Learning from Mistakes; Ula's Error Prevention Program

Learning From Mistakes; ULA’s Error Prevention Program

James E. Allison; United Launch Alliance; Denver, Colorado, USA

Keywords: error prevention, error reporting, lessons learned, root cause analysis

Abstract

The ability to learn from one’s mistakes or errors has long been recognized as a positive trait and effective tool.

Dale Carnegie stated “The successful man will profit from his mistakes and try again in a different way”

(Quotations Book 3). This paper describes how United Launch Alliance (ULA) has applied this valuable concept in

an aerospace environment.

ULA has implemented an Error Prevention Program that recognizes errors as learning opportunities and develops

and maintains a workforce culture that rewards error reporting instead of punishing employees when errors occur.

ULA’s Error Prevention Program rigorously processes errors regarding both rocket production, test operations and

launch operations. Each reported error is tracked through resolution as follows: 1) root cause analysis, 2) corrective

action review via formal Corrective Action review boards, 3) executive management review (called an Error

Prevention Council) that extracts lessons learned and issues action items to reduce error occurrence company wide.

Lessons Learned are formally documented and released company-wide via one or more of the following forums: 1)

Safety Bulletins, 2) weekly Perfect Product Delivery emails, 3) Error Prevention Success Stories. These

publications promote enterprise learning from past errors and encourage proactive elimination / mitigation of

hazards that may lead to future errors. In addition, ULA’s Error Prevention Program collects a variety of data and

has developed metrics to measure program progress and effectiveness.

Introduction:

The ability to learn from one’s mistakes and errors has long been recognized as a positive trait and effective tool.

Dale Carnegie stated “The successful man will profit from his mistakes and try again in a different way” (ref. 3)....