Running head: WEEK 6 WRITTEN 1

Week 6 Written

University of the People

December 25, 2019

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Abstract

Case Study: In 1999, NASA lost the Mars Climate Orbiter, a 338 kg robotic space probe (with a

cost of $327.6 million) due to a failed translation of British units into metric units in the mission

software. This mistake triggered an unintentional de-orbit of the probe and its subsequent

disintegration in Mars’ upper atmosphere (Isbell & Savage, 1999). As a response to this case,

the following will answer the questions ‘Which quality approaches, methods and tools would

you propose to mitigate each of the 8 contributing factors identified in the release?’ and ‘Which

considerations would you take in order to implement your proposals within the organization?’ as

they relate to the case.

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Week 6 Written

Which quality approaches, methods and tools would you propose to mitigate each of the

8 contributing factors identified in the release?

The necessity for quality and safety improvement initiatives should be part of

organizations like NASA, where every operation/process is critical and interdependent on other

processes. Any failure to detect or resolve a minor issue may be eventually compounded and

reflected as a significant problem during critical missions.

Since the processes did not catch the root cause in place in the Mars Climate Orbiter

(MCO) project, the event showcased the glaring issues with review and defect logging effort for

mission-critical projects. Since most of the eight contributing factors are either categorized as

human error or inadequate defect tracking, the following quality approaches and methods can be

used to mitigate such issues in the future. (Isbell & Savage, 1999)

 Independent Assessments and Reviews: Ensure safety and success of NASA

missions by resolving all technical and operational issues before the flight by

evaluation through independent and competent authority on critical NASA

processes. (Ortiz & Saunders, 2009)

 Systems Engineering: Use analytic methods to perform the operational and

engineering analyses to define and optimize missions. This will also ensure

conformity to mission requirements during the development phase. (NASA

Website, n.d.)

 Quality Management: Quality studies for maximum benefit at project completion

and resolution of minor/major issues before the flight.

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 Test Effectiveness: Undertake test flights and provide test data analyses correlated

against flight performance to tailor test programs to specific mission

requirements.

 Failure Modes and Effect Analysis: Identify and eliminate known and potential

problems/errors from the system, design, process, and service before they occur.

The above considerations should be undertaken to ensure that future issues do not happen

during missions.

Which considerations would you take in order to implement your proposals within the

organization?

The failures can be avoided if all the failure scenarios are appropriately understood, and

mitigation plans are in place. I would suggest the use of the following approaches:

 This project could have been analyzed and executed using the DMAIC (Define,

Measure, Analyze, Improve, and Control) approach. It would have brought in the

clarity inflow of the idea. (DMAIC Tools Website, n.d.)

 Value Stream Mapping (VSM) is a crucial tool to document processes and

eliminate waste. The step-wise VSM helps to understand the processes which add

value (Value Added process), processes that enable/enhance value addition

(VEA), and processes which do not add any value to the process (NVA). Since a

Mission to Mars must have had several micro-processes, it was essential to

identify which one of those was the most crucial ones.

 Failure Mode & Effect Analysis (FMEA) is a risk assessment tool that helps in

prioritizing risks in a process and find areas to focus on minimizing performance

risks. An essential tool to understand before a megaproject like the one mentioned
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above. The failure in the conversion of British Units to metric units could have

been easily avoided had the step-level FMEA was performed. It not only

highlights the failure modes or also helps in finding the mitigations of those

failure modes.

For recommendations on mitigation of failure modes, Situation, Behavior, and Impact

(SBI) approach could have been used. The situation explains the causes of the failure mode, and

Behavior explains the recommendation for a change in process, and Impact explains how the

new behavior would change the outcome.

Apart from that, the behavioral training modules that inculcate group thinking and

collaborative effort could have been employed to avoid communication gaps.

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References

DMAIC Tools Website. (n.d.). https://www.dmaictools.com/

Isbell, D., & Savage, D. (1999). Mars climate orbiter failure board releases report, numerous

NASA actions underway in response (Release: 99-134). Washington, DC: Government

Printing Office.

NASA Website. (n.d.). https://www.nasa.gov/offices/oce/functions/lessons/index.html

Ortiz, J., & Saunders, M. (2009). Nobody’s perfect: the benefits of independent review.

Retrieved from https://appel.nasa.gov/2009/09/01/nobodys-perfect-the-benefits-of-

independent-review/