Avoiding Common Pitfalls in Lessons Learned Processes that Support Decisions with Significant Risks

Since the Columbia accident, the National Aeronautics and Space Administration (NASA) has worked extensively to improve its "Lessons Learned" processes so that NASA can avoid repeating past decision making errors. This paper identifies the most serious pitfalls in lessons learned processes that support decisions that must be made in situations with significant risks. We focus on three steps in the lessons learned process: collecting lessons learned, managing lessons learned systems, and applying lessons learned appropriately to future missions. By identifying the pitfalls in each of these three processes, we hope to improve lessons learned systems to support current and future missions. Also, we describe steps taken at Goddard Space Flight Center (GSFC) and for the Exploration Systems Mission Directorate (ESMD) to improve the lessons learned process and to support the development of a learning organization.