of the Presidential Commission on the Space Shuttle Challenger Accident


[43] PART 1


Recommendation IV


[44] Presidential Commission Recommendation IV


Safety Organization. NASA should establish an Office of Safety, Reliability and Quality Assurance to be headed by an Associate Administrator, reporting directly to the NASA Administrator. It would have direct authority for safety, reliability, and quality assurance throughout the agency. The office should be assigned the work force to ensure adequate oversight of its functions and should be independent of other NASA functional and program responsibilities.

The responsibilities of this office should include:




NASA has established an Office of Safety, Reliability, Maintainability, and Quality Assurance (SRM&QA). A new position, Associate Administrator for SRM&QA, has been established, reporting directly to the NASA Administrator. Mr. George Rodney, previously with the Martin Marietta Corporation, was appointed to fill this position. The NASA Office of the Chief Engineer was abolished, and the appropriate functions and resources of that office were transferred to the Associate Administrator for SRM&QA.

In December 1986, the Administrator signed and published NASA Management Instruction 1103.9A, Roles and Responsibilities-Associate Administrator for Safety, Reliability, Maintainability, and Quality Assurance (SRM&QA). This instruction (Appendix G) established the objectives, organizational setting, and responsibilities of the SRM&QA program, and provided for a separate and independent assessment function.

The following goals have been set for this office:


A short-range (2-year) SRM&QA Program Plan has been published, and preparation of a long-range (5-year) program plan and a strategic (10-year) plan are under way. The short-range plan requires each NASA center to develop plans that document the goals and determine the resource requirements necessary to establish and maintain effective center programs.

[46] Five areas have been identified that will assist in accomplishing the goals of the new organization. Each is defined in the master plan, together with a schedule of milestones to be met in the implementation process. The following is an overview of each element and its role in the overall achievement of the SRM&QA mandate.



The NASA Headquarters SRM&QA organization is shown in Figure 20, while Figure 21 reflects the previous organization of the Office of Chief Engineer. The center organizations are shown in Figures 22, 23, and 24. The Reliability, Maintainability, and Quality Assurance Division, the Safety Division, and the Programs Assurance Division constitute the core organizational elements of the Headquarters Office. The first two of these divisions establish, document, and maintain the SRM&QA policies, plans, procedures, and standards for the agency. The Programs Assurance Division provides the necessary day-to-day support to the program offices, reporting to the Associate Administrator on the status of those programs.

The Deputy Associate Administrator for Systems Assurance is responsible for ensuring that problems/trends are identified and communicated to the proper management level and that a strong system of independent checks and balances is established at headquarters and the centers. Other functional responsibilities include cognizance and control over system assessments, audits, and agency risk management.

The maintainability functional responsibility has been integrated into the headquarters and Marshall Space Flight Center (MSFC) organizations. Johnson Space Center (JSC) and Kennedy Space Center (KSC) are increasing their emphasis on this function and assessing where it should be located in their organizations.

The Space Flight Safety Panel was established to independently assess flying safety and the mission preparation and operations processes. Membership on this panel includes astronaut Bryan O'Connor, chairman, and a JSC flight director, KSC test director, and MSFC mission manager. The....


Figure 20. SRM&QA Organization Chart- NASA Headquarters

Figure 20. SRM&QA Organization- NASA Headquarters


Figure 21. Office of Chief Engineer Chart- NASA Headquarters (Pre-STS 51-L).

Figure 21. Office of Chief Engineer- NASA Headquarters (Pre-STS 51-L).


...panel reports to the Associate Administrator for SRM&QA, who provides the Chief, Operational Safety Branch, as an advisor to the panel. This panel provides the Associate Administrator for Space Flight with an independent assessment of NSTS operational issues.



The SRM&QA organization is defining its resource requirements in terms of manpower and budget. A plan to upgrade the skills of the SRM&QA professional staff and to establish a career development intern pro-...


Figure 22. SRM&QA Organization Chart - Marshall Space Flight Center.

Figure 22. SRM&QA Organization - Marshall Space Flight Center.


[48] gram is being developed to attract highquality people to the agency. Recruitment of personnel to maintain adequate oversight at Government and contractor facilities and to provide the proper levels of internal coordination and review has been initiated.

A preliminary manpower analysis has been conducted to determine NASA's total SRM&QA personnel requirements, including civil service, support contractor, and Department of Defense (DOD) quality inspectors. This analysis has resulted in an estimate of baseline and projected requirements through Fiscal Year 1988. The NASA civil service SRM&QA work force will increase by approximately 24 percent in 1987 and is expected to increase by about 35 percent in 1988. The analysis is being continued to determine the long-term requirements.

The centers are providing periodic reports on requirements and authorizations to the Associate Administrator for SRM&QA. These reports provide early identification of changes in requirements and highlight problems in acquiring qualified personnel, so that appropriate action can be taken. The centers will develop similar insight into their major contractors' SRM&QA capabilities to ensure that viable programs are maintained or developed.



One of the primary objectives of the SRM&QA Office is to establish firmly defined policies and procedures that will ensure the uniform application of standards throughout the agency. Areas being emphasized include systems assurance, safety, problem reporting and trend analysis, systems assessment, software assurance, nondestructive evaluation, and an electronic parts standardization program. Each of these areas is integrally tied to NASA's overall risk management policies.

The basic concept of the NASA risk management program is to maximize safety and reliability within program constraints and operational limitations. New initiatives that provide a stronger, more centralized risk management capability have been initiated. Specific risk management directives and an overall risk assessment methodology are being developed.

Problem reporting, corrective action, and trend analysis are closely related to risk management. NASA Management Instruction 8070.3, Problem Reporting and Corrective Action, and Trend Analysis Requirements, establishes the responsibilities for this activity. The Deputy Associate Administrator for...


Figure 23. SR&QA Organization Chart- Johnson Space Center.

Figure 23. SR&QA Organization- Johnson Space Center.


Figure 24. SR&QA Organization Chart -Kennedy Space Center

Figure 24. SR&QA Organization-Kennedy Space Center


....Systems Assurance, whose organization contains the Data Systems/Trend Analysis Division and Systems Assessment Division, is responsible for implementing this activity. An intercenter problem reporting and corrective action information system and a program compliance assessment status system are being developed to assist in the analysis and reporting of significant problems and trends.

This problem reporting and corrective action data base, developed by SRM&QA, is scheduled to become fully operational in October 1987. The system will contain all relevant "problem reporting" data for the NSTS and will provide access to the individual problem reporting data bases at JSC, KSC, MSFC, and selected contractors.

A set of common data elements has been established to enable each center to display and analyze information collected at the other centers. This technique will increase visibility into significant problems and improve the ability to perform independent technical assessments and in-depth trend analyses.

The System Integrity Assurance Program (SIAP), being developed by the NSTS and described in the response to Recommendation IX, will contain information on requirements verification, risk decision/hazard analyses, integrated problem assessments, trend analysis, and failure modes and effects analysis (FMEA)/Critical Items list (CIL). The intercenter problem reporting system will interface with this system and will be the basis for the integrated problem assessments. SRM&QA is participating in the development of requirements for the SIAP and will utilize information from it to support independent technical assessments.

Development of nondestructive evaluation (NDE) methods for inspection, assessment, and control of hardware is crucial to cost-effective risk analysis. An NDE Center of Excellence at the NASA Langley Research Center has been established to develop the needed tools. The major goals of the center are to develop one new NDE method or technique for field use each year and to develop and strengthen workmanship standards.

[50] The NDE process being developed will enhance cost-effective methods for inspection, including assessment and control of hardware, and surveillance of manufacturing processes. Improvements in the NDE process are expected to provide a means of ensuring quality and integrity of products that have traditionally been difficult to test or that required testing to destruction.

The requirements for on-orbit repair/ maintenance indicate the need to establish a policy on maintainability and its relationship with reliability and systems engineering. The specific engineering and analytical requirements for maintainability will be defined and published later this year. A preferred methodology, and a series of training courses associated with it, is being developed.

Software assurance is an ongoing activity within the Reliability, Maintainability, and Quality Assurance Division. A software acquisition life-cycle management methodology and software documentation standards are being developed, as are guide books and training courses for software acquisition and product assurance functions.



A milestone schedule for release of procedures to implement the SRM&QA policies and guidelines has been developed. The reviews, reassessments, reports, and other activities necessary to ascertain status, progress, and problem areas are identified in the schedule. This schedule will assist in reviewing the implementation of policies, directives, and guidelines, and in determining any areas that require modification.

A significant-problem report (SPR) has been developed to ensure adequate communication and assessment of problems and trends in the agency. Initial use of this report will be devoted to the Space Shuttle and associated payloads; however, it will be expanded in the future to include other areas. The categories of problems shown in Table 4 will be considered in the preparation of an SPR.

The Office of the Associate Administrator will play an integral role, along with center SRM&QA offices, in the mission planning process. The center offices will be involved in the review of the day-to-day detailed planning process. The Headquarters Office will monitor the overall planning process, ensuring that such areas as schedule, overtime rates, spares availability, and reviews do not adversely affect safety. Particular attention will be given to identifying any trends or indications of potential problem areas that result in undue schedule pressure.

A plan for an enhanced safety program is being developed that includes the risk management safety program, the STS safety program, and the Space Station safety program. Specific programs focusing on landing and crew safety are being instituted.

An STS Safety Risk Assessment Ad Hoc Committee has been formed to review center and contractor risk assessment procedures and to provide comments and criteria for policy documents.

A standardized mishap reporting and corrective action system is being implemented agency-wide and will become fully operational by early next year. The system requires management review and approval of all corrective action plans and provides a mechanism for disseminating lessons-learned summaries through electronic communications.

A supplemental safety information channel, the NASA safety reporting system, is being implemented to enable NASA and contractor personnel to notify SRM&QA of safety problems or hazards that could potentially result in loss of mission capability.

Using this system, individuals will be able to communicate safety concerns to an independent agent when, in their opinions, standard reporting channels lack the proper degree of response to a critical problem. This system, patterned after the FAA's aviation safety reporting system, is not intended to replace normal management channels for reporting hazards or safety concerns.

A NASA safety information system is being established. This system and a comprehensive review and upgrade of directives, handbooks, guidelines, and manuals are part of the overall strengthening of NASA's safety program. The safety information system will provide a complete, readily accessible, [51] centralized source of agency-wide information. It will compile information to allow the tracking and evaluation of known safety concerns and for the detection and identification of safety concerns not previously known. The system will respond to a wide range of specific and general requests from headquarters, field installations, programs, and contractors. It will support risk, risk/benefit, and risk/cost/banefit analyses in the NASA risk management program.

The Associate Administrator for SRM&QA has developed guidelines for contract award fee criteria. Center offices will participate in award fee determinations and ensure that contractual provisions provide appropriate clauses and incentives to focus contractor attention and efforts on SRM&QA activities.

To guide and execute the SRM&QA goals and tasks successfully, close coordination and cooperation between NASA and its contractors must be maintained. The NASA Excellence Award for Quality and Productivity will continue to be given in recognition of outstanding contractors and subcontractors who demonstrate continuing improvement in hardware and/or service performance.



Formal audits and evaluation of center, contractor, program, project, and special problem areas are planned. Audit teams composed of individuals from NASA, DOD, other federal agencies, and industry will be formed under the direction of the Deputy Associate Administrator for Systems Assurance. Team members will be selected for their experience and skills to ensure that thorough, comprehensive inspections and audits are performed.

Audit results will be reported to the Associate Administrator for SRM&QA and to the concerned center and program director. The NASA Administrator and appropriate associate administrators will be briefed on selected audit results. A corrective action response will be required from institutions, contractors, and programs on all unsatisfactory or marginal findings. Critical problem areas will be entered into a tracking system to monitor progress and ensure prompt and proper resolution.

These audits are intended to ensure compliance with the established policies, to ensure prompt and correct identification of....



Table 4. Significant-Problem Report Source Data

NSTS: Open Criticality 1 and 1 R problem reports, waivers, and associated trends

NSTS payloads or upper stages: Open problem reports, waivers, and associated trends that have the potential for causing critical failure modes or hazards

Selection guideline: SRM&QA management, in coordination with the management of other center organizations, will, at each reporting level, determine which problems in this category warrant the attention of the next-higher level of management.

NSTS: In-flight anomalies and trends/problems related to Criticality 1, 1 R, 2, and 2R items

Selection guideline: all problems in this category should be included in the SPR.

NSTS: Unexplained anomalies on Criticality 1 and 1 R hardware and software

NSTS payloads or upper stages: Unexplained anomalies that have the potential for causing critical failure modes

Selection guideline: all problems in this category should be included in the SPR.

NSTS and NSTS payloads or upper stages: System safety trends or specific safety problems

Selection guideline: SRM&QA management, in coordination with the management of other center organizations, will, at each reporting level, determine which problems in this category warrant the attention of the next-higher level of management.



[52] ....any major problems, to provide assistance to other organizations for related SRM&QA programs, and to promote proper discipline among all NASA organizations.

New or revised safety policies are being developed in such areas as explosives, software, lasers, system safety, aviation, mishap investigation, radiation, range operations, facilities, and others. A major effort to establish software assurance policies and procedures is under way.



A new Director of SR&QA has been named at each of the centers, reporting directly to the Center Director. At MSFC and KSC, the reliability and quality assurance functions have been removed from the engineering organizations and combined with safety in an organizational alignment similar to that which existed at JSC. SR&QA manpower has been increased at both MSFC and JSC and is being increased at KSC.

Several astronauts have been placed in key positions in the SR&QA offices, including that of Safety Director at JSC and the Safety Operations Branch Chief at NASA Headquarters. Other astronauts are monitoring safety-related activities at KSC and MSFC.

The new SRM&QA organization is participating actively and directly in specific NSTS activities, such as the hardware redesign, failure mode and effects analysis, critical item identification, hazard analysis, risk assessment, and space flight system assurance. This approach allows the NSTS Program line management at headquarters and in the field to benefit, on a continuing basis, from the professional safety contributions of an independent office without interrupting the two different reporting lines to top management.

Additional safeguards have been added by both the line project management and the SRM&QA organization to ensure that there is free, open, rapid communication upward and downward within all agency activities responsible for safety of flight.

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