Case study assignment

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Case Studies
Case One The NASA Knowledge Map
At 11:38 a.m. on January 28, 1986, the space shuttle orbiter Challenger launched from
Cape Canaveral, Florida. Less than a second later, gray smoke streamed out from a hot
flare burning in the rocket motor. The flare ignited liquid hydrogen and nitrogen inside
the fuel tank, which exploded 73 seconds after liftoff. The Challenger was torn apart,
and all seven astronauts were killed.
In the days and weeks following the disaster, it became clear that two O-ring seals
within the rocket booster had failed. Engineers working for the space agency had
warned of just such a failure. In particular, they had expressed concerns that the O-ring
seals could fail when outside temperatures dropped below 53 degrees Fahrenheit. On
the morning of January 28, the temperature was 36 degrees. The launch pad was
covered with solid ice.
In response to the Challenger disaster, NASA established the Program and Project
Initiative whose purpose was to improve individual competency for NASA employees—
and to prevent another catastrophe. The Challenger, however, was followed by the
failure of three expensive Mars missions. The software system used for the Mars
Climate Orbiter mission erred when one part of the software used pound-force units to
Book Title: eTextbook: Fundamentals of Information Systems
Chapter 7. Knowledge Management and Specialized Information Systems
Case Studies
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calculate thrust, whereas another part used the newton metric unit. Less than a month
later, the Mars Polar Lander crashed into the surface of the planet at too high velocity—
triggering the failure of a concurrent mission, the Mars Deep Space 2 probes. A review
of the Deep Space 2 mission revealed that NASA engineers had decided to skip a
complete system impact test in order to meet the project’s tight deadline. In the wake of
these failures, NASA sought to improve communication and collaboration among teams.
Yet in 2003, a large piece of insulation foam broke off from the Columbia space shuttle
during launch, creating a hole in its wing, ultimately causing a catastrophic breach of the
shuttle during reentry; again, all seven astronauts on board were killed.
These terrible losses brought about a fundamental change in NASA’s approach to
knowledge management. In 1976, NASA had created the Office of the Chief Engineer
(OCE), which was initially staffed by only one employee whose job was to offer advice
and expertise on NASA’s administration. In response to the Challenger disaster, NASA
established the Academy of Project/Program and Engineering Leadership (APPEL) as a
resource for developing NASA’s technical staff. In 2004, the agency moved APPEL to
the OCE in order to promote talent development through the analysis of lessons learned
and through knowledge capture—the codification of knowledge. The purpose was to
improve not only individual but also team performance and to overcome the disconnect
between the different engineering and decision-making teams across the huge
organization. The overarching goal was to create an organization that learns from its
mistakes. APPEL emphasized not only technical training curriculum but also the sharing
of practitioner experience, storytelling, and reflective activities. In 2012, NASA furthered
this initiative and established the role of chief knowledge officer whose mission is to
capture implicit and explicit knowledge. Today, the agency has an extensive knowledge
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management system called NASA Knowledge Map, which is a tool that helps
employees navigate the enormous collection of knowledge within NASA. The map
encompasses six major categories:
Case Studies and Publications,
Face-to-Face Knowledge Services,
Online Tools,
Knowledge Networks,
Lessons Learned and Knowledge Processes, and
Search/Tag/Taxonomy Tools.
Fifteen organizations within NASA contribute to Case Studies and Publications. The
Goddard Space Flight Center, for example, publishes studies that range from analysis of
the Challenger disaster to an analysis of a protest submitted by a NASA contractor who
lost a follow-up contract. The latter case may not seem critical, but in one such case, the
Office of Inspector General had to launch a formal investigation that cost NASA time,
money, and energy. This case study was then integrated into the APPEL curriculum with
the goal of avoiding the mistakes that led to the protest. The Johnson Space Center
issues oral history transcripts, as well as newsletters, case studies, and reports. The Jet
Propulsion Laboratory publishes conference papers and a Flight Anatomy wiki that
tracks prelaunch and in-flight anomalies.
Face-to-Face Knowledge Services comprise programs that are conducted in person at
many locations, including, for example, workshops presented by the NASA Engineering
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and Safety Center. Within the Online Tools category are video libraries, portals,
document repositories, and synchronous and asynchronous collaboration and sharing
sites. Some of these tools are quite sophisticated. For example, Human Exploration and
Operations (HEO) deploys a GroupSystems Think Tank decision support tool to improve
group decision making. The Knowledge Networks category includes information about
formal and informal communities of practice, mass collaborative activities, and methods
for locating and accessing experts, and group workspaces for projects such as static
code analysis.
Twenty organizations within NASA contribute data to the Lessons Learned and
Knowledge Processes databases, which capture and store knowledge, lessons learned,
and best practices. These include, for example, HEO’s knowledge-based risks library
with topics covering project management, design and development, systems
engineering, and integration and testing. HEO also sponsors lessons-learned
workshops and forums on topics such as solar array deployment, shuttle transition and
retirement, system safety, and risk management.
Finally, the system’s Search/Tag/Taxonomy Tools allow individuals to access
organization-specific sites as well as the abundance of materials offered through the five
other KM programs. This final category within the KM system may be the most
important, as NASA’s own inspector general issued a report indicating that the
tremendous wealth of KM resources is still significantly underutilized. For instance,
NASA managers rarely consult the Lessons Learned Information System (LLIS) despite
NASA requirements that they do so. The Glenn Research Center received $470,000
over two years to support LLIS activities, but contributed only five reports to the system
during that time. Moreover, the inspector general concluded that inconsistent policy
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direction, disparate KM project development, and insufficient coordination marginalize
the system.
NASA is clearly at the bleeding edge of large-scale KM system development, creating
the tools of the future. APPEL and other NASA teams are able to make use of some
amazing tools that are being developed within the agency. It may be, however, that
NASA’s KM system suffers from the same disjointed development and communication
barriers that led to the space shuttle disasters and the failures of the Mars missions. Yet,
it is vital that NASA learn to make use of its state-of-the-art KM system as the success
of every NASA mission requires that thousands of employees are able to make the most
of NASA’s vast collection of knowledge.
Critical Thinking Questions
1. How is the KM system at NASA different from other KM systems that you have studied within
the chapter? How is it similar?
2. What steps can NASA take to make sure that the KM system is better utilized by individuals
and teams?
3. What can NASA do to ensure that individuals and teams can find what they need within the
mountain of data residing within the KM system?
4. Is NASA’s KM system, as it exists now, a good way to combat the type of failures the agency
has experienced in the past? If not, how could the KM system be changed to support mission
5. Are there other measures that NASA should take in addition to or in conjunction with the
development of its KM system?
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SOURCES: Oberg, James, “7 Myths about the Challenger Shuttle Disaster,” NBC News, January 25, 2011,
11031097/ns/technology_and_science-space/t/myths-about-challenger-shuttle-disaster/#.U2AsyIFdUrU; Atkinson, Joe, “Engi
neer Who Opposed Challenger Launch Offers Personal Look at Tragedy,” NASA Researcher News, October 5, 2012, www.nasa.go
v/centers/langley/news/researchernews/rn_Colloquium1012.html; “Challenger Disaster,” History Channel,
opics/challenger-disaster, accessed April 29, 2014; “Failure as a Design Criteria,” Plymouth University,
me/interactive_resources/tutorials/failurecases/hs1.html, accessed April 29, 2014; Lipowicz, Alice, “Is NASA’s Knowledge Ma
nagement Program Obsolete?,” GCN Technology, Tools and Tactics for Public Sector IT, March 19, 2012,
/2012/03/15/NASA-knowledge-management-IG.aspx; Luttrell, Anne, “NASA’s PMO: Building and Sustaining a Learning Organ
ization,” Project Management Institute,, accessed February 9, 2015; Hoffman, Edward
J. and Boyle, Jon, “Tapping Agency Culture to Advance Knowledge Services at NASA,” ATD, September 15, 2013,
s-at-NASA; “Knowledge Map,” NASA,, accessed February 9, 2015.
Case Two Doctor on Demand Enables Physicians to Make House Calls
In addition to cost, provider availability and travel time are barriers for many Americans
seeking access to healthcare services. In fact, a recent study of 4,000 patients
determined that, on average, patients spend 38 minutes on travel time to and from
outpatient appointments. Improving patient’s access to care continues to be a priority for
healthcare providers and government agencies across the United States, and an
increasing number of companies have begun offering telemedicine services, such as
video-based doctors’ appointments, as a potential solution.
Founded in 2013, Doctor on Demand, offers the possibility of increasing access to
health care through video visits with doctors who can diagnose and treat a range of
noncritical symptoms for patients who are unable or unwilling to visit a clinic. Using the
Doctor on Demand services, patients can connect with one of more than 1,400 licensed
physicians through the company’s Web site using a Chrome, Firefox, or Safari browser
or via an Android or iOS app. In addition to video conferences, the Doctor on Demand
app allows patients to upload high-resolution images so that doctors can better assess
certain conditions.
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The top conditions treated by the service are cold and flu symptoms, sore throats,
urinary tract infections, skin rashes, diarrhea and vomiting, eye issues, sports injuries,
and travel-related illnesses. The site also offers video visits with board-certified lactation
consultants for women who are breastfeeding. In addition, patients who need
psychological or psychiatric services can consult with mental health professionals via
the service.
According to Adam Jackson, CEO of Doctor on Demand, the most frequent users of the
company’s services are working mothers, who often have questions about their
children’s health but aren’t always able (or willing) to take time off to get every question
answered. According to Jackson, 92 percent of video consultations require no in-person
Although Doctor on Demand suggests that patients have access to Wi-Fi to ensure the
highest quality appointment, the company promises a smooth experience as long as
patients have a 4G or LTE connection. Patients who have connection problems can also
switch to audio only to complete a visit, if necessary. The Doctor on Demand network
runs on a cloud-based platform run by Amazon Web Services. Due to the nature of the
communication, the company had to go through several steps to ensure that all of its
infrastructure was compliant with HIPAA (Health Insurance Portability and Accountability
Act) requirements.
Most experts predict a shift to telemedicine, including video doctors’ visits, will continue.
In fact, a report by analytics company IHS Technology predicts that video consultations
will increase from 2 million in 2015 to 5.4 million by 2020. For some patients, however,
technology limitations will continue to impede their ability to access health care through
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telemedicine services. A grainy connection or one that cuts out in the middle of an
appointment is unlikely to result in a high quality of care. Other hurdles that will also
need to be overcome include patient’s privacy concerns, patients’ uncertainty about
when a video appointment is appropriate in terms of symptoms, and patients’ lack of
trust that a virtual provider can accurately diagnose and treat them. That concern was
reinforced by a recent study published in the JAMA Internal Medicine that found
significant variations in the quality of care provided by different companies offering
virtual visits for the diagnosis and treatment of common acute illnesses.
Critical Thinking Questions
1. Would you consider using Doctor on Demand or a similar service to access treatment for a
minor healthcare issue? If not, which aspects of the service are most concerning to you
(privacy, quality of care, security or other technology issues, etc.)?
2. Do more research online about Doctor on Demand and two of its competitors (such as
Amwell, MDLive, and Teladoc). What information does each company provide on its Web site
that is designed to ease patients’ concerns about privacy, quality, and technology-related
issues? Which company does the best job of convincing you that their service is safe and
3. In the study on patient travel time, researchers found that minority patients and those who
were unemployed faced longer travel times when visiting a doctor. Rural Americans also often
have more difficulty accessing health care. Is a video-based telemedicine app likely to
improve access for those populations? How might this technology be used in a way that
would be more likely to improve healthcare access for those populations?
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SOURCES: Doyle, Kathryn, “Study: How Long You Wait to See a Doctor Is Linked to Race, Employment,” Huffington Post, Octo
ber 6, 2015,
3b0cbe4b0baa355ad2621; “Troubleshooting,” Doctor on Demand,
218868-Troubleshooting, accessed April 9, 2016; “Our Mission,” Doctor on Demand,,
April 8, 2016; Lapowsky, Issie, “Video Is about to Become the Way We All Visit the Doctor,” Wired,
ited-healthcare-telemedicine; Van Thoen, Lindsay, “Healthcare IT is Failing (And It Needs AWS), Logicworks (blog), July 20, 20
15,; Japsen, Bruce, “Doctors’ Virtual Consults with Patients to Do
uble by 2020,” Forbes, August 9, 2015,
ults-to-double-by-2020/#639cbc4e5d66; “Press Release: “39% of Tech-Savvy Consumers Have Not Heard of Telemedicine: Heal
thMine Survey,” HealthMine, March 27, 2016,
rd-of-telemedicine-healthmine-survey-300241737.html#continue-jump; Schoenfield, Adam J., et al., “Variation in Quality of U
rgent Health Care Provided during Commercial Virtual Visits,” JAMA Internal Medicine, April 4, 2016, http://archinte.jamanetw

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