For the ASKing

One of the few things of value to survive the knowledge management movement of the late 1990s is an online site for managers at, interestingly enough, NASA. The publication, with the awkward name of Academy Sharing Knowledge, or ASK, gives NASA managers the opportunity to tell each other stories about successes, failures and lessons learned. It is a publication every federal manager should read.

ASK uses a young technology, the Web, to disseminate the lessons, but it uses an ancient technique, storytelling, to help managers become better at their jobs. It's a refreshing change from consultant-speak books filled with jargon and catchphrases. It's far easier to peruse than Government Accountability Office and inspector general reviews, which force managers to read between the lines for leadership lessons. In ASK, managers tell stories in their own words.

Take a recent submission on risk management by Marty Davis, a Goddard Space Flight Center manager. He asked his employees to come up with a list of risks facing their weather satellite program. He told them not to use silly, unlikely risks such as someone dropping the satellite.

Shortly after, someone dropped the satellite.

"A 3,000-pound spacecraft dropping 3 feet onto a concrete floor gets damaged," Davis wrote. "How damaged was a bit more complicated, but estimates ran up to $200 million."

The contractor on the program should have had 11 people moving the satellite, but had only six. The quality assurance officials who should have carefully observed the procedure didn't do so. An inspection of the cart to move the satellite didn't happen, and when someone noticed something on the cart looked different than usual, no one stopped to examine it. It turned out bolts were missing. After the team put the satellite on the cart, it fell.

Next came an investigation. Some of the contractor employees were fired. Davis discovered that similar accidents had happened in the past on other projects. What were the lessons learned? "None of these are simple cases where a team missed one step and so the accident happened," Davis wrote. "It's always a combination of skipped steps or miscommunications or dangerous assumptions.

"We need to properly identify the risk. . . .The real risk wasn't necessarily 'dropping the spacecraft,' even though it was the end result. The risk in our case would more accurately be called 'complacency,' " Davis wrote. He said moving a heavy, expensive spacecraft is always risky, even though it is routine, and should always be treated as risky. "Safety requires strict adherence to procedures. Period!" he said.

A key strength of ASK is the goal to find lessons, not to assess blame. Managers feel free to talk about what happens without worrying that someone will take the fall for what they write. Davis, for example, was troubled by which employees lost their jobs. "The way I saw it, the people who got fired weren't necessarily the people who should have been blamed, because they weren't the root cause of the accident," he says. The source was the contractor's complacency about moving the satellite.

Storytelling is a way to bring out those kinds of lessons. Government often is ruled by the cover-your-butt method of management, in which people point fingers and eventually someone (usually a mid- or low-level supervisor or employee) takes the blame. Instead, ASK teaches managers that mistakes happen, lessons can be learned and people can improve.