Organization and Policy Management

¶a. Management Structure Issue 1

¶Does the management of the Shuttle Program adequately define the lines of authority and are managers given authority commen- surate with their responsibilities? Finding

¶The management of the Shuttle Program is complex and diversi- fied and it is not always clear who has authority or responsibility. NASA's "lead center" concept has resulted in placing the manage- ment of the program at JSC, one of three centers participating in the program; however, because Johnson does not have control of the other centers' resources, the NSTS Program Manager's author- ity to manage the program is limited and the responsibility is un- clear. Recomrnendation

¶NASA should restructure the Shuttle Program management to define clear lines of authority and responsibilities. This restructur- ing should take into account the special role each center must play and be especially sensitive to the need for the cooperation and sup- port of all the participants to achieve a common goal. NASA should give special consideration to moving the Program Manager to NASA Headquarters to avoid the confusion and intercenter ri- valry that result from having a large multi-center program man- aged out of one of the participating centers. Issue 2

¶Are astronauts adequately represented in management? Finding

¶The Committee finds no evidence that astronauts are denied the opportunity to enter management if they so choose.

¶b. Communication Issue 1

¶Are there adequate opportunities to communicate problems within the Shuttle Program management structure? Finding

¶There are many regularly scheduled meetings and telecons at all levels of management throughout the Shuttle Program. In addi- tion, "special" meetings and telecons are routine. No evidence was found to support a conclusion that the system inhibited communi- cation or that it was difficult to surface problems.

¶Issue 2

¶Is too much information being disseminated so that important in- formation is lost? Finding

¶Large amounts of information are disseminated on a routine basis, often with little or no indication of its importance to all of the recipients. Recommendation

¶NASA management should review the process of providing infor- mation on significant actions so that awareness by concerned man- agers is assured. Issue 3

¶Are communications filtered so that important information is prevented from reaching the decision makers? Finding

¶NASA managers delegated the responsibility for making techni- cal judgments to lower level managers or assistants. Therefore, the information that reached the top decision makers was "filtered" in that it was interpreted by others that were presumed to have more specialized experience or expertise in a given area. There is no evi- dence that middle level managers suppressed information that they themselves deemed to be significant. In fact, as discussed in the section on technical expertise, the failure was not the problem of technical communications, but rather a failure of technical decision making.

¶c. Safety, Reliability and Quality Assurance Issue 1

¶Is NASA's decision to establish a new Office of Safety, Reliability and Quality Assurance appropriate and, if so, what should its role be? Finding

¶The Committee finds that the Rogers Commission recommenda- tion that NASA should establish an Office of Safety, Reliability and Quality Assurance that reports directly to the Administrator is indeed appropriate. However, it is not clear what the activities of this office will encompass. Recommendations

The Associate Administrator for Safety, Reliability and Qual- ity Assurance (SWQA) should provide to the Committee the agen- cy's draft plan delineating the organization, goals, implementation strategies and resource requirements of the Office of SR&QA.
After the Office of SR&QA is fully operational, the Committee will wish to continue oversight over its activities.

¶Issue 2

¶Has NASA applied sufficient resources to support adequate SR&QA efforts within the NSTS program? Findings

The Committee finds that reductions in NASA civil service personnel that have occurred over the past decade have adversely impacted the agency's ability to maintain the appropriate level of oversight and control of the SR&QA activities within the NSTS.
NASA has become increasingly dependent upon outside SR&QA support from the Department of Defense (Defense Contract Administration Services (DCAS) and Air Force Plant Representa- tive Office [AFPRO]) and contractors.
NASA has reduced or reassigned to other program areas in- house safety, reliability and quality assurance tasks such as test- ing, analyses and instrumentation and has reduced or shut down in-house facilities for performing SR&QA research and technology development. The degree to which these factors have adversely im- pacted the safety, reliability and quality assurance activities within the NSTS program has not been adequately assessed. Recommendations
NASA should establish and maintain a strong and effective SR&QA program. Continuing support for such a program must come directly from the Administrator.
Although it is appropriate to establish strong contractor capa- bilities in the areas of SR&QA, the internal oversight responsibil- ities and coordination of SR&QA tasks milst be the responsibility of NASA itself. In order to assure that the appropriate interfaces among the various subsystem elements that comprise the NSTS are maintained, a sufficient complement of NASA SR&QA manage- ment and support staff must be available to perform the necessary oversight and coordination tasks. Issue 3

¶Are the responsibilities of safety engineers and design engineers adequately specified within NASA's "risk management" program? Finding

¶The roles of safety, design as well as reliability engineers are not adequately and uniformly defined throughout the NSTS program. In some cases, the Committee learned that safety engineers were not participating in major decisions related to flights of the Shut- tle. Recommendation

¶It should be the responsibility of the new Associate Administra- tor for SR&QA to fully specify the roles of safety and reliability en- gineering as well as quality assurance personnel within the NSTS program, so that all critical aspects of the program and decisions related to the adequacy of hardware and subsystem performance are fully reviewed by these disciplines.

¶Issue 4

¶Does the SR&QA program require improved coordination be- tween centers, contractors and NASA Headquarters? Findings

Although guidelines have been published that describe the re- sponsibility of contractors in the areas of SR&QA, NASA's guide- lines do not adequately distinguish these various activities as dis- tinct disciplines requiring specialized skills and centralized coordi- nation.
In its review of the agency's reliability and quality assurance programs as they relate to the Space Shuttle, the Committee found there was little commonality among the cognizant officials at MSFC, JSC, KSC, and Headquarters in the perception of the vari- ous responsibilities associated with these separate and distinct dis- ciplines. Recommendations
It is important that a clear delineation of responsibilities for the separate SR&QA disciplines be appropriately documented. It is also essential that the relative importance of each of the three sep- arate disciplines be established as an integral part of the NSTS program. These functions are the responsibility of NASA Head- quarters.
NASA must carefully review the staff and resources devoted to the SR&QA function within NASA and contractor organizations for adequacy. The Administrator shall report to the Committee with his findings and recommendations.

¶d. Contractor Incentives Issue

¶Key Shuttle contracts (e.g., Solid Rocket Booster Production Con- tract and the Shuttle Processing Contract (SPC)) provide incentives both for reliability, integrity, and safety of products and services on the one hand, and for cost and schedule on the other. Do these con- tracts provide an appropriate balance between the two types of in- centives? That is, does NASA utilize contracts to reward and pro- mote operational safety? Findings

The SPC provides far greater incentives to the contractor for minimizing costs and meeting schedules than for features related to safety and performance. SPC is a cost-plus, incentive/award fee contract. The amount of the incentive fee is based on contract costs (lower costs yields a larger incentive fee) and on safe and successful launch and recovery of the Orbiter. The award fee is designed to permit NASA to focus on those areas of concern which are not sen- sitive to the incentive fee provisions, including the safety record of the contractor. However, the incentive fee dwarfs the award fee- while the maximum value of the award fee is only one percent of the value of the SPC, the incentive fee could total as much as 14 percent of the SPC.

During the developmental phases of the Thiokol contract for Solid Rocket Booster production (1980-1983), the contractor re- ceived consistent ratings of "Excellent-Plus" or "Superior" under the cost-plus, award-fee contract. NASA contracted with Thiokol on a cost-plus, incentive-fee (CPIF) basis beginning in July 1983. The CPIF contract pays strictly on the basis of costs, although penalties may be invoked for delays in delivery or for Shuttle accidents due to SRB failure. At the time of the Challenger accident, Thiokol was eligible to receive a very large incentive fee, probably on the order of $75 million. Recornmendations
NASA should reexamine all Shuttle contracts and report to the Committee with its findings and recommendations on whether more incentives for safety and quality can be built into these con- tracts. This report should address, inter alia, the SRB Production Contract and the SPC.
NASA's new Office of SR&QA should be involved in the pro- curement and award fee processes, both to establish reasonable guidelines and rewards in new contracts and to judge performance of ongoing contracts.

BACKGROUND INITIAL EVENTS FOLLOWING THE ACCIDENT

¶On January 28, Chairman Fuqua stated on the floor of the House that the Committee would conduct comprehensive hearings and prepare its report on the Challenger accident and its implications after the National Aeronautics and Space Administration had com- pleted its immediate investigation. NASA's effort was to follow the same investigative approach it had taken after the Apollo 204l fire.

¶In preparation for this time, Mr. Fuqua working with Mr. Lujan, the Ranking Republican Member, appointed a steering group of Committee Members two days following the accident to guide the Committee's work. This group consisted of: Don Fuqua Manuel Lujan, Jr. Harold Volkmer Robert Walker Bill Nelson Ron Packard

¶However, this plan and timetable were changed when President Reagan, by Executive Order, established a Presidential Commission on the Space Shuttle Challenger Accident on February 3, 1986. The order directed the Rogers Commission to make its final report to the President and the Administrator of NASA within 120 days. The order directed the Commission to: "(1) Review the circumstances surrounding the accident to establish the probable cause or causes of the accident; and (2) Develop recommendations for corrective or other action based upon the Commission's findings and determina- tions."

¶With this important new development, the Committee Steering Group met and decided to modify its earlier approach of investigat- ing NASA's inquiry to that of reviewing the Rogers Commission's investigation. It was determined that the Committee's formal work would begin as soon as practicable after the Rogers Commission issued its report.

PREPARATION COMMITTEE

¶On February 5, the Chairman, Mr. Fuqua, and Mr. Lujan, wrote a letter to Chairman William P. Rogers stating their support for the serious task which was ahead of the Presidential Commission. In that letter Messrs. Fuqua and Lujan also outlined the Commit- tee's approach, saying:

We would like to begin our oversight process by asking you to establish procedures for providing us with progress reports as appropriate so that we can be kept advised of

¶On January 27, 1967, astronauts Virgil Grissom, Edward White I1 and Roger Chafee were killed when their Apollo spacecraft was destroyed by fire on the launch pad.

¶(35)

the activities of your Commission. At the conclusion of the Commission's work, we will undertake a thorough review of your report; we expect that this review will be similar to the review and hearings held after the Apollo 204 fire and the Apollo 13 incident.2 It is our understanding that the Commission is tasked

¶with completing its report in 120 days. In light of this fact, we would like to request your appearance before the Science and Technology Committee during the first week in

¶June, or within one week of your final report, should you complete it sooner.

¶The letter to Chairman Rogers also noted that a similar letter had been sent that same day to the NASA Acting Administrator, Dr. William R. Graham. It stated that the Committee also planned, after hearing from the Commission, to take testimony from NASA management on the accident, and "closely review NASA proposed management plans designed to implement the Commission's recom- mendations."

¶Chairman Fuqua and Chairman Rogers then worked out an in- formal arrangement for the Committee Steering Group so that when there was sufficient reason to meet, in the opinion of the two chairmen, Chairman Rogers would brief the Steering Group on the progress of the investigation.

¶By April 22, the Steering Group felt it had heard sufficient infor- mation to brief the Members of the full Committee on Science and Technology. This was done in a closed meeting that day.

¶On May 16, 1986, Chairman Fuqua sent a memorandum to all Members stating that he had asked Congressman Robert Roe, the Ranking Majority Member, to chair the Committee hearings on the Challenger accident, stating that "there is a distinct possibility that follow-through activities related to the hearings will carry over into the next Congress in which I shall not serve."

COMMITTEE TRIP

¶When it appeared that the Rogers Commission would be able to meet its 120-day deadline, Mr. Roe arranged to take a group of Committee Members and key staff to the Kennedy Space Center on June 6, 1986. At the Center the Members heard detailed accident briefings, took a tour of the Vehicle Assembly Building where a set of Solid Rocket Motors and External Tank was examined, and viewed the recovered debris from the Challenger spacecraft.

THEHEARINGS

¶The Rogers Commission report was released on June 9, 1986. Im- mediately thereafter, the full Committee began its inquiry under the direction of Mr. Roe. The Committee heard from 60 witnesses during 10 days of hearings, for a total of 41 hours. A compilation follows:

¶On April 13, 1971, Apollo 13's Command and Service Modules were disabled by an oxygen tank explosion en route to the Moon. The crew waa recovered safely.