PAST REPORTS REVIEWED

¶During the course of the investigation, more than 50 past reports regarding NASA and the Space Shuttle Program were reviewed. The principal purpose of these reviews was to note what factors that reports examined, what findings were made, and what response, if any, NASA may have made to the findings. Board members then used these findings and responses as a benchmark during their investigation to compare to NASAʼs current programs. In addition to an extensive 300-page examination of every Aerospace Safety Advisory Panel report (see Appendix D.18), the reports listed on the accompanying chart were examined for specific factors related to the investigation. A complete listing of those past reportsʼ findings, plus the full text of the reports, is contained in Appendix D.18.

¶Report Reviewed Topic Examined

¶Risk

Infrastructure Maintenance Communica- Quality Safety Workforce Contracts Security tions Management Issues Assurance Programs

¶Rogers Commission Report – 1986 • • • • • • •

¶STS-29R Prelaunch Assessment – 1989 •

¶"Augustine Report" – 1990 • • • • •

¶Paté-Cornell Report – 1990 • •

¶"Aldridge Report" – 1992 •

¶GAO: NASA Infrastructure – 1996 • •

¶GAO: NASA Workforce Reductions – 1996 • • Super Light Weight Tank Independent

¶• • Assessment – 1997 Process Readiness Review – 1998 • • •

¶S&MA Ground Operations Report – 1998 • GAO: NASA Management Challenges

¶• • • – 1999 Independent Assessment JS-9047 – 1999 •

¶Independent Assessment JS-9059 – 1999 •

¶Independent Assessment JS-9078 – 1999 • •

¶Independent Assessment JS-9083 – 1999 •

¶S&MA Ground Operations Report – 1999 • • Space Shuttle Independent Assessment Team

¶• • • • • – 1999 Space Shuttle Ground Operations Report

¶• – 1999 Space Shuttle Program (SSP) Annual Report

¶• – 1999

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Risk Infrastructure

¶tions

¶GAO: Human Capital & Safety – 2000 Independent Assessment JS-0032 – 2000 Independent Assessment JS-0034 – 2000 Independent Assessment JS-0045 – 2000 IG Audit Report 00-039 – 2000 NASA Independent Assessment Team – 2000 • Space Shuttle Program Annual Report – 2000 • ASAP Report – 2001 • GAO: NASA Critical Areas – 2001 GAO: Space Shuttle Safety – 2001 Independent Assessment JS-1014 – 2001 • Independent Assessment JS-1024 – 2001 • Independent Assessment KS-0003 – 2001 • Independent Assessment KS-1001 – 2001 Workforce Survey-KSC – 2001 Space Shuttle Program Annual Report – 2001 • SSP Processing Independent Assessment – 2001 ASAP Report – 2002 • GAO: Lessons Learned Process – 2002 Independent Assessment KS-1002 – 2002 Selected NASA Lessons Learned – 1992-2002 • NASA/Navy Benchmarking Exchange – 2002 • Space Shuttle Program Annual Report – 2002 • ASAP Leading Indicators -- 2003 • NASA Quality Management System – 2003

¶Maintenance munica- Quality Safety Workforce

¶Contracts Security tions Management Issues

¶Assurance Programs

• •

¶• • • • •

• • • • • • • • • • •

¶• • • • • • • • • •

• • • • •

¶• •

• • • • • • • • •

¶•

¶• • • • • • • • • • • •

¶• • • • • •

¶• QAS Tiger Team Report – 2003 • Shuttle Business Environment – 2003 •

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Fiscal Year Upgrades 1994 $454.5

1995 $247.2 1996 $224.5

1997 $215.9 1998 $206.7 1999 $175.2

2000 $239.1 2001 $289.3 2002 $379.5

¶2003 $347.5

¶Figure 5.5-3. Shuttle Upgrade Budgets (in millions of dollars). (Source: NASA)

¶In 1995, for instance, the Kraft Report embraced the principle that NASA should "freeze the design" of the Shuttle and defer upgrades due to the vehicleʼs "mature" status and the need for NASA to "concentrate scarce resources on developing potential replacements for the Shuttle."58 NASA subsequently halted a number of planned upgrades, only to reverse course a year later to "take advantage of technologies to improve Shuttle safety and the need for a robust Space Shuttle to assemble the ISS."59

¶In a June 1999 letter to the White House, NASA Administrator Daniel Goldin declared that the nation faced a "Space Launch Crisis." He reported on a NASA review of Shuttle safety that indicated the budget for Shuttle upgrades in Fiscal year 2000 was "inadequate to accommodate upgrades necessary to yield significant safety improvements."60 After two "close calls" during STS-93 in July 1999 Goldin also chartered a Shuttle Independent Assessment Team (SIAT) chaired by Harry McDonald, Director of NASA Ames Research Center. Among the teamʼs findings, reported in March 2000:61

"Over the course of the Shuttle Program … processes, procedures and training have continuously been improved and implemented to make the system safer. The SIAT has a major concern … that this critical feature of the Shuttle Program is being eroded." The major factor leading to this concern "is the reduction in allocated resources and appropriate staff … There are important technical areas that are ʻone-deep.ʼ " Also, "the SIAT feels strongly that workforce augmentation must be realized principally with NASA personnel rather than with contractor personnel."
The SIAT was concerned with "success-engendered safety optimism … The SSP must rigorously guard against the tendency to accept risk solely because of prior success."
"The SIAT was very concerned with what it perceived as Risk Management process erosion created by the desire to reduce costs … The SIAT feels strongly that NASA Safety and Mission Assurance should be restored to its previous role of an independent oversight body, and not be simply a ʻsafety auditor.ʼ "
"The size and complexity of the Shuttle system and of

¶NASA/contractor relationships place extreme importance on understanding, communication, and information handling … Communication of problems and concerns upward to the SSP from the ʻfloorʼ also appeared to leave room for improvement."62

¶The Shuttle Independent Assessment Team report also stated that the Shuttle "clearly cannot be thought of as ʻoperationalʼ in the usual sense. Extensive maintenance, major amounts of ʻtouch laborʼ and a high degree of skill and expertise will always be required." However, "the workforce has received a conflicting message due to the emphasis on achieving cost and staff reductions, and the pressures placed on increasing scheduled flights as a result of the Space Station."63

¶Responding to NASAʼs concern that the Shuttle required safety-related upgrades, the Presidentʼs proposed NASA budget for Fiscal Year 2001 proposed a "safety upgrades initiative." That initiative had a short life span. In its Fiscal Year 2002 budget request, NASA proposed to spend $1.836 billion on Shuttle upgrades over five years. A year later, the Fiscal Year 2003 request contained a plan to spend $1.220 billion – a 34 percent reduction. The reductions were primarily a response to rising Shuttle operating costs and the need to stay within a fixed Shuttle budget. Cost growth in Shuttle operations forced NASA to "use funds intended for Space Shuttle safety upgrades to address operational, sup- portability, obsolescence, and infrastructure needs." 64

¶At its March 2001 meeting, NASAʼs Space Flight Advisory Committee advised that "the Space Shuttle Program must make larger, more substantial safety upgrades than currently planned … a budget on the order of three times the budget currently allotted for improving the Shuttle systems" was needed.65 Later that year, five Senators complained that "the Shuttle program is being penalized, despite its outstanding performance, in order to conform to a budget strategy that is dangerously inadequate to ensure safety in Americaʼs human space flight program."66 (See Chapter 7 for additional discussion of Shuttle safety upgrades.)

¶Deteriorating Shuttle Infrastructure

¶The same ambiguity about investing in Shuttle upgrades has also affected the maintenance of Shuttle Program ground infrastructure, much of which dates to Project Apollo and 1970s Shuttle Program construction. Figure 5.5-4 depicts the age of the Shuttleʼs infrastructure as of 2000. Most ground infrastructure was not built for such a protracted lifespan. Maintaining infrastructure has been particularly difficult at Kennedy Space Center, where it is constantly exposed to a salt water environment.

¶Board investigators have identified deteriorating infrastructure associated with the launch pads, Vehicle Assembly Building, and the crawler transporter. Figures 5.5-5 and 5.5-6 depict some of this deterioration. For example, NASA has installed nets, and even an entire sub-roof, inside the Vehicle Assembly Building to prevent concrete from the buildingʼs ceiling from hitting the Orbiter and Shuttle stack. In addition, the corrosion-control challenge results in zinc primer

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