10.5 MAINTENANCE DOCUMENTATION

¶The Board reviewed Columbiaʼs maintenance records for any documentation problems, evidence of maintenance flaws, or significant omissions, and simultaneously investigated the organizations and management responsible for this documentation. The review revealed both inaccurate data entries and a widespread inability to find and correct these inaccuracies.

¶The Board asked Kennedy Space Center and United Space Alliance to review documentation for STS-107, STS-109, and Columbiaʼs most recent Orbiter Major Modification. A NASA Process Review Team, consisting of 445 NASA engineers, contractor engineers, and Quality Assurance personnel, reviewed some 16,500 Work Authorization Documents, and provided a list of Findings (potential relationships to the accident), Technical Observations (technical concerns or process issues), and Documentation Observations (minor errors). The list contained one Finding related to the External Tank bipod ramp. None of the Observations contributed to the accident.

¶The Process Review Teamʼs sampling plan resulted in excellent observations.24 The number of observations is relatively low compared to the total amount of Work Authorization Documents reviewed, ostensibly yielding a 99.75 percent accuracy rate. While this number is high, a closer review of the data reveals some of the systemʼs weaknesses. Technical Observations are delineated into 17 categories. Five of

¶these categories are of particular concern for mishap prevention and reinforce the need for process improvements. The category entitled "System configuration could damage hardware" is listed 112 times. Categories that deal with poor incorporation of technical guidance are of particular interest due to the Boardʼs concern over the backlog of unincorporated engineering orders. Finally, a category entitled "paper has open work steps," indicates that the review system failed to catch a potentially significant oversight 310 times in this sample. (The complete results of this review may be found in Appendix D.14.)

¶The current process includes three or more layers of oversight before paperwork is scanned into the database. However, if review authorities are not aware of the most common problems to look for, corrections cannot be made. Routine sampling will help refine this process and cut errors significantly.

¶Observations:

¶O10.5-1 Quality and Engineering review of work docu-

ments for STS-114 should be accomplished using statistical sampling to ensure that a representative sample is evaluated and adequate feedback is communicated to resolve documentation problems.

¶O10.5-2 NASA should implement United Space Allianceʼs

suggestions for process improvement, which recommend including a statistical sampling of all future paperwork to identify recurring problems and implement corrective actions.

¶O10.5-3 NASA needs an oversight process to statistically

sample the work performed and documented by Alliance technicians to ensure process control, compliance, and consistency.