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

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.

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.