Technical Management

¶a. Risk Management Issues Issue

¶Is there a coordinated and effective risk management program in the NSTS? Findings

NASA does not explicitly use a centralized program that co- ordinates all the factors that encompass an adequate risk manage- - ment program.
As a result of the accident, NASA is reexamining the Failure Modes and Effects Analyses (FMEA) and Hazard Analyses (HA) to reassess risks associated-with the designs of Shuttle subsystems.
NASA's lack of statistical data on the performance of certain components will limit the usefulness of sound engineering judg- ment in much the same way as it limits the usefulness of probabi- listic risk assessment. Recommendations
NASA should develop and provide to the Committee a descrip- tion of an overall risk management program as it relates to the Space Shuttle. This effort should include a determination of wheth- er or not a more centralized coordination of a risk management program and issuance of direct risk management guidance direc- tiv& are needed.
NASA should review anahtical methods utilized in the per- formance of risk assessment, including statistical analyses, trend analyses and probabilistic risk assessment methodologies to deter- mine their applicability to the NSTS program. Assistance from the National Academy of Sciences, or other appropriate organizations with expertise in these matters, may be required to adequately per- form this review.
NASA should review its certification testing to ensure that all critical items are adequately tested. Data obtained from these testa should be used when appropriate in conducting a formal risk as- sessment.

¶b. Launch Decision Process Issue 1

¶Is the process for establishing launch constraints and dealing with them effective? Findings

There is no clear understanding or agreement among the vari- ous levels of NASA management as to what constitutes a launch constraint or the process for imposing and waiving constraints.
Launch Constraints were often waived after developing a ra- tionale for accepting the problem rather than correcting the prob- lem; moreover, this rationale was not always based on sound engi- neering or scientific principles.

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¶Recommendations

NASA should establish rigorous procedures for identifying and documenting launch constraints. The individual(s1 responsible for implementing this procedure should be clearly identified, and well defined and understood criteria for waiving them should be estab- lished.
NASA should exercise extreme caution in waiving launch con- straints before correcting the problem that led to the launch con- straint. The rationale should be based on rigorous scientifWengi- neering analyses or tests and should be understood and accepted by the program manager. Isslle 2

¶Are the Launch Commit Criteria procedures adequate to ensure the safety of the mission? Findings

The procedure used for developing launch commit criteria is systematic and thorough; however, violations of the criteria do not necessarily mean "no go". Therefore, NASA sometimes has relied on engineering judgments made during the terminal countdown in determining whether to launch.
Launch commit criteria were sometimes waived without ade- quate engineering analysis or understanding of the technical rea- sons for establishing the criteria. Recommendations
NASA should review the launch commit criteria procedures, especially those for dealing with violations, to lessen the reliance on engineering judgments under stress.
When situations arise where "real time" judgments are un- avoidable, NASA should adopt a more conservative approach to waiving previously established criteria. In no case should a crite- rion be waived without a thorough understanding of the rationale for the establishment of the criterion. Issue 3

¶Are launch readiness review procedures and communications adequate? Finding

¶The Committee finds that the review procedures and communica- tions used to assure flight readiness were systematic, thorough, and comprehensive and provided ample opportunity for surfacing hard- ware problems prior to flight. Level I FRRS are usually recorded (audio); however, there is often no record made of other key pre- launch meetings. Recommendation

¶NASA should make every reasonable effort to record meetings where key decisions might be made; in particular, all formal Flight Readiness Reviews, including the G 1 and the Mission Manage ment Team meeting should be recorded, where feasible by video.

¶Issue 4

¶W as the failure to inform the Level I or Level I1 Program Man- agers of the Teleconference involving NASA and Morton Thiokol on the eve of the launch a factor in the decision to launch? Findings

The Committee finds that Marshall management used poor judgment in not informing the NSTS Program Manager or the a Level I Manager of the events that took place the ni ht before the launch, specifically the stated concerns of the Thio 01 engineers. However, the Committee finds no evidence to support a suggestion that the outcome would have been any different had they been told.
The Committee finds the efforts of Thiokol engineers to post- pone the launch commendable; however, Thiokol had numerous op- portunities throughout the normal flight readiness process follow- ing flight 51-C in January 1985 to have the new minimum temper- ature criteria established. Issue 5

¶Do the principal contractors have an appropriate role in the launch decision making process? Finding

¶The principal contractors have an active role throughout the de- cision making process right up to the launch; however, the lack of a firm requirement for their concurrence at the time of launch does partially relieve them of responsibility for mission success. Recommendation

¶Principal contractors should be required to make a clear, unam- bigous statement concerning launch readiness just prior to launch. Issue 6

¶Are astronauts adequately represented in the decision making process? Finding

¶The astronauts believe they currently have the opportunity to make inputs into the process and are reluctant to assume a greater responsibility for the decision to launch.

¶c. Technical Expertise of Personnel Issue

¶Does NASA have an adequate level of in-house technical exper- tise to manage the Shuttle Program properly? Findings

During the last decade NASA has had significant decreases in manpower. A disproportionate reduction may have occurred in the safety, reliability and quality assurance staff at NASA headquar- ters and at the Marshall Space Flight Center. Additionally during the period preceding the Challenger accident, the Office of Space

¶Flight also suffered a decline in staff. The decreases may have lim- ited the ability of those offices to perform their review functions.

The information presented to NASA headquarters on August 19, 1985 was sufficient to require immediate and concentrated ef- forts to remedy the joint design flaws. The fact that NASA did not take stronger action to solve this problem indicates that its top technical staff did not fully accept or understand the seriousness of the joint problem. Recommendations
NASA should review the numbers and qualifications of key staff in technical and management positions and should consider additional training and recruitment of individuals to further the quality and safety of NASA's missions.
The Committee should maintain on-going oversight of this analysis and conduct an in-depth examination upon the conclusion of NASA's review.

¶d. Change Control Process Issue 1

¶Has the pressure to maintain operational flight rates and sched- ules for the Shuttle compromised the hardware Change Control Process? Findings

When NASA declared the Space Shuttle to be an operational system, additional pressure to increase flight rates impacted other aspects of the overall program such as the ability to implement, evaluate, test, and certify changes in hardware design.
As a result of attempting to operate the Shuttle at increased flight rates, controlling other aspects of the program such as the flight production process and manifest also became a more complex and difficult aspect of program administration. Recomrnendations
NASA must reconsider its efforts to categorize the Shuttle as an operational transportation system.
The Configuration Management System designed to control such changes must be reexamined by NASA as to its effectiveness in assuring that all hardware changes take place in a safe and reli- able fashion. Issue 2

¶Is the change control process sufficiently defined for all elements of the Shuttle system? Findings

The NSTS engineering and process change guidelines are, for the most part, sufficiently well-defined for the majority of the sub- systems that comprise the Space Shuttle.
NASA gives the same level of scrutiny to changes involving a minor component (such as moving Velcro strips in the Orbiter) as those involving mission critical elements of flight hardware.

¶Recommendation

¶NASA should review its change control process to determine the usefulness of differentiating between minor changes and significant changes.