Aerospace Safety Advisory Panel Review of Shuttle Program Risks

Review of Issues Associated with Safe Operation and Management of the Space Shuttle Program, Aerospace Safety Advisory Panel

November 1996


At the request of the President of the United States through the Office of Science and Technology Policy (OSTP), the NASA Administrator tasked the Aerospace Safety Advisory Panel with the responsibility to identify and review issues associated with the safe operation and management of the Space Shuttle program arising from ongoing efforts to improve and streamline operations. These efforts include the consolidation of operations under a single Space Flight Operations Contract (SFOC), downsizing the Space Shuttle workforce and reducing costs of operations and management.

The Panel formed five teams to address the potentially significant safety impacts of the seven specific topic areas listed in the study Terms of Reference. These areas were (in the order in which they are presented in this report):

-- Maintenance of independent safety oversight

-- Implementation plan for the transition of Shuttle program management to the Lead Center

-- Communications among NASA Centers and Headquarters

-- Transition plan for downsizing to anticipated workforce levels

-- Implementation of a phased transition to a prime contractor for operations

-- Shuttle flight rate for Space Station assembly

-- Planned safety and performance upgrades for Space Station assembly

The study teams collected information through briefings, interviews, telephone conversations and from reviewing applicable documentation. These inputs were distilled by each team into observations and recommendations which were then reviewed by the entire Panel. The main observations and all of the recommendations are presented in the balance of this summary.


Maintenance of Independent Safety Oversight

The ongoing transitions were assessed with respect to their potential impacts on the independence of the Safety and Mission Assurance (S&MA) organizational structure of both NASA and its contractors, the existence of independent reporting paths for safety concerns and the existence and strength of independent assessment functions.

Organizational independence has not changed significantly as a result of the ongoing transitions. NASA's S&MA organization remains independent of its line operations. The new SFOC contractor, United Space Alliance (USA), retains the same organization as its predecessor in which the S&MA function does not report independently of line operations. Hence, the status quo with respect to the organizational independence of both the NASA and contractor S&MA functions has been maintained.

The withdrawal of NASA personnel from day-to-day interfaces with their contractor counterparts has the potential to eliminate a significant independent reporting path. Even though NASA plans to retain a strong presence on the work floor and in contractor facilities, some of the team aspect of the NASA/contractor relationship will surely be lost. This may reduce the likelihood of contractor personnel utilizing their NASA associates to elevate issues they are reluctant to raise to their own management. Also, given the long established working relationships of most of the current individuals in the NASA and contractor contract management positions, the extra layer of management imposed by the SFOC structure should not represent an impediment to accurate or timely reporting. A problem could arise, however, with any successors to the incumbents who may not have the same depth of working relationship upon which to rely.

The independent assessment functions of both NASA and the contractor have been broadened. This will provide somewhat increased evaluation of processes and promulgation of lessons learned but is not intended as a total replacement for the NASA in- line S&MA activities which have been eliminate.

In the longer range outlook, independence may be further eroded through the loss of critical skills and experience among NASA personnel. NASA should not be misled by the apparent initial success of all of the transition efforts. A major test of the robustness of the new approach will likely be faced after there is significant turnover among incumbents at all levels. It is therefore important to maintain an adequate level of independent assessment and surveillance even after it appears that the transitions have been successfully accomplished.

Lead Center/Communications

NASA has transitioned the Space Shuttle program to a Lead Center management organization. The essence of the Lead Center type management is the delegation to a single NASA field center of the overall program management authority for an activity that involves the participation of other NASA field centers. This concept is not new to either NASA or the Space Shuttle program.

The Lead Center management mode for the Space Shuttle is working well under the leadership of the existing managers. To date, the project and element managers appear generally satisfied with the arrangement and seem to be active participants in it. This can likely be attributed to the fact that these individuals have been working together for over a decade and have come to know, respect and trust one another.

A multiplicity of formal communications channels exist and are used for transmitting information both upward and downward in the program. In addition, horizontal informal communication is encouraged and keeps counterparts and other interacting individuals among the several organizations in daily contact about events and issues of mutual interest.

The center directors involved are generally satisfied with their roles under the Lead Center mode. Their ability to quickly deploy their center's resources against emerging problems is especially appreciated. Some did express a concern about the impact of "full cost accounting" and the potential of having to re-program their budgets before taking necessary actions.

As yet, the governing documents that are the formal mechanisms for establishing and describing the Lead Center mode of management have not been issued. It is understood that there are teams working on the development of such documents, and they are nearing completion. It is vital that these documents clearly define the scope of authority of all levels of managers so as to minimize micro-management from above.

The managers of the projects and elements are, for the most part, long-term NASA employees, many of whom are approaching the age for voluntary retirement. It was agreed by those interviewed that it is not too soon to take steps to assure the availability of well- trained successors experienced in the Lead Center management mode.


NASA is projecting a significant "downsizing" of its civil service workforce in response to budgetary pressures and the reorganization of government departments. It is clear that this downsizing represents a substantial management challenge and a potential safety concern as the agency shifts program management responsibility from Headquarters to field centers and implements the Space Flight Operations Contract for managing the Space Shuttle.

The downsizing plans raise four separate but closely related questions:

(1~ Are the projected personnel levels in the fiscal year 99/00 timeframe at NASA and the United Space Alliance (USA) acceptable in terms of maintaining safety?

(2) Do NASA and USA have the appropriate skills and experience mix to maintain acceptable safety levels during this period of downsizing?

(3) What management tools and incentives are needed to achieve the projected personnel levels during this period while still maintaining the requisite skills and experience mix?

(4) Will the downsizing process itself become a significant disruption and obstacle to successful Space Shuttle and International Space Station (ISS) operations?

Although the Johnson Space Center (JSC), Marshall Space Flight Center (MSFC), and Kennedy Space Center (KSC) will all be hard pressed to meet outyear personnel targets without an involuntary Reduction in Force (RIF) and its attendant disruption, the circumstances that confront NASA management and employees at KSC are particularly difficult. NASA top management had previously explored with the Office of Management and Budget (OMB) and the Congress an enhanced buyout provisions that would have provided between 50 percent and 80 percent of current salary to NASA personnel who were eligible for retirement, but this version was rejected. Amounts of $50,000 and $35,000 were also explored and rejected. Instead, the earlier buyout incentive of $25,000 was renewed. Linking the current buyout to innovative part-time work or phased retirement arrangements such as the Career Plus Program at JSC will improve the attractiveness of the $25,000 amount as well as keeping experienced NASA employees available for part-time work. However, these linkages will require a legislative change to permit persons who accept any buyout to have the opportunity to continue part-time NASA employment. This approach could provide NASA the flexibility needed to attempt to reach targeted personnel cuts and maintain a balance of skills and experience during this period of intense activity and transition.

Space Flight Operations Contract

In order to reduce costs through efficiencies believed to be inherent in the private sector and reorient NASA's focus from operations to research, development and technology, NASA has implemented a plan for privatizing space flight operations for the Space Shuttle. The first phase of that plan is a consolidation of a majority of Space Shuttle processing support contractors and some NASA operational activities into a single Space Flight Operations Contract negotiated with United Space Alliance.

Based upon the Program Management Plan and the personnel, organization and management philosophies of the United Space Alliance, the Space Flight Operations Contract appears to be a comprehensive and workable document espousing safety as paramount throughout.

Overall, the documentation reviewed and discussions held reflect minimal adverse safety implications, especially in the short term. This is largely because the people currently in place are dedicated to making the new scheme work. There is some uncertainty about the future, however. Careful and continuous monitoring by top management and the safety organizations of both NASA and USA will be required to ensure continued safe operations as new people come on the scene, budget pressures continue to mount and the profit imperative increases on the part of the contractor.

Further reductions of funding could derail an otherwise well planned SFOC implementation. This could wreak hardships on people and foster an over confident or "workaround" attitude, either of which could have serious safety implications. While "safety" is a popular byword in the Space Shuttle program, dollar constraints may limit the ability to perform the tasks necessary to minimize risk. It is not evident how a situation such as this would be handled should it develop.

Manifest/Shuttle Enhancements

The manifest for the next six years is challenging. The planned schedule of seven launches per year, with surges to eight, is feasible with current personnel levels. An augmented schedule, at a rate of eight or nine launches per year, may be feasible only with additional resources, but it is probably too early to make a proper judgment in view of all of the changes underway. In any case, slips of several months for individual launches should be expected.

There is no additional safety risk related to the present manifest which arises from the move to a single operations contractor. However, the rewards and penalties of the incentive SFOC may motivate the contractor to actions which are unanticipated by either party today and which may pose additional risks to safe operations in the future.

The planned program for Space Shuttle enhancements appears well conceived and capable of meeting the needs of the International Space Station (ISS). Many of the changes being incorporated reduce risk as well which provides an overall safety benefit to the program. While the changes all seem conceptually sound, adequate testing and certification are required before they are used.


Maintenance of Independent Safety Oversight

Recommendation 1. NASA and USA should retain the present S&MA processes with respect to safety critical operations until surveillance results and the performance of USA as the SFOC contractor clearly indicate that safety controls, including the maintenance of realistic independent safety reporting channels, are well established. Thereafter, sufficient surveillance and independent assessment activities should remain so that any difficulties arising from subsequent personnel turnover can be identified.

Recommendation 2. NASA should retain a physical presence on the work floor at the space flight centers and at all contractors performing safety critical operations. True insight into safety practices requires personal interfaces and assured access to work in process at all times. Periodic independent assessment activities, audits and analyses of metrics are not sufficient to provide the degree of independent safety oversight required to operate the Space Shuttle program at minimum risk levels in the absence of a NASA physical presence on the work floor.

Recommendation 3. NASA should evolve its independent safety oversight efforts into a system in which it receives notification of all changes, anomalies and recertifications from the SFOC contractor. These notifications should carry the contractor's assessment of whether they are in- or out-of-family. NASA should retain approval authority for the contractor's classification of the action. When NASA judges a change or anomaly to be critical, it should exercise final approval authority over the contractor's plans and activities. It is considered vital to the maintenance of independent safety oversight that NASA maintain the final judgment relative to the application of the definition of in- and out-of-family events.

Recommendation 4. The long term maintenance of independent safety oversight will require NASA to develop and implement programs for critical skills retention and for the generation of direct Space Shuttle operating experience among NASA employees.

Recommendation 5. NASA should continue its announced policy that "anyone involved can stop a Space Shuttle launch." Together with the NASA Safety Reporting System, this should help encourage people to employ the available independent reporting pathways.

Lead Center/Communications

Recommendation 6. The development of the governing documents for the Lead Center mode of program management should be expedited. Particular attention should be given to assure that the resulting documents establish clear and unambiguous definitions of the scope of responsibilities and authorities of all levels of management within a program. Provisions should be incorporated to preclude the possibility of micromanagement. Acknowledgment should be given to the importance of mutual respect and trust among the managers for the success of this (and any other) mode of management of complex programs.

Recommendation 7. There should be a high level, internal, periodic review of the Lead Center management structure and its operations. This review should examine whether the concept is functioning as intended.

Recommendation 8. Measures should be taken to assure that individuals ascending to positions of authority within the program are properly trained in the Lead Center philosophy so that deviations in management operations will not occur.


Recommendation 9. NASA workforce downsizing should be preceded by successful reductions in work requirements to ensure that arbitrary employment targets do not adversely affect the safety of Space Shuttle and International Space Station operations. Field centers, especially the Kennedy Space Center, should be given latitude and flexibility in achieving scope of work reductions and revising targeted personnel levels as the work content changes.

Recommendation 10. NASA should renew its appeal to OMB and the Congress to gain approval of an enhanced buyout provision of at least $50,000. The Congress is urged to consider the request favorably. Using the flexibility achieved through an attractive buyout package, NASA should be permitted to resume limited hiring of younger engineering and scientific personnel. An enhanced buyout provision would be an important to- I to help avoid a disruptive involuntary Reduction in Force (RIF) along with the distortions in skills and experience that will likely be a direct byproduct of a RIF.

Recommendation 11. NASA should seek legislative approval to combine its buyout authority, regardless of amount, with the phased retirement, Partners in Education, and Partners in Technology provisions of the Career Plus program. This approach will enhance the attractiveness of any buyout package and keep available for part-time work some of NASA's most knowledgeable employees during this period of intense activity and transition.

Recommendation 12. The institutional and functional role of the Kennedy Space Center in the post-2000 period should be defined, and a personnel strategy for KSC and the SFOC contractor that is appropriate to that role should be devised. A prompt decision on this issue will also be of considerable value to USA as it implements the terms of the SFOC.

Recommendation 13. NASA should continue to develop alternative employment opportunities, such as those associated with Space Shuttle upgrades and ISS integration, for KSC employees who otherwise would leave to avoid a RIF or who would be involuntarily separated through a RIF.

Space Flight Operations Contract

Recommendation 14. Plans should be developed to assure that successor managers for both NASA and the SFOC contractor are nurtured in an environment that cultivates mutual respect and trust for one another typical of the excellent organization in place today.

Recommendation 15. NASA should continue to monitor the transition to the SFOC to assure that all requirements are being met in an orderly way and that the safety of operations remains the prime consideration.

Recommendation 16. Congress and NASA should provide a level of funding sufficient to assure a safe SFOC implementation.

Recommendation 17. A periodic audit of the standards by which NASA monitors the safety performance of the SFOC contractor should be conducted by an independent group.

Recommendation 18. NASA and USA must maintain an adequate focus on resolving current and future obsolescence and logistics support issues in order to avoid potential safety problems.

Manifest/Shuttle Upgrades

Recommendation 19. The Space Shuttle program and the SFOC contractor should continue to emphasize safety first as a way of life and enforce the precedence of safety, manifest and cost in Space Shuttle operations.

Recommendation 20. NASA and SFOC contractor managements should enforce the safety priority using good management judgment and, if possible, derive measures of processing and launch crew efficiency and fatigue as they affect the safety of operations.

Recommendation 21. Any decision to move to a higher launch rate (8 or 9 per year) should be delayed until more experience is gained with the new contractual setup and some of the ISS launch constraints have been resolved.

Recommendation 22. NASA should ensure that all enhancements and upgrades are fully tested and assessed prior to implementation. Funding profiles and schedule pressures should not be allowed to shorten any critical testing or validation processes.

  • submit to reddit


Battelle Research and Infrastructure.
Support SpaceRef, NASA Watch and the Astrobiology Web on Patreon.

Join our mailing list

Monthly Archives

About this Entry

This page contains a single entry by Keith Cowing published on December 16, 1996 5:18 PM.

Service Module Update was the previous entry in this blog.

Multicultural Leadership Program Training is the next entry in this blog.

Find recent content on the main index or look in the archives to find all content.