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NASA's Implementation Plan for Return to Flight and Beyond: Summary

Status Report From: NASA HQ
Posted: Monday, September 8, 2003

image Overview

The Columbia Accident Investigation Board (CAIB) report has provided NASA with the roadmap for moving forward with our return to flight efforts. The CAIB, through its diligent work, has determined the causes of the accident and provided a set of comprehensive recommendations to improve the safety of the Space Shuttle Program. NASA accepts the findings of the CAIB, we will comply with the Board's recommendations, and we embrace the report and all that is included in it. This implementation plan outlines the path that NASA will take to respond to the CAIB recommendations and safely return to flight.

At the same time that the CAIB was conducting its assessment, NASA began pursuing an intensive, Agencywide effort to further improve our human space flight programs. We are taking a fresh look at all aspects of the Space Shuttle Program, from technical requirements to management processes, and have developed a set of internally generated actions that complement the CAIB recommendations.


Summary (PDF; 367 Kb)
Full Report (PDF; 15 Mb)

NASA will also have the benefit of the wisdom and guidance of an independent, advisory Return to Flight Task Group, led by two veteran astronauts, Apollo commander Thomas Stafford and Space Shuttle commander Richard Covey. Members of this Task Group were chosen from among leading industry, academia, and government experts. Their expertise includes knowledge of fields relevant to safety and space flight, as well as experience as leaders and managers of complex systems. The diverse membership of the Task Group will carefully evaluate and publicly report on the progress of our response to implement the CAIB's recommendations.

The space program belongs to the nation as a whole; we are committed to sharing openly our work to reform our culture and processes. As a result, this first installment of the implementation plan is a snapshot of our early efforts and will continue to evolve as our understanding of the action needed to address each issue matures. This implementation plan integrates both the CAIB recommendations and our self-initiated actions. This document will be periodically updated to reflect changes to the plan and progress toward implementation of the CAIB recommendations, and our return to flight plan.

In addition to providing recommendations, the CAIB has also issued observations. Follow-on appendices may provide additional comments and observations from the Board. In our effort to raise the bar, NASA will thoroughly evaluate and conclusively determine appropriate actions in response to all these observations and any other suggestions we receive from a wide variety of sources, including from within the Agency, Congress, and other external stakeholders.

Through this implementation plan, we are not only fixing the causes of the Columbia accident, we are beginning a new chapter in NASA's history. We are recommitting to excellence in all aspects of our work, strengthening our culture and improving our technical capabilities. In doing so, we will ensure that the legacy of Columbia guides us as we strive to make human space flight as safe as we can.

Key CAIB Findings

The CAIB focused its findings on three key areas:

  • Systemic cultural and organizational issues, including decision making, risk management,
  • Requirements for returning safely to flight; and
  • Technical excellence.

This summary addresses NASA's key actions in response to these three areas.

Changing the NASA Culture

The CAIB found that NASA's history and culture contributed as much to the Columbia accident as any technical failure. NASA will pursue an in-depth assessment to identify and define areas where we can improve our culture and take aggressive corrective action. In order to do this, we will

  • Create a culture that values effective communication and empowers and encourages employee ownership over work processes.
  • Assess the existing safety organization and culture to correct practices detrimental to safety.
  • Increase our focus on the human element of change management and organizational development.
  • Remove barriers to effective communication and the expression of dissenting views.
  • Identify and reinforce elements of the NASA culture that support safety and mission success.
  • Ensure that existing procedures are complete, accurate, fully understood, and followed.
  • Create a robust system that institutionalizes checks and balances to ensure the maintenance of our technical and safety standards.
  • Work within the Agency to ensure that all facets of cultural and organizational change are continually communicated within the NASA team.

To strengthen engineering and safety support, NASA

  • Is reassessing its entire safety and mission assurance leadership and structure, with particular focus on checks and balances, line authority, required resources, and funding sources for human space flight safety organizations.
  • Is restructuring its engineering organization, with particular focus on independent oversight of technical work, enhanced technical standards, and independent technical authority for approval of flight anomalies.
  • Has established a new NASA Engineering and Safety Center to provide augmented, independent technical expertise for engineering, safety, and mission assurance. The function of this new Center and its relationship with NASA's programs will evolve over time as we progress with our implementation of the CAIB recommendations.
  • Is returning to a model that provides NASA subsystem engineers with the ability to strengthen government oversight of Space Shuttle contractors.
  • Will ensure that Space Shuttle flight schedules are consistent with available resources and acceptable safety risk.

To improve communication and decision making, NASA will

  • Ensure that we focus first on safety and then on all other mission objectives.
  • Actively encourage people to express dissenting views, even if they do not have the supporting data on hand, and create alternative organizational avenues for the expression of those views.
  • Revise the Mission Management Team structure and processes to enhance its ability to assess risk and to improve communication across all levels and organizations.

To strengthen the Space Shuttle Program management organization, NASA has

  • Increased the responsibility and authority of the Space Shuttle Systems Integration Office in order ensure effective coordination among the diverse Space Shuttle elements. Staffing for the Office will also be expanded.
  • Established a Deputy Space Shuttle Program Manager to provide technical and operational support to the Manager.
  • Created a Flight Operations and Integration Office to integrate all customer, payload, and cargo flight requirements.

To continue to manage the Space Shuttle as a developmental vehicle, NASA will

  • Be cognizant of the risks of using it in an operational mission, and manage accordingly, by strengthening our focus on anticipating, understanding, and mitigating risk.
  • Perform more testing on Space Shuttle hardware rather than relying only on computer-based analysis and extrapolated experience to reduce risk. For example, NASA is conducting extensive foam impact tests on the Space Shuttle wing.
  • Address aging issues through the Space Shuttle Service Life Extension, including midlife recertification.

To enhance our benchmarking with other high-risk organizations, NASA is

  • Completing a NASA/Navy benchmarking exchange focusing on safety and mission assurance policies, processes, accountability, and control measures to identify practices that can be applied to NASA programs.
  • Collaborating with additional high-risk industries such as nuclear power plants, chemical production facilities, military flight test organizations, and oil-drilling operations to identify and incorporate best practices.

To expand technical and cultural training for Mission Managers, NASA will

  • Exercise the Mission Management Team with realistic in-flight crisis simulations. These simulations will bring together the flight crew, flight control team, engineering staff, the Mission Management Team, and other appropriate personnel to improve communication and to teach better problem recognition and reaction skills.
  • Engage independent internal and external consultants to assess and make recommendations that will address the management, culture, and communications issues raised in the CAIB report.
  • Provide additional operational and decision-making training for mid- and senior-level program managers. Examples of such training include, Crew Resource Management training, a US Navy course on the Challenger launch decision, a NASA decision-making class, and seminars by outside safety, management, communications, and culture consultants.

Returning Safely to Flight

The physical cause of the Columbia accident was insulation foam debris from the External Tank left bipod ramp striking the underside of the leading edge of the left wing, creating a breach that allowed superheated air to enter and destroy the wing structure during entry. To address this problem, NASA will identify and eliminate critical ascent debris and will implement other significant risk mitigation efforts to enhance safety.

Critical Ascent Debris

To eliminate critical ascent debris, NASA

  • Is redesigning the External Tank bipod assembly to eliminate the large foam ramp and replace it with electric heaters to prevent ice formation.
  • Will assess other potential sources of critical ascent debris and eliminate them. NASA is already pursuing a comprehensive testing program to understand the root causes of foam shedding and develop alternative design solutions to reduce the debris loss potential.
  • Will conduct tests and analyses to ensure that the Shuttle can withstand potential strikes from noncritical ascent debris.

Additional Risk Mitigation

Beyond the fundamental task of eliminating critical debris, NASA is looking deeper into the Shuttle system to more fully understand and anticipate other sources of risk to safe flight. Specifically, we are evaluating known potential deficiencies in the aging Shuttle, and are improving our ability to perform on-orbit assessments of the Shuttle's condition and respond to Shuttle damage. Assessing Space Shuttle Condition

NASA uses imagery and other data to identify unexpected debris during launch and to provide general engineering information during missions. A basic premise of test flight is a comprehensive visual record of vehicle performance to detect anomalies. Because of a renewed understanding that the Space Shuttle will always be a developmental vehicle, we will enhance our ability to gather operational data about the Space Shuttle.

To improve our ability to assess vehicle condition and operation, NASA will

  • Implement a suite of imagery and inspection capabilities to ensure that any damage to the Shuttle is identified as soon as practicable.
  • Use this enhanced imagery to improve our ability to observe, understand, and fix deficiencies in all parts of the Space Shuttle. Imagery may include
    • ground-, aircraft-, and ship-based ascent imagery
    • new cameras on the External Tank and Solid Rocket Boosters
    • improved Orbiter and crew handheld cameras for viewing the separating External Tank
    • cameras and sensors on the International Space Station and Space Shuttle robotic arms
    • International Space Station crew inspection during Orbiter approach and docking

  • Establish procedures to obtain data from other appropriate national assets.
  • For the time being we will launch the Space Shuttle missions in daylight conditions to maximize imagery capability until we fully understand and can mitigate the risk that ascent debris poses to the Shuttle.

Responding to Orbiter Damage

If the extent of the Columbia damage had been detected during launch or on orbit, NASA would have done everything possible to rescue the crew. In the future, we will fly with plans, procedures, and equipment in place that will offer a greater range of options for responding to on-orbit problems.

To provide the capability for Thermal Protection System onorbit repairs, NASA is

  • Developing materials and procedures for repairing Thermal Protection System tile and reinforced carbon-carbon panels in flight. Thermal Protection System repair is feasible but technically challenging. The effort to develop these materials and procedures is receiving the full support of the Agency's resources, augmented by experts from industry, academia, and other U.S. Government agencies.

To enhance the safety of our crew, NASA

  • Is evaluating a contingency concept for an emergency procedure that will allow stranded Shuttle crew to remain on the International Space Station for extended periods until they can safely return to Earth.
  • Will apply the lessons learned from Columbia on crew survivability to future human-rated flight vehicles. We will continue to assess the implications of these lessons for possible enhancements to the Space Shuttle.

Enhancing technical excellence

The CAIB and NASA have looked beyond the immediate causes of the Columbia tragedy to proactively identify both related and unrelated technical deficiencies.

To improve the ability of the Shuttle to withstand minor damage, NASA will

  • Develop a detailed database of the Shuttle's thermal protection system, including reinforced carbon-carbon and tiles, using advanced nondestructive inspection and additional destructive testing and evaluations.
  • Enhance our understanding of the reinforced carbon-carbon operational life and aging process.
  • Assess potential thermal protection system improvements for Orbiter hardening.

To improve our vehicle processing, NASA

  • And our contractors are returning to appropriate standards for defining, identifying, and eliminating foreign object debris during vehicle maintenance activities to ensure a thorough and stringent debris prevention program.
  • Has begun a review of existing Government Mandatory Inspection Points. The review will include an assessment of potential improvements, including development of a system for adding or deleting Government Mandatory Inspection Points as required in the future.
  • Will institute additional quality assurance methods and process controls, such as requiring at least two employees at all final closeouts and at External Tank manual foam applications.
  • Will improve our ability to swiftly retrieve closeout photos to verify configurations of all critical subsystems in time critical mission scenarios.
  • Will establish a schedule to incorporate engineering changes that have accumulated since the Space Shuttle's original design into the current engineering drawings. This may be best accomplished by transitioning to a computer-aided drafting system, beginning with critical subsystems.

To safely extend the Space Shuttle's useful life, NASA

  • Will develop a plan to recertify the Space Shuttle, as a part of the Shuttle Service Life Extension
  • Is revalidating the operational environments (e.g., loads, vibration, acoustic, and thermal environments) used in the original certification.
  • Will continue pursuing an aggressive and proactive wiring inspection, modification, and refurbishment program that takes full advantage of state-of-the-art technologies.
  • Is establishing a prioritized process for identifying, approving, funding, and implementing technical and infrastructure improvements.

To address the public overflight risk, NASA will

  • Evaluate the risk posed by Space Shuttle overflight during entry and landing. Controls such as entry ground track and landing site changes will be considered to balance and manage the risk to persons, property, flight crew, and vehicle.

To improve our risk analysis, NASA

  • Is fully complying with the CAIB recommendation to improve our ability to predict damage from debris impacts. We are validating the Crater debris impact analysis model use for a broader range of scenarios. In addition, we are developing improved physics-based models to predict damage. Further, NASA is reviewing and validating all Space Shuttle Program engineering, flight design, and operational models for accuracy and adequate scope.
  • Is reviewing its Space Shuttle hazard and failure mode effects analyses to identify unacknowledged risk and overly optimistic risk control assumptions. The result of this review will be a more accurate assessment of the probability and severity of potential failures and a clearer outline of controls required to limit risk to an acceptable level.
  • Will improve the tools we use to identify and describe risk trends. As a part of this effort, NASA will improve data mining to identify problems and predict risk across Space Shuttle program elements.

To improve our Certification of Flight Readiness, NASA is

  • Conducting a thorough review of the Certification of Flight Readiness process at all levels to ensure rigorous compliance with all requirements prior to launch.
  • Reviewing all standing waivers to Space Shuttle program requirements to ensure that they are necessary and acceptable. Waivers will be retained only if the controls and engineering analysis associated with the risks are revalidated. This review will be completed prior to return to flight.

Next Steps The CAIB directed that some of its recommendations be implemented before we return to flight. Other actions are ongoing, longer-term efforts to improve our overall human space flight programs. We will continue to refine our plans and, in parallel, we will identify the budget required to implement them. NASA will not be able to determine the full spectrum of recommended return to flight hardware and process changes, and their associated cost, until we have fully assessed the selected options and completed some of the ongoing test activities.

Conclusion

The American people have stood with NASA during this time of loss. From all across the country, volunteers from all walks of life joined our efforts to recover Columbia. These individuals gave their time and energy to search an area the size of Rhode Island on foot and from the air. The people of Texas and Louisiana gave us their hospitality and support. We are deeply saddened that some of our searchers also gave their lives. The legacy of the brave Forest Service helicopter crew, Jules F. Mier, Jr., and Charles Krenek, who lost their lives during the search for Columbia debris will join that of the Columbia's crew as we try to do justice to their memory and carry on the work for the nation and the world to which they devoted their lives.

All great journeys begin with a single step. With this initial implementation plan, we are beginning a new phase in our return to flight effort. Embracing the CAIB report and all that it includes, we are already beginning the cultural change necessary to not only comply with the CAIB recommendations, but to go beyond them to anticipate and meet future challenges.

With this and subsequent iterations of the implementation plan, we take our next steps toward return to safe flight. To do this, we are strengthening our commitment to foster an organization and environment that encourages innovation and informed dissent. Above all, we will ensure that when we send humans into space, we understand the risks and provide a flight system that minimizes the risk as much as we can. Our ongoing challenge will be to sustain these cultural changes over time. Only with this sustained commitment, by NASA and by the nation, can we continue to expand human presence in space-not as an end in itself, but as a means to further the goals of exploration, research, and discovery.

The Columbia accident was caused by collective failures; by the same token, our return to flight must be a collective endeavor. Every person at NASA shares in the responsibility for creating, maintaining, and implementing the actions detailed in this report. Our ability to rise to the challenge of embracing, implementing, and perpetuating the changes described in our plan will ensure that we can fulfill the NASA mission-to understand and protect our home planet, to explore the Universe and search for life, and to inspire the next generation of explorers.

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