or No Go for Launch decision
3 3
Launch?
Building the Team: The Ares I-X Expertise; Facilities renovation; Large scale
10 4
Upper Stage Simulator fabrication; Staffing; Retraining
Collaborative Problem-Solving: The Problem-solving; Collaboration
13 5
STS-119 Flow Control Valve Issue
Shuttle accident; Decision making;
Columbia's Final Mission 33 6
Communication; Crisis management;
Beliefs; Crisis communication; Crisis prevention;
Columbia’s Final Mission (Multimedia
n/a Group behavior; Group dynamics; Managerial 7
Case)
skills
Communication Aberration 4 Hubble; Communication; Risk management 8
Cover Blown - The WIRE Spacecraft On-orbit failure; Test-as-you-fly; Peer reviews
4 9
Mishap
R&D environment vs. operational environment;
Earth Observing System Data
35 Developers vs. users; Instability of requirements; 10
Information System (EOSDIS)
Acquisition strategy
Fender Bender - DART's Automated Navigational system error; On-orbit failure
4 11
Collision
Shuttle accident; Decision making; Risk
Final Voyage of the Challenger 35 12
management
Design and material issues; Quality control;
Fire in the Cockpit - The Apollo 1
4 Emergency preparedness; Budget and schedule 13
Tragedy
pressures; Complacency
Goddard Space Flight Center: 20+ Organizational learning
14
Building A Learning Organization 12
GOES-N: Long and Winding Road to Managing fixed-price contract; Technical role in
8 15
Launch launch decision; Managing exigencies
Schedule pressures; Launch decisions; Risk
Gravity Probe B 11 16
management; Risk mitigation
Hit the Bricks 4 Launch facilities; Safety; KSC; Space Shuttle 17
HMS Thetis and Apollo XIII 21 Disaster management 18
Hubble Space Telescope: Systems Systems engineering
69 19
Engineering Case Study
IBEX: Managing Logistical Exigencies 1 Logistics; Communication 20

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA i
Case Title Length Subject Focus Page
Budget; Schedule; Science; Team; Project
IMAGE n/a 21
management
International Project Management: On-orbit failure; Telemetry; International
14 22
The Cassini-Huygens Mission collaboration; ITAR
International Space Station: Systems Systems engineering; Partnerships
105 23
Engineering Case Study
Launching New Horizons: The RP-1 Governance model; Independent technical
16 24
Tank Decision authority; Transparent decision making
Risk management; Communication,
Launching the Vasa 6 Organizational culture; Technologies, 25
Requirements, Schedules, Budgeting; Accidents
Launch decision; Safety, Organizational culture;
Lessons from the Challenger Launch
13 Risk management; decision making; engineering 26
Decision
design
Lewis Spins out of Control 4 ―Faster, better, cheaper‖ (FBC); On-orbit failure 27
Risk management; Communication;
Lifting NOAA-N Prime 4 28
Organizational culture; Contract management
Lost in Translation - The Mars Climate Spacecraft trajectory; Ground software
4 29
Orbiter Mishap
Lost in Space: A Case Study in Engineering problem solving; ―Faster, better,
8 30
Engineering Problem Solving cheaper‖ (FBC)
Lunar Crater Observation and Risk management; Communication, Project
8 31
Sensing Satellite (LCROSS) management
Managing Knowledge and Learning at Knowledge management; Organizational learning
NASA and the Jet Propulsion 30 32
Laboratory (JPL)
Mechanical Systems Engineering Organizational culture; Communication; Contract
4 33
Support Contract Re-Compete management
Failure; Investigation; Contract management; Risk
Mission to Mars 4 34
management
M.S.T.I.: Optimizing the Whole Systems engineering across a project
27 35
System
NASA After Challenger: Restoring an Disaster management; Media relations;
18 36
Image Management communication
NEAR (Near Earth Asteroid Redesign; Managing change
n/a 37
Rendezvous)
NOAA-N Prime Case Study 38 Safety; Risk management; Accidents 38
Pegasus XL-HESSI: Last-Minute Decision making; Communication; Risk
8 39
Decisions in Flight-Based Launch Management
Redesigning the Cosmic Background Launch vehicle; Redesign; Matrix management;
10 40
Explorer (COBE) Mass; Co-location; Test-as-you-fly

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA ii
Case Title Length Subject Focus Page
Searching for Life on Mars: The Instrument development; Project management
Development of the Viking Gas
8 41
Chronomatograph Mass
Spectrometer
Software anomaly; "Test as you fly"; Anomaly
Shuttle Software Anomaly 4 42
documentation
Sitting on the Fence: Launching a Launch vehicle; Decision making; Safety; Failure;
10 43
Balloon in the Outback Accidents
Skin in the Game: Questioning Contract management; Decision making
4 44
Organizational Conflict of Interest
Behavior; Human resources management;
Space Shuttle 6 Organizational behavior; Organizational structure; 45
Quantitative analysis
Space-to-Space communications Schedule pressures; Testing; Space
6 46
System communications; In-house development
Spektr of Failure 4 Hubble; Communication; Risk management 47
ST5 - Miniaturized Space Technology 4 Communication 48
STEREO: Organizational Cultures in Organizational culture; Communication; Tests;
5 49
Conflict Schedules; Budgeting
Stormy Weather: Lightning Strike on Shuttle launch; Decision-making
n/a 50
the Launch Pad
Super Lightweight Tank: A Risk Risk management; Risk mitigation: Risk
Management Case Study in Mass 44 assessment 51
Reduction
TDRSS: Fixed-Cost versus Cost-Plus Contract management; Organizational culture;
7 52
Contracting Schedules; Budgeting
TDRSS K, L: Working with a Fixed Contract management; Requirements
6 53
Price Contract
The CALIPSO Mission: Project Interagency communication; Roles; Relationships;
Management in the "PI Mode": Who's 9 ITAR and international partnerships 54
in Charge?
The CEV Seat: Seeking a Semi- Contract management; Requirements;
7 55
Custom Fit in an Off-the-Rack World Engineering; Schedule; Review; Learning
Communication; Contract management;
The Dart Mission: Changing
Engineering; Instruments; ITAR; Launch vehicles;
Environment, Shifting Priorities, Hard 6 56
Politics; Project management; Roles;
Decisions
Technologies; Tests
The Million Mile Rescue - SOHO Lost In space recovery; Extending the mission; Ground
4 57
in Space operations
The NFIRE Launch: Beating the Choosing your biggest worry; Launch decision
Sophomore Slump at the Wallops 7 making 58
Range

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA iii
Case Title Length Subject Focus Page
Communication; Organizational silence;
The Pursuit of Images of Columbia 6 59
Accidents; Hierarchical barriers; Safety
The Tour Not Taken - NASA's Comet On-orbit failure; Team integration; Faulty design
4 60
Nucleus Tour (CONTOUR)
Thermosphere Ionosphere Programmatic challenges; Mission requirements;
Mesosphere Energetics and Center buy-in; Managing expectations; Lines of
21 61
Dynamics Project (TIMED) Case authority; Rules of engagement; Complex
Study relationships; Personality conflicts
Vegetation Canopy Lidar 12 Weak project management; Institutional oversight; 62
Contract management; Risk management;
Wait, Wait, Don’t Launch 4 63
Decision making
"Faster, better, cheaper" mandate; Geographically
Wide-Field Infrared Explorer (WIRE) 16 64
dispersed teams; Communications;

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA iv
INDEX BY CASE LENGTH
Case Title Length Page
IMAGE n/a 21
NEAR (Near Earth Asteroid Rendezvous) n/a 37
Stormy Weather: Lightning Strike on the Launch Pad n/a 50
Columbia’s Final Mission (Multimedia Case) n/a 6
IBEX: Managing Logistical Exigencies 1 20
Atlas Centaur-67: Go or No Go for Launch? 3 3
ABCs of OCI: Know You Don’t 4 1
Communication Aberration 4 8
Cover Blown - The WIRE Spacecraft Mishap 4 9
Fender Bender - DART's Automated Collision 4 11
Fire in the Cockpit - The Apollo 1 Tragedy 4 13
Hit the Bricks 4 17
Lewis Spins out of Control 4 27
Lifting NOAA-N Prime 4 28
Lost in Translation - The Mars Climate Orbiter Mishap 4 29
Mechanical Systems Engineering Support Contract Re-Compete 4 33
Mission to Mars 4 34
Shuttle Software Anomaly 4 42
Skin in the Game: Questioning Organizational Conflict of Interest 4 44
Spektr of Failure 4 47
ST5 - Miniaturized Space Technology 4 48
The Million Mile Rescue - SOHO Lost in Space 4 57
The Tour Not Taken - NASA's Comet Nucleus Tour (CONTOUR) 4 60
Wait, Wait, Don’t Launch 4 63
STEREO: Organizational Cultures in Conflict 5 49
The Pursuit of Images of Columbia 6 59
Space-to-Space communications System 6 46
The Dart Mission: Changing Environment, Shifting Priorities, Hard Decisions 6 56
Space Shuttle 6 45
Launching the Vasa 6 25
TDRSS K, L: Working with a Fixed Price Contract 6 53
The NFIRE Launch: Beating the Sophomore Slump at the Wallops Range 7 58

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA v
Case Title Length Page
TDRSS: Fixed-Cost versus Cost-Plus Contracting 7 52
The CEV Seat: Seeking a Semi-Custom Fit in an Off-the-Rack World 7 55
GOES-N: Long and Winding Road to Launch 8 15
Pegasus XL-HESSI: Last-Minute Decisions in Flight-Based Launch 8 39
Searching for Life on Mars: The Development of the Viking Gas Chronomatograph 8
41
Mass Spectr.
Lost in Space: A Case Study in Engineering Problem-Solving 8 30
Lunar Crater Observation and Sensing Satellite (LCROSS) 8 31
The CALIPSO Mission: Project Management in the "PI Mode": Who's in Charge? 9 54
Building the Team: The Ares I-X Upper Stage Simulator 10 4
Sitting on the Fence: Launching a Balloon in the Outback 10 43
Redesigning the Cosmic Background Explorer (COBE) 10 40
Gravity Probe B 11 16
Vegetation Canopy Lidar 12 62
Collaborative Problem-Solving: The STS-119 Flow Control Valve Issue 13 5
Lessons from the Challenger Launch Decision 13 26
International Project Management: The Cassini-Huygens Mission 14 22
Launching New Horizons: The RP-1 Tank Decision 16 24
Wide-Field Infrared Explorer (WIRE) 16 64
NASA After Challenger: Restoring an Image 18 36
Thermosphere Ionosphere Mesosphere Energetics and Dynamics Project (TIMED) 21
61
Case Study
HMS Thetis and Apollo 13 21 18
Goddard Space Flight Center: Building A Learning Organization 20 +12 14
M.S.T.I.: Optimizing the Whole system 27 35
Managing Knowledge and Learning at NASA and the Jet Propulsion Laboratory 30
32
(JPL)
Columbia's Final Mission 33 6
AGATE: The Turning Point for General Aviation 35 2
Earth Observing System Data Information System (EOSDIS) 35 10
Final Voyage of the Challenger 35 12
NOAA-N Prime Case Study 38 38
Super Lightweight Tank: A Risk Management Case Study in Mass Reduction 44 51
Hubble Space Telescope: Systems Engineering Case Study 69 19
International Space Station: Engineering Case Study 105 23

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA vi
INDEX BY SOURCE
Office of the Chief Knowledge Officer (OCKO), NASA/GSFC
Case Title Length Page

ABCs of OCI: Know You Don’t 4 1

Atlas Centaur-67: Go or No Go for Launch? 3 3

GOES-N: Long and Winding Road to Launch 8 15

IBEX: Managing Logistical Exigencies 1 20

Launching the Vasa 8 25

Lessons from the Challenger Launch Decision 13 26

Lifting NOAA-N Prime 4 28

Mechanical Systems Engineering Support Contract Re-Compete 4 33

Pegasus XL-HESSI: Last-Minute Decisions in Flight-Based Launch 8 39

Sitting on the Fence: Launching a Balloon in the Outback 10 43

Skin in the Game: Questioning Organizational Conflict of Interest 4 44

ST5 - Miniaturized Space Technology 4 48

STEREO: Organizational Cultures in Conflict 5 49

TDRSS: Fixed-Cost versus Cost-Plus Contracting 7 52

TDRSS K, L: Working with a Fixed Price Contract 6 53

The CALIPSO Mission: Project Management in the "PI Mode": Who's in Charge? 9 54

The CEV Seat: Seeking a Semi-Custom Fit in an Off-the-Rack World 7 55

The Dart Mission: Changing Environment, Shifting Priorities, Hard Decisions 6 56

The NFIRE Launch: Beating the Sophomore Slump at the Wallops Range 7 58

The Pursuit of Images of Columbia 6 59

Wait, Wait, Don’t Launch 4 63

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA vii
NASA Safety Center (NSC)
Case Title Length Page

Communication Aberration 4 8

Cover Blown - The WIRE Spacecraft Mishap 4 9

Fender Bender - DART's Automated Collision 4 11

Fire in the Cockpit - The Apollo 1 Tragedy 4 13

Hit the Bricks 4 17

Lewis Spins out of Control 4 27

Lost in Translation - The Mars Climate Orbiter Mishap 4 29

Mission to Mars 4 34

Shuttle Software Anomaly 4 42

Spektr of Failure 4 47

The Million Mile Rescue - SOHO Lost in Space 4 57

The Tour Not Taken - NASA's Comet Nucleus Tour (CONTOUR) 4 60

NOAA-N Prime Case Study 38 38

Academy of Program/Project & Engineering Leadership (APPEL), NASA

Case Title Length Page

Building the Team: The Ares I-X Upper Stage Simulator 10 4

Collaborative Problem-Solving: The STS-119 Flow Control Valve Issue 13 5

Earth Observing System Data Information System (EOSDIS) 35 10

Gravity Probe B 11 16

IMAGE n/a 21

International Project Management: The Cassini-Huygens Mission 14 22

Launching New Horizons: The RP-1 Tank Decision 16 24

Lunar Crater Observation and Sensing Satellite (LCROSS) 8 32

NEAR (Near Earth Asteroid Rendezvous) n/a 37

Redesigning the Cosmic Background Explorer (COBE) 10 40

Searching for Life on Mars: The Development of the Viking Gas Chronomatograph 8 41
Mass Spectrometer

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA viii
Space-to-Space communications System 6 46

Stormy Weather: Lightning Strike on the Launch Pad n/a 50

Thermosphere Ionosphere Mesosphere Energetics and Dynamics Project (TIMED) 21 61

Case Study

Vegetation Canopy Lidar 12 62

Wide-Field Infrared Explorer (WIRE) 16 64

NASA, Exploration Systems Mission Directorate (ESMD)

Case Title Length Page

Super Lightweight Tank: A Risk Management Case Study in Mass Reduction 44 51

Center for Systems Engineering, Air Force Institute of Technology

Case Title Length Page

Hubble Space Telescope: Systems Engineering Case Study 69 19

International Space Station: Systems Engineering Case Study 105 23

Darden, University of Virginia

Case Title Length Page
Goddard Space Flight Center: Building A Learning Organization 20+12 14

Harvard Business School Publishing

Case Title Length Page

Columbia's Final Mission 33 6

Columbia’s Final Mission (Multimedia Case) n/a 7

Final Voyage of the Challenger 35 12

HMS Thetis and Apollo 13 21 18

Managing Knowledge and Learning at NASA and the Jet Propulsion Laboratory 30 32
(JPL)

NASA After Challenger: Restoring an Image 18 36

Space Shuttle 6 45

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA ix
Virginia Polytechnic Institute
Case Title Length Page

AGATE: The Turning Point for General Aviation 35 2

M.S.T.I.: Optimizing the Whole System 27 35

National Center for Case Study Teaching in Science

Case Title Length Page

Lost in Space: A Case Study in Engineering Problem-Solving 8 30

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA x
Case Title ABCs of OCI: Know You Don’t

Project Name n/a

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/305/

# of Pages 4

Abstract This case study focuses on an Organizational Conflict of Interest (COI)

issue within NASA contracting based on a contractor's ongoing work
within one contract which could potentially conflict with a new contract
the contractor is now preparing to bid for.

Subject Contract management; Decision making

Focus

Learning Understand how NASA's contracting workforce needs to be pro-active in

Points identifying potential conflict of interest issues across contracts and
across activities undertaken in different centers and at headquarters as
well as in taking decisive action early in the process.

Other
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 1
Case Title AGATE: The Turning Point for General Aviation

Project Name AGATE

Source Virginia Polytechnic Institute

URL http://www.nasa.gov/pdf/293210main_58527main_agate_casestudy_042604
.pdf

# of Pages 35

Abstract This is a full length historical case of how NASA became involved in a project
to revitalize the General Aviation industry in America which had been
declining for 15 years. Set in the early 1990s it documents the steps and
involvement of the government through AGATE to address this decline.
AGATE is the Advanced General Aviation Transportation Experiments.

Subject project management; revitalizing industry

Focus

Learning Industrial decline and revitalization. Government intervention. National

Points technology capability.

Other AGATE factsheet:

Resources http://www.nasa.gov/centers/langley/news/factsheets/AGATE.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 2
Case Title Atlas Centaur-67: Go or No Go for Launch?

Project Name AC-67

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/28

# of Pages 3

Abstract Thunderstorms are building near the launch facility at Cape Canaveral,
Florida, when countdown commences for the Atlas Centaur-67 mission.
Prior to AC-67, with its military communications satellite payload, the
Atlas Centaur rocket had been deployed in 66 consecutive NASA
missions. The launch team debates ambiguous weather and safety
launch criteria as problems with communications equipment, and a small
launch window for an eager customer, complicate the go/no-go decision
in the final moments of countdown.

Subject Focus launch decision

Learning The importance of understanding the origin and context of safety

Points requirements. When operating near the limit of specifications, extra
caution needs to be added if the requirements are not well understood. If
things look really bad, they might be really bad. How to speak up in a
fast-paced, high pressure environment (launch).

Associated The Teaching Note provides suggestions for guiding classroom

Documents discussions of the case as well as additional resources.
For access to the Teaching Note contact the Office of the Chief
Knowledge Officer /Goddard Space Flight Center.

Other Christian, H. J., V. Mazur, B. D. Flsher, L. H. Ruhnke, K. Crouch, and R.

Resources P. Perala (1989), The Atlas/Centaur Lightning Strike Incident, J.
Geophys. Res., 94(D11), 13,169–13,177.

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 3
Case Title Building the Team: The Ares I-X Upper Stage Simulator

Project Name ARES

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/pdf/352126main_Ares_I-X_Case_Study.pdf

# of Pages 10

Abstract The opportunity to build a new launch vehicle that can lift humans into
space does not come along often. The Ares family of launch vehicles,
conceived in response to the Vision for Space Exploration, presented
the first chance for NASA engineers to get hands-on experience
designing and building human spacecraft hardware since the
development of the Space Shuttle thirty years ago. In 2005, NASA
Headquarters solicited proposals from Integrated Product Teams for
different segments of the Ares I-X test flight vehicle. A team at Glenn
Research Center won the bid for the job of building the Ares I-X Upper
Stage Simulator (USS). A fabrication job of this size required not only
renovation of some facilities but also putting a team together with the
right mix of skills.

Subject Focus expertise; facilities renovation; large scale fabrication; staffing; retraining

Learning The organizational context of a NASA center can determine the types of
Points challenges faced by a project manager; Project leaders may be required
to employ a number of strategies and tactics to adjust the composition of
the team in order to get to the right results; professional development
activities may play a key role in the makeup of the final team?.

Other http://spaceflightsystems.grc.nasa.gov/LaunchSystems/Simulator/
Resources http://askmagazine.nasa.gov/pdf/pdf34/NASA_APPEL_ASK_34s_buildin
g_the_team.pdf

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 4
Case Title Collaborative Problem-Solving: The STS-119 Flow Control
Valve Issue

Project Name STS-119 & STS-126

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/pdf/468375main_STS-119_flow_control_valve.pdf

# of Pages 13

Abstract On November 14, 2008, as Space Shuttle Endeavor rocketed skyward

on STS-126, flight controllers monitoring data during the ascent noted
an unexpected hydrogen flow increase from one of the shuttle's main
engines. Despite this in-flight anomaly, the launch proceeded
smoothly—since three flow control valves (one per main engine) work in
concert to maintain proper pressure in the hydrogen tank, one of the
other valves reduced flow to compensate for the greater flow from the
valve that malfunctioned. This issue would require immediate attention
as soon as STS-126 landed safely on November 30.
The challenge this problem would pose was a familiar one. To ensure
the safety of future shuttle missions, management, along with the
technical community, would need the best possible analysis to
understand what happened on STS-129 and its implications for future
missions. Leaders would have to promote and ensure open
communication among the multiple organizations involved in the shuttle
program so that all relevant information would be available to decision
makers with the responsibility to approve or delay future shuttle flights.

Subject Focus problem-solving; collaboration

Learning What is the role of cognitive diversity in resolution of technical

Points problems? How do different individuals exercise leadership at different
points in time? How does communication among stakeholders help
shape outcomes?

Other STS-119 -
Resources http://www.nasa.gov/mission_pages/shuttle/shuttlemissions/sts119/main
/index.html
STS-126
http://www.nasa.gov/mission_pages/shuttle/shuttlemissions/sts126/main
/index.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 5
Case Title Columbia's Final Mission

Project Name STS-107

Source Harvard Business School Publishing

URL http://hbr.org/product/columbia-s-final-mission/an/304090-PDF-
ENG?Ntt=columbia

# of Pages 33

Abstract Describes the 16-day final mission of the space shuttle Columbia in
January 2003 in which seven astronauts died. Includes background on
NASA and the creation of the human space flight program, including the
1970 Apollo 13 crisis and 1986 Challenger disaster. Examines NASA's
organizational culture, leadership, and the influences on the
investigation of and response to foam shedding from the external fuel
tank during shuttle launch.

Subject Focus shuttle accident; decision-making; communication; crisis management;

Learning To analyze the flawed response to an ambiguous but potentially

Points threatening signal during a period in which recovery of the shuttle was
possible. (Source: HBR)

Other Remembering Columbia (NASA History website):

Resources http://history.nasa.gov/columbia/index.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 6
Case Title Columbia's Final Mission (Multimedia case)

Project Name STS-107

Source Harvard Business School Publishing

URL http://hbsp.harvard.edu/multimedia/columbia/305032/html_bundle/index.
html

# of Pages n/a

Abstract On February 1, 2003, the Shuttle Columbia disintegrated upon re-entry

into the Earth's atmosphere, and the seven astronauts onboard lost their
lives. Explores Columbia's final mission from the perspective of six key
managers and engineers associated with NASA's Space Shuttle
Program. An introductory video and interactive timeline present
background information. An application replicates the desktop
environment of six real-life managers and engineers involved in decision
making during the period prior to Columbia's re-entry.

Each student is preassigned a particular role and, through a password

system, enters the role-play application. Students review the
protagonists' actual e-mails, listen to audio re-enactments of crucial
meetings, and review space agency documents. Students must be
prepared to play the role of the protagonist in a classroom re-enactment
of a critical Mission Management Team meeting that took place on Flight
Day 8 (January 24, 2003). Students examine the organizational causes
of the tragedy rather than focus on the technical cause.

Subject Focus beliefs, crisis communication, crisis prevention, group behavior, group
dynamics, managerial skills

Learning To enhance understanding of organizational decision making and

Points learning as well as catastrophic failures; to help students understand
how failures can evolve; to think about how to prevent failures in an
organization; and to examine how to manage crises effectively. Also, to
learn leadership behavior and how to build an organization that is less
susceptible to significant preventable failures.

Other Michael A. Roberto, Richard Bohmer, Amy C. Edmondson, Facing

Resources Ambiguous Threats, R0611F-PDF-ENG.

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 7
Case Title Communication Aberration

Project n/a
Name

Source NASA Safety Center

URL http://nsc.nasa.gov/SFCS/SystemFailureCaseStudyFile/Download/190/

# of Pages 4

Abstract When NASA launched the Hubble Space Telescope in 1990,

astronomers boasted that Hubble would probe the universe to a degree
unparalleled by earthbound observatories, and the images it would
capture would be of unrivaled quality. Hubble has fulfilled these claims,
and the telescope is presently credited with providing data for more than
6,000 published scholarly articles. Fortunately, Hubble’s past and current
successes now overshadow the debacle in which it was mired during its
early years. After Hubble’s Wide Field Planetary Camera recorded its first
photograph, a voracious press clamored for weeks to see the result. They
were met with disappointment. The picture - a severely blurred image of a
star cluster in the Carina constellation - fell far short of the crystal
representation everyone expected, and a difficult truth became strikingly
evident: the telescope was flawed.

Subject Hubble; Communication; Risk management

Focus

Learning In an industry dominated by engineering and in an Agency endeavoring

Points to expand technology's limits, scientific emphasis can sometimes
overrule social contexts. NASA's leaders must possess "soft skills" to
enhance team-building and better identify managerial shortcomings
before they result in broken team interfaces and technical mistakes, as
they did during the HST project. NASA's official Optical Systems Failure
Report lists key lessons to take away from the HST mishap.

Other NASA Website:

Resources http://www.nasa.gov/mission_pages/hubble/main/index.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 8
Case Title Cover Blown - The WIRE Spacecraft Mishap

Project Name WIRE

Source NASA Safety Center (NSC)

URL http://nsc.nasa.gov/SFCS/SystemFailureCaseStudyFile/Download/16/

# of Pages 4

Abstract Launched on March 4, 1999, the Wide-Field Infrared Explorer (WIRE)

carried an infrared telescope that was meant to study the formation of
galaxies. To prevent the satellite's heat from interfering with faint
infrared signals, the telescope was stored in a cryostat cooled by tanks
of frozen hydrogen.
Approximately twenty minutes after WIRE separated from its launch
vehicle, a transient electronic signal released the cryostat cover,
exposing the hydrogen tanks to heat from the sun and earth. The
hydrogen sublimated and escaped through the vents, sending the
spacecraft into an uncontrolled spin. In less than thirty-six hours, the
entire four-month supply of solid hydrogen needed to cool the
telescope's infrared sensors was gone.

Subject Focus on-orbit failure; test-as-you-fly; peer reviews

Learning Underlying issues identified by the Mishap Investigation Board (MIB)

Points included the following: 1) Failure to consider off-nominal conditions; 2)
Lack of peer reviews; 3) Incomplete test procedures and analysis.

Other Listed at the end of the case study document

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 9
Case Title Earth Observing System Data Information System (EOSDIS)

Project Name EOSDIS

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/pdf/384155main_EOSDIS_case_study.pdf

# of Pages 35

Abstract The Earth Observing System Data and Information System (EOSDIS)
was started as part of the Earth Observing System (EOS). This system
was meant to collect, process, distribute, and archive the large amount
of data that was to be generated by the EOS program and to archive
and distribute NASA Earth science data. The purpose of this case study
on EOSDIS is to help NASA managers, engineers, and scientists
understand what happened during the implementation of the EOSDIS in
order to be able to apply the lessons learned to future programs and
projects.

Subject Focus R&D environment vs. operational environment; developers vs. users;
instability of requirements; acquisition strategy

Learning 1) Don't overreact or let the pendulum swing too far in the other
Points direction; 2) Know what you want to build and be able to define it; 3a)
Acquisition strategy must be tailored to any system where the user
needs are difficult to articulate and subject to technological evolution and
enhancement; 3b) A build-it-by-the-yard approach is desirable to
maintain cost control while allowing flexibility for evolutionary changes;
3c) Flexible options must be available for the outer concentric
developments; 4) Control expectations; tell the truth about capabilities;
5) Choose the appropriate organizational structure, staff it accordingly,
and stay with it; 6) Keep the flight operating system (FOS) tied to the
flight segment; 7) A strong systems engineering capability is needed for
large, complex system development; 8) If the underlying processes are
not in place, you don't have a chance; 9) Program, Project, and
executive leadership must be aware of the environment; 10) Strong
leadership, at all levels, is criticial to the development of a new,
complext, highly-visible system; 11) Maintaining partnerships between
the teams is necessary for a successful development; 12) A large
government program with high visibility draws political attention that can
impact development; 13) Endless reviews do not help a struggling
project.

Other References are listed at the end of the case document.

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 10
Case Title Fender Bender - DART's Automated Collision

Project Name DART

Source NASA Safety Center (NSC)

URL http://nsc.nasa.gov/SFCS/SystemFailureCaseStudyFile/Download/31/

# of Pages 4

Abstract The Demonstration of autonomous Rendezvous Technology (DART)

program intended to demonstrate that a spacecraft could independently
rendezvous with an orbiting satellite without human intervention.
The DART spacecraft was successfully launched in April 2005.
Following a series of navigational system errors and problems with fuel
management, DART crashed into its rendezvous partner spacecraft.

Subject Focus navigational system error; on-orbit failure

Learning Underlying issues included 1) Flawed software requirements and

Points validation approach; 2) Ineffective design choices, and; 3) Lack of
training, experience and oversight.
The mission illustrated the importance of independent assessments,
audits, and peer reviews throughout the various stages of a mission.

Other Listed at the end of the case study document.

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 11
Case Title Final Voyage of the Challenger

Project Name STS-51L

Source Harvard Business School Publishing

URL http://hbr.org/product/final-voyage-of-the-challenger/an/691037-PDF-
ENG

# of Pages 35

Abstract On January 28, 1986, seven astronauts were killed when the space
shuttle they were piloting, the Challenger, exploded just over a minute
into the flight. The failure of the solid rocket booster O-rings to seat
properly allowed hot combustion gases to leak from the side of the
booster and burn through the external fuel tank. The failure of the O-ring
was attributed to several factors, including faulty design of the solid
rocket boosters, insufficient low- temperature testing of the O-ring
material and the joints that the O-ring sealed, and lack of proper
communication between different levels of NASA management. The
case "provides a summary of technical and organizational details that
led to the decision to launch the Challenger Space Shuttle, and to the
ensuing accident.

Subject Focus shuttle accident; decision-making; risk management

Learning Details of design and testing milestones of the Space Shuttle, with a
Points focus on the Solid Rocket Booster, offer opportunities for project
management and organizational analysis. NASA's risk management
structure and its use for the Space Shuttle program exposes students to
issues of risk associated with the use of technology. Principles of
engineering versus managerial decision making, the role of professional
knowledge, and issues related to data representation, and qualitative
versus quantitative analysis are addressed.
Some issues of professional ethics and individual responsibilities, as
related to complex decision making in a technology intensive
environment are presented in a context of a crisis situation. The analysis
of the case should include assessment of project management, and
ideas about organizational changes to avoid recurrence." (Source: HBR
website)

Other STS-51L Challenger Accident (NASA History website):

Resources http://history.nasa.gov/sts51l.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 12
Case Title Fire in the Cockpit - The Apollo 1 Tragedy

Project Name Apollo 1

Source NASA Safety Center (NSC)

URL http://nsc.nasa.gov/SFCS/SystemFailureCaseStudyFile/Download/44

# of Pages 4

Abstract A seminal event in the history of human spaceflight occurred on the

evening of January 27th, 1967, at Kennedy Space Center (KSC) when a
fire ignited inside the Apollo 204 spacecraft during ground test activities.
The 100% oxygen atmosphere, flammable materials and a suspected
electrical short created a fire that quickly became an inferno. Virgil
Grissom, Edward White II, and Roger Chaffee (the prime crewmembers
for Apollo mission AS-204 -- later designated Apollo 1) perished in the
flames before the hatch could be opened.

Subject Focus design and material issues; quality control; emergency preparedness;
budget and schedule pressures; complacency

Learning The Apollo 1 case study is particularly important for NASA to consider in
Points development of designs for the Orion spacecraft and Ares family of
booster rockets. The Apollo 1 case demonstrates how previous success
with a recognized, but not properly mitigated condition, can lull
managers, designers and operators into complacency.
The case also underscores the need to understand material properties
across the full range of operating environments. Finally, the case
illustrates how solutions to one problem can become the source of new
problems.

Other Listed at the end of the case study document

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 13
Case Title Goddard Space Flight Center: Building A Learning
Organization

Project Name n/a

Source Darden, University of Virginia

URL https://store.darden.virginia.edu/business-case-studies

# of Pages 20 (Case A) + 12 (Case B)

Abstract While reading the Wall Street Journal, Edward Rogers notices an
advertisement for a Knowledge Management Architect at the Goddard
Space Flight Center in Greenbelt, Maryland. Rogers is an academic
whose scholarship centers on developing models of how and why
people cooperate intellectually. After submitting his résumé and
completing the interview process, Rogers is offered the position for a
term appointment of three years.

After one month on the job, Rogers wonders how he should proceed in
helping the Goddard Space Flight Center become a learning
organization. It is, in fact, the kind of opportunity Rogers has looked
forward to for many years, but what will his plan of attack look like? How
can he help this collection of rocket scientists work better together?

The A case presents an undisguised picture of a NASA center that is

fostering a learning approach to developing the organization. In the B
case, Rogers’s action plan is presented, together with input from NASA
engineers, scientists and other key players. See also the A case (UVA-
OB-0833).

Subject Focus organizational learning; knowledge management

Learning
Points

Other OCKO website: http://www.nasa.gov/goddard/ocko

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 14
Case Title GOES-N: Long and Winding Road to Launch

Project Name GOES-N

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/33

# of Pages 8

Abstract GOES-N was built to be the most advanced meteorological satellite in

space, the first in the next generation of ―geostationary operational
environmental satellites.‖ Getting GOES-N into orbit is proving to be
extremely difficult. For months in 2005-06, during a string of delays and
resets due to lightning strikes to the rocket and strikes by contractor
technicians, the satellite has sat on the pad while project managers
wrestle with launch issues: on-ground duration without systems
retesting, whether to de-stack, and when an observatory and spacecraft
have been on the launch pad too long.

Subject Focus Contract management; Decision making; Tests; Systems engineering;

schedules

Associated The Teaching Note provides guidance for classroom discussions and an
Documents optional epilogue handout.
For access to the Teaching Note contact the Office of the Chief
Knowledge Officer /Goddard Space Flight Center.

Learning The role of the Systems Engineer to marshal the project towards launch.
Points How engineering (technical) issues spill over into procurement (contract)
issues. Implications of a fixed price delivery contract for space missions
and launch services. Making judgment calls on equipment readiness.

Other GOES-N Web page: http://www.nasa.gov/mission_pages/goes-n/main/

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 15
Case Title Gravity Probe B

Project Name GP-B

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/pdf/384132main_Gravity_Probe_B_case_study.pdf

# of Pages 11

Abstract In the summer of 2003, NASA Program Manager Rex Geveden was
eager to ship the Gravity Probe B (GP-B) spacecraft to Vandenberg Air
Force Base for integration and testing and then launch. In April the
program had undergone a termination review, which in Geveden’s
estimation, had been a close call. Getting the spacecraft to the launch
pad would remove the threat of imminent cancellation. After the
spacecraft arrives at Vandenberg, problems with the Experimental
Control Unit (ECU) are identified. Will these problems require the
launch to be postponed until the issues are satisfactorily addressed?

Subject Focus schedule pressures; launch decisions; risk management; risk mitigation

Learning Different types of pressures can affect the behavior of key stakeholders.
Points Different stakeholders can characterize anomalies differently in risk
management terms. Various organizational and managerial factors can
complicate the decision-making process for the program manager.

Other Gravity Probe B website at Stanford University:

Resources http://einstein.stanford.edu/; NASA Mission Page:
http://www.nasa.gov/mission_pages/gpb/index.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 16
Case Title Hit the Bricks

Project Name n/a

Source NASA Safety Center

URL http://nsc.nasa.gov/SFCS/SystemFailureCaseStudyFile/Download/159/

# of Pages 4

Abstract "Flawless" was one description of the May 31, 2008 launch of the Space
Shuttle Discovery on mission STS-124. So when the NASA Safing team
at Kennedy Space Center set out to inspect Launch Pad 39A following
that launch, they were surprised to find the area littered with debris.
Powerful exhaust from Discovery's liftoff breached the flame trench wall
at the base of the pad. Hot gases had penetrated the trench lining
system, blasting 3,540 refractory bricks into and beyond the trench.
Direct damage cost was estimated at $2.5 million.

Subject Safety; Launch facilities; KSC; Space Shuttle

Focus

Learning The failure in the flame trench was a result of several factors, but the
Points sweeping transition from Apollo to the Space Shuttle Program play a
most significant role. Flame trench upkeep was driven by assumptions
based on an apparent reliable history. Signs of a deteriorating
infrastructure were not recognized.

Other
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 17
Case Title HMS Thetis and Apollo XIII

Project Name Apollo XIII

Source Harvard Business School Publishing

URL http://hbr.org/product/hms-thetis-and-apollo-xiii/an/696097-HCB-ENG

# of Pages 21

Abstract Explores the management of technical disasters in which time plays a

central role. Uses the experience of HMS Thetis and Apollo 13 to look at
both successful and unsuccessful approaches.

Subject Focus disaster management

Learning
Points

Other
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 18
Case Title Hubble Space Telescope: Systems Engineering Case Study

Project Name HUBBLE

Source Center for Systems Engineering, Air Force Institute of Technology

URL http://www.afit.edu/cse/csdl.cfm?case=18&p=0&file=Hubble SE Case

Study.pdf

# of Pages 69

Abstract This is a full length case exploring in depth the systems engineering
challenges of building the Hubble Space Telescope. The issue of the
mirror is dealt with and why it was missed in development and build. The
case explains the various instruments and has detailed photos and
charts. References are made to the NASA systems engineering
guidebook which has since been updated.

Subject Focus systems engineering

Learning Early and full participation of customer is essential. Pre-program trade

Points studies can help keep early discussions focused on technical
considerations when political concerns are trying to play with the project.
Systems integration and testing need to be a significant portion of
program resources. Life cycle support is critical from day one. Number
of players introduces risk that needs to be addressed.

Other Hubble website: http://hubble.nasa.gov/

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 19
Case Title IBEX: Managing Logistical Exigencies

Project Name IBEX

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/1

# of Pages 1

Abstract The Interstellar Boundary Explorer (IBEX) will provide images that will
reveal properties of the interstellar boundaries that separate our
heliosphere from the local interstellar medium. When the time comes to
move IBEX and its attached rocket assembly the 15 miles to the launch
pad, it becomes obvious that it will not fit in the moving container. The
fall-back—double-bagging the assembly in plastic—is for much shorter
trips. Numerous risks are considered.

Subject Focus logistics, communication

Learning Just because it says somewhere it can be done, doesn't mean that it's
Points the right thing to do. How can a safety officer push back and get support
for an unpopular but safety first decision? The responsibility to protect
flight hardware.

Other IBEX website: http://ibex.swri.edu/

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 20
Case Title IMAGE

Project Name IMAGE

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/flash/293122main_image_study.swf

# of Pages n/a – self-learning multimedia presentation

Abstract In this interactive case study you will be presented with a real
management situation faced by the NASA-contracted Southwest
Research Institute team during the groundwork of the Imager for
Magnetopause-to-Aurora Global Exploration (IMAGE) mission. As the
Project Manager you will need to respond in the most effective and
timely manner possible. Your decision will directly affect the outcome of
the entire mission. When faced with the following problems, you will
want to respond as a Project Manager and to think about ways that you
can encourage your team to do the same.

Subject Focus budget; schedule; science; team; project management

Learning
Points

Other IMAGE Mission website: http://image.gsfc.nasa.gov/

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 21
Case Title International Project Management: The Cassini-Huygens
Mission

Project Name CASSINI-HUYGENS

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/offices/oce/appel/knowledge/publications/cassini.html

# of Pages 14 (slides)

Abstract The Cassini-Huygens Mission is a United States/European mission to

explore the ringed planet. NASA and the Italian Space Agency developed
the Cassini spacecraft, and the European Space Agency (ESA) designed
and built the Huygens probe. Cassini-Huygens was launched October
1997 on a 6.7-year voyage to Saturn. A failure in Cassini's telemetry
system as the spacecraft approached Saturn, after a multi-year journey
through deep space, posed a critical problem for the mission management
team.

Subject on-orbit failure; telemetry; international collaboration; ITAR

Focus

Learning This NASA mini-Case Study looks at the programmatic and technical
Points complexities of an international deep-space mission in which there is zero
room for error. It elucidates some of the mission's primary challenges and
their solutions.

Other Cassini Equinox Mission (JPL website): http://saturn.jpl.nasa.gov/

Resources Cassini-Huygens (ESA website): http://www.esa.int/SPECIALS/Cassini-
Huygens/index.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 22
Case Title International Space Station: Systems Engineering Case Study

Project Name International Space Station

Source Center for Systems Engineering, Air Force Institute of Technology

URL http://www.afit.edu/cse/cases.cfm?case=25&a=detail

# of Pages 105

Abstract This case study on the International Space Station considers what many
believe to have been the ultimate international engineering project in history.
The initial plans involved the direct participation of 16 nations, 88 launches
and over 160 spacewalks—more space activities than NASA had
accomplished prior to the 1993 International Space Station decision.
Probably more important was the significant leap in System Engineering (SE)
execution that would be required to build and operate a multi-national space
station. In a short period of time, NASA and its partners had to work out how
to integrate culturally different SE approaches, designs, languages and
operational perspectives on risk and safety.

Subject Focus Systems engineering; Partnerships

Learning Case Study learning principles are discussed on the website of the Air Force
Points Center for Systems Engineering
(http://www.afit.edu/cse/page.cfm?page=49&%20sub=78 )

Other NASA International Space Station

Resources http://www.nasa.gov/mission_pages/station/main/index.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 23
Case Title Launching New Horizons: The RP-1 Tank Decision

Project Name New Horizons

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/pdf/337384main_New_Horizons_RP!_Tank_Case_St
udy.pdf

# of Pages 16

Abstract Four months before the planned launch of the New Horizons mission to
Pluto (scheduled for January 2006), the manufacturer of the launch
vehicle reported that its fuel tank experienced a failure during the final
stages of qualification testing. The questions raised by this failure
ultimately presented a test case for the agency's recently revamped
governance model. The programmatic, engineering, and safety
communities had fundamental disagreements about difficult technical
questions, which ultimately led to an appeal to the NASA Administrator.

Subject governance model; independent technical authority; transparent decision

Focus making

Learning One of the most vigorous and healthy discussions at NASA over the past
Points several years has concerned the establishment of the formal process for
ensuring that dissenting opinions receive a full and fair hearing. That
process, now codified in NASA Procedural Requirement (NPR) 7120.5D:
NASA Space Flight Program and Project Management Requirements,
applies to unresolved issues of any nature (technical, programmatic,
safety, or other), and delineates an orderly way of raising difficult issues
and, when necessary, elevating them to higher levels of management for
resolution.

Other NASA Mission page:

Resources http://www.nasa.gov/mission_pages/newhorizons/main/index.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 24
Case Title Launching the Vasa

Project Name VASA

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/6

# of Pages 6

Abstract The 17th-century warship Vasa sank upon launch with great loss of life
owing to many political, and engineering development factors. Lessons
from this historic example are used as a prescriptive warning for large
projects like those NASA’s Exploration Systems Mission Directorate
(ESMD)

Subject Focus Risk management; Communication: Organizational culture;

Technologies; Requirements; Schedules; Budgeting; Accidents

Learning Define risks in actionable ways. What everyone knows but no-one says
Points can doom a project in subtle ways. Know what your test means and
what success means before you conduct the test. Stick by the results of
your test. Getting risks identified is the way to get them discussed.

Associated The Teaching Note provides guidance for using the case to stimulate
Documents classroom discussions.
For access to the Teaching Note, contact the Office of the Chief
Knowledge Officer /Goddard Space Flight Center.

Other There is also a Harvard Vasa case study.

Resources
VASA Museum website: http://www.vasamuseet.se/en/
Famous Failures: The VASA (PPT):
www.cs.huji.ac.il/course/2003/postPC/docs/Famous_Failures_Vasa.ppt
Additional resources are listed in the Teaching Note.

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 25
Case Title Lessons from the Challenger Launch Decision

Project Name STS-51L

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/285

# of Pages 13

Abstract On January 28, 1986, seven astronauts abroad the Space Shuttle
Challenger lost their lives as the orbiter exploded 73 seconds after
launch. The investigation that followed uncovered both the technical
causes of the accident and some underlying, contributing causes. This
case, primarily based on the findings of the investigation as detailed in
the Report of the Presidential Commission on the Space Shuttle
Challenger Accident, is meant to highlight key aspects of technical
communication challenges and decision-making.

Subject Focus Launch decision; Safety; Organizational culture; Risk management;

Decision making; Engineering design

Learning Look beyond simplistic explanations

Points Ask the right questions
Take corrective action

Associated The Teaching Note provides suggestions for guiding classroom

Documents discussions of the case as well as additional resources for background
information.
For access to the Teaching Note, contact the Office of the Chief
Knowledge Officer /Goddard Space Flight Center.

Other Final Voyage of the Challenger – Harvard Case Study (see page 10)
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 26
Case Title Lewis Spins out of Control

Project Name Lewis

Source NASA Safety Center (NSC)

URL http://nsc.nasa.gov/SFCS/SystemFailureCaseStudyFile/Download/50

# of Pages 4

Abstract The Lewis Spacecraft Mission was conceived as a demonstration of

NASA's Faster, Better, Cheaper (FBC) paradigm. Lewis was
successfully launched on August 23, 1997, from Vandenberg Air Force
Base, California on a Lockheed Martin Launch Vehicle (LMLV-1). Over
the next three days a series of on-orbit failures occurred including a
serious malfunction of the attitude control system (ACS). The ACS
issues led to improper vehicle attitude, inability to charge the solar array,
discharge of batteries, and loss of command and control. Last contact
was on August 26, 1997. The spacecraft re-entered the atmosphere
and was destroyed 33 days later. This mission may have been faster
and cheaper, but in retrospect it was at the expense of better.

Subject Focus ―faster, better, cheaper‖ (FBC); on-orbit failure

Learning Weak project management, a poorly articulated approach (FBC), and

Points poor hardware/software verification can all lead to project failure. The
NASA Lewis spacecraft serves as a cautionary tale for those proposing
radical cost saving or cycle-time reduction techniques in complex space
programs.

Other NASA Lewis Mishap Investigation Report (121998) NASA.

Resources http://spacese.spacegrant.org/Failure%20Reports/Lewis_MIB_2-98.pdf

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 27
Case Title Lifting NOAA-N Prime

Project Name NOAA-N PRIME

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/37

# of Pages 4

Abstract NOAA-N PRIME was one of a series of polar-observing satellites used

for weather prediction. While being rotated (vertical to horizontal) on a
turnover cart for a routine procedure in the builder’s facility the satellite
fell off the cart, sustaining significant and costly damage. Complacency
and poor management, planning, communication, and procedures
contributed to a mishap that easily could have been avoided.

Subject Focus Risk management; Communication; Organizational culture; Contract

management

Learning • Lax observance and control of even the most mundane, standardized
Points procedures can have devastating consequences.
• Safety and asset management always trump potential cost and
schedule savings resulting from using unconventional or hasty
procedures.
• An organizational environment allowing for a ―we do this all the time‖
modus operandi is a pretext for disaster.
• Oversight of joint projects is every manager’s first priority, whether
contractor or government agency.
• There is no substitute for onsite, visual inspection and verification.
• Ignore at your peril engineering input from any level.

Associated The Teaching Note provides guidance regarding key issues and
Documents questions to guide discussions as well as related resources.
For access to the Teaching Note, contact the Office of the Chief
Knowledge Officer /Goddard Space Flight Center.

Other Mishap Investigation Board Report: URL:

Resources http://www.nasa.gov/pdf/65776main_noaa_np_mishap.pdf
NOAA-N PRIME website: http://www.nasa.gov/mission_pages/NOAA-N-
Prime/main/index.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 28
Case Title Lost in Translation - The Mars Climate Orbiter Mishap

Project Name Mars Climate Orbiter (MCO)

Source NASA Safety Center (NSC)

URL http://nsc.nasa.gov/SFCS/SystemFailureCaseStudyFile/Download/4/

# of Pages 4

Abstract The signal from NASA's Mars Climate Orbiter disappeared on Thursday,
September 23, 1999. After a nine-month journey from earth, the
spacecraft was moving into orbit around Mars when communications
stopped. Ground software had miscalculated the spacecraft's trajectory.
Instead of lightly skimming the Martian atmosphere, the spacecraft was
orbiting more than 170 kilometers below its target altitude. Heat and
drag from the atmosphere presumably destroyed the satellite.

Subject Focus spacecraft trajectory; ground software

Learning The proximate cause of the failure was a discrepancy between the use
Points of English units vs. metric units in treating data from the ground
navigation software. Underlying issues included the following: 1) the
software interface control process and interface verification were not
sufficiently rigorous; 2) communication between project elements was
deficient; 3) the operations navigation team was unprepared,
oversubscribed, and operating based on limited understanding of the
MCO's specific design.

Other Listed at the end of the case study document

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 29
Case Title Lost in Space: A Case Study in Engineering Problem-Solving

Project Name Mars Climate Orbiter (MCO)

Source National Center for Case Study Teaching in Science

URL http://ublib.buffalo.edu/libraries/projects/cases/space/lost.html

# of Pages 8

Abstract This four-part case deals with 1) making a case for space exploration
(Part I: Exploration--Opportunity or Albatross?); 2) the rationale for going
to Mars (Part II: Why Go to Mars?); 3) trying to land on Mars (Part III:
Going to Mars—The Mars Climate Orbiter Mission) and 4) reviewing the
findings of the Mishap Investigation Board (Part IV: Mars Climate Orbiter
Mishap Investigation).

Subject Focus engineering problem solving; "Faster, Better, Cheaper"

Learning
Points

Other
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 30
Case Title Lunar CRater Observation and Sensing Satellite (LCROSS)

Project LCROSS
Name

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/pdf/474589main_LCROSS_case_study_09_23_10.pdf

# of Pages 8

Abstract When NASA announced that the Lunar Reconnaissance Orbiter (LRO)
would upgrade from a Delta II to a larger Atlas V launch vehicle, a window
of opportunity opened for an additional mission to go to the moon. The
Atlas V offered more capacity than LRO needed, creating space for a
secondary payload.
The Exploration Sciences Mission Directorate (ESMD) posed a challenge
to interested secondary payload teams: The chosen mission could not
interfere with LRO, it could not exceed a mass of 1000 kilograms (kg), it
could not go over a $79 million cost cap, and it had to be ready to fly on
LRO's schedule. Of the 19 proposals submitted, ESMD chose the Lunar
CRater Observation and Sensing Satellite (LCROSS)—a mission that
sought to search for water on the moon by firing a rocket into the lunar
surface and studying the debris resulting from the impact.

Subject risk management; communication, project management

Focus

Learning How did the constraints of the mission shape the project management
Points challenge? What role did communication play in building a team that could
work within the mission constraints? How did the project manage its
approach to risk?

Other NASA LCROSS website:

Resources http://www.nasa.gov/mission_pages/LCROSS/main/index.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 31
Case Title Managing Knowledge and Learning at NASA and the Jet
Propulsion Laboratory (JPL)

Project Name n/a

Source Harvard Business School Publishing

URL http://hbr.org/product/managing-knowledge-and-learning-at-nasa-and-
the-je/an/604S24-PDF-SPA

# of Pages 30

Abstract Jet Propulsion Laboratory (JPL) faces a serious loss of knowledge--both

because of the "faster, better, cheaper" mandate for Mars missions and
from the retirement of key personnel. An extensive knowledge
management system for NASA/JPL includes formal knowledge-capture
mechanisms such as Web pages and digitized manuals and such
informal ones as storytelling. The former are much easier to get funded
and to implement than the latter, but chief knowledge architect Jeanne
Holm is concerned that technology cannot solve some of the most
difficult issues she faces.

This case focuses more on managing the tacit knowledge held in the
heads of scientists and experienced project managers than on the
information technology that Holm has put in place. The switch from
expensive but infrequent Mars missions to 2 missions every 26 months
propelled a number of junior managers into positions of responsibility
and decision making for which they had inadequate experience. In the
face of increasingly tight budgets, Holm must decide what kinds of
knowledge management initiatives to back--and how to encourage the
cultural change that is needed in the organization.

Subject Focus knowledge management; organizational learning

Learning To highlight the challenges in managing the transfer of knowledge, both

Points between experts and between projects.

Other
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 32
Case Title Mechanical Systems Engineering Support Contract Re-
Compete

Project Name n/a

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/35

# of Pages 4

Abstract Competitive procurement for providing mechanical, thermal, and other

engineering services to Goddard’s Applied Engineering and Technology
Directorate in support of space technology development, Earth and
Space Science missions, and NASA’s Exploration Program resulted in a
$400 million contract award, replacing the contractor in place for 25
years. This case looks at the very difficult contracting process and
litigious aftermath that ultimately ended in success.

Subject Focus Organizational culture; Contract management; Communication

Learning Responsibility to Government procurement policy and procedures,

Points where does Government responsibility end in meeting procurement
policy goals? How can Government procurement affect mission
success now and in the future through unintended consequences
relating to capabilities and workforce development. Thinking strategically
in procurement, planning ahead, avoiding hostage situations.

Associated The Teaching Note provides guidance regarding key issues and
Documents questions to guide discussions as well as related resources.
For access to the Teaching Note, contact the Office of the Chief
Knowledge Officer /Goddard Space Flight Center.

Other
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 33
Case Title Mission to Mars

Project Name Mars Observer

Source NASA Safety Center (NSC)

URL http://nsc.nasa.gov/SFCS/SystemFailureCaseStudyFile/Download/147/

# of Pages 4

Abstract After eleven months in transit, and only three days away from entering
the red planet’s orbit, Mars Observer dropped from contact with its
Earthbound NASA controllers. The project team could not restore
communication with the spacecraft; no signals were detected from it in
the following months, and NASA was forced to declare Mars Observer
permanently lost. NASA Administrator Dan Goldin asked the Naval
Research Laboratory to form an investigation board.

Subject Focus Failure; Investigation; Contract management; Risk management

Learning The Mars Observer example shows us that unexpected consequences

Points can follow from each design and risk management decision. A
thorough, well-conceived and executed testing plan that meets or
exceeds all mission demands is the best defense. When assessing
commercial capability to deliver spacecraft with unique and complex
missions, caution should be exercised and sufficient budget "margin"
built in to take advantage of the best experience and oversight
available.

Other NASA Website:

Resources http://heasarc.nasa.gov/docs/heasarc/missions/marsobs.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 34
Case Title M.S.T.I.: Optimizing the Whole System

Project Name M.S.T.I.

Source Virginia Polytechnic Institute

URL http://www.nasa.gov/pdf/293212main_58529main_msti_casestudy_042
604.pdf

# of Pages 27

Abstract MSTI or Miniature Seeker Technology Integration tried to optimize over

the whole project and not allow sub-optimizations to hinder the project.
MSTI launched in 1992 and was managed by JPL.

Subject Focus Systems engineering across a project

Learning The importance of an aggressive schedule and working to the schedule

Points to realize project level optimization of components and 'fast track
procurement." Led to the Mission Design Center and System Test Bed
at JPL.

Other http://www.fas.org/spp/military/program/test/msti.htm
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 35
Case Title NASA After Challenger: Restoring an Image

Project Name Challenger, STS-51L

Source Harvard Business School Publishing

URL http://hbr.org/product/nasa-after-challenger-restoring-an-
image/an/591009-PDF-ENG?Ntt=challenger%2520

# of Pages 18

Abstract In the days following the loss of the space shuttle Challenger and its
crew in January of 1986, NASA officials were unwilling to communicate
with the media or the public. A siege mentality took hold, and the press
and public responded with intense criticism and inquiry. The case
describes NASA's harmonious relationship with the media before
Challenger, and the many obstacles William Sheehan faced when he
stepped in to attempt to restore NASA's image and relationship with the
media after Challenger. The issues include the special problems faced
by a public institution with a history of poor internal communication, and
the compounded difficulties of attempting to create effective internal
policy while also trying to restore credibility with the media and deal with
investigative probes.

Subject Focus disaster management, media relations, management communication

Learning
Points

Other
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 36
Case Title NEAR (Near Earth Asteroid Rendezvous)

Project Name NEAR

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/flash/293123main_near_study.swf

# of Pages n/a – self-learning multimedia presentation

Abstract It's 1995. You're the Johns Hopkins University APL Project Manager and
have been contracted by NASA for the NEAR mission. Near's Critical
Design Review (CDR) has already passed, and everything's been
designed and coded. You're right on target to meet the lofty goal of
launching the spacecraft only 27 months from the mission's inceptions.
Suddenly, you find out that a change to the mission has been proposed;
several team members want you to make a modification to the missions
XGRS instrument. They want this change because it would allow the
NEAR mission to collect data on gamma ray bursts. They propose that
you modify the software, the hardware, or both. But changing any of the
hardware or software at this late stage in the project would have an
impact on the science, the schedule, the budget, and the team. What
are you going to do? What will you need to know to make your decision?

Subject Focus redesign; managing change

Learning
Points

Other NEAR website at JHUAPL: http://near.jhuapl.edu/

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 37
Case Title NOAA-N Prime Case Study

Project Name NOAA-N Prime

Source NASA Safety Center

URL http://nsc.nasa.gov/Home/ (NASA Only)

# of Pages 38 (PowerPoint slides with space for notes)

Abstract This case study is delivered within the NASA Safety and Mission
Assurance Technical Excellence Program (STEP). The case provides a
brief overview of the NOAA-N Prime mishap which occurred in 2003.
The mishap involved damage to the satellite during pre-flight ground
processing. Covered in this brief case study is a summary of events
leading up to the accident, a discussion of approximate and root causes,
and the role of SMA in the accident.

Subject Focus Safety; Risk Management; Accidents

Learning Describe the NOAA-N Prime mishap

Points Identify the mishap proximate cause
Identify a subset of the mishap root causes
Identify Safety and Mission Assurance Lessons from the NOAA-N Prime
mishap.

Other  Lifting NOAA-N Prime (NASA/GSFC/OCKO case study)

Resources  Mishap Investigation Board Report: URL:
http://www.nasa.gov/pdf/65776main_noaa_np_mishap.pdf
 NOAA-N PRIME website: http://www.nasa.gov/mission_pages/NOAA-
N-Prime/main/index.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 38
Case Title Pegasus XL-HESSI: Last-Minute Decisions in Flight-Based
Launch

Project Name HESSI

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/9

# of Pages 8

Abstract The High Energy Solar Spectroscopic Imager (HESSI), a flight-based

launch on a Pegasus rocket, was designed to provide high-resolution
imaging of solar flares, which can damage satellites, radio
communications, and power grids on Earth. Flight-based launches are
dynamic, often hectic events for launch teams. The Pegasus XL-HESSI
launch demonstrates why communication dropouts and a critical
technical issue are still being debated during final countdown for a brief
launch window.

Subject Focus Decision making; Communication; Risk Management

Learning Manage 'launch fever." The pressure to launch is immense the closer to
Points the date. Understand the importance of pre-agreed criteria, what is
critical and what is not. How a launch decision or scrub is made in real
time. Slowing down for a caution sometimes means you will get stuck at
the light.

Associated The Teaching Note provides suggestions for guiding classroom

Documents discussions of the case as well as additional background information.
For access to the Teaching Note, contact the Office of the Chief
Knowledge Officer /Goddard Space Flight Center.

Other HESSI web page: http://hesperia.gsfc.nasa.gov/hessi/

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 39
Case Title Redesigning the Cosmic Background Explorer

Project COBE
Name

Source Academy of Program/Project & Engineering Leadership (APPEL),

NASA

URL http://www.nasa.gov/pdf/384131main_COBE_case_study.pdf

# of Pages 10

Abstract COBE was slated to launch on the Shuttle in 1989 from Vandenberg Air
Force Base. The Shuttle would place the satellite at an altitude of 300
kilometers, and an on-board propulsion system would then raise it to a
circular 900 kilometer sun-synchronous orbit. The loss of the Space
Shuttle Challenger 73 seconds after liftoff on January 28, 1986, changed
everything. The Shuttle program’s future was now uncertain and this had
dramatic consequences across NASA, not only for the human space
flight program. The COBE team was forced back to the drawing board.

Subject launch vehicle; redesign; matrix management; mass; co-location; test-

Focus as-you-fly

Learning Since spacecrafts are designed based on pre-identified launch vehicles,

Points a change in launch vehicles will likely result in a significant redesign,
added costs and schedule slips. With the appropriate support at the
Center level and from headquarters, financial and human resources can
be applied to get things done and organizational structures can be re-
aligned to fit the needs of a project. "Test as you fly" in order to catch
problems before launch.

Other Cobe Satellite Marks 20th Anniversary -

Resources http://www.nasa.gov/topics/universe/features/cobe_20th.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 40
Case Title Searching for Life on Mars: The Development of the Viking Gas
Chronomatograph Mass Spectrometer

Project Name Viking

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/pdf/384151main_Viking_GCMS_case_study.pdf

# of Pages 8

Abstract The Viking mission was set to be the first mission to attempt as soft
landing on Mars. The opportunity to conduct experiments on the
planet's surface led to an extremely ambitious scientific agenda featuring
thirteen scientific instruments. The primary objective of the Viking
mission was to determine if there was evidence of life on Mars. In 1971,
the project manager added the Gas Chromatograph-Mass Spectrometer
(GCMS) to his "Top Ten Problems" list. While the project was managed
from the Langley Research Center, the GCMS was the responsibility of
the Jet Propulsion Lab (JPL). This arrangement failed to provide the
desired results.

Subject instrument development; project management

Focus

Learning Get the right technical expertise to solve technical problems; reach out
Points to other industries and the private sector to identify solutions (even when
they are proprietary); consider using a "Top Ten Problems" list to give
visibility to challenges that could threaten the viability of the mission.

Other NASA's Viking webpage: http://www.nasa.gov/mission_pages/viking/

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 41
Case Title Shuttle Software Anomaly

Project Name STS-126

Source NASA Safety Center (NSC)

URL http://nsc.nasa.gov/SFCS/SystemFailureCaseStudyFile/Download/10

# of Pages 4

Abstract A few minutes after the Shuttle Endeavour reached orbit for STS-126 on
November 14, 2008, mission control noticed that the shuttle did not
automatically transfer two communications processes from launch to
orbit configuration. While the software problems did not endanger the
mission, they caught management's attention because "in-flight"
software anomalies on the shuttle are rare. This case looks at what
happened, the proximate cause, underlying issues, as well as
implications for future NASA missions.

Subject software anomaly; "test as you fly"; anomaly documentation

Focus

Learning The STS-126 illustrates the need to ensure critical elements are
Points embedded in design and procedures, provide sufficient training,
complete rigorous end-to-end testing and verification, follow the oft-
quoted mantra, "Test as you fly," and find the real causes of all
anomalies.

Other ―Flight Software Readiness.‖ STS-119 Joint Shuttle/Station Flight

Resources Readiness Review. United Space Alliance Presentation, 02/03/09.
―Space Shuttle Orbiter Systems.‖ HSF-The Shuttle.
http://spaceflight.nasa.gov/shuttle/reference/shutref/orbiter/
Fishman, Charles. ―They Write the Right Stuff.‖ FastCompany.com.
1996. http://www.fastcompany.com/magazine/06/

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 42
Case Title Sitting on the Fence: Launching a Balloon in the Outback

Project Name n/a

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/309/

# of Pages 4

Abstract On April 29, 2010, a NASA High Visibility, Type B Mishap occurred at
the Alice Springs International Airport in Alice Springs, Northern
Territory, Australia. During the launch attempt of the Nuclear Compton
Telescope (NCT) scientific balloon payload, the payload inadvertently
broke free of the launch vehicle and was dragged by the wind-driven
balloon through the airport fence and into the privately owned vehicle of
a spectator. While no injuries occurred, the payload suffered extensive
damage and several spectators were nearly struck. NASA convened a
Mishap Investigation Board (MIB) to investigate this event. The MIB
collected data and evidence and, using NASA’s Root cause Analysis
methodology, was able to determine to proximate, intermediate, and root
causes. The Board’s investigation, findings and recommendations are
discussed in this case study.

Subject Launch vehicle; Decision making; Safety; Failure; Accidents

Focus

Learning Understand the role of Balloon missions within NASA and how they are
Points conducted. Understand the process involved in launching a balloon and
how such an accident could happen.

Other Nuclear Compton Telescope Balloon Launch in Alice Springs, Northern

Resources Territory, Australia High Visibility Type B Mishap
http://www.nasa.gov/centers/goddard/pdf/491345main_Master%20Repo
rt%20Vol%20I%20-Final.pdf

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 43
Case Title Skin in the Game: Questioning Organizational Conflict of Interest

Project Name n/a

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/307/

# of Pages 4

Abstract This case study focuses on a procurement protest. In this instance, the
incumbent contractor was protesting after losing a follow-on contract to
another company and the protest was based on (among other things) a
claim of Organizational Conflict of Interest (OCI) which also resulted in a
formal investigation by the Office of Inspector General (OGI). How
much would all this cost Goddard (both financially and in terms of time
lost and stress?

Subject Contract management; Decision making

Focus

Learning Understand the amount of work involved in procurement protests and

Points the level of care that needs to be taken in handling procurement
processes, including potential claims of conflict of interest.

Other
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 44
Case Title Space Shuttle

Project Name n/a

Source Harvard Business School Publishing

URL http://hbr.org/product/space-shuttle/an/909E09-PDF-
ENG?Ntt=space%2520shuttle

# of Pages 6

Abstract After the successful Apollo series NASA formulated a new vision for the
space program, incorporating a space station and guaranteeing routine
access to space via a reusable space shuttle. In 1986, the space shuttle
design included two solid-rocket launchers which required the use of O-
rings to seal the joints. After each launch the launchers were retrieved,
inspected and possibly reused is they did not display evidence of O-ring
distress. The space shuttle Challenger had flown 9 successful missions
into space and was gearing up for its tenth with great fanfare due to
NASA's successful public relations program, "The Teacher in Space
Program".

The evening prior to the January 28, 1986 launch saw representatives
from the Kennedy Space Centre, the Marshall Space Flight Centre and
contractor Morton Thiokol participate in a 3-hour teleconference to
discuss if the predicted low temperatures would have any effect on the
expected performance of the O-rings. In addition to the statistical
analysis of the historical O-ring failure, the stakeholders needed to
communicate their results in the appropriate flow of information.

Subject Focus Behavior; human resources management; organizational behavior;

organizational structure; quantitative analysis

Learning
Points

Other
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 45
Case Title Space-to-Space communications System

Project SSCS
Name

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/pdf/384149main_SSCS_case_study.pdf

# of Pages 6 (+appendices)

Abstract The Space-to-Space Communications System (SSCS) is a sophisticated

two-way data communication system designed to provide voice and
telemetry among three on-orbit systems: the Space Shuttle orbiter, the
International Space Station; and the Extra Vehicular Activity Mobility Unit
(EMU) (aka, the spacesuit). NASA decided to treat SSCS as an in-house
development at the Johnson Space Center (JSC). Numerous
organizational and technical challenges emerged over time while the
project was under pressure to deliver the system for use on the Space
Station. After encountering multiple failures on-orbit, the team was told to
"fix it" and eventually had the time and resources to do it right.

Subject schedule pressures; testing; space communications; in-house

Focus development

Learning Do it right the first time or you'll have to start over. Schedule pressures
Points and organizational challenges can lead to band-aid fixes and equipment
that isn't truly ready for flight.

Other http://www.nasa.gov/offices/oce/appel/knowledge/publications/SSCS.html
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 46
Case Title Spektr of Failure

Project n/a
Name

Source NASA Safety Center (NSC)

URL http://nsc.nasa.gov/SFCS/SystemFailureCaseStudyFile/Download/168/

# of Pages 4

Abstract On June 25, 1997, a manually controlled rendezvous and docking test
between a Progress automated supply vehicle and Space Station Mir
became a threat to crew survival. The Mir crew controlled the Progress
remotely, but loss of telemetry data crippled their efforts to steer a
spacecraft they could not see. By the time the Progress spacecraft
entered their line of sight, it was moving too fast to control. Progress
slammed into a solar array and ricocheted into the Spektr module,
sending the station into a slow tumble. The impact punctured Mir's hull
and resulted in the first decompression on board an orbiting spacecraft.

Subject Flawed testing; Economic pressure; Insufficient test knowledge

Focus

Learning One of the key achievements of international spaceflight partnership

Points since the Mir project has been agreement to share that information
mutually identified as essential to mission success and safety of flight.
As commercial companies compete for government-sponsored
spaceflight work, it would be dangerous (a failure of nerve) to ignore the
risks posed by information considered proprietary and essential to flight
safety. Technology and research that increases safety margins merits
the ultimate accolade of becoming ―open source.‖ To proceed otherwise
will incur costs far beyond those required to repair Mir as a result of this
incident.

Other
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 47
Case Title ST5 - Miniaturized Space Technology

Project Name ST5

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/34

# of Pages 4

Abstract It was clear soon after the project began that the schedule for the ST5
(Space Technology 5) mission would be stretched regardless of how
development of the complex technology proceeded, for one reason: the
mission lacked a launch vehicle. Cancellation was a constant threat for a
mission without an LV, and five years later, ST5—a demonstration
project to test and flight-qualify innovative miniaturized technologies on
three identical micro-satellites—is still in limbo, and project managers
face the daily challenge of keeping the team focused on a mission
whose fate is uncertain.

Subject Focus Communication

Learning Co-location of a project development team can be integral to mission

Points success; Integrating the entire project team into the process, particularly
in the case of distributed teams, should be a primary objective of the
project manager; Consistently communicating the message that
everyone's contribution is critical to the mission success is important;
Regularly scheduled forums and open channels of communication
between project management and team members, involving as many
people as possible, is essential; In projects with new and inexperienced
team members, the opportunity to mentor can help achieve success;
Ensuring that team members clearly understand their roles and the
importance of their jobs is critical, particularly on a project experiencing
extensive delays.

Associated The Teaching Note provides guidance for classroom discussions and an
Documents optional 1-page epilogue handout with additional resources.
For access to the Teaching Note contact the Office of the Chief
Knowledge Officer /Goddard Space Flight Center.

Other Pause and Learn brochure:

Resources http://www.nasa.gov/centers/goddard/pdf/431367main_OCKO-Pal-
Brochure-Rev_noLOGO.pdf
NASA's ST5 website: http://www.nasa.gov/mission_pages/st-
5/main/index.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 48
Case Title STEREO: Organizational Cultures in Conflict

Project Name STEREO

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/7

# of Pages 5

Abstract The Solar Terrestrial Relations Observatory (STEREO) mission

observes solar eruptions by imaging the Sun’s coronal mass ejections
from two nearly identical observatories simultaneously. The STEREO
team includes members from Goddard Space Flight Center (GSFC),
NASA HQ, the Johns Hopkins University’s Applied Physics Laboratory
(APL), and universities around the world. During STEREO’s formulation
and early implementation, cultural differences have arisen between APL
and GSFC personnel. Project management from both APL and GSFC
recognize this and address the challenge in a unique fashion.

Subject Focus Organizational culture; Communication; Tests; Schedules; Budgeting

Learning Teaming issues are worth addressing head on and early in the project
Points lifecycle. Different cultures that partners bring can cause problems
unless addressed and dealt with methodically like a project would deal
with technical issues. Frequent attention to teaming issues can keep
them from disrupting a team that spans different organizations.
Clarifying roles and accepting roles is important for partnerships.

Associated The Teaching Note provides suggestions for guiding classroom

Documents discussions of the case as well as additional resources for background
information.

Other STEREO website: http://stereo.gsfc.nasa.gov/

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 49
Case Title Stormy Weather: Lightning Strike on the Launch Pad

Project Name Shuttle

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/externalflash/stormy_weather/index.html

# of Pages n/a – self-learning multimedia presentation

Abstract

Subject Focus shuttle launch; decision-making

Learning
Points

Other
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 50
Case Title Super Lightweight Tank: A Risk Management Case Study in
Mass Reduction

Project Name Space Shuttle Program

Source NASA, Exploration Systems Mission Directorate

URL http://www.nasa.gov/externalflash/irkm-slwt/index.html

# of Pages 44 pages for the text version. See also the multimedia version
(PowerPoint with embedded video clips).

Abstract This case study exercise provides lessons learned from the
development and operations of the Space Shuttle Program (SSP). It is
intended to highlight key transferable aspects of risk management,
which may vary slightly from a particular case study to the next.
Transferable principles include the identification of risks, evaluation of
risks, mitigation of risks, risk trades, and risk management processes.
The proper application of risk management principles examined here
can help manage life-cycle costs, development schedules, and risk,
resulting in safer and more reliable systems for Constellation and other
future programs. This case study format is intended to simulate the
experience of facing the same difficult challenges and making the same
critical decisions as the original managers, engineers, and scientists in
the SSP. The case study will provide the background information and
complementary data necessary to analyze the situation and answer the
questions posed at key decision points in the case study. Solutions from
the SLWT Team on what they actually did to solve the key decision
questions are provided in the Appendices, followed by an Epilogue in
which the actual decisions and outcomes are presented. The key
lessons learned from conducting this exercise address how risks were
identified, how they were evaluated, and how final choices were made.

Subject Focus risk management, risk identification, risk mitigation

Learning 1. Developing risk identification skills

Objectives
2. Understanding the broad range of control and mitigation options
3. Recognizing the power of collaboration - the ―big brain‖
4. Gaining experience in using powerful structured logic methods
6. Understanding challenges of introducing new technology

Other Resources Teaching notes, multimedia version of the case.

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 51
Case Title TDRSS: Fixed-Cost versus Cost-Plus Contracting

Project Name TDRSS

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/8

# of Pages 7

Abstract For the Tracking and Data Relay Satellite System (TDRSS), a series of
geosynchronous communications satellites tracking low Earth-orbiting
satellites and relaying the data to a single U.S. ground station, NASA
awarded a fixed-price, leased-services contract. Numerous problems and
requirements changes critically affected cost and schedule, and
communications were strained between NASA, the prime contractor, and
the subs. TDRSS offers excellent insight into the costs and benefits of
both fixed-price and cost-plus award-fee contracting.

Subject Contract management; Organizational culture; Schedules; Budgeting

Focus

Learning Understand contract consequences; when the government doesn't own

Points the asset, it doesn’t control its use. Commercial priorities will take
precedence over science. Contracting choices will affect project for many
years so be wary of short-term contracting solutions that have lasting
effects on program viability.

Associated The Teaching Note provides suggestions for guiding classroom

Documents discussions of the case as well as additional resources for background
information.
For access to the Teaching Note, contact the Office of the Chief
Knowledge Officer / Goddard Space Flight Center.

See also the companion case: TDRSS K, L: Working with a Fixed Price
Contract.

Other TDRSS website:

Resources https://www.spacecomm.nasa.gov/spacecomm/programs/tdrss/default.cfm

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 52
Case Title TDRSS K, L: Working with a Fixed Price Contract

Project Name TDRSS

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/265

# of Pages 6

Abstract This is a follow on to the "TDRSS: Fixed-Price vs. Cost-Plus

Contracting" case which addressed the first generation TDRSS. This
case focuses on the procurement strategy for the K and L satellites in
the series and addresses both the contractor and NASA perspectives.

Subject Contract Management; Requirements

Focus

Learning After nearly 40 years of building TDRSS with four different types of
Points contracts, what has NASA learned about structuring procurements to
enable successful and viable space missions?

Associated A Teaching Note provides suggestions for guiding classroom

Documents discussions of the case as well as additional resources for background
information.
For access to the Teaching Notes, contact the Office of the Chief
Knowledge Officer / Goddard Space Flight Center.
See also the companion case: TDRSS: Fixed-Cost versus Cost-Plus
Contracting.

Other TDRSS website:

Resources https://www.spacecomm.nasa.gov/spacecomm/programs/tdrss/default.cf
m

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 53
Case Title The CALIPSO Mission: Project Management in the "PI Mode":
Who's in Charge?

Project Name CALIPSO

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/3

# of Pages 9

Abstract CALIPSO (Cloud-Aerosol Lidar and Infrared Pathfinder Satellite

Observations), a joint mission between NASA and the French space
agency CNES, was designed as a pioneering tool for observing Earth’s
atmosphere. Project development has been hampered for years by a
complex organizational structure, management conflicts between NASA
centers, international-partnership issues, and instrument and spacecraft
problems—issues that appear to require a project replan.

Subject Focus interagency communication, roles, relationships; ITAR and international

partnerships

Associated The Teaching Note provides suggestions for guiding classroom

Documents discussions of the case, a short supplement case addressing the
CALIPSO Propulsion Safety Launch Decision, and a 2-page optional
epilogue handout.
For access to the Teaching Note contact the Office of the Chief
Knowledge Officer /Goddard Space Flight Center.

Learning Define roles and responsibilities. Multiple centers, international partners,

Points fixed price and cost-plus bring complexity to a project that needs
addressing. Complex project structures have difficulty solving problems
efficiently. Know when to push on HQ for definition and direction.
Managing across borders and across contractors.

Other NASA CALIPSO website:

Resources http://www.nasa.gov/mission_pages/calipso/main/index.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 54
Case Title The CEV Seat: Seeking a Semi-Custom Fit in an Off-the-Rack
World

Project Name CEV

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/5

# of Pages 7

Abstract Developing a seat subsystem for the Orion crew exploration vehicle
presented unique engineering challenges. With Preliminary Design
Review approaching, the NASA engineer in charge of the project looked
to the world of auto racing and ―monster trucks‖ for innovation ideas,
then undertook a hands-on approach to building a seat prototype

Subject Focus contractor, requirements, engineering, schedule, review, learning

Associated A Teaching Note provides suggestions for guiding classroom

Documents discussions of the case as well as a list of aditional resources.
For access to the Teaching Note contact the Office of the Chief
Knowledge Officer /Goddard Space Flight Center.

Learning The innovation process of go wide in thinking, go practical in prototype

Points and go thorough in testing. Using seemingly dissimilar fields (NASCAR)
to improve NASA thinking. Challenges of parallel development when
requirements are being specified on the fly in parallel iterations.

Other CEV Seat Attenuation System. URL:

Resources http://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20070010702_2007
005306.pdf

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 55
Case Title The Dart Mission: Changing Environment, Shifting Priorities,
Hard Decisions

Project Name DART

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/36

# of Pages 6

Abstract DART (Demonstration of Autonomous Rendezvous Technology)

originated as a low-profile project to demonstrate that a spacecraft could
rendezvous with a satellite without the assistance of ground control. The
mission emerged, however, as NASA’s ―first flight demonstration of new
exploration capability,‖ the vanguard of the Vision for Space Exploration.
With the high profile came high pressure. After a cost increase of more
than 100 percent and schedule delays, DART failed halfway through its
mission. Software development and testing in the guidance/navigation/
control system, and inadequate systems engineering, were identified as
causes. Could failure have been prevented?

Subject Focus communication, contractors, engineering, instrumentation, ITAR, LV,

politics, project management, roles, technical, technology, testing

Learning Understanding the context of heritage hardware and software--how to

Points verify and assure usage as accepted. The use of Lessons Learned and
the danger of relying on LL without context and continued monitoring of
application. Dealing with program changes, shifting risk postures and
international partners.

Associated The Teaching Note provides suggestions for guiding classroom

Documents discussions of the case as well as additional resources for background
information.
For access to the Teaching Note, contact the Office of the Chief
Knowledge Officer / Goddard Space Flight Center.

Other DART MIB Overview Report

Resources http://www.nasa.gov/pdf/148072main_DART_mishap_overview.pdf

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 56
Case Title The Million Mile Rescue - SOHO Lost in Space

Project Name SOHO

Source NASA Safety Center (NSC)

URL http://nsc.nasa.gov/SFCS/SystemFailureCaseStudyFile/Download/25

# of Pages 4

Abstract The Solar Heliospheric Observatory Spacecraft (SOHO) is a major

element of the joint ESA/NASA International Solar Terrestrial Program.
Launched on December 2, 1995, it successfully completed its primary
mission by 1997. After implementation of code modifications meant to
increase SOHO's lifetime during its extended operations phase, multiple
errors in the new command sequence repeatedly sent the spacecraft
into an emergency safe mode. One key error remained undetected
while ground controllers made a critical mistake based on an
unconfirmed and faulty assumption. SOHO's attitude progressively
destabilized until all communication was lost in the early hours of June
25, 1998. It took three months to miraculously recover and restore
SOHO to full mission status.

Subject Focus in space recovery; extending the mission; ground operations

Learning The joint ESA/NASA Investigation Board (IB) determined that the
Points mishap was a direct result of ground operations errors and that there
were no anomalies on-board the spacecraft itself. Underlying issues
included: 1) lack of change control; 2) failure to follow procedures; 3)
overly aggressive task scheduling; 4) inadequate staffing and training.

Other Listed at the end of the case study document

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 57
Case Title The NFIRE Launch: Beating the Sophomore Slump at the
Wallops Range

Project Name NFIRE

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/6

# of Pages 7

Abstract NFIRE (Near-Field Infrared Experiment) is scheduled as the second

orbital launch from the Wallops Flight Facility within five months,
coming on the heels of TacSat-2. Two such launches in this
timeframe from the small range on Virginia’s Eastern Shore is
ambitious. NFIRE is benefiting from lessons from TacSat-2, but
problematic systems and other issues threaten the NFIRE launch,
and could lead to destacking and launch delay. With the Range
Readiness Review the next day, and launch two weeks away, the
Range chief is prioritizing the issues in preparation for making a
―ready‖ or ―not ready‖ decision.

Subject Focus choosing your biggest worry; launch decision making

Learning Apply lessons learned on a quick turnaround. Fast pace (sounding

Points rocket program) requires rapid learning and application of lessons
learned. Deciding which problems are show-stoppers and which are
not. Listening to the customer and being on the same risk-page. Who
is taking the risk for certain decisions?

Associated The Teaching Note provides suggestions for guiding classroom

Documents discussions of the case as well as additional resources for
background information.
For access to the Teaching Note, contact the Office of the Chief
Knowledge Officer / Goddard Space Flight Center.

Other NFIRE web page:

Resources http://www.nasa.gov/centers/wallops/missions/nfire.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 58
Case Title The Pursuit of Images of Columbia

Project Name COLUMBIA

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/32

# of Pages 6

Abstract Soon after the launch of Columbia STS-107, a piece of insulating foam
struck the orbiter’s left wing. Launch video did not reveal the extent of
the damage, and engineers’ analyses were inconclusive. The case
follows the futile attempts of the chief structural engineer at Johnson
Space Center to persuade upper management that obtaining images of
Columbia’s wing is critical to the safe return of ship and crew.

Subject Focus communication, organizational silence, hierarchical barriers

Learning The struggle of voicing a dissenting opinion in a hierarchical and fast

Points moving organization. The challenge of being heard in a matrix
organization. The need for clear assignment of responsibility to special
teams- What is their report and to whom? The personal struggles of an
engineer in getting heard.

Related Three short video interviews with Rodney Rocha are posted online with
Documents the case study.
The Teaching Note includes several appendices, including a student
activity around alternative email communications, several transcripts of
short interviews with Rodney Rocha, and a list of additional resources.
For access to the Teaching Note, contact the Office of the Chief
Knowledge Officer /Goddard Space Flight Center.

Other Harvard Case: "Columbia's Final Mission" (Multimedia Case)

Resources http://hbr.org/product/columbia-s-final-mission-multimedia-
case/an/305032-MMC-ENG
Columbia Accident Investigation Board (CAIB) Report: URL:
http://caib.nasa.gov

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 59
Case Title The Tour Not Taken - NASA's Comet Nucleus Tour
(CONTOUR)

Project Name CONTOUR

Source NASA Safety Center (NSC)

URL http://nsc.nasa.gov/SFCS/SystemFailureCaseStudyFile/Download/132/

# of Pages 4

Abstract The Comet Nucleus Tour (CONTOUR) mission is a story of lost

opportunities and incomplete communication. The spacecraft was
developed to gain insight into the nature of comets. While in orbit,
CONTOUR fired its motor to put itself on the trajectory toward its first
comet. During this time, the team did not schedule telemetry coverage,
but they expected to regain contact once the burn was over. After many
attempts to reestablish communication with CONTOUR, the project
team officially declared the spacecraft lost.

Subject Focus on-orbit failure; team integration; faulty design

Learning CONTOUR illustrates the value of integrating with contractors and other
Points organizations on a project team. The mission also illustrates the need to
identify programmatic risk and in this case, to identify mission-critical
events and provide telemetry data for these events. Telemetry tracking
is critical for understanding a failed mission.

Other Listed at the end of the case study document

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 60
Case Title Thermosphere Ionosphere Mesosphere Energetics and
Dynamics Project (TIMED) Case Study

Project Name TIMED

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/pdf/384153main_TIMED_case_study.pdf

# of Pages 21

Abstract The TIMED mission was conceived around 1990 as a very ambitious
multi-spacecraft mission. It was eventually launched on December 7,
2001 as a more modest mission with a single spacecraft. The program
was caught in all the dramatic changes that NASA went through in this
time period. At one point it came close to termination. The case study
is presented in three distinct phases that characterize the development
of the program.

Subject Focus programmatic challenges; mission requirements; center buy-in;

managing expectations; lines of authority; rules of engagement; complex
relationships; personality conflicts

Learning Phase One Lessons Learned: 1) It is necessary to recognize and

Points respond to ground rule changes in a timely manner; 2) Control
expectations; 3) Center buy-in and cooperation is necessary; 4) Basic
mission requirements must be set early, prioritized, and maintained.
Phase Two Lessons Learned: 1) Building and employing an ETU for a
new hardware development is still a good idea. Phase Three Lessons
Learned: 1) Clear lines of authority and reporting are necessary and
must be followed; 2) The rules of engagement must be agreed to and
put into writing; 3) A clear decision on the method of implementation of a
project must be made and the relationship of the program and project
defined for that method; 4) The Center must take ownership of any
project for which it has responsibility and staff it accordingly; 5)
Management processes appropriate for NASA funded projects need to
be in place, verified and used no matter where the project is developed;
6) It is necessary to adhere to the processes developed for integrating
and testing a spacecraft; 7) Co-manifesting multiple missions on the
same launch vehicle is still an appropriate cost-saving technique but it
should be employed within one Enterprise only; 8) Personality conflicts
can be real and should be addressed and resolved to assure efficient
functioning of the project team.

Other TIMED Mission website: http://www.timed.jhuapl.edu/WWW/index.php

Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 61
Case Title Vegetation Canopy Lidar

Project VCL
Name

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/pdf/384157main_VCL_case_study.pdf

# of Pages 12

Abstract The Vegetation Canopy Lidar (VCL) was selected in March 1997 as the First
Earth System Science Pathfinder (ESSP) spaceflight mission. It was
scheduled for launch in January 2000. Technology challenges (specifically
with the Multi-Beam Laser Altimeter or MBLA) and project management
challenges under the "PI-Mode" of mission management led to the mission
being postponed indefinitely.

Subject weak project management & institutional oversight

Focus

Learning 1) A formal process utilizing a team of independent recognized experts for

Points reviewing and approving project proposals is crucial to assure that only
viable proposals are submitted; 2) The project selection process must not
stop at the desirability of the science being proposed. It must include the
viability of the mission implementation plan as well; 3) Managers leading a
proposal effort must address the above considerations as part of their
proposal preparation process; 4) The project management of a fast-paced
low-cost mission requires a strong, yet streamlined, central management
structure with short communication paths; 5) The management of a fast-
paced, low-cost project still requires the project discipline necessary to
assure that the project meets its technical and programmatic objectives; 6)
The above two lessons learned imply that an experienced project manager
is highly desirable for any fast-paced low-cost project; 7) Projects involving a
U.S. government entity, such as a NASA Center, as a subcontractor to an
outside PI must formally document their subcontracting relatinoship; 8)
Independent cost estimates or assessments must be done in conjunction
with independent technical and managerial reviews.

Other VCL website:

Resources http://ilrs.gsfc.nasa.gov/satellite_missions/list_of_satellites/vcl__general.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 62
Case Title Wait, Wait, Don’t Launch

Project Name

Source Office of the Chief Knowledge Officer (OCKO), NASA/GSFC

URL http://gsfcir.gsfc.nasa.gov/casestudies/303/

# of Pages 4

Abstract This case study looks at the impact of a fixed-price contract and on-orbit
delivery on a launch decision when the contractor responsible for launch
and NASA are having differences of opinion over launch commit criteria.

Subject Contract management; Risk management; Decision making

Focus

Learning Contract types can have a critical impact on ownership of risks and
Points decision-making responsibility for both NASA and the contractors
involved. A firm-fixed-price contract for on-orbit delivery can significantly
limit NASA's ability to intervene in a process under the responsibility of
the contractor. While fixed-price contracts can bring good value to
NASA, differences of opinion can become costly under such contracts.

Other
Resources

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 63
Case Title Wide-Field Infrared Explorer (WIRE)

Project Name WIRE

Source Academy of Program/Project & Engineering Leadership (APPEL), NASA

URL http://www.nasa.gov/pdf/384167main_WIRE_case_study.pdf

# of Pages 16

Abstract The Wide-Field Infrared Explorer (WIRE) was meant to study the
formation and evolution of galaxies. Its delicate telescope was sealed
inside a solid hydrogen cryostat. Shortly after launch, a digital error
ejected the cryostat's cover prematurely. As a result, hydrogen
discharged with a force that sent the Small Explorer craft tumbling wildly
through space. The subsequent investigation identified several
opportunities, in review and testing, to have caught the fatal design
error. Why wasn't it caught? Senior managers provide their insights.

Subject Focus "faster, better, cheaper" mandate; geographically dispersed teams;

communications;

Learning Lessons highlighted in the case study include the following: 1) The
Points proper application of Field Programmable Gate Arrays; 2) The
importance of proper peer reviews of critical mission subsystems and
components; 3) The importance of effective closed-loop tracking of
system and peer review action items; 4) Greater care is necessary when
managing a project across major organizational boundaries; 5) Extra
vigilance is required when deviating from full system end-to-end testing;
6) System designs must consider both nominal and off-nominal
solutions.

Other WIRE Mission Home Page

Resources http://sunland.gsfc.nasa.gov/smex/wire/mission/

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 64
Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 65
 NASA/GSFC/OCKO Case Study Documents

Case Studies Magazine

http://www.nasa.gov/centers/goddard/pdf/452484main_Case_Study_M
agazine.pdf
This magazine is a collection of case studies put together by the NASA
Safety Center and Office of the Chief Knowledge Officer, Goddard
Space Flight Center. It includes four decision-oriented case studies,
three system failure case studies, two cases of interest as well as a
condensed version of the case study methodology.

A Catalog of NASA-related Case Studies

http://www.nasa.gov/centers/goddard/pdf/450420main_NASA_Case_S
tudy_Catalog.pdf
This catalog of NASA-Related Case Studies lists cases from a range of
sources, including NASA's APPEL program, NASA/Goddard's Office of
the Chief Knowledge Officer, NASA's Safety Center, as well as the
Harvard Business Review and the Center for Systems Engineering at
the Air Force Institute of Technology.

Case Study Methodology

http://www.nasa.gov/centers/goddard/pdf/292342main_GSFC-
Methodology-1.pdf
Case studies are an integral part of organizational learning at Goddard,
used in workshops, conferences, training programs, and interactive
media. This guide examines the rationale for the case-study method
and describes the step-by-step methodology the Office of the Chief
Knowledge Officer (OCKO) at Goddard uses to develop, publish, and
implement cases studies in NASA missions and projects.

Digital Case Study Library

http://gsfcir.gsfc.nasa.gov/casestudies
This repository of OCKO case studies includes cases that vary in
length and focus.

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 66
 Case Study Collections
NASA APPEL Case Studies
http://www.nasa.gov/offices/oce/appel/knowledge/publications/case_studies.html

NASA System Failure Case Studies

http://nsc.nasa.gov/SFCS

NASA Cases of Interest

http://nsc.nasa.gov/Articles/CasesOfInterest

Harvard Business School Case Studies

http://www.library.hbs.edu/hbs_cases.html

INSEAD (Institute European d’ Administration des Affaires)

http://knowledge.insead.edu/find.cfm?ptypelist=8

Darden Business School, University of Virginia

https://store.darden.virginia.edu/business-case-studies

The National Center for Case Study Teaching in Science - Case Collection
http://ublib.buffalo.edu/libraries/projects/cases/ubcase.htm

ICMR Center for Management Research

http://www.icmrindia.org/Case%20Study%20Method.htm

European Case Clearing House (ECCH) Cases

http://www.ecch.com/about/Cases.cfm

The Electronic Hallway

https://hallway.org/index.php?PHPSESSID=n5cecejbgoupoae90sqoahpvu7

Stanford Graduate School of Business Case Studies

https://gsbapps.stanford.edu/cases/

Air Force Case Studies

http://www.afit.edu/cse/cases.cfm

Richard Ivey School of Business

http://cases.ivey.uwo.ca/cases/pages/home.aspx

Engineering Case Studies – Role-Hulman Institute of Technology, Carleton

University
http://www.civeng.carleton.ca/ECL/5index.html

Office of the Chief Knowledge Officer, Goddard Space Flight Center, NASA 67
National Aeronautics and Space Administration

NASA Goddard Space Flight Center

8800 Greenbelt Road
Greenbelt, MD 20771
http://www.nasa.gov/centers/goddard

www.nasa.gov