2018 HPRCT Conference

Roughly 4 years ago, Luca, an astronaut from Italy, nearly drowned during a spacewalk after a potentially dangerous amount of water accumulated in his helmet.   After this event, NASA performed a traditional root cause analysis and implemented corrective actions.   Then NASA asked, “Could this happen again?”  Looking to resilience engineering to provide a different perspective, International Space Station leadership commissioned a team to assess and make recommendations to increase the resilience of their organization.  In this talk, I report on elements the team deemed relevant in assessing resilience and brittleness.  I contrast resilience engineering with traditional root cause analysis, both in how an event is analyzed and the differences in subsequent strategies and actions including methods to increase resilience.