9.2 MID-TERM: CONTINUING TO FLY

¶It is the view of the Board that the present Shuttle is not inherently unsafe. However, the observations and recommendations in this report are needed to make the vehicle safe enough to operate in the coming years. In order to continue operating the Shuttle for another decade or even more, which the Human Space Flight Program may find necessary, these significant measures must be taken:

Implement all the recommendations listed in Part One of this report that were not already accomplished as part of the return-to-flight reforms.
Institute all the organizational and cultural changes called for in Part Two of this report.
Undertake complete recertification of the Shuttle, as detailed in the discussion and recommendation below.

¶The urgency of these recommendations derives, at least in part, from the likely pattern of what is to come. In the near term, the recent memory of the Columbia accident will mo- tivate the entire NASA organization to scrupulous attention to detail and vigorous efforts to resolve elusive technical problems. That energy will inevitably dissipate over time. This decline in vigilance is a characteristic of many large organizations, and it has been demonstrated in NASAʼs own history. As reported in Part Two of this report, the Human Space Flight Program has at times compromised safety because of its organizational problems and cultural traits. That is the reason, in order to prevent the return of bad habits over time, that the Board makes the recommendations in Part Two calling for changes in the organization and culture of the Human Space Flight Program. These changes will take more time and effort than would be reasonable to expect prior to return to flight.

¶Through its recommendations in Part Two, the Board has urged that NASAʼs Human Space Flight Program adopt the characteristics observed in high-reliability organizations. One is separating technical authority from the functions of managing schedules and cost. Another is an independent Safety and Mission Assurance organization. The third is the capability for effective systems integration. Perhaps even more challenging than these organizational changes are the cultural changes required. Within NASA, the cultural im- pediments to safe and effective Shuttle operations are real and substantial, as documented extensively in this report. The Boardʼs view is that cultural problems are unlikely to be corrected without top-level leadership. Such leadership will have to rid the system of practices and patterns that have been validated simply because they have been around so long. Examples include: the tendency to keep knowledge of problems contained within a Center or program; making technical decisions without in-depth, peer-reviewed technical analysis; and an unofficial hierarchy or caste system created by placing excessive power in one office. Such factors interfere with open communication, impede the sharing of lessons learned, cause duplication and unnecessary expen- diture of resources, prompt resistance to external advice, and create a burden for managers, among other undesirable outcomes. Collectively, these undesirable characteristics found in Chapter 11. threaten safety.

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¶Unlike return-to-flight recommendations, the Boardʼs management and cultural recommendations will take longer to implement, and the responses must be fine-tuned and adjusted during implementation. The question of how to follow up on NASAʼs implementation of these more subtle, but equally important recommendations remains unanswered. The Board is aware that response to these recommenda- R9.2-1 tions will be difficult to initiate, and they will encounter some degree of institutional resistance. Nevertheless, in the Boardʼs view, they are so critical to safer operation of the Shuttle fleet that they must be carried out completely. Since NASA is an independent agency answerable only to the White House and Congress, the ultimate responsibility for enforcement of the recommended corrective actions must reside with those governmental authorities.

¶Recertification

¶Recertification is a process to ensure flight safety when a vehicleʼs actual utilization exceeds its original design life; such a baseline examination is essential to certify that vehicle for continued use, in the case of the Shuttle to 2020 and possibly beyond. This report addresses recertification as a mid-term issue.

¶Measured by their 20 or more missions per Orbiter, the Shuttle fleet is young, but by chronological age – 10 to 20 years each – it is old. The Boardʼs discovery of mass loss in RCC panels, the deferral of investigation into signs of metal corrosion, and the deferral of upgrades all strongly suggest that a policy is needed requiring a complete recertification of the Space Shuttle. This recertification must be rigorous and comprehensive at every level (i.e., material, component, subsystem, and system); the higher the level, the more critical the integration of lower-level components. A post- Challenger, 10-year review was conducted, but it lacked this kind of rigor, comprehensiveness and, most importantly, integration at the subsystem and system levels.

¶Aviation industry standards offer ample measurable criteria for gauging specific aging characteristics, such as stress and corrosion. The Shuttle Program, by contrast, lacks a closed-loop feedback system and consequently does not take full advantage of all available data to adjust its certification process and maintenance practices. Data sources can include experience with material and component failures, non-con- formances (deviations from original specifications) discovered during Orbiter Maintenance Down Periods, Analytical Condition Inspections, and Aging Aircraft studies. Several of the recommendations in this report constitute the basis for a recertification program (such as the call for nondestructive evaluation of RCC components). Chapters 3 and 4 cite instances of waivers and certification of components for flight based on analysis rather than testing. The recertification program should correct all those deficiencies.

¶Finally, recertification is but one aspect of a Service Life Extension Program that is essential if the Shuttle is to continue operating for another 10 to 20 years. While NASA has such a program, it is in its infancy and needs to be pursued with vigor. The Service Life Extension Program goes beyond the Shuttle itself and addresses critical associated components

¶in equipment, infrastructure, and other areas. Aspects of the program are addressed in Appendix D.15.

¶The Board makes the following recommendation regarding recertification:

¶R9.2-1 Prior to operating the Shuttle beyond 2010,

develop and conduct a vehicle recertification at the material, component, subsystem, and system levels. Recertification requirements should be included in the Service Life Extension Program.