Post-Challenger Evaluation of Space Shuttle Risk Assessment and Management (1988) / Chapter Skim
Currently Skimming:
Appendix C: Letter Reports to the Administrator of NASA and NASA Response
Appendix C: Letter Reports to the Administrator of NASA and NASA Response
Pages 97-114
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 97... ...
lmplen~entation of the Recommendations of The Presidential Commission on the Space Shuttle Challenger Accident, NASA, June 1987, excerpts from pp.
|
From page 98... ...
The Ccmmitt~e has been a functioning entity since its first meeting on September 22, 1986. We have thus far received presentations from and engaged in detailed discussions with NA5A Heac qua rters, the National Space Transportation System program office, Johnson Space Center, Marshall Space Flight Center, and Kennedy Space Censor.
|
From page 99... ...
O Linkage between the STS eng m eer m g change activities and the FMEA/CIL,hazard analysis processes should be assured. SETTING PRIORITIES FOR CRITICALITY 1 AND 1R ITEMS NASA does not now set priorities for Criticality 1 and 1R items nor does it consider the prrh~hility of occurrence of an event in the treatment of these items.
|
From page 100... ...
The Committee suggests that NASA consider a modification of the Critical Items List to account for these differences, help the priority selection process, and better focus present or future efforts to achieve safer Shuttle cgerations. INTEGRATED SPACE TRANSPORTATION SYSTEM ANALYSIS m e Committee oncerstards that various Mechanisms are being used by NINA to examine total system operation, including propagation of failure modes to interfac Meg or physically adjacent modules or ~obsy~te=~.
|
From page 101... ...
Slat v _ . Coleman Committee on Shuttle Criticality Review and Hazard Analysis It 1
|
From page 102... ...
In parallel with the prioritization technique development, an effort is also under way to assess the utility of probabilistic risk assessment in the NSTS FMEA/CIL process. Activities have been initiated to engage two independent firms with expertise in probabilistic risk assessment to perform detailed reviews of the orbiter auxiliary power unit and the shuttle main propulsion pressurization system.
|
From page 103... ...
NRC Comment: "Linkage between the STS engineering change activities and the FMEA/CIL hazard analysis processes should be assured." NASA Response: Engineering changes are processed through the same Space Shuttle configuration control boards that conduct the review of the FMEA/CIL. A recent change to the procedure requires an assessment of each change request to determine if it affects any Criticality 1 or 2 hardware.
|
From page 104... ...
Report to the President IMPLEMENTATION of the RECOMMENDATIONS of the Presidential Commission on the Space Shuttle Challenger Acciclent June 1987 6 104
|
From page 105... ...
NATIONAL RESEARCH COUNCIL AUDIT The Shuttle Criticality Review and Hazard Analysis Audit Committee of the National Research Council (NRC) , chaired by retired USAF General Alton Slay, reports directly to the NASA Administrator and is responsible for verifying the adequacy of the proposed actions for returning the Space Shuttle tO flight status (see Appendix F for panel membership and a summary of responsibilities)
|
From page 106... ...
Also being reviewed are the overall safety, reliability, maintainability, and quality assurance program, the definition of structural analysis requirements, the establishment and verification of analyses for margins of safety, the risk management processes for software, and the processes for analyzing payload safety. Interim findings and recommendations from these reviews will be submitted to the NASA Administrator through letter reports, as required.
|
From page 107... ...
Since our last report, the full Committee has met six more times, ~nclud mg visits to Marshall Space Flight Center, Kennedy Space Center, I again to Rocket~yne on the Space Shuttle Main Engine (SSME) , and with Rockwell Space Transportation System Division on STS integration.
|
From page 108... ...
However, we are concerned that it is not adequately staffed to cope with the demands placed upon it, and recognize that close collaboration with the centers and program offices is necessary to improve risk management in NASA. o A risk assessment report, based upon both the FMEA/CIL/retention rationale and a comprehensive hazard and safety assessment, should be the basis for the acceptance rationale in consider Meg waivers to fly Criticality l components.
|
From page 109... ...
that advise key NASA decision makers are not adequately staffed with people skilled in the statistical sciences of data analysis, statistical inference, and probabilistic risk assessment; persons with such skills should be added to provide 1mprcved support of the decision mating process. A greater effort is needed to plan for additional elimination or reduction of risks in the STS.
|
From page 110... ...
Integrated Space Transportation System analysis The Committee is pleased to note that the NASA Associate Administrator for SRMMQA has been directed to develop an agency-wide risk management system. We believe that it is important to call attention to the totality of "risk management" as the sum of a number of separate processes which ultimately must be considered on an integrated basis.
|
From page 111... ...
We presume that each of these entities recommends an action to an appropriate official, such as a project manager at Level III or the Deputy Director of the NSTS Program at Level II, who actually makes and takes responsibility for the decision. The Committee is concerned about a possible attitudinal problem regarding the decision process on the part of the NASA personnel engaged in it.
|
From page 112... ...
The output of these two processes (FMEA/CIL/ retention rationale on the one hand, and hazard analyses on the other) are individually approved by the Program Requirements Control Board (PRCB)
|
From page 113... ...
A risk assessment report, embracing the design retention rationale and the hazards/safety assessment, should provide the acceptance rationale for consideration by Level II and I managers in reachm g their decisions on the grant mg of waivers. Differences in FMEA/CIL reevaluation process among STS elements In the Committee's audit of the reevaluation of the FMEA/CILs, a number of differences were found in the process being used by different element project offices and contractors.
|
From page 114... ...
Among these are the design qualification and flight certification processes; a further look at integrated systems analysis; launch commit criteria and waiver policy; the process for general mg, review m g, revis m g and approving the retention rationale for waivers to permit flight of the Shuttle with critical items that affect safety; the process for structural analysis, establishment of margins, and verification of analyses and margins; the risk management process for STS software; and the process for analyz m g the effect of payloads on the safety of the Shuttle, ground personnel, and flight crews. 6 Admiral Richard H
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.