From: Marshall Space Flight Center
Posted: Monday, December 15, 2003
FROM: DA01/David A. King
SUBJECT: MSFC Safety and Mission Success (SMS) Week Feedback
I would like to express my sincere appreciation for your participation in the Safety and Mission Success (SMS) Week activities. The time spent reading the Columbia Accident Investigation Board (CAIB) final report and reviewing the CAIB Agencywide Action Team (CAWAT) recommendations was significant. However, the subsequent group discussions were very valuable in not only initiating a broad dialogue on the cultural issues faced by MSFC and the Agency, but also in identifying creative solutions to the issues identified in the CAIB report.
An MSFC "rollup" of the issues and recommendations that were most widely identified from the Center's directorates and offices was developed, based on the feedback that you provided. This product was forwarded to the CAWAT for potential inclusion in their final report and is included as an enclosure for your information. There are several important points to be emphasized relative to this product and the SMS process at MSFC. First, the issues and recommendations in the enclosure are not prioritized. They are simply the major issues for consideration by the CAWAT. Second, after reviewing the MSFC submittal, you may find that what you considered to be a significant issue/solution was not included. There is absolutely no intent to stifle any MSFC employee's feedback, so you have the option of providing your input directly to the CAWAT at http://www.smscomments.nasa.gov. This Web site will be available until mid-February.
Third, SMS week is over, the MSFC input has been provided to the CAWAT, but our work is just beginning. MSFC employees identified many significant issues and recommendations that are within our Center's realm of control. As such, we are developing a process to assure that each item is reviewed again, with a focus on what each organizational unit can do to address the issues identified by its employees. There will also be a similar process for Center-wide issues and recommendations.
Again, I thank each one of you who participated in the SMS activity. Your responses reaffirmed my confidence in the high caliber of the MSFC workforce. As we work to address the issues that were identified, I know that I can count on your continued support.
' original signed by'
David A. King
MSFC Issues and Recommendations Identified during
Safety and Mission Success (SMS) Week
CATEGORY: Schedule & Budget Pressures
ISSUE: Much is made in the CAIB Report about the adverse impact of trying to satisfy relentless schedule and cost pressures - schedule often does not line up with the allocated resources.
RECOMMENDATION: Cost and schedule pressure will always be present to some degree. Managers and employees must push back on unrealistic pressures, to include scaling back on operations when necessary, to avoid sacrificing the quality and safety of the products/processes.
ISSUE: Shuttle was initially marketed as a cargo/crew vehicle that could easily satisfy all of the government's needs. Other programs have started and then been cancelled due to promising goals that could not be subsequently supported by up-front system analysis.
RECOMMENDATION: NASA programs/projects must perform realistic up-front system analyses and technical reviews to develop implementable programs having adequate resources consistent with the technology maturation.
CATEGORY: Communication & Dissenting Opinions
ISSUE: Lack of opportunity to express minority opinions is clearly seen in the reluctance of middle management to let upper management know about problems. Upper management often identifies issues based on information and data received from middle management. A major part of the problem with the Columbia accident was a lack of integrated management across the program elements.
RECOMMENDATION: The communication process within each organization should be examined from the top down. Types of information exchanged and necessary distribution should be identified. Existing information flow channels should be examined to determine whether they are effective in assuring that the identified information types are received by all of the desired recipients. Changes to the information flow scheme should be implemented as necessary to assure a timely and effective exchange of information. An efficient problem reporting information flow channel should be developed along with this exercise that ensures identified problems are promptly evaluated and additional actions initiated where appropriate.
ROF#: F6.3-15 through F6.3-28
ISSUE: As long as the Safety & Mission Assurance Office and the Engineering Directorate receives funding from the programs/projects, their independence is subject to question. Same issue with Code Q.
RECOMMENDATION: Establish funding stream independent of the programs/projects to assure appropriate level of insight/oversight by Safety & Mission Assurance, and other appropriate independent support organizations.
CATEGORY: Independence of Project Chief Engineer
ISSUE: Chief Engineers (CE's) are far too involved in project management. In some cases, the project manager and CE are the same person. This will lead to compromises in the quality of engineering decisions being made because of budget or schedule concerns.
Project CE should be separate/independent from the Project Office. CE should only represent the technical side of issues.
CATEGORY: Columbia & Challenger Training
ISSUE: As time passes and the current NASA employees retire, many of the valuable lessons learned from the CAIB report may be lost. If so, sensitivity to the conditions leading up to Columbia (and Challenger) will be forgotten.
RECOMMENDATION: All NASA and contractor employees should be periodically re-educated on the Columbia and Challenger events. NASA should develop a training module and deliver to all employees and contractors.
ISSUE: From R3.8-2 CAWAT Matrix: Develop, validate, and maintain physics-based computer models to evaluate TPS damage from debris impacts...
RECOMMENDATION: All programs should produce, maintain, and validate models, theoretical analyses, and software code to assess the state of their systems and components. These tools should be continually updated and validated against the experimental and operational data to determine the appropriate course(s) of action and repair.
ROF#: CAWAT R3.8-2
ISSUE: By the eve of the Columbia accident, institutional practices that were in effect at the time of the Challenger accident - such as inadequate concern over deviations from expected performance, a silent safety program, and schedule pressures - had returned to NASA.
RECOMMENDATION: Managers must be familiar with their risk identification and control tools (i.e. Hazard Analysis, FMEA/CILs, Probabilistic Risk Assessment). Issues/concerns within NASA should be assessed/understood based on risk information. Performance deviations must be fully understood and managed as a risk.
CATEGORY: Training & Certification Program for Leaders
ISSUE: Inexperienced and/or inadequately trained managers or decision makers are being promoted into positions of influence. New managers are often reluctant to ask for help, or do not recognize when they need help. This trend is occurring throughout the NASA organization.
RECOMMENDATION: NASA should implement a clearly defined career development program and certification process for managers, supervisors, project managers and supporting program/project control personnel. In addition, training accountability (testing) should be implemented.
CATEGORY: Civil Service Analytical Capabilities
ISSUE: Numerous examples are given that point to the fact that NASA has turned too much technical and analytical responsibilities over to the contractors. Civil service often accepts the results without performing an adequate independent check. This has resulted from two things: 1) budget constraints, and 2) hiring freezes where blocks of technical expertise have been lost.
RECOMMENDATION: Rebuild civil service analytical capabilities within the agency, particularly in area of systems analysis - will require additional resources, but need additional checks and balances between government and contractor personnel.
CATEGORY: Administrative Initiatives
ISSUE: Imposed on Personnel NASA technical personnel are faced with major administrative initiatives (i.e. ISO, IFMP, workforce competency database, VPP) that compete with resources dedicated to achieve NASA's scientific and technical mission. Many of these well-intentioned efforts are implemented with the goal of increased efficiency, productivity, and safety. However, it is not apparent that this goal is being achieved in several instances.
RECOMMENDATION: A representative team of personnel should assess these initiatives to validate that NASA is receiving an adequate return on its investment rather than simply creating additional systems.
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