From: NASA HQ
Posted: Monday, March 13, 2000
The full report is online as a Adobe Acrobat file (473K)
The Mars Climate Orbiter mission was conducted under NASA's "Faster, Better, Cheaper" philosophy, developed in recent years to enhance innovation, productivity and cost-effectiveness of America's space program. The "Faster, Better, Cheaper" paradigm has successfully challenged project teams to infuse new technologies and processes that allow NASA to do more with less. The success of "Faster, Better, Cheaper" is tempered by the fact that some projects and programs have put too much emphasis on cost and schedule reduction (the "Faster" and "Cheaper" elements of the paradigm). At the same time, they have failed to instill sufficient rigor in risk management throughout the mission lifecycle. These actions have increased risk to an unacceptable level on these projects.
The Mishap Investigation Board conducted a series of meetings over several months with the Jet Propulsion Laboratory and Lockheed Martin Astronautics to better understand the issues that led to the failure of the Mars Climate Orbiter. The Board found that the Mars Surveyor Program, agreed to significant cuts in monetary and personnel resources available to support the Mars Climate Orbiter mission, as compared to previous projects. More importantly, the project failed to introduce sufficient discipline in the processes used to develop, validate and operate the spacecraft; nor did it adequately instill a mission success culture that would shore up the risk introduced by these cuts. These process and project leadership deficiencies introduced sufficient risk to compromise mission success to the point of mission failure.
It should be noted that despite these deficiencies, the spacecraft operated as commanded and the mission was categorized as extremely successful until right before Mars orbit insertion. This is a testament to the hard work and dedication of the entire Mars Climate Orbiter team. The Board recognizes that mistakes and deficiencies occur on all spacecraft projects. It is imperative that all spacecraft projects have sufficient processes in place to catch mistakes before they become detrimental to mission success. Unfortunately for the Mars Climate Orbiter, the processes in place did not catch the root cause and contributing navigational factors that ultimately led to mission failure. Building upon the lessons learned from the Mars Climate Orbiter and a review of seven other failure investigation board results, this second report puts forth a new vision for NASA programs and projects - one that will improve mission success within the context of the "Faster, Better, Cheaper" paradigm. This vision, Mission Success First, entails a new NASA culture and new methods of managing projects. To proceed with this culture shift, mission success must become the highest priority at all levels of the program/project and the institutional organization. All individuals should feel ownership and accountability, not only for their own work, but for the success of the entire mission. Examining the current state of NASA's program and project management environment, the Board found that a significant infrastructure of processes and requirements already is in place to enable robust program and project management. However, these processes are not being adequately implemented within the context of "Faster, Better, Cheaper." To move toward the ideal vision of Mission Success First, the Board makes a series of observations and recommendations that are grouped into four categories, providing a guide by which to measure progress.
The Board recognizes that one of the most important assets to a program and project is its people. Success means starting with top-notch people and creating the right cultural environment in which they can excel. Thus, Mission Success First demands that every individual on the program/project team continuously employ solid engineering and scientific discipline, take personal ownership for their product development efforts and continuously manage risk in order to design, develop and deliver robust systems capable of supporting all mission scenarios.
Teamwork is critical for mission success. Good communication between all project elements - government and contractor, engineer and scientist - is essential to maintaining an effective team. To ensure good teamwork, the project manager must guarantee an appropriate level of staffing, and all roles and responsibilities must be clearly defined.
Even the best people with the best motivation and teamwork need a set of guidelines to ensure mission success. In most cases NASA has very good processes in place, but there are a few areas for improvement.
A concise set of mission success criteria should be developed and frozen early in the project life cycle.
During the mission formulation process, the program office and the project should perform the system trades necessary to scope out the expected costs for mission success. This should be accomplished independently of any predefined dollar cap. If necessary, consider mission scope changes to drive the costs to a level that the program can afford. Scope should never be decreased below a minimum threshold for science and for technical achievement as defined by the mission success criteria. Both the project and the program should hold adequate contingency reserves, to ensure that mission success is achievable. Projects and programs that wind up with inadequate funding should obtain more funds or consider cancellation before proceeding with inadequate funds.
Close attention should be paid from project outset to the plan for transition between development and operations. Adequate systems engineering staffing, particularly a mission systems engineer, should be in place to provide a bridge during the transition between development and operations, and also to support risk management trade studies. Greater attention needs to be paid to risk identification and management. Risk management should be employed throughout the life cycle of the project, much the way cost, schedule and content are managed. Risk, therefore, becomes the "fourth dimension" of project management - treated equally as important as cost and schedule.
Project managers should copy the checklist located in the back of this report, putting it to constant use and adding to it in order to benchmark the performance of their project team. Moreover, this checklist should be distributed to all members of the project team as a 360-degree benchmark tool, to identify and reduce potential risk areas.
Most mission failures and serious errors can be traced to a breakdown in existing communication channels, or failure to follow existing processes - in other words, a failure in execution. To successfully shift to the Mission Success First culture, it is necessary for the institutional line management to become more engaged in the execution of a project. As such, line managers at the field centers need to be held accountable for the success of all missions at their centers.
Let us be clear that this role of institutional line management accountability should not be construed as a return to the old management formula, wherein NASA civil servants provided oversight for every task performed by the contractor or team. Instead, we recommend that NASA conduct more rigorous, in-depth reviews of the contractor's and the team's work - something that was lacking on the Mars Climate Orbiter. To accomplish this, line management should be held accountable for asking the right questions at meetings and reviews, and getting the right people to those reviews to uncover mission-critical issues and concerns early in the program. Institutional management also must be accountable for ensuring that concerns raised in their area of responsibility are pursued, adequately addressed and closed out.
Line organizations at the field centers also must be responsible for providing robust mechanisms for training, mentoring, coaching and overseeing their employees, project managers and other project team leaders. An aggressive mentoring and certification program should be employed as the first step toward nurturing competent project managers, systems engineers and mission assurance engineers for future programs. Line organizations, in conjunction with the projects, also must instill a culture that encourages all internal and external team members to forcefully and vigorously elevate concerns as far as necessary to get attention within the organization. Only then will Mission Success First become a reality.
Technological innovation is a key aspect in making the "Faster, Better, Cheaper" approach a reality. Through such innovation, smaller, lighter, cheaper, and better-performing systems can be developed. In addition, innovative processes enable quicker development cycles. To enable this vision, NASA requires adequately funded technology development, specifically aimed at Agency needs. Programs and projects must conduct long-range planning for and champion technology infusions resulting in delivery of low-risk products for project incorporation.
Mechanisms which minimize technology infusion risk, such as the New Millennium Program, should be employed to flight-validate high risk technologies prior to their use on science missions.
Agenda for the Future
The Mars Climate Orbiter Mishap Investigation Board perceives its recommendations as the first step in an agenda that will be revisited and adjusted on an ongoing basis. The aim is to make Mission Success First a way of life - a concern and responsibility for everyone involved in NASA programs.
The recommendations of this report must trigger the first wave of changes in processes and work habits that will make Mission Success First a reality. To implement this agenda with a sense of urgency and propagate it throughout the Agency, NASA Headquarters and the NASA centers must address the recommendations presented in this report. NASA must further assign responsibility to an organization (such as the Office of the Chief Engineer) for including the recommendations in Agency policy and in training courses for program and project management.
These actions will ensure that Mission Success First serves as a beacon to guide NASA as the future unfolds.
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