Course Summary:
Engineering Risk Management Training
DURATION: 2 days, 1 day, 1/2 day
Overview — Complex Engineering lessons learned course:
This course is designed to provide insights, lessons learned, and mitigation strategies to address the root causes of complex aerospace and civil infrastructure system failures.
The course reviews dozens of extraordinary engineering failures and near misses in detail, exploring the engineering, quality, systems, and management aspects that led to disaster. In addition to uncovering the root causes, specific lessons for avoidance of these types of mishaps are outlined. For example, the details of the Space Shuttle Columbia accident are presented along with an introduction to the concept “Normalization of Deviance, in which system behaviours deviating from an established requirement are rationalized and accepted, with catastrophic results. Other notable cases include the perils of Faster, Better, Cheaper programs and the special challenges associated with mission software development, including Mars missions and the Ariane 501 cases. Rules of Practice and other concrete strategies are shared that apply to the current works of each participant to reduce risk and maximize success.
Who Should Attend:
This course is designed for engineers, systems engineers, engineering managers, and project leaders working in complex, high-risk technical environments. It is especially valuable for professionals responsible for engineering decision-making, risk management, and project execution across the full life cycle—from design and development through testing and operations.
The training is well suited for early-career through senior-level professionals in aerospace, spaceflight, infrastructure, and other industries where failure prevention, human factors, and disciplined engineering practices are critical.
Training Methods:
The course information is shared in a graphical, story format for better understanding, engagement, and retention. There are frequent interactive conversations to reflect on the content, lessons learned, and strategies for complex and challenging projects. Participants are encouraged to ask questions and dig deeper into the content. Participants will also take part in two class exercises where small groups will be asked to discuss which mishaps and lessons were most relevant to them and why. Furthermore, discussions will cover their own engineering challenges and how the course material offers potential solutions. Key insights from the small groups will be shared with the larger group to help build a community of learning across disciplines.
A Sample of Recent Attendee Evaluations:
From European Space Agency, ESTEC…
“Your delivery of complicated engineering case studies was inspired.”
“Ann and Randy were some of the most experienced speakers I've ever had in a training. They were there when these things happened and shared their (sometimes painful) experiences with us.”
“The case study method was engaging, and it felt like we were learning something new the whole time.”’
“The course was brilliant. I would recommend it to everyone at ESA who wants/needs to understand how critical it is to learn from engineering mistakes. And how many mistakes can be made on multi-stage, muti-year projects like the ones ESA runs”
“Principles learned here will guide me my whole career.”
From NASA International Project Management …
“Precise and new info of the failure case studies!”
“I really appreciated the case examples for each type of failure, and it was interesting to hear the broader groups examples”
“Amazing Lessons learned!”
“Understood the importance of the intent of requirements.”
From Vaya Space (rocket start-up) …
“The examples chosen to illustrate various issues and failures were delivered well and articulated for all team members to understand how they play a role in creating a safe environment.”
“Really appreciate knowledge level, experience brought in, and engagement.”
“Good balance of humor, seriousness, and emphasis on the importance of the subject”
“The failure modes were plentiful, and videos/photos assisted in understanding the problems and prevention. The final slides on mitigation were gems.”
Course outline:
Introduction
Overview of Failure Types
Lessons from Past Missions
· Screening Out Design Errors
· Screening Out Procedural Errors
· Impact of Weak Testing Practices
· Systems Engineering Lapses
· Software Mishaps
· Information Flow Breakdowns
· Flawed Processes
· Experienced Teams make Mistakes
· Normalizing Deviance
· Missed Advanced Warnings
· Perils of Heritage Systems
· Management Issues
4. Near Misses
5. Mishap Summaries
6. The Human Element
7. Applying the Lessons: “Rules of Practice”
8. Working Group Exercises (end of each day)
9. Conclusions
Apollo 13 video showing damage to the Service Module shortly before earth return.
Astronaut Chris Cassidy explains what happened during EVA #23.
COURSE SAMPLE: APOLLO 13
What really happened and why?
You may know that an oxygen tank over pressurized during the ill-fated mission Apollo 13. However, do you know why? We will dig into the back story of multiple times people made mistakes during pre-flight analysis and testing. We’ll also explain how the crew made it home safely, largely due to engineers who predicted a worst case, and how to survive it. Apollo 13 is one of over 60 cases we chose to present and draw out the lessons learned you won’t find in a failure report.
COURSE SAMPLE 2: EVA #23
An astronaut was enveloped with water in his helmet during an EVA. Why did it happen?
The answer might surprise you. The root cause was not on-orbit, and, it was a bad management decision.
WHO SHOULD ATTEND:
Engineering staff, technical managers, and program/project managers engaged in the development of aerospace and other high technology systems, or those responsible for oversight in these areas.
WHAT YOU WILL LEARN:
This 2-day course is designed to provide insights, lessons learned, and mitigation strategies to address the root causes of complex aerospace and civil infrastructure system failures.
The course reviews dozens of extraordinary engineering failures and near misses in detail, exploring the engineering, quality, systems, and management aspects that led to disaster. In addition to uncovering the root causes, specific lessons for avoidance of these types of mishaps are outlined. For example, the details of the Space Shuttle Columbia accident are presented along with an introduction to the concept “Normalization of Deviance, in which system behaviours deviating from an established requirement are rationalized and accepted, with catastrophic results. Other notable cases include the perils of Faster, Better, Cheaper programs and the special challenges associated with mission software development, including Mars missions and the Ariane 501 cases. “Rules of Practice” and other concrete strategies are shared that apply to the current works of each participant to reduce risk and maximize success.
TYPICAL COURSE OUTLINE*
(Content will vary slightly depending on the tailoring and as updated material is included)
Introduction
Overview of Failure Types
Lessons from Past Missions
Screening Out Design Errors
Screening Out Procedural Errors
Impact of Weak Testing Practices
Systems Engineering Lapses
Software Mishaps
Information Flow Breakdown
Flawed Processes
Experienced Teams Make Mistakes
Normalizing Deviance
Missed Advanced Warnings
Perils of Heritage Systems
Management Issues
Chain of Errors Concept
Near Misses
Mishap Summaries
The Human Element
Applying the Lessons: “Rules of Practice”
Working Group Discussions (end of each day)
Conclusions
*Traditionally a two-day course, but a wide scope of options ranging from lectures to two full days are available. Content will vary.
GOALS
This 2-day course has the following goals for developers of technical systems. Participants will:
· Develop early recognition of potential failure risks given the awareness of the twelve most common themes in the extensive database of cases.
· Achieve a broader awareness and new perspectives based on the variety of engineering cases that either failed or had a near miss.
· Anticipate, recognize, and reduce the risks for human error in the system, given the root cause of most complex engineering failures is driven by human elements.
· Recognize and take action to avoid common pitfalls through the life cycle of projects, from design through operations.
· Adopt applicable “Rules of Practice” for their own projects, especially useful to create a culture for engineering processes, risk management, and decision making to minimize or eliminate root causes of failures.
“Honestly, every program at NASA should have this training.”
— Kennedy Space Center
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AR NexGen translates lessons into concrete strategies that will minimize or eliminate root causes of engineering system mishaps and near misses.