Reports that Matter

Investigation of the Challenger Accident

2 . OPERATIONS

Section 19 of 55

2 . OPERATIONS

a. Shuttle Processing Issues (including Spare Parts) Issue

In 1983, NASA consolidated fifteen separate contracts and awarded a single Shuttle Processing Contract (SPC) encompassing all ground processing related to launch and landing of the Space Shuttle. There are two issues associated with this contract: (1)How sound is the concept of a unified SPC; and (2) How well has the SPC contractor actually performed? A related issue is the quality of essential logistical support, especially spare parts, provided to the contractor by NASA. Findings

  1. Performance under the SPC has improved since the inception of the contract. However, up to the time of the Challenger accident, contractor performance continued to be plagued by excessive over- time, persistent failures to follow prescribed work procedures, and inadequate logistical support from NASA.

  2. High overtime rates have hampered SPC performance. Over- time rates had increased significantly during the six months prior ~

T 2 Discussion with NASA officials, Washington, D.C., August 13, 1986.

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to the Challenger launch, to the point that critical personnel were working weeks of consecutive workdays and multiple strings of 11- and 12-hour days. Fatigue resulting from work patterns of this sort can constitute a threat to safety. In fact, worker fatigue was a con- tributing factor in a mission-threatening incident on Flight 61-C, the mission immediately prior to the January 28 Challenger launch.

  1. There are numerous documented cases when contractor em- ployees failed to comply with guidelines for carrying out assigned duties, including specific "Operations and Maintenance Instruc- tions" (OMI's). Such failures contributed to both of the major mis- haps in 1985 involving Shuttle processing-namely, the November 8, 1985, "handling ring" episode which led to significant damage to a Solid Rocket Motor segment slated for use on STS51-L, and the March 8, 1985, "payload bay access platform" episode which led to significant damage to a payload bay door. Failure to follow an OM1 also led to improper (and mission-threatening) handling of the hy- drogen disconnect valve during the 51-L launch operations. All of these incidents show a lack of discipline, both with respect to fol- lowing prescribed procedures and with respect to reporting viola- tions of these procedures.

  2. At the time of the Challenger accident, the lack of spare parts caused a degree of cannibalization (i.e., the removal of a part from one Orbiter to satisfy a need for a spare part on another Orbiter), which was the highest in the history of the Shuttle program and which was a threat to flight schedule and flight safety. Excessive cannibalization leads to multiple installations, retesting, added doc- umentation, delayed access to parts, and increased damage poten- tial. As a result, cannibalization contributes directly to excessive overtime.

  3. There is no clear evidence whether or not greater involvement of the development contractors would improve Shuttle operations. Recommendations

  4. Because of the serious quality and safety concerns surround- ing the contract, NASA should conduct a careful review of Shuttle processing, the SPC contract, and the relationship of flight hard- ware contractors and report its findings, recommendations, and proposed contract modifications to the Committee. NASA's reexam- ination should include a comparison of efficiency and safety under the SPC versus efficiency and safety during pre-1983 Shuttle proc- essing operations, which heavily involved the development contrac- tors.

  5. NASA should examine the issues of spares availability and cannibalization and provide the Congress with a management and budgetary plan for correcting previous logistical problems.

  6. NASA should stop routine cannibalization and develop guide- lines (including appropriate control and review procedures and roles €or the SWQA office) governing permissible cannibalization.

  7. The Committee recommends that NASA provide its re-invig- orated safety office with the authority to enforce scheduling that leads to safe overtime rates.

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Discussion

In a press release dated September 5, 1986, NASA announced that it has extended the SPC with Lockheed for three additional years, beginning October 1, 1986. Admiral Truly also announced his intent to conduct a thorough review of the SPC, a process which might lead to contract amendments.

Lockheed's award fees at the Kennedy Space Center have not been at the highest possible levels due to mishaps and management problems. The contractor has received the following award fees for Shuttle processing at KSC: