W

TO: M/Associate Administrator for Space Flight

Q/Associate Administrator for Safety and Mission Assurance

FROM: W/Assistant Inspector General for Inspections and Assessments

SUBJECT: Timing of Independent Team Meetings and Communications for

Shuttle-Mir and International Space Station (ISS) Missions

The Office of Inspector General (OIG) is conducting an inquiry on U.S.
participation in the Phase I Russian Mir Space Station Program. NASA
used independent external reviews to identify and analyze issues for the
first Shuttle-Mir rendezvous. The Agency continues to use this approach
for subsequent Shuttle-Mir missions during the Phase 1 Program. We
believe NASA can better ensure safety and mission success if these
independent review teams schedule key meetings and communications in a
more timely manner. Specifically, we are recommending that NASA task the
independent review teams to raise and/or resolve critical
recommendations and issues prior to the Phase 1 Joint Mission Readiness
Review (JMRR),[^1] but no later than the Flight Readiness Review
(FRR).[^2] This recommendation applies both to the remaining Shuttle-Mir
mission currently scheduled and all ISS missions for which NASA requests
independent reviews.

We received NASA's response to our draft report on November 7, 1997 (See
Appendix A). In addition, we received separate responses from the Office
of Safety and Mission Assurance

(Code Q) and the Stafford Task Force. These responses are provided in
Appendix B, for information purposes only. Based on these comments, we
have made changes to the report, as appropriate.

**A. Background**

In May 1994, the Acting Deputy Administrator established a special Task
Force to assess Shuttle-Mir rendezvous and docking missions under the
charter of the NASA Advisory Council (NAC). Lieutenant General Thomas P.
Stafford (Retired) was appointed chair of the Task Force on the
Shuttle-Mir Rendezvous and Docking Missions (Stafford Task Force). The
charter provided that the Stafford Task Force submit reports to the NAC
(See Appendix C for NAC Stafford Task Force charters).

During 1994 and 1995, the Stafford Task Force issued five separate
reports in preparation of the STS-71 and STS-74 rendezvous and docking
missions to the Russian space station Mir. In addition, beginning with
STS-71, the Task Force issued separate letters to the Administrator
assessing the flight readiness of Shuttle-Mir missions. In March 1995,
NASA revised the terms of the Task Force to include briefings and
interviews with individuals and parties from Russia and the Commonwealth
of Independent States (the Space Station Liaison Office, the Russian
Space Agency Headquarters, Mission Control Center - Moscow, Baikonur
launch facility, Gagarin Cosmonaut Training Center, and other facilities
as appropriate).[^3]

A charter between the Stafford Task Force and Academician Vladimir
Utkin's Advisory Expert Council (AEC)[^4] was signed on September 11,
1995 (Appendix D). This charter authorizes the two groups to jointly
assess issues concerning the technical issues, risk mitigation plans,
and lessons learned from Shuttle-Mir rendezvous and docking missions.
Subsequently, the Stafford Task Force issued reports to the NASA
Administrator directly and/or through the NAC, and the AEC issued
reports to the Russian Space Agency. In June 1996, the Stafford Task
Force and the AEC issued their first report providing joint independent
assessments of Shuttle-Mir missions. The Task Force's letters of flight
readiness for STS-84 and STS-86 (dated May 7, 1997, and September 23,
1997, respectively) include joint Stafford Task Force/AEC activities and
assessments. In November 1996, NASA chartered the Stafford Task Force to
conduct reviews and assessments and issue recommendations to the NAC
regarding the ISS operational readiness (See Appendix C).

**B. Shuttle-Mir Safety Assurance Process (A Three-Fold Approach)**

On July 10, 1997, the Chairman of the House Committee on Science sent a
letter to NASA regarding certification of Mir to meet or exceed U.S.
safety standards. In response, the Agency forwarded a document entitled,
*Shuttle-Mir Safety Assurance Summary* (Summary) (Appendix E).[^5] In
essence, NASA employs a three-fold approach that includes assessments
from: (1) the Phase 1 Program Office, (2) the NASA Office of Safety and
Mission Assurance, and (3) independent assessments (the Stafford Task
Force). The Summary outlines NASA's Safety Assurance Process,
Shuttle-Mir Safety Assurance Methods, Phase 1 Program Office Flight
Readiness Review and Certification, and the FRR.[^6]

As part of the safety assurance process, the Phase 1 Program Office
conducts JMRR's for each Shuttle-Mir mission prior to the FRR. The JMRR
certifies that all U.S. and Russian activities required to conduct a
safe Shuttle-Mir mission have been completed. As a result of these JMRR
activities, a Certificate of Flight Readiness is jointly signed by U.S.
and Russian managers and officials (Appendix F).

According to the Summary, all assessment activities for every Space
Shuttle mission culminate with the FRR. During the FRR, all activities
and elements necessary to conduct a mission from prelaunch through
mission completion are reviewed and addressed prior to the Shuttle
launch.

**C. Parallel Role of the Task Force Assessment In the Safety Process**

The Stafford Task Force communicates with the Phase 1 Program Office,
the Office of Safety and Mission Assurance, and others involved in the
Shuttle-Mir Program during its assessments and determinations of flight
readiness.[^7] However, the Task Force does not make formal
presentations in the JMRR's or FRR's (See Appendix G for a listing of
JMRR topics and presenters). It also is not a member of the formal
System Safety Review Panel or the Shuttle Safety, Reliability, and
Quality Assurance Commit-To-Flight Panel; the Phase 1 Program;
Headquarters Safety and Mission Assurance; or Certificate of Flight
Readiness processes as currently established for Shuttle-Mir Phase 1
(Appendix H). Instead, final reports, letters, and other determinations
from the Stafford Task Force are used by the Administrator and others as
independent checks for mission assurance.

**D. Timeliness of Independent Assessments**[^8]

Useful insights and critical issues developed in the Stafford Task Force
reports should be reported prior to 1 week before launch, preferably
prior to the Phase 1 JMRR, but not later than the FRR. This would allow
the Task Force's insights, questions, and recommendations to be
appropriately addressed and resolved by U.S. and Russian officials. (See
Appendix I for a summary of the Shuttle-Mir Missions and
Review/Assessment Timing of Major Activities).

The Task Force or its subgroups should schedule fact finding and other
meetings early enough in the process so that its reports and assessments
can be generally communicated to NASA prior to the Phase 1 JMRR.[^9] If
the Task Force does not conduct its Russian meetings in advance of the
FRR process, its ability to provide useful information to NASA is
circumscribed.[^10] In addition, Stafford Task Force/AEC joint reports
should be issued separately if waiting for the joint release will delay
the issuing of letters/assessments of flight readiness beyond the
JMRR/FRR time frames.

Requiring timely transmittal of information in no way diminishes the
independence of the Task Force. It still selects its members, determines
the issues it will consider, and freely accesses Agency information and
personnel. In fact, timely reporting will enhance the effectiveness of
the Task Force's mission as set forth in the Stafford Task Force/AEC
charter (Appendix D):

In addition to their joint efforts, the independent work of the Advisory
Expert Council and the Task Force will continue through Phase 1 with the
participation in and the review of all aspects of the activity of their
respective programs. Each will continue to produce independent separate
reports containing necessary recommendations *[prior]{.underline}* to
each mission and, should the need arise, for emergent issues. (Emphasis
added.)

**E. Recommendation:**

NASA should task the independent review teams to raise and/or resolve
critical recommendations and issues prior to the JMRR, but no later than
the FRR. This includes recommendations and issues raised by the Stafford
Task Force, joint Stafford Task Force/AEC, and other Shuttle/Station
independent groups.

**F. Summary of NASA Management's Response**

NASA's response states that our recommendation is based on a
misunderstanding of the role the Task Force plays in the NASA management
system. NASA describes the role of the Task Force as independent and not
part of the FRR process. It contends that including the Task Force in
the FRR process would harm the Task Force's ability to provide
independent assessments. Further, timely resolution of issues identified
by the Task Force are implemented through good communications as issues
occur. Finally, NASA does not consider Phase 1 JMRR an end to the flight
readiness review process. It is a culmination of months of extensive
reviews, but continued work and preparation occurs during the last 2
weeks leading up to launch.[^11]

**G. Evaluation of Management Response**

We are not recommending that independent review teams be subordinate to
NASA program review teams, but that they timely schedule their
activities so their insights can enhance the NASA review teams
processes. This requires that Task Force and joint Stafford Task
Force/AEC issues, for the most part, be communicated and resolved
between NASA and the Russian Space Agency *before* Certificates of
Flight Readiness are signed during the JMRR process.

Our recommendation in no way inhibits continued review by the Task Force
of the results of the Flight Readiness Review and issues that arise
after the review. Naturally, we encourage safety and oversight processes
from prelaunch through mission completion. Instead, our recommendation
allows the Task Force the time it needs to (1) assemble or informally
contact the experts it requires to evaluate issues, (2) schedule
communications with relevant Russian or other personnel, and (3)
evaluate these communications with additional expert consultation if
applicable.

We will continue to review the process and evaluate the application of
the recommended change.

**H. Conclusion**

NASA characterizes the independent assessments of the Stafford Task
Force and other independent groups as vital for the safety and flight
readiness of Shuttle-Mir missions and ISS Phase II and Phase III
operational readiness. The timeliness of the assessments is therefore
essential so that mission-critical issues (both U.S. and Russian) can be
resolved before the JMRR's and FRR's.

David M. Cushing

10 Enclosures

cc:

Distribution

**Distribution**

**[National Aeronautics and Space Administration (NASA)
Officials-In-Charge]{.underline}**

A/Administrator

AD/Acting Deputy Administrator

AT/Associate Deputy Administrator (Technical)

G/General Council

J/Associate Administrator for Management Systems and Facilities

L/Associate Administrator for Legislative Affairs

M/Associate Administrator for Space Flight

P/Associate Administrator for Public Affairs

U/Associate Administrator for Life & Microgravity Sciences &
Applications

Z/Associate Administrator for Policy and Plans

**[NASA Advisory Council Officials]{.underline}**

Chairman, NASA Advisory Committee

Chairman, NASA Aerospace Safety Advisory Panel

Chairman, Advisory Committee on the International Space Station

Chairman, Shuttle-Mir Rendezvous and Docking Missions and ISS
Operational Readiness

Task Force

**[Chairman and Ranking Minority Member of each of the following
Congressional]{.underline}**

**[Committees and Subcommittees:]{.underline}**

Senate Committee on Appropriations

Senate Subcommittee on VA-HUD-Independent Agencies

Senate Committee on Commerce, Science and Transportation

Senate Subcommittee on Science, Technology and Space

Senate Committee on Government Affairs

House Committee on Appropriations

House Subcommittee on VA-HUD-Independent Agencies

House Committee on Government Reform and Oversight

House Subcommittee on National Security, International Affairs, and
Criminal Justice

House Committee on Science

House Subcommittee on Space and Aeronautics

[^1]: The Phase 1 Joint Mission Readiness Review also is referred to as
    the Joint Flight Readiness Review, the Phase 1 Flight Readiness
    Review, or the Shuttle/Mir Joint CoFR Process.

[^2]: Obviously, if critical issues impacting safety and mission
    assurance arise after the JMRR and FRR, these issues should be
    immediately reported to the Phase 1 Program Office, the Office of
    Safety and Mission Assurance, the Administrator, and other relevant
    officials.

[^3]: Appendix C, March 30, 1995, Terms of Reference for the Stafford
    Task Force, Page 1.

[^4]: Russian Space Agency General Director Koptev appointed Academician
    Utkin to chair the AEC. The AEC provides independent assessments of
    the joint Russian-U.S. missions and serves as the Stafford Task
    Force's counterpart in Russia.

[^5]: The Summary does not represent the Stafford Task Force's separate,
    independent, parallel role in the Review Process (i.e., Appendix E,
    Figure 1 and the text regarding timing of Task Force
    recommendations, page 2) (See Agency comments, Appendix A).

[^6]: ^?^ During his September 25, 1997, press briefing, Administrator
    Goldin reiterated NASA's safety review process. The Administrator
    explained the process is comprised of three components: (1) a
    comprehensive all systems analysis headed by Phase 1 Program Manger
    Frank Culbertson, (2) an internal review led by Associate
    Administrator for Safety and Mission Assurance Fred Gregory, and (3)
    an independent review by the Stafford Task Force led by General
    Stafford.

[^7]: ^?^ For example, during its fact finding meetings, the Stafford
    Task Force receives presentations on Mir systems and other related
    areas. Members of the Task Force may also request additional
    information on an as needed basis.

[^8]: In response to increased Congressional oversight and in support of
    the STS-86 launch on September 18, 1997, Administrator Goldin
    initiated another independent group headed by A. Thomas Young to
    review the OIG letter dated August 29, 1997, sent to the House
    Committee on Science, and NASA's response to that letter. In
    addition, Young's group focused on communications with the Phase 1
    Program Office and the Office of Safety and Mission Assurance, and
    adequacy of NASA's safety assessment process vis-à-vis the STS-86
    launch. Young's final report was delivered to the Administrator on
    September 24, 1997, 1 day before the launch. This independent review
    was initiated 7 days before the September 25, 1997, launch. We do
    not know whether this group will be tasked with further inquiries.
    If the group will play a continued role in mission assurance, then
    our recommendations also apply to this group's activities.

[^9]: The Task Force has utilized advance teams to meet with the
    Russians. For example, in the preparation of the *Fifth Report of
    the Task Force on the Shuttle-Mir Rendezvous & Docking Missions*,
    General Stafford formed a team of Task Force members led by Colonel
    James C. Adamson (Retired) to conduct extensive discussions with
    NASA and Russian officials. The presentation of their findings to
    the Task Force occurred about

    2 months before the publication of the final report and almost 3
    months prior to the JMRR.

[^10]: ^?^ The timing of the Task Force's meetings with Russia for
    Shuttle-Mir STS-86 contrasts to its actions for the Shuttle-Mir
    mission STS-84 (See Appendix J). Earlier contacts with the Russians
    regarding the Shuttle STS-86 mission seemed warranted. September 12,
    1997, was the earliest meeting between the Task Force members and
    their Russian counterparts even though there were serious unresolved
    safety issues (e.g., determining the causes of the February 1997
    fire and Progress collision in June 1997). There were also increased
    problems compared to earlier Shuttle-Mir flights (e.g., ethylene
    glycol leaks, computer anomalies). More timely, candid, and
    technical discussions between the Task Force and the Russians may
    have enhanced NASA's review process and diminished the uncertainty
    and tension surrounding the decision to launch the STS-86, where the
    Administrator received the Task Force's information the day before
    the scheduled launch.

[^11]: In his response, General Stafford characterizes the role of the
    Task Force, among other responsibilities, to provide the
    Administrator with an independent assessment of operational
    readiness *[just]{.underline}* prior to each

    Shuttle-Mir mission (Emphasis added, see Appendix B).