6.2 SCHEDULE PRESSURE

6.2 SCHEDULE PRESSURE

¶Countdown to Space Station "Core Complete:" A Workforce Under Pressure

¶During the course of this investigation, the Board received several unsolicited comments from NASA personnel regarding pressure to meet a schedule. These comments all concerned a date, more than a year after the launch of Columbia, that seemed etched in stone: February 19, 2004, the scheduled launch date of STS-120. This flight was a milestone in the minds of NASA management since it would carry a section of the International Space Station called "Node 2." This would configure the International Space Station to its "U.S. Core Complete" status.

¶At first glance, the Core Complete configuration date seemed noteworthy but unrelated to the Columbia accident. However, as the investigation continued, it became apparent

¶that the complexity and political mandates surrounding the International Space Station Program, as well as Shuttle Program managementʼs responses to them, resulted in pressure to meet an increasingly ambitious launch schedule.

¶In mid-2001, NASA adopted plans to make the over-budget and behind-schedule International Space Station credible to the White House and Congress. The Space Station Program and NASA were on probation, and had to prove they could meet schedules and budgets. The plan to regain credibility focused on the February 19, 2004, date for the launch of Node 2 and the resultant Core Complete status. If this goal was not met, NASA would risk losing support from the White House and Congress for subsequent Space Station growth.

¶By the late summer of 2002, a variety of problems caused Space Station assembly work and Shuttle flights to slip beyond their target dates. With the Node 2 launch endpoint fixed, these delays caused the schedule to become ever more compressed.

¶Meeting U.S. Core Complete by February 19, 2004, would require preparing and launching 10 flights in less than 16 months. With the focus on retaining support for the Space Station program, little attention was paid to the effects the aggressive Node 2 launch date would have on the Shuttle Program. After years of downsizing and budget cuts (Chapter 5), this mandate and events in the months leading up to STS- 107 introduced elements of risk to the Program. Columbia and the STS-107 crew, who had seen numerous launch slips due to missions that were deemed higher priorities, were further affected by the mandatory Core Complete date. The high-pressure environments created by NASA Headquarters unquestionably affected Columbia, even though it was not flying to the International Space Station.

¶February 19, 2004 – "A Line in the Sand"

¶Schedules are essential tools that help large organizations effectively manage their resources. Aggressive schedules by themselves are often a sign of a healthy institution. However, other institutional goals, such as safety, sometimes compete with schedules, so the effects of schedule pressure in an organization must be carefully monitored. The Board posed the question: Was there undue pressure to nail the Node 2 launch date to the February 19, 2004, signpost? The management and workforce of the Shuttle and Space Station programs each answered the question differently. Various members of NASA upper management gave a defi- nite "no." In contrast, the workforce within both programs thought there was considerable management focus on Node 2 and resulting pressure to hold firm to that launch date, and individuals were becoming concerned that safety might be compromised. The weight of evidence supports the workforce view.

¶Employees attributed the Node 2 launch date to the new Administrator, Sean OʼKeefe, who was appointed to execute a Space Station management plan he had proposed as Deputy Director of the White House Office of Management and Budget. They understood the scrutiny that NASA, the new Administrator, and the Space Station Program were under, but now it seemed to some that budget and schedule were of paramount concern. As one employee reflected:

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¶I guess my frustration was … I know the importance of showing that you … manage your budget and thatʼs an important impression to make to Congress so you can continue the future of the agency, but to a lot of people,

¶February 19th just seemed like an arbitrary date …

¶It doesnʼt make sense to me why at all costs we were marching to this date.

¶The importance of this date was stressed from the very top. The Space Shuttle and Space Station Program Managers briefed the new NASA Administrator monthly on the status of their programs, and a significant part of those briefings was the days of margin remaining in the schedule to the launch of Node 2 – still well over a year away. The Node 2 schedule margin typically accounted for more than half of the briefing slides.

¶Figure 6.2-1 is one of the charts presented by the Shuttle Program Manager to the NASA Administrator in December 2002. The chart shows how the days of margin in the existing schedule were being managed to meet the requirement

¶

• SSP Core Complete — 3

• 1 Schedule Margin - Past — 28

¶Margin (in months)

¶-1

¶
• -2 1 — 2

¶12.01 03.02 06.02

¶SSP Core Complete Schedule Threats

¶STS-120/Node 2 launch subject to 45 days of schedule risk

¶• HQ mitigate Range Cutout

¶• HQ and ISS mitigate Soyuz

¶• HQ mitigate Range Cutout

¶• HQ and ISS mitigate Soyuz

¶• HQ and ISS mitigate Soyuz

¶of a Node 2 launch on the prescribed date. The triangles are events that affected the schedule (such as the slip of a Russian Soyuz flight). The squares indicate action taken by management to regain the lost time (such as authorizing work over the 2002 winter holidays).

¶Figure 6.2-2 shows a slide from the International Space Station Program Managerʼs portion of the briefing. It indicates that International Space Station Program management was also taking actions to regain margin. Over the months, the extent of some testing at Kennedy was reduced, the number of tasks done in parallel was increased, and a third shift of workers would be added in 2003 to accomplish the processing. These charts illustrate that both the Space Shuttle and Space Station Programs were being managed to a particular launch date – February 19, 2004. Days of margin in that schedule were one of the principle metrics by which both programs came to be judged.

¶NASA Headquarters stressed the importance of this date in other ways. A screen saver (see Figure 6.2-3) was mailed to managers in NASAʼs human spaceflight program that depicted a clock counting down to February 19, 2004 – U.S. Core Complete.

Late OMM start (Node 2 was on 1 OV-103)

¶18 2 Moved Node2 to OV-105

¶3 Accommodate 4S slip 1 week

¶4 ISS adding wrist joint on UF2

¶
• -9 — 9

5 Moved OV-104 Str. Ins. to 9th flt -21 10

6 Engine Flowliner cracks Reduced Structural Inspection

¶Requirements

8 Accommodate 4S slip 9 O2 flexline leak/ SRMS damage 10 Defer reqmts; apply reserve

¶09.02 12.02 Management action

Schedule impact event Management Options • USA commit holiday/weekend reserves and apply additional resources (i.e., 3rd shift) to hold schedule (Note: 3rd shift not yet included) • HQ mitigate Range Cutout • HQ and ISS mitigate Soyuz conflict threat

¶Figure 6.2-1. This chart was presented by the Space Shuttle Program Manager to the NASA Administrator in December 2002. It illustrates how the schedule was being managed to meet the Node 2 launch date of February 19, 2004.

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¶While employees found this amusing because they saw it as a date that could not be met, it also reinforced the message that NASA Headquarters was focused on and promoting the achievement of that date. This schedule was on the minds of the Shuttle managers in the months leading up to STS-107.

¶The Background: Schedule Complexity and Compression

¶In 2001, the International Space Station Cost and Management Evaluation Task Force report recommended, as a cost-saving measure, a limit of four Shuttle flights to the International Space Station per year. To meet this requirement, managers began adjusting the Shuttle and Station manifests to "get back in the budget box." They rearranged Station assembly sequences, moving some elements forward and taking others out. When all was said and done, the launch of STS-120, which would carry Node 2 to the International Space Station, fell on February 19, 2004.

¶The Core Complete date simply emerged from this planning effort in 2001. By all accounts, it was a realistic and achievable date when first approved. At the time there was more concern that four Shuttle flights a year would limit the

ISS Schedule Reserve 3.0 ISS Core Complete Schedule Margin - Past

2.0 45 days

¶Margin (in months)

¶1.0 22.5 days 22.5 days

¶0 days

¶

• 0.0 — 6

• -1.0 — 3

¶-30 days

¶-2.0

-3.0 6/01 9/01 2/02

¶ISS Core Complete Schedule Threat

¶• O/D KSC date will likely slip another 2 months

• Alenia financial concerns • KSC test problems

¶• Node ships on time but work or paper is not complete 0-1

month impact • Traveled work "as-built" reconciliation • Paper closure

¶Figure 6.2-3. NASA Headquarters distributed to NASA employees this computer screensaver counting down to February 19, 2004.

¶capability to carry supplies to and from the Space Station, to rotate its crew, and to transport remaining Space Station segments and equipment. Still, managers felt it was a reast Schedule margin decreased 0.75

1 month due to KSC Systems Test growth and closeouts growth

1.75 months slip to on dock (O/D) Time 2 at KSC. Alenia build and

Now subcontractor problems Reduced KSC Systems Test 3 Preps/Site Activation and Systems Test scope

¶0 days 0 days

¶3 months slip to O/D at KSC.⁶⁶ Quoted in Jenkins, Space Shuttle, p. 171. Press, 1996). 7 18 Memorandum from J. Fletcher to J. Rose, Special Assistant to the See John M. Logsdon, "Return to Flight: Richard H. Truly and the President, November 22, 1971; Logsdon, John, "The Space Shuttle Recovery from the Challenger Accident," in Pamela E. Mack, editor, Program: A Policy Failure?" Science, May 30, 1986, Volume 232, pp. From Engineering to Big Science: The NACA and NASA Collier Trophy 1099-1105. Research Project Winners, NASA SP-4219 (Washington: GovernmentShow full note 4 Alenia assembly and financial

problems Reduced scope and testing;⁵⁵ Heppenheimer, The Space Shuttle Decision, pp. 278-289, and Roger in 1985 when adjusted for inflation becomes $52.9 million in 1971 A. Pielke, Jr., "The Space Shuttle Program: ʻPerformance vs. Promise,ʼ" dollars or nearly seven times the 1971 estimate. "Pricing Options for the Center for Space and Geosciences Policy, University of Colorado, August Space Shuttle." 31, 1991; Logsdon, "The Space Shuttle Program: A Policy Failure?" pp. 17 See Diane Vaughan, The Challenger Launch Decision: Risky Technology, 1099-1105. Culture, and Deviance at NASA (Chicago: The University of Chicago U.S.C. App § §1 et seq. (1972). Harold W. Gehman to Sean OʼKeefe, February 25, 2003. 238 Report Volume I August 2003Show full note worked KSC tasks in parallel (e.g.: Closeouts & Leak Checks) 7 1.25 months slip to O/D at KSC 6 Alenia work planning inefficiencies -37.5 days Increased the number of KSC

¶5 tasks in parallel, and adjusted

¶7 powered-on testing to 3 7.5 days shifts/day/5days/week

¶4/02 11/02 As of Date Schedule Time

ISS Management Options • Hold ASI to delivery schedule • Management discussions with ASI and ESA • Reduce testing scope • Add Resources/Shifts/Weekends@KSC (Lose contingency on Node)

¶Figure 6.2-2. At the same December 2002 meeting, the International Space Station Program Manager presented this slide, showing the actions being taken to regain margin in the schedule. Note that the yellow triangles reflect zero days remaining margin.

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¶sonable goal and assumed that if circumstances warranted a slip of that date, it would be granted.

¶Shuttle and Station managers worked diligently to meet the schedule. Events gradually ate away at the schedule margin. Unlike the "old days" before the Station, the Station/Shuttle partnership created problems that had a ripple effect on both programsʼ manifests. As one employee described it, "the serial nature" of having to fly Space Station assembly missions in a specific order made staying on schedule more challenging. Before the Space Station, if a Shuttle flight had to slip, it would; other missions that had originally followed it would be launched in the meantime. Missions could be flown in any sequence. Now the manifests were a delicate balancing act. Missions had to be flown in a certain order and were constrained by the availability of the launch site, the Russian Soyuz and Progress schedules, and a myriad of other processes. As a result, employees stated they were now experiencing a new kind of pressure. Any necessary change they made on one mission was now impacting future launch dates. They had a sense of being "under the gun."

¶Shuttle and Station program personnel ended up with manifests that one employee described as "changing, changing, changing" all the time. One of the biggest issues they faced entering 2002 was "up mass," the amount of cargo the Shuttle can carry to the Station. Up mass was not a new problem, but when the Shuttle flight rate was reduced to four per year, up mass became critical. Working groups were actively evaluating options in the summer of 2002 and bartering to get each flight to function as expected.

¶Sometimes the up mass being traded was actual Space Station crew members. A crew rotation planned for STS-118 was moved to a later flight because STS-118 was needed for other cargo. This resulted in an increase of crew duration on the Space Station, which was creeping past the 180-day limit agreed to by the astronaut office, flight surgeons, and Space Station international partners. A space station worker described how this one change created many other problems, and added: "… we had a train wreck coming …" Future on-orbit crew time was being projected at 205 days or longer to maintain the assembly sequence and meet the schedule.

¶By July 2002, the Shuttle and Space Station Programs were facing a schedule with very little margin. Two setbacks occurred when technical problems were found during routine maintenance on Discovery. STS-107 was four weeks away from launch at the time, but the problems grounded the entire Shuttle fleet. The longer the fleet was grounded, the more schedule margin was lost, which further compounded the complexity of the intertwined Shuttle and Station schedules. As one worker described the situation:

¶… a one-week hit on a particular launch can start a steam roll effect including all [the] constraints and by the time you get out of here, that one-week slip has turned into a couple of months.

¶In August 2002, the Shuttle Program realized it would be unable to meet the Space Station schedule with the available Shuttles. Columbia had never been outfitted to make

¶a Space Station flight, so the other three Orbiters flew the Station missions. But Discovery was in its Orbiter Maintenance Down Period, and would not be available for another 17 months. All Space Station flights until then would have to be made by Atlantis and Endeavour. As managers looked ahead to 2003, they saw that after STS-107, these two Orbiters would have to alternate flying five consecutive missions, STS-114 through STS-118. To alleviate this pressure, and regain schedule margin, Shuttle Program managers elected to modify Columbia to enable it to fly Space Station missions. Those modifications were to take place immediately after STS-107 so that Columbia would be ready to fly its first Space Station mission eight months later. This decision put Columbia directly in the path of Core Complete.

¶As the autumn of 2002 began, both the Space Shuttle and Space Station Programs began to use what some employees termed "tricks" to regain schedule margin. Employees expressed concern that their ability to gain schedule margin using existing measures was waning.

¶In September 2002, it was clear to Space Shuttle and Space Station Program managers that they were not going to meet the schedule as it was laid out. The two Programs proposed a new set of launch dates, documented in an e-mail (right) that included moving STS-120, the Node 2 flight, to mid-March 2004. (Note that the first paragraph ends with "… the 10A [U.S. Core Complete, Node 2] launch remains 2/19/04.")

¶These launch date changes made it possible to meet the early part of the schedule, but compressed the late 2003/ early 2004 schedule even further. This did not make sense to many in the program. One described the system as at "an uncomfortable point," noted having to go to great lengths to reduce vehicle-processing time at Kennedy, and added:

¶… I donʼt know what Congress communicated to

¶OʼKeefe. I donʼt really understand the criticality of

¶February 19th, that if we didnʼt make that date, did that mean the end of NASA? I donʼt know … I would like to think that the technical issues and safely resolving the technical issues can take priority over any budget issue or scheduling issue.

¶When the Shuttle fleet was cleared to return to flight, attention turned to STS-112, STS-113, and STS-107, set for October, November, and January. Workers were uncomfortable with the rapid sequence of flights.

¶The thing that was beginning to concern me … is I wasnʼt convinced that people were being given enough time to work the problems correctly.

¶The problems that had grounded the fleet had been handled well, but the program nevertheless lost the rest of its margin. As the pressure to keep to the Node 2 schedule continued, some were concerned that this might influence the future handling of problems. One worker expressed the concern:

¶… and I have to think that subconsciously that even though you donʼt want it to affect decision-making, it probably does.

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From: THOMAS, DAWN A. (JSC-OC) (NASA) Sent: Friday, September 20, 2002 7:10 PM To: 'Flowers, David'; 'Horvath, Greg'; 'O'Fallon, Lee'; 'Van Scyoc, Neal'; 'Gouti, Tom'; 'Hagen, Ray'; 'Kennedy, John'; 'Thornburg, Richard'; 'Gari, Judy'; 'Dodds, Joel'; 'Janes, Lou Ann'; 'Breen, Brian'; 'Deheck-Stokes, Kristina'; 'Narita, Kaneaki (NASDA)'; 'Patrick, Penny O'; 'Michael Rasmussen (E-mail)'; DL FPWG; 'Hughes, Michael G'; 'Bennett, Patty'; 'Masazumi, Miyake'; 'Mayumi Matsuura'; NORIEGA, CARLOS I. (JSC-CB) (NASA); BARCLAY, DINA E. (JSC-DX) (NASA); MEARS, AARON (JSC-XA) (HS); BROWN, WILLIAM C. (JSC-DT) (NASA); DUMESNIL, DEANNA T. (JSC-OC) (USA); MOORE, NATHAN (JSC-REMOTE); MONTALBANO, JOEL R. (JSC-DA8) (NASA); MOORE, PATRICIA (PATTI) (JSC-DA8) (NASA); SANCHEZ, HUMBERTO (JSC-DA8) (NASA) Subject: FPWG status - 9/20/02 OA/MA mgrs mtg results

The ISS and SSP Program Managers have agreed to proceed with the crew rotation change and the following date changes: 12A launch to 5/23/03, 12A.1 launch to 7/24/03, 13A launch to 10/2/03, and 13A.1 launch to NET 11/13/03. Please note that 10A launch remains 2/19/04.

The ISS SSCN that requests evaluation of these changes will be released Monday morning after the NASA/Russian bilateral Requirements and Increment Planning videocon. It will contain the following:

• Increments 8 and 9 redefinition - this includes baseline of ULF2 into the tactical timeframe as the new return flight for Expedition 9
• Crew size changes for 7S, 13A.1, 15A, and 10A
• Shuttle date changes as listed above
• Russian date changes for CY2003 that were removed from SSCN 6872 (11P launch/10P undock and subsequent)
• CY2004 Russian data if available Monday morning
• Duration changes for 12A and 15A
• Docking altitude update for 10A, along with "NET" TBR closure.

The evaluation due date is 10/2/02. Board/meeting dates are as follows: MIOCB status - 10/3/02; comment dispositioning - 10/3/02 FPWG (meeting date/time under review); OA/MA Program Managers status - 10/4/02; SSPCB and JPRCB - 10/8/02; MMIOCB status (under review) and SSCB - 10/10/02.

The 13A.1 date is indicated as "NET" (No Earlier Than) since SSP ability to meet that launch date is under review due to the processing flow requirements.

There is no longer a backup option to move ULF2 to OV-105: due to vehicle processing requirements, there is no launch opportunity on OV-105 past May 2004 until after OMM.

The Program Managers have asked for preparation of a backup plan in case of a schedule slip of ULF2. In order to accomplish this, the projected ISS upmass capability shortfall will be calculated as if ULF2 launch were 10/7/04, and a recommendation made for addressing the resulting shortfall and increment durations. Some methods to be assessed: manifest restructuring, fallback moves of rotation flight launch dates, LON (Launch on Need) flight on 4/29/04.

[ISS=International Space Station, SSP=Space Shuttle Program, NET=no earlier than, SSCN=Space Station Change Notice, CY=Calendar Year, TBR=To Be Revised (or Reviewed), MIOCB=Mission Integration and Operations Control Board, FPWG=Flight Planning Working Group, OA/MA=Space Station Office Symbol/Shuttle Program Office Symbol, SSPCB=Space Station Program Control Board, JPRCB=Space Shuttle/Space Station Joint Program Requirements Control Board, MMIOCB=Multi-Lateral Mission Integration and Operations Control Board, SSCB=Space Station Control Board, ULF2=U.S. Logistics Flight 2, OMM=Orbiter Major Modification, OV-105=Endeavour]

¶This was the environment for October and November of The Operations Tempo Following STS-107 2002. During this time, a bipod foam event occurred on STS- 112. For the first time in the history of the Shuttle Program, After STS-107, the tempo was only going to increase. The the Program Requirements Control Board chose to classify vehicle processing schedules, training schedules, and mission that bipod foam loss as an "action" rather than a more seri- control flight staffing assignments were all overburdened. ous In-Flight Anomaly. At the STS-113 Flight Readiness Review, managers accepted with little question the rationale The vehicle-processing schedule for flights from February that it was safe to fly with the known foam problem. 2003, through February 2004, was optimistic. The schedule could not be met with only two shifts of workers per day. In late 2002, NASA Headquarters approved plans to hire a third shift. There were four Shuttle launches to the Space Station scheduled in the five months from October 2003, through the launch of Node 2 in February 2004. To put this in perspective, the launch rate in 1985, for which NASA was criticized by the Rogers Commission, was nine flights in 12 months – and that was accomplished with four Orbiters and a manifest that was not complicated by Space Station assembly.

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¶Endeavour was the Orbiter on the critical path. Figure 6.2-4 shows the schedule margin for STS-115, STS-117, and STS-120 (Node 2). To preserve the margin going into 2003, the vehicle processing team would be required to work the late 2002-early 2003 winter holidays. The third shift of workers at Kennedy would be available in March 2003, and would buy eight more days of margin for STS-117 and STS-120. The workforce would likely have to work on the 2003 winter holidays to meet the Node 2 date.

¶Figure 6.2-5 shows the margin for each vehicle (Discovery, OV-103, was in extended maintenance). The large boxes indicate the "margin to critical path" (to Node 2 launch date). The three smaller boxes underneath indicate (from

SSP Schedule Reserve Time Now Mar 03 "3rd shift". Adds + 8 day reserve per flow to mitigate "threats"

¶

¶+25

¶+18 STS-115 Flow +17 STS-117 Flow

¶_ Work 2003 Xmas

holidays to preserve 18 day margin Potential 15 day schedule impact for each flow = 45 day total threat (+/- 15 days)

¶5/23/03

¶STS-115

¶12A

¶
• 11 2002 12 1 2 3 4 5 2003 6 7 — 8

SSP Core Complete Schedule Threats STS-120/Node 2 launch subject to 45 days of schedule risk • Space Shuttle technical problems • Station on-orbit technical problems/mission requirements impact • Range launch cutouts • Weather delays • Soyuz and Progress conflicts

¶left to right) vehicle processing margin, holiday margin, and Dryden margin. The vehicle processing margin indicates how many days there are in addition to the days required for that missionʼs vehicle processing. Endeavour (OV-105) had zero days of margin for the processing flows for STS-115, STS-117, and STS-120. The holiday margin is the number of days that could be gained by working holidays. The Dryden margin is the six days that are always reserved to accommodate an Orbiter landing at Edwards Air Force Base in California and having to be ferried to Kennedy. If the Orbiter landed at Kennedy, those six days would automatically be regained. Note that the Dryden margin had already been surrendered in the STS-114 and STS-115 schedules. If bad weather at Kennedy forced those two flights to land at Edwards, the schedule would be directly affected.

¶The clear message in these charts is that any technical problem that resulted in a slip to one launch would now directly affect the Node 2 launch.

¶The lack of housing for the Orbiters was becoming a factor as well. Prior to launch, an Orbiter can be placed in an Orbiter Processing Facility, the Vehicle Assembly Building, or on one of the two Shuttle launch pads. Maintenance and

+27 Work 2003 Xmas holidays

¶+19 STS-120 Flow to hold schedule, if req'd

2/19/04 10/02/03 STS-120 STS-117 Node 2 13A Core Complete

¶
• 9 10 11 12 1 2 2004 3 4 — 5

Management Options • USA commit holiday/weekend reserves and apply additional resources to hold schedule 1. Flex 3rd shift avail––Mar 03 2. LCC 3rd shift avail––Apr 03 • HQ mitigate Range Cutout • HQ and ISS mitigate Soyuz conflict threat

¶Figure 6.2-4. By late 2002, the vehicle processing team at the Kennedy Space Center would be required to work through the winter holidays, and a third shift was being hired in order to meet the February 19, 2004, schedule for U.S. Core Complete.

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¶refurbishment is performed in the three Orbiter Processing Facilities at Kennedy. One was occupied by Discovery during its scheduled extended maintenance. This left two to serve the other three Orbiters over the next several months. The 2003 schedule indicated plans to move Columbia (after its return from STS-107) from an Orbiter Processing Facility to the Vehicle Assembly Building and back several times in order to make room for Atlantis (OV-104) and Endeavour (OV-105) and prepare them for missions. Moving an Orbiter is tedious, time-consuming, carefully orchestrated work. Each move introduces an opportunity for problems. Those 2003 moves were often slated to occur without a day of margin between them – another indication of the additional risks that managers were willing to incur to meet the schedule.

¶The effect of the compressed schedule was also evident in the Mission Operations Directorate. The plans for flight controller staffing of Mission Control showed that of the seven flight controllers who lacked current certifications during STS-107 (see Chapter 4), five were scheduled to work the next mission, and three were scheduled to work the next three missions (STS-114, -115, and -116). These controllers would have been constantly either supporting missions or supporting mission training, and were unlikely to have

Margin to Critical Path SSP Schedule Reserve Processing Holiday Dryden Days of Margin Margin Reserve Reserve

Constraints Range Launch Cutout Cutout

¶
• OV-102 — 16

¶3/1/03

¶
• OV-104 16 16 — 16

¶8 9 26 3

STS-114 ULF1 12A.1 5/23/03 Critical path

¶

• OV-105 0 — 0

• 18 — 9

STS-115 12/02 12A 11/02 02/03 05/03

SSP Core Complete Schedule Threats STS-120/Node 2 launch subject to 45 days of schedule risk • Space Shuttle technical problems • Station on-orbit technical problems/mission requirements impact • Range launch cutouts • Weather delays • Soyuz and Progress conflicts

the time to complete the recertification requirements. With the pressure of the schedule, the things perceived to be less important, like recertification (which was not done before STS-107), would likely continue to be deferred. As a result of the schedule pressure, managers either were willing to delay recertification or were too busy to notice that deadlines for recertification had passed.

¶Columbia: Caught in the Middle

STS-112 flew in October 2002. At 33 seconds into the flight, a piece of the bipod foam from the External Tank struck one of the Solid Rocket Boosters. As described in Section 6.1, the STS-112 foam strike was discussed at the Program Requirements Control Board following the flight. Although the initial recommendation was to treat the foam loss as an In-Flight Anomaly, the Shuttle Program instead assigned it as an action, with a due date after the next launch. (This was the first instance of bipod foam loss that was not designated an In-Flight Anomaly.) The action was noted at the STS-113 Flight Readiness Review. Those Flight Readiness Review charts (see Section 6.1) provided a flawed flight rationale by concluding that the foam loss was "not a safety-of-flight" issue.

¶Launch Launch Launch Launch Cutout Cutout Cutout Cutout

¶11/13/03

¶
• U/R 2 — 6

¶STS-118

¶7/24/03 13A.1 1/15/04

¶

• 16 — 17

• 26 3 6 U/R 10 — 6

¶STS-116 STS-119 12A.1 15A

¶10/2/03 2/19/04

¶
• 0 — 0

¶17 2 6 19 10 6

STS-117 STS-120 13A Node 2 08/03 11/03 02/04

Management Options • USA commit holiday/weekend reserves and apply additional resources (i.e., 3rd shift) to hold schedule (Note: 3rd shift not yet included) • HQ mitigate Range Cutout • HQ and ISS mitigate Soyuz conflict threat

¶Figure 6.2-5. This slide shows the margin for each Orbiter. The large boxes show the number of days margin to the Node 2 launch date, while the three smaller boxes indicate vehicle processing margin, holiday margin, and the margin if a Dryden landing was not required.

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¶Interestingly, during Columbiaʼs mission, the Chair of the those same people (and this same culture) have difficulty Mission Management Team, Linda Ham, would characterize admitting that something "canʼt" or "shouldnʼt" be done, that reasoning as "lousy" – though neither she nor Shuttle that the margin has been cut too much, or that resources are Program Manager Ron Dittemore, who were both present at being stretched too thin. No one at NASA wants to be the the meeting, questioned it at the time. The pressing need to one to stand up and say, "We canʼt make that date." launch STS-113 to retrieve the International Space Station Expedition 5 crew before they surpassed the 180-day limit STS-107 was launched on January 16, 2003. Bipod foam and to continue the countdown to Node 2 were surely in the separated from the External Tank and struck Columbiaʼs left back of managersʼ minds during these reviews. wing 81.9 seconds after liftoff. As the mission proceeded over the next 16 days, critical decisions about that event By December 2002, every bit of padding in the schedule would be made. had disappeared. Another chart from the Shuttle and Station Program Managersʼ briefing to the NASA Administrator The STS-107 Mission Management Team Chair, Linda summarizes the schedule dilemma (see Figure 6.2-6). Ham, had been present at the Program Requirements Control

¶Board discussing the STS-112 foam loss and the STS-113 Even with work scheduled on holidays, a third shift of work- Flight Readiness Review. So had many of the other Shuttle ers being hired and trained, future crew rotations drifting Program managers who had roles in STS-107. Ham was also beyond 180 days, and some tests previously deemed "re- the Launch Integration Manager for the next mission, STS- quirements" being skipped or deferred, Program managers 114. In that capacity, she would chair many of the meetings estimated that Node 2 launch would be one to two months leading up to the launch of that flight, and many of those late. They were slowly accepting additional risk in trying to individuals would have to confront Columbiaʼs foam strike meet a schedule that probably could not be met. and its possible impact on the launch of STS-114. Would the

¶Columbia foam strike be classified as an In-Flight Anomaly? Interviews with workers provided insight into how this situ- Would the fact that foam had detached from the bipod ramp ation occurred. They noted that people who work at NASA on two out of the last three flights have made this problem a have the legendary can-do attitude, which contributes to the constraint to flight that would need to be solved before the agencyʼs successes. But it can also cause problems. When next launch? Could the Program develop a solid rationale workers are asked to find days of margin, they work furious- to fly STS-114, or would additional analysis be required to ly to do so and are praised for each extra day they find. But clear the flight for launch?

¶Summary

• Critical Path to U.S. Core Complete driven by Shuttle Launch Program Station assessment: up to 14 days late Program Shuttle assessment: up to 45 days late
• Program proactively managing schedule threats
• Most probable launch date is March 19-April 19 Program Target Remains 2/19/04

¶Figure 6.2-6. By December 2002, every bit of padding in the schedule had disappeared. Another chart from the Shuttle and Station Program Managersʼ briefing to the NASA Administrator summarizes the schedule dilemma.

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From: HAM, LINDA J. (JSC-MA2) (NASA) Sent: Wednesday, January 22, 2003 10:16 AM To: DITTEMORE, RONALD D. (JSC-MA) (NASA) Subject: RE: ET Briefing - STS-112 Foam Loss

Yes, I remember....It was not good. I told Jerry to address it at the ORR next Tuesday (even though he won't have any more data and it really doesn't impact Orbiter roll to the VAB). I just want him to be thinking hard about this now, not wait until IFA review to get a formal action.

¶[ORR=Orbiter Rollout Review, VAB=Vehicle Assembly Building, IFA=In-Flight Anomaly]

¶In fact, most of Linda Hamʼs inquiries about the foam strike were not to determine what action to take during Columbiaʼs mission, but to understand the implications for STS-114. During a Mission Management Team meeting on January 21, she asked about the rationale put forward at the STS-113 Flight Readiness Review, which she had attended. Later that morning she reviewed the charts presented at that Flight Readiness Review. Her assessment, which she e-mailed to Shuttle Program Manager Ron Dittemore on F6.2-3 January 21, was "Rationale was lousy then and still is …" (See Section 6.3 for the e-mail.)

¶One of Hamʼs STS-114 duties was to chair a review to determine if the missionʼs Orbiter, Atlantis, should be rolled from the Orbiter Processing Facility to the Vehicle Assembly Building, per its pre-launch schedule. In the above e-mail to Ron Dittemore, Ham indicates a desire to have the same individual responsible for the "lousy" STS-113 flight rationale start working the foam shedding issue – and presumably present a new flight rationale – very soon. F6.2-4

¶As STS-107 prepared for re-entry, Shuttle Program managers prepared for STS-114 flight rationale by arranging to have post-flight photographs taken of Columbiaʼs left wing rushed to Johnson Space Center for analysis. F6.2-5

¶As will become clear in the next section, most of the Shuttle Programʼs concern about Columbiaʼs foam strike were not about the threat it might pose to the vehicle in orbit, but about the threat it might pose to the schedule. F6.2-6

¶Conclusion

¶The agencyʼs commitment to hold firm to a February 19, 2004, launch date for Node 2 influenced many of decisions in the months leading up to the launch of STS-107, and may well have subtly influenced the way managers handled the STS-112 foam strike and Columbiaʼs as well.

¶When a program agrees to spend less money or accelerate a schedule beyond what the engineers and program man- R6.2-1 agers think is reasonable, a small amount of overall risk is added. These little pieces of risk add up until managers are no longer aware of the total program risk, and are, in fact, gambling. Little by little, NASA was accepting more and more risk in order to stay on schedule.

¶Findings

¶F6.2-1 NASA Headquartersʼ focus was on the Node 2 launch date, February 19, 2004. F6.2-2 The intertwined nature of the Space Shuttle and

Space Station programs significantly increased the complexity of the schedule and made meeting the schedule far more challenging.

¶F6.2-3 The capabilities of the system were being

stretched to the limit to support the schedule. Projections into 2003 showed stress on vehicle processing at the Kennedy Space Center, on flight controller training at Johnson Space Center, and on Space Station crew rotation schedules. Effects of this stress included neglecting flight controller recertification requirements, extending crew rotation schedules, and adding incremental risk by scheduling additional Orbiter movements at Kennedy.

¶F6.2-4 The four flights scheduled in the five months

from October 2003, to February 2004, would have required a processing effort comparable to the effort immediately before the Challenger accident.

¶F6.2-5 There was no schedule margin to accommodate

unforeseen problems. When flights come in rapid succession, there is no assurance that anomalies on one flight will be identified and appropriately addressed before the next flight.

¶F6.2-6 The environment of the countdown to Node 2 and

the importance of maintaining the schedule may have begun to influence managersʼ decisions, including those made about the STS-112 foam strike.

¶F6.2-7 During STS-107, Shuttle Program managers

were concerned with the foam strikeʼs possible effect on the launch schedule.

¶Recommendation:

¶R6.2-1 Adopt and maintain a Shuttle flight schedule that

is consistent with available resources. Although schedule deadlines are an important management tool, those deadlines must be regularly evaluated to ensure that any additional risk incurred to meet the schedule is recognized, understood, and acceptable.

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¶6.3 DECISION-MAKING DURING THE FLIGHT OF STS-107

¶Initial Foam Strike Identification

¶As soon as Columbia reached orbit on the morning of January 16, 2003, NASAʼs Intercenter Photo Working Group began reviewing liftoff imagery by video and film cameras on the launch pad and at other sites at and nearby the Kennedy Space Center. The debris strike was not seen during the first review of video imagery by tracking cameras, but it was noticed at 9:30 a.m. EST the next day, Flight Day Two, by Intercenter Photo Working Group engineers at Marshall Space Flight Center. Within an hour, Intercenter Photo Working Group personnel at Kennedy also identified the strike on higher-resolution film images that had just been developed.

¶The images revealed that a large piece of debris from the left bipod area of the External Tank had struck the Orbiterʼs left wing. Because the resulting shower of post-impact fragments could not be seen passing over the top of the wing, analysts concluded that the debris had apparently impacted the left wing below the leading edge. Intercenter Photo Working Group members were concerned about the size of the object and the apparent momentum of the strike. In searching for better views, Intercenter Photo Working Group members realized that none of the other cameras provided a higher-quality view of the impact and the potential damage to the Orbiter.

¶Of the dozen ground-based camera sites used to obtain images of the ascent for engineering analyses, each of which has film and video cameras, five are designed to track the Shuttle from liftoff until it is out of view. Due to expected angle of view and atmospheric limitations, two sites did not capture the debris event. Of the remaining three sites positioned to "see" at least a portion of the event, none provided a clear view of the actual debris impact to the wing. The first site lost track of Columbia on ascent, the second site was out of focus – because of an improperly maintained lens – and the third site captured only a view of the upper side of Columbiaʼs left wing. The Board notes that camera problems also hindered the Challenger investigation. Over the years, it appears that due to budget and camera-team staff cuts, NASAʼs ability to track ascending Shuttles has atrophied – a development that reflects NASAʼs disregard of the developmental nature of the Shuttleʼs technology. (See recommendation R3.4-1.)

¶Because they had no sufficiently resolved pictures with which to determine potential damage, and having never seen such a large piece of debris strike the Orbiter so late in ascent, Intercenter Photo Working Group members decided to ask for ground-based imagery of Columbia.