Space Shuttle:

Need to Sustain Launch Risk Assessment Process Improvements

NSIAD-96-73, Mar 26, 1996

Contact:

Louis J. Rodrigues
(202) 512-4841
contact@gao.gov

 

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Pursuant to a congressional request, GAO reviewed the National Aeronautics and Space Administration's (NASA) management of risk associated with space shuttle flights, focusing on NASA attempts to: (1) increase the flow and communication of risk information; and (2) use quantitative methods for assessing risk.

GAO found that: (1) NASA has successfully created numerous formal and informal communication channels and an open organizational culture that encourages people to discuss safety concerns and to elevate unaddressed concerns to higher management levels; (2) while most personnel agreed that the current culture encourages discussions of safety concerns, there was not universal agreement about the kinds of risk information needed for final launch decisions; (3) some personnel expressed concerns about the effects of pending cost reductions and program changes on shuttle safety; (4) NASA primarily relies on qualitative methods to assess and prioritize significant shuttle risk; (5) costs, lack of expertise, and lack of data have hindered NASA progress in increasing its use of quantitative methods to assess shuttle safety risks; and (6) NASA databases do not always provide timely, accessible, accurate, and complete information to facilitate quantitative assessment or decisionmaking.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: The Administrator, NASA, should identify guiding principles of good risk management, such as those contained in Chapter 2 of this report, and ensure that terms and conditions of the planned shuttle operations contract reflect these principles.

    Agency Affected: National Aeronautics and Space Administration

    Status: Closed - Implemented

    Comments: NASA revised the Shuttle Flight Operations Contract Request for Proposal and Statement of Work to reflect the eight principles of good risk management described in the GAO report.

    Recommendation: The Administrator, NASA, should take steps to ensure that flight readiness review participants understand and agree on the minimum issues that should always be discussed at the review and the level of detail that should be provided.

    Agency Affected: National Aeronautics and Space Administration

    Status: Closed - Implemented

    Comments: NASA revised its "Space Shuttle Requirements and Procedures for Certification of Flight Readiness (NSTS-08117/Revision L) to update and clarify the roles and responsibilities of each program element and organization relative to the Flight Readiness Review.

    Recommendation: The Administrator, NASA, should establish a strategy, to include specific milestones, for deciding whether and how quantitative methods, such as probabilistic risk assessments, might be used as a supplemental tool to assess shuttle risk.

    Agency Affected: National Aeronautics and Space Administration

    Status: Closed - Implemented

    Comments: NASA revised its "Space Shuttle Requirements and Procedures for Certification of Flight Readiness" to update and clarify the roles and responsibilities of each program element and organization participating in flight readiness reviews, and developed a strategy for deciding whether and how quantitative methods might be used as a supplemental tool to assess shuttle flight risk. To support these actions, NASA is developing quantitative methods, training materials, models, and tools, and a list of individuals at various NASA field centers with quantitative methods expertise to provide assistance.

    Recommendation: The Administrator, NASA, should assess the shuttle program's centralized database, as well as other databases, to ensure that data required to conduct risk assessments and inform decisionmakers are accessible, timely, accurate, and complete.

    Agency Affected: National Aeronautics and Space Administration

    Status: Closed - Implemented

    Comments: A team of NASA engineers examined the adequacy of the database for the Program Compliance Assurance and Status System. Also, the databases for the Problem Reporting and Corrective Actions Systems at each Center were reviewed. As a result of these efforts, NASA is changing its core database requirements and improving its Hazards database.

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