Investigation of the Challenger Accident
TECHNICAL MANAGEMENT
TECHNICAL MANAGEMENT
¶a. Risk Management Issues Issue
¶There a coordinated and effective risk management program in the NSTS? Findings
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NASA does not explicitly use a centralized program that co- ordinates all the factors that encompass an adequate risk manage- ment program.
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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.
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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. Recomnenda tions
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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- tives are needed.
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NASA should review analytical 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.
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NASA should review its certification testing to ensure that all critical items are adequately tested. Data obtained from these tests should be used when appropriate in conducting a formal risk as- sessment. Discussion
¶NASA does not have a specifically labeled risk management pro- gram. The process is accomplished by the agency through its con- figuration management program and the FMEA performed on each component of the Space Shuttle. The identification of critical items is the principal product of these analyses. The ability to make the programmatic or engineering changes necessary to enhance the safety and performance of flight systems while controlling costs and schedule is the task of the risk management activity.
139¶The process of risk management as applied to systems such as the Shuttle can be described schematically as shown in Figure VI- 3,123which shows the various steps that might be imposed upon flight systems such as the Shuttle through a risk management pro- gram.
¶lZ3Douglas B. Feaver, "Succeea Relaxed NASA's Vigilence", Washington Post, May 26, 1986, pp. A-1, A-10.
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